Canadian Health Care System

[PPCLI Guy]

Working in ER at the Children's, if we were allowed to turn people away because junior has a fever of 37 degrees   : we'd save millions.   Perhaps once I'm elected supreme ruler and grand poo-bah of Canada...  

Or you can be my Minister of Health - and Infanteer can be the Minister of Truth...

Dave

 

[Torlyn]

Or you can be my Minister of Health - and Infanteer can be the Minister of Truth...

Dave

Hmm...  It's a bit 1984, but I've always thought we should rename the health department as MiniHell...  Fits, wot? 

T

 

[a_majoor]

Who will be the Minister of Peace?

 

[a_majoor]

Bad things come to those who wait


Monday, 22 November 2004
Mark Steyn


What's the defining characteristic of a government health service? It's one word, a word that, in its medical context, doesn't exist south of the border--"waiting," as in "waiting list," "waiting times," waiting, waiting, waiting.

I was sick over the summer and, down in New Hampshire, I went to see the local doctor, who referred me to a specialist. Let's just run through that manoeuvre again, in case it happened too quickly for those accustomed to Quebec levels of treatment: I saw the GP on Tuesday, got referred, saw the specialist Thursday. As is often the case in the U.S., the doctor was Canadian, and indeed came from a long line of Canadian doctors--both his parents practise in Ottawa. Making idle chitchat as his fingers felt his way around my fleshly delights, he explained that "waiting" is built into the concept of a government health service: "If you need surgery," he said, "it's in my interest to get you in and operated on as soon as possible, because that's money for me. The faster it happens, the better my cash flow. But when the government runs the system, every time you get operated on it costs the government money. So it's in their interest to restrict or delay your access. When you look at the overall budgets--salaries, buildings--it's not hard to understand that the level of service you provide to the patient is one of your few discretionary costs. So the incentive is to reduce that."

He was chuckling merrily as he explained this, and I got the feeling he'd said it to many Canadians over the years. Defenders of our system often point out that America spends a higher proportion of its GDP on health care than Canada and yet has lower life expectancy. I'm not sure I quite understand the point they're making. I have employees on both sides of the border. When my assistant in New Hampshire has a doctor's appointment at 9 a.m., she's in his office by 9:07 and back in my office by 11. My assistant in Quebec, living in a jurisdiction with the lowest doctor-patient ratio in the western world, can't get a doctor's appointment, so she goes to her local CLSC at 9 a.m., and waits, and waits and waits and waits all day to be seen.

I doubt Chantal's and my loss of economic activity is factored into those health-care-as-a-proportion-of-GDP costs. In Canada, we accept that if you get something mildly semi-serious, it drags on while you wait to be seen, wait to be diagnosed, wait to be treated. Meanwhile, you're working under par. The default mode of the system is to "control health care costs" by providing less health care. Once it becomes natural to wait six months for an MRI, it's not difficult to persuade you that it's natural to wait 10 months, or 15. Acceptance of the initial concept of "waiting" is what matters.

The other week, I made some remarks about C. difficile in The Chicago Sun-Times and observed that it was caused by inattention to hygiene--"by unionized, unsackable cleaners who don't clean properly; by harassed overstretched hospital staff who don't bother washing their hands as often as they should." Michael Miner, in the city's "alternative weekly," The Chicago Reader, took exception to this, mainly because, in a clean American convalescence home, his mother had contracted C. difficile and died. He has my sympathies. I'm not sure that it's wise to trash my argument purely on personal experience, but, since he brought up his mother, let me bring up my wife.

A few years back, she felt herself beginning to miscarry. Nobody was at home so she called a cab and went to the emergency room at the Royal Victoria. Knowing what "emergency" means in the Quebec system, she grabbed a novel on the way out--an excellent choice, Mr. Standfast by John Buchan, our late Governor General. It's 304 pages, and my wife had the time to read every single one of them before any medical professional saw her. While she was reading, she was bleeding, all over the emergency room floor, the pool of large dark red around her growing bigger and bigger, until eventually a passing cleaner ran her mop over the small lake and delivered a small rebuke to my wife for having the impertinence not to cease bleeding.

Maybe it was just bad luck. Michael Miner at The Chicago Reader got U of T's John Marshall on the phone to assure him that "Canadian medical standards are on average every bit as high as American medical standards. It has nothing to do with the structures of the health care system." Oh, really? If Miner's mother was dissatisfied with her convalescence home, she could always pick another. And don't give me all the fine print about HMOs and co-payers: in the last resort, you or your loved ones can always reach into your billfold and go anywhere you can afford. At the Royal Vic, no matter how many bills you wave around, you still have to bleed all over the floor because they're the only game in town. Universal lack of access. Equality of crap--very literally, as the C. difficile outbreak demonstrates.

Since my wife's experience, the average wait time in Montreal emergency rooms has apparently gone up to 48 hours. So don't pack an overnight bag, take two, and the complete works of John Buchan. The natural consequence of a system built on waiting is that more people do what she did--sit in the hospital, waiting to be seen, bleeding all over the floor until a cleaner (and it's one cleaner per two floors at many Montreal hospitals) wipes it up with a dirty mop and then runs the same mop over the floor in the isolation ward upstairs.

That's the C. difficile story. That's why the fatality rate in Montreal is four times (officially) the North American average. "In many institutions, housekeeping staff has been reduced while nursing workloads have increased," reports Quebec's Clostridium Difficile-Associated Diarrhea Clinical Study Investigators Group. "Compliance with hand hygiene has been shown to decrease as workloads increase . . . Wards and emergency departments have become more crowded, and bed turnover is rapid. This makes containment of C. difficile exceedingly difficult, especially among patients with fecal incontinence." According to Dr. Louise Poirier of the Quebec microbiologists' association, "It's not that easy if you are a nurse and you have six patients. You take your gloves off and you go far away, find a sink, wash your hands, go back, put on another gown. You do that sometimes 20 times in an afternoon."

Hygiene is the number one issue in Canadian hospitals, and a problem with hygiene is the logical consequence of a system built on "waiting." On March 7 last year, Tse Chi Kwai went to Scarborough Grace Hospital and, as is traditional, was left on a gurney in emergency for 12 hours, exposed to hundreds of people. Two days earlier, his mother had died of SARS but, despite displaying to her doctor all the symptoms detailed in the several health alerts on the subject, had cause of death listed as "heart attack." And at Scarborough Grace, even after discovering that Tse's mother had recently died after returning from Hong Kong, Dr. Sandy Finkelstein concluded that, even if Tse was infectious, it was only with TB. Lying next to Tse on that ER gurney hour after hour was Joe Pollack, who was being treated for an irregular heartbeat. He was subsequently sent home but returned on March 16 with symptoms of SARS. He was admitted and isolated, but apparently it never occurred to the hospital to isolate Mrs. Pollack. So she wandered around the wards and infected an 82-year-old man from a Catholic Charismatic group.

Mr. Pollack, Mrs. Pollack, the 82-year-old Catholic Charismatic and his wife all died. None of these people went anywhere near Southeast Asia. They were exposed to SARS by the Toronto health care system, as was the 82-year-old's son, who was also unknowingly infected at Scarborough Grace and went on to expose another 500 to SARS at a religious retreat. As I wrote in the National Post at the time, "Only in Canada does the virus owe its grip on the population to the active co-operation of the medical profession. In Toronto, the system that's supposed to protect us from infection instead infected us. They breached the most basic medical principle: first do no harm."

Almost all scandals in Canadian hospitals boil down to the same thing: a decrepit system unable to observe basic rules of hygiene and quarantine. Sometimes it's SARS, sometimes it's C. difficile, sometimes it's hundreds of women going in to the Captain William Jackman Memorial Hospital in Labrador City and being gynecologically examined with unsterilized instruments-and thereby potentially exposed to chlamydia, gonorrhea, hepatitis or HIV. And almost all these crises are due to, in Dr. Marshall's words, "the structures"--a system that ensures sick people wait longer in crowded rooms in dirtier hospitals will, by definition, spread disease.

One day it will be something much worse than C. difficile.

 

[couchcommander]

You have to pay the bucks if you want the best care in the world.  We don't get the system we should be getting.  You are right, health care is more expensive in the States (I've read the same sorts of stats), but do you think it is better to spend less and have a system that is fraught with waiting lists, is falling behind in technological fields (we have an MIR per capita rate equivalent to Central American countries), and loses talent to better paying positions in the US?

The key point here was for the same procedure. That means if take a guy and do the exact same thing to him, once in a private hospital, once in a public, the cost in the private one will be significantly higher as a result of the administrative and mangerial costs associated with a for profit delivery system. As well, we WERE falling behind in technological fields, that was before the first 5 billion investment in diagnostic technologies back in the late nineties, then the health care deal under Chretien, and then this last deal under Martin. Services are improving. The fact that the University medical centre here in Edmonton has 4 new buildings going up is a testament to this (a heart centre, two research buildings, and yes, a diagnostic centre).

Is "Health Care" the reason for this?  I would think that the "inferior" stats stem from the problems facing US inner cities, and hence are related to specific issues such as race relations, etc, etc (when you take these areas out of the equation, statistics on violent crime are the same in both the US and Canada).  I don't know if Health Care is going to prove to be a big thing when kids are wheeled in with gunshot wounds from gangwars and drug abuse is rampant in urban ghettos.

These are the "basic indicators" that the WHO uses to measure the health care system. Further, I would add, though I am not 100% sure, so don't quote me on this, that the homicide rate in the US isn't high enough to really affect their average life span. Further, homicide doesn't usually factor into infant mortality rate, which IS indeed a very good measure of the level of care availible to a person.

The "50 Million un-insured Americans" is really quite a myth in that it implies that these 50,000,000 Americans are the same people who are constantly looking for proper health care insurance.

This "50 Million" is a rapidly shifting population.  The poor are covered by Medicare and the Elderly by Medicaid (or is it the other way around?).  Most Americans have insurance through their employer.  The 50 million are people in between jobs, students not under their parents coverage, etc, etc.  Canada has the same problem at times - I was not covered by Health Insurance for about 6 months because I had lapsed from my parents plan and never really put the effort into signing into the provincial system.  As well, many important health care services are unavailable to many Canadians because the public adminstration has, in the effort to cut costs, eliminated them from basic coverage (ie: dental work - healthy teeth and gums is pretty important health wise, is it not?)  Don't have "Extended Coverage" through the private insurence of an employer?  Sorry, you're crap out of luck, just like an American.

All canadians are guaranteed a basic level of health care coverage free of charge. No canadian is without basic medical coverage (even you for those six months, had something happened to you, you would have been treated, no charge). And furthermore, I might add that this number, 50 million, represents Americans with no coverage, that INCLUDES medicaid. They have nothing, no government coverage, nadda. So no, it's not a myth but a terrible reality.


What both the US and Canada need is a privately managed system that is truly universal and comprehensive - Canada's system is so fraught with exceptions, regulations, and loopholes (ie: inter-provincial service is tricky) that people slick through the cracks here as well (this is the "perverse incentive" that public administration has)

The point was that a privately managed system will be MUCH more expensive and less efficient.

I'm sure they are right as well. :  Just in the last election, everyone was bleating for more money for the Health Care system.  Since the 1970's, Canada's spending on health as a percentage of GDP has been steadily increasing.  I think the figure pointed out that if we continued on the trend that we've been on, we would be spending 100% on health care in a few decades.  Clearly, due to the fact that technology becomes more and more important in health care (driving up the average costs), demographics are shifting (meaning more elderly people are going to need the system), and that there never seems to be "enough" money for the system, the need for reform is staring us in the eyes.

History teaches us important lessons.  By looking at the Soviets, we should have learned that command economies (regardless of sector) don't work.  That's why we won and why China is moving with the times.


Horrible predictions of health care taking up all of our money I think are a little unfounded. The point is that amazingly, right now, we actually do have enough money, and it's not going to break the bank.

I might add, the costs associated with having an elderly population willl be around whether or not there is a private or public system, the fact is that these costs will just be higher in a private system.

And I agree with a cost for health services (as I mentioned before, charge somebody like 10 bucks to go to the doctor... just enough so that it won't actually stop someone who is really sick, but so that it just not FREE). I just don't think that HSA are the best way to do it as I can already forsee skyrocketing inefficiences.


Don't compare the Canadian Health Care System to the Americans - it is a straw man theory.  We both suffer from the same debilitating problem in that we are stuck to large bureaucracies (public or private) to manage and direct how we approach our personal health and, in the process, create a false patient/doctor relationship that is full of perverse incentives.

The American system is big market economy example that acts as a counterpoint to our own system, and to which we are often compared by BOTH sides. Of course if we want we can start comparing to systems in France and Britain, which are mixed system, both have their highlights, and their horrible failures (notably the national health service in Britain).

One tends to come to the conclusion that private delivery of health care results in better health care for those people who are able to pay for it, and unfortunately does it rather inefficiently. It does little to affect the plight of your low to middle income average joe.


I am all for a universal system of coverage - like vehicle insurance, the costs are too high to go around without it.  However, it needs to be done properly, resting responsibility for individual health in, surprisingly, the individual.

I couldn't agree more.

 

[Infanteer]

The key point here was for the same procedure. That means if take a guy and do the exact same thing to him, once in a private hospital, once in a public, the cost in the private one will be significantly higher as a result of the administrative and mangerial costs associated with a for profit delivery system.

So, you are pointing out that price controls keep an artificial low cost to procedures - no news here.   Are you implying that low-balling our doctors and nurses, which is where the "lower price for the same procedure" come from (no profit and government set wages) is a good way to go about things?   I'm sure driving competent and highly skilled health care professionals to greener pastures is indicative of a strong system of health care delivery - we lost about 10,000 in the 1990's alone.

http://www.cato.org/dailys/07-24-04.html

As Brad Sallows said earlier:

"I would be inclined to take them seriously if proponents of our system could explain in detail why US health care expenditures are greater than Canadian expenditures, particularly in light of the facts that health care professionals here complain of underpay and overwork.   Do you suppose if we had more health care providers and paid them at least whatever fair wage a free market would set, that we might pay more per capita for health care?"

As well, I can't for the life of me figure out where you get "increased managerial and administrative costs" in a system of private delivery.   A private system will have no government administrative unit (only regulatory ones) and thus no "managerial and administrative costs" - the companies rather then the taxpayer are responsible for this.   Be careful not to confuse a system of publically funded universal coverage with publically delivered health services.

As well, we WERE falling behind in technological fields, that was before the first 5 billion investment in diagnostic technologies back in the late nineties, then the health care deal under Chretien, and then this last deal under Martin. Services are improving. The fact that the University medical centre here in Edmonton has 4 new buildings going up is a testament to this (a heart centre, two research buildings, and yes, a diagnostic centre).

It's not so much a matter of what technology we have, as Canada is, by being a G8 country, liable to be at the cutting edge of technology, but rather an issue of the availability of this technology.   As I said before, we have an MRI per capita level on par with Latin American countries.   As the article above stated, waiting lists exist for MRI, CT and ultrasound exist in Canada and have been getting longer every year as these high-technology instruments become recognized as essential for adequate treatment with more and more health problems.

A privately delivered system is better equipped to deal with rising health care costs that are associated with technology:

"Also, policy efforts should incorporate both the benefits and costs of new technologies. One typical argument is that a desire for high-technology care, coupled with the relatively low prices for medical care faced by well-insured consumers, tends to lead to the consumption of services whose value is much lower than the cost to society. However, effective price competition in health care markets, in which those receiving the benefits of services also have an appreciation for their cost, has the potential to reduce excess, inefficient use. For example, health plan policies that help consumers better identify the costs associated with their consumption choices, particularly for nonacute treatment decisions, may be effective policies to consider. In turn, these could affect the incentives associated with the purchase of new equipment."

http://content.healthaffairs.org/cgi/content/full/hlthaff.w3.537v1/DC2

If perverse incentives exist due to the structure of our system, how are we ever going to ensure that we can encourage high-technology growth in the health sector.   Raise the taxes, you say?

These are the "basic indicators" that the WHO uses to measure the health care system. Further, I would add, though I am not 100% sure, so don't quote me on this, that the homicide rate in the US isn't high enough to really affect their average life span. Further, homicide doesn't usually factor into infant mortality rate, which IS indeed a very good measure of the level of care availible to a person.

You missed the point - I was pointing out that America possesses a far different problem with regards to large, inner city populations that face a gamut of problems from overcrowding, low education, rampant gang violence and drug abuse, etc, etc.   I fail to see how these issues, which are serious and weigh in on QOL issues (infant mortality rate, life expectency), are factored around the Health Care system.   I am willing to bet that, like the statistics on violence, once you remove outliers like poor inner-city conditions which simply do not exist on the same scale in Canada, the average statistics on QOL issues between Canadians and Americans isn't much different.

Again, as Brad Sallows pointed out (and you failed to address):

"Do you suppose the quantity and health of immigrants, particularly illegal ones with poor health backgrounds, has any impact on the cost of US health care, infant mortality, and life expectancy?   I would sure like to see someone filter out that particular background "noise" from any comparison to Canada."

All canadians are guaranteed a basic level of health care coverage free of charge. No canadian is without basic medical coverage (even you for those six months, had something happened to you, you would have been treated, no charge). And furthermore, I might add that this number, 50 million, represents Americans with no coverage, that INCLUDES medicaid. They have nothing, no government coverage, nadda. So no, it's not a myth but a terrible reality.

It is a myth in that is presented as a large population of people (I remember it being 40 million - when did it go up?) that are constantly without health care coverage and are in need of health care services.   As I said, this isn't true, and most of these people move through the "uninsured" category and get insured in a short period of time, not really facing any problems what so ever.   Quit trying to depict the stats as some formless mob of people crying out for doctors - this is a highly fluid population of people who face a lack of insurance (usually for a short period of time) for a variety of reasons.

That being said, one cannot pick and choose when they need access to health care, which is why I don't dispute a publically funded system of universal coverage.   But don't confuse this with also keeping a system of public delivery of health care - just because the province of BC provides auto insurance to all motorists doesn't mean that they should or are capable of owning and managing every auto body shop.

As I've argued many times before, Dr David Gratzer addresses this issue along with many others you've presented in his book Code Blue

http://www.chapters.indigo.ca/item.asp?Catalog=books&Section=books&Lang=en&Item=978155022393&N=35&zxac=1

Look at the book - it is meticulously researched and referenced - and decide if you are going to stick to your guns....

The point was that a privately managed system will be MUCH more expensive and less efficient.

Bullocks.

"A quick look back over the last 11 years provides additional perspective. Between 1993 and 2004, inflation adjusted health care spending per person increased by 27 percent, while waiting lists nationally grew by an incredible 92 percent. Statistical analyses of this bizarre relationship have confirmed that past increases in provincial spending, unless specifically targeted to physicians or pharmaceuticals, were indeed correlated with increases in waiting times, which is not all that surprising considering that provinces that spent more on health care were also found to be providing fewer major surgeries for patients.

If we ended up with longer wait times and a reduction of services when we spent more in the past, why should Canadians expect any different this time around?

Dr. Max Gammon, after studying health expenditures and health services in the British National Health Service, formulated what he called â Å“the theory of bureaucratic displacement,â ? now known as Gammon's Law. The law states that an increase in expenditures in a bureaucratic system will be matched by a fall in production. As Dr. Gammon put it, â Å“Such systems will act rather like 'black holes', in the economic universe, simultaneously sucking in resources, and shrinking in terms of 'emitted production'.â ?

Considering that the Canadian health care program was originally modeled on the now failing British NHS, it should not come as a surprise to anyone that we are subject to the same results from increases in health expenditures. That giant sucking sound you hear, and the related lightness you'll soon feel in your wallet, is Gammon's Law at work."

http://www.fraserinstitute.ca/shared/readmore1.asp?sNav=ed&id=332

Horrible predictions of health care taking up all of our money I think are a little unfounded. The point is that amazingly, right now, we actually do have enough money, and it's not going to break the bank.

Again, look at the Gratzer book.   The statistics are there to back the claims.   I don't have access to the book right now, or I would put them up here.

I might add, the costs associated with having an elderly population willl be around whether or not there is a private or public system, the fact is that these costs will just be higher in a private system.

Just as the CPP will ultimately fall short of providing adequate incomes to people due to demographics, so will the publically delivered health care system.   The goal is, along with Pension reform, to ensure a system that structures the a persons income into private accounts (that may be also fed from public funds) rather then lumping their contributions into "General Revenue" (ie: Adscam, HRDC, pork-barrelling).   If you take this money (public, private, or a mix) out of Ottawa's hands and put it into the hands of individuals, you can get around the fact that in centralized command systems, providers support the elderly rather then "storing away" for their own senior years - this is something that will become a bigger factor in the future and that our system will be harder and harder pressed to deal with if it relies solely on the public purse.

And I agree with a cost for health services (as I mentioned before, charge somebody like 10 bucks to go to the doctor... just enough so that it won't actually stop someone who is really sick, but so that it just not FREE). I just don't think that HSA are the best way to do it as I can already forsee skyrocketing inefficiences.

If you think 10 bucks is going to eliminate the perverse incentives of our health care system and eliminate rationing of a limited and publically derived pool of resources, I think you're dreaming.

As for skyrocketing inefficiencies, all the research I've looked at (Gratzer, Fraser Institute, "Gammon's Law", etc) seems to point to the opposite direction.   Are you going to give me anything to substantiate your claims that Health or Medical service accounts or private delivery of health services will introduce radical inefficieny into our system?   Looking at the creaking edifice of our 1960's derived system as it stands right now, I'm doubting we could do worse, Comrade.

http://www.fraserinstitute.ca/shared/readmore.asp?sNav=pb&id=658
http://www.fraserinstitute.ca/shared/readmore.asp?sNav=pb&id=222
http://www.fraserinstitute.ca/shared/readmore1.asp?sNav=ed&id=330

Say what you want and dismiss the Fraser Institute on ideological grounds, but they do put up the numbers in terms of objective quantitative statistics and if you are going to prove to me that they way things are going now are ideal, you should start with these concepts and prove them wrong.

The American system is big market economy example that acts as a counterpoint to our own system, and to which we are often compared by BOTH sides. Of course if we want we can start comparing to systems in France and Britain, which are mixed system, both have their highlights, and their horrible failures (notably the national health service in Britain).

One tends to come to the conclusion that private delivery of health care results in better health care for those people who are able to pay for it, and unfortunately does it rather inefficiently. It does little to affect the plight of your low to middle income average joe.

Alot of rhetoric, and not much in validation.  

Instead of arguing this, I will fall back to Brad Sallows' (usual) excellent analysis earlier in this thread:

http://forums.army.ca/forums/threads/28296.15.html

" Generally in medicine it is best to intervene at the earliest opportunity.   A system with significant wait times is not much better than none at all.   If you miss a window of a few weeks during which your cancer might have been detected in time for treatment, it isn't going to matter that it costs you nothing to slowly waste away in a hospital bed with tubes leading in and out of you.   I frankly do not care if someone can buy Tier 1 Rolls-Royce health care if my Tier 2 publicly-insured health care is timely and competent, and the key to that is to have enough providers and facilities....

If health care workers are dissatisfied with working conditions and remuneration, it strikes me the only way to establish proper expectations is by free market mechanisms.   I fully expect we will discover that health care costs "more".   The point of health care delivery is to have enough capacity to meet reasonable demand.   Since we are dealing with what is pretty much a personalized service and not an infrastructure megaproject, I think it safe to assume this is one area in which the usual free market mechanisms can meet demand.   There will be reasons for government to participate in that market - for example, to meet the needs of small or isolated communities - but I believe a government near-monopoly is harmful.

There is nothing rigorous about all of the above; but, in short, I believe the reason the Canadian and US systems are perceived by some as dissatisfactory is that the optimum path probably lies somewhere in the general direction of the public insurance/private delivery vector."

I couldn't agree more.

Do you, you seem to be argueing here that a MSA system where people are responsible for management of their own health care expenditure (combined with "blowout" coverage for serious problems) is something that will be fraught with "high costs and inefficiency".   That's odd, as I've never heard this claim lobbed at private markets by the command-economy crowd.

You've yet to address the fact that perverse incentives at all levels of the health care system, which stem from a faulty doctor/patient relationship (which is based upon product/cost), are inherent in command economies.

 

[couchcommander]

lol, well firstly thank you for giving me something to do at this ungodly hour.
So, you are pointing out that price controls keep an artificial low cost to procedures - no news here.  Are you implying that low-balling our doctors and nurses, which is where the "lower price for the same procedure" come from (no profit and government set wages) is a good way to go about things?....

As well, I can't for the life of me figure out where you get "increased managerial and administrative costs" in a system of private delivery.  A private system will have no government administrative unit (only regulatory ones) and thus no "managerial and administrative costs" - the companies rather then the taxpayer are responsible for this.  Be careful not to confuse a system of publically funded universal coverage with publically delivered health services.

No, what I was saying was that by virture of being a for profit hospital the costs of conducting the exact same procedure, even using equivalently paid staff, the same technology, etc. etc., are significantly higher than in a public hospital due to adminstrative and mangerial costs. To quote a NEJM study, "At for-profit hospitals, administrative costs averaged 34.0 percent of total cost...at private not-for-profit hospitals they averaged 24.5 percent.... and at public hospitals they averaged 22.9 percent."... this was done by an American by the by...


It's not so much a matter of what technology we have, as Canada is, by being a G8 country, liable to be at the cutting edge of technology, but rather an issue of the availability of this technology.

It's availibility that these investments, especially the first I mentioned, are designed to deal with.


For example, health plan policies that help consumers better identify the costs associated with their consumption choices, particularly for nonacute treatment decisions, may be effective policies to consider."

I agree with him, the public should be more aware of the costs associated with deliverying health care. In Alberta here, in most doctor's offices that I have been too, there is a big chart hanging on the wall listing the costs of some of the common things you would have done at that office. I think that is a good start, but falls horribly short of what is needed.


"Do you suppose the quantity and health of immigrants, particularly illegal ones with poor health backgrounds, has any impact on the cost of US health care, infant mortality, and life expectancy?  I would sure like to see someone filter out that particular background "noise" from any comparison to Canada."


The fact that they are illegal immigrants makes me doubt that they would be counted in official US government census data. Further, we have many immigrants here in Canada.

I am willing to bet that, like the statistics on violence, once you remove outliers like poor inner-city conditions which simply do not exist on the same scale in Canada, the average statistics on QOL issues between Canadians and Americans isn't much different.

Show me, and I shall believe    Just a note though, to quote the US Government, Infant mortality "is used to compare the health and well being of population within and between countries". It's used as one of the primary indicators of the effectiveness of health care systems by most governments and NGO's.

For the record (regarding you statement about overcrowding), Japan, which has  a population density ten times that of the states, has an infant mortality rate one third of the US' (side note, this a country that has an interesting health care model, one which I suspect is close to what you are getting at, and is admittidly actually very efficient, though it could be more so as it still suffers from the costs of running a national insurance program that pays out to for profit health providers, as well it suffers from a lack of availibility of some of the more advanced technologies and procedures that makes the stuff here look plentiful).

Considering that the Canadian health care program was originally modeled on the now failing British NHS, it should not come as a surprise to anyone that we are subject to the same results from increases in health expenditures. That giant sucking sound you hear, and the related lightness you'll soon feel in your wallet, is Gammon's Law at work."

I don't know where he is getting this from, the Canadian health care system is quite different NHS. In large part the reason the NHS is failing is because of the "internal market" reforms of the 80's that seem to be where a lot of conservatives want to push us.

Regarding the CPP argument.... once again, the costs don't go away. People are either going to pay to the government, or pay themselves. I have not seen any material that can actually prove that the method you describe will actually be more efficient.

Are you going to give me anything to substantiate your claims that Health or Medical service accounts or private delivery of health services will introduce radical inefficieny into our system?

See the resposne from the NEJM (recapping, for profit or private hospitals are inherently more expensive). As well, go pick up a copy of Joseph Heath's (I think that's how you spell it...) "The Efficient Society", which goes into depth on the costs of for profit delivery, and the various sources of these horrible inefficiences  (I haven't even brought up the percentage points of GDP that the US spends on overhead for health insurance companies that we DO NOT have to pay for here, but would become a reality if we started using MSA's... you have to pay someone to administer them, which means more people and more money going to something other than actually providing health care... another expense that we presently don't have and are better off not having...further, a smal user fee will have the same positive effect... see below...)

Regarding the Frasier Institute stuff....

All the MSA's article from the Frasier institute proves is that people will use the health system less if there is a fee involved. You will notice there isn't much of a difference between 25%, 75%, 95%, and 100% (If I remember correctly, been a while since I read that..... and yes, this evil socialist does get the Fraser Forum everymonth and has done so for many years...). The thing to take from this is just by making something "not free" you will drastically reduce it's usage, which is why I am saying 10 bucks.

Regarding "How good is Canadian health care".... I don't even want to talk about. That report is so amazingly doctored (no pun intended) that I laughed the first time I read it. Just to mention one thing,  and one of the more important things for them to make their point, they list Canada as number 1 for percent of GDP spent on health care in OECD countries in "age adjusted dollars." Firstly, they've got some of their numbers wrong (not significantly, but still...). Secondly, I find it amusing how they have to "adjust" the GDP spending to make their point. lol. You can "adjust" dollars to pretty much do whatever it is you want them to do (for example, if too many people pass a class a prof will often "adjust" the marks so the proper amount fail....).

And lastly, Kliens "Third Way" fails to deal with the issues I have outlined above with having for profit delivery system. Namely that they are more expensive.

So no, I don't dismiss them on ideological grounds. I dismiss them on the grounds that they don't prove their point.

Generally in medicine it is best to intervene at the earliest opportunity.

I agree. However it has NOT been proven that private or for profit delivery of health care would be any better at solving these problems. Rather, it appears, at least to me, that we should work within the framework of our system (a publically ran system, which IS a VERY, if not THE, most efficient delivery model....further I might add that in NONE of this literature has the efficiency of a public hospital been questioned, rather it is the system as a whole and it's operation that has been challenged), to try and improve it's effectiveness by using a combination of modest funding increases (already done), minor changes to the structure and operation of the system to improve patient care (such as national treatment standards to ensure proper treatment, and acceptable wait time standards to ensure timely access), and minor changes to the delivery of health care to the patient to decrease abuse of the system (such as a small user fee).

These changes, from my perspective, will result in a lot better care for patients than would switching to a drastically different model who's benefits cannot be proven and who's detractors are far too obvious.

 

[Infanteer]

lol, well firstly thank you for giving me something to do at this ungodly hour.

No problem, that's really what the "Politics" forum is for...

No, what I was saying was that by virtue of being a for profit hospital the costs of conducting the exact same procedure, even using equivalently paid staff, the same technology, etc. etc., are significantly higher than in a public hospital due to adminstrative and mangerial costs. To quote a NEJM study, "At for-profit hospitals, administrative costs averaged 34.0 percent of total cost...at private not-for-profit hospitals they averaged 24.5 percent.... and at public hospitals they averaged 22.9 percent."... this was done by an American by the by...

Okay.   As I said, I acknowledged that private delivery has higher costs; Gratzer addresses this specifically in his book, using a doctor that practices on both sides of the border as an example.   However, I'm wondering how much of the "administrative costs" in a public hospital are defrayed by government administrative units within the bureaucracy (ie: Provincial Health Department which manages hospitals)?

That being said, the prime concern is having an effective system, ensuring that people are dealt with promptly - something that a publicly managed system is proven to be incapable of doing (the wait list stats in Canada don't lie).   I'm sure people (or the Canadian Taxpayer if using universal health insurance) would be willing to pay 5 to 10 percent more for services if they got that important surgery within a month instead of maybe in a year.

It's availibility that these investments, especially the first I mentioned, are designed to deal with.

If there are not enough of them or there are long wait lists, then they are not available when time is of the essence for treatment.   I'm looking for some more current stats, but I imagine that the wait lists for these things are still as bad as they were 5 years ago.   As high-technology becomes accepted as a treatment method for more and more ailments (ie: scans following a blow to the head, etc) the demand is only likely to increase.   Judging from our track record in the last 20 years, it appears that a public delivery system can't keep up.

I agree with him, the public should be more aware of the costs associated with deliverying health care. In Alberta here, in most doctor's offices that I have been too, there is a big chart hanging on the wall listing the costs of some of the common things you would have done at that office. I think that is a good start, but falls horribly short of what is needed.

I'm sure that chart is about as effective as the Nutrition Chart the McDonalds puts up in their restaurants.   As long as the perverse incentive is there, people will abuse it.

Show me, and I shall believe  

Yeah, I would be satisfied by a statistic as well.   But the answer is kind of intuitive.   I go to my families place in the US (middle-class) and look at the same income class here and the QOL is the same.   If you take South Central LA, you will get a different story.   Canada has nowhere near the problems that the US has in these regards, both in locations - a few spots in urban centers (ie: East Hastings, which doesn't have gangland shootouts), and some Native reserves - and the number of people that live in these areas.

Just a note though, to quote the US Government, Infant mortality "is used to compare the health and well being of population within and between countries". It's used as one of the primary indicators of the effectiveness of health care systems by most governments and NGO's.

I don't deny that it is important, I am trying to point out that when significant portions of society are not properly serviced by health care coverage (as well as suffering from a variety of other social issues) that you will see these segments taking up a disproportionate percentage of lower QOL numbers.   They are essentially outliers - and I would venture that problems in many US cities means more outliers then Canada.   Again, intuitive, is it not?

Universal coverage would help to eliminate outliers - which is why I support it in general - but it won't eliminate the fact that people living in a shitty environment won't live as long as others.

For the record (regarding you statement about overcrowding), Japan, which has   a population density ten times that of the states, has an infant mortality rate one third of the US' (side note, this a country that has an interesting health care model, one which I suspect is close to what you are getting at, and is admittidly actually very efficient, though it could be more so as it still suffers from the costs of running a national insurance program that pays out to for profit health providers, as well it suffers from a lack of availibility of some of the more advanced technologies and procedures that makes the stuff here look plentiful).

Are you comparing population density of downtown Tokyo to the population density of certain quarters of Los Angeles, Detroit or Chicago?   Apples and oranges - one is due to space concerns (Japan has lots of people and no space) and the other is due to significant social problems for many Black and Hispanic communities in the United States.

I don't know where he is getting this from, the Canadian health care system is quite different NHS. In large part the reason the NHS is failing is because of the "internal market" reforms of the 80's that seem to be where a lot of conservatives want to push us.

The theory seems to fit the economic trend that we've spent more per person in the last ten years and wait lists are growing more and more.   Where is the money going?   Probably the same place that other command-economies have seen there funds go....-flush-

Regarding the CPP argument.... once again, the costs don't go away. People are either going to pay to the government, or pay themselves. I have not seen any material that can actually prove that the method you describe will actually be more efficient.

No costs don't go away, but as I've said, reducing perverse incentives should reduce the burden on the system.

See the resposne from the NEJM (recapping, for profit or private hospitals are inherently more expensive). As well, go pick up a copy of Joseph Heath's (I think that's how you spell it...) "The Efficient Society", which goes into depth on the costs of for profit delivery, and the various sources of these horrible inefficiences   (I haven't even brought up the percentage points of GDP that the US spends on overhead for health insurance companies that we DO NOT have to pay for here, but would become a reality if we started using MSA's... you have to pay someone to administer them, which means more people and more money going to something other than actually providing health care... another expense that we presently don't have and are better off not having...further, a smal user fee will have the same positive effect... see below...)

I'll pick up "The Efficient Society" - I've glanced at it a few times in Chapters.   You should pick up Gratzer's book, it is a Canadian award winner and is worth the read.

That being said, the MSA system as I've proposed it doesn't involve private health insurance companies - HMO's are as bad as Government Health Departments (hence why I said don't compare the US and Canada).   Of course the Health Care system will require government agencies to overwatch both the accounts and to regulate the private users.   Just like auto insurance, the government makes sure you are insured against calamities and makes sure that the auto shops aren't bilking the system.   It doesn't mean yours or my tax dollars should go to paying bureaucrats to decide how much janitors should make in hospitals or how to ration the limited health resources that the government sees fit to provide.

Regarding the Frasier Institute stuff....

All the MSA's article from the Frasier institute proves is that people will use the health system less if there is a fee involved. You will notice there isn't much of a difference between 25%, 75%, 95%, and 100% (If I remember correctly, been a while since I read that..... and yes, this evil socialist does get the Fraser Forum everymonth and has done so for many years...). The thing to take from this is just by making something "not free" you will drastically reduce it's usage, which is why I am saying 10 bucks.

Gratzer quotes a huge RAND report study in California that put families on a "free" system and a "not free system" and giving them universal coverage for the big stuff.   They observed these peoples consumption of health care over a long period of time (at least a decade if I remember) and found that, as you said, having to pay for something means it reduces its usage.   They found that people would think more about using the system for the routine health issues.

The important part of the study was that the quality of life for both groups remained the same.   People spent less when faced with a cost but suffered no adverse health problems from not using the doctor everytime they felt like it.   The perverse incentive of "free health" care was removed and resulted in a better system of delivery.

That being said, I don't think 10 bucks will be significant enough.   As I've proposed with the Medical Service Account system that Gratzer proposed, the government either provides all or matches private contributions (there is a few ways to do it) into the account.   The account can be used for the routine health care costs (checkup, prescription, etc, etc) or to cover the deductible of a serious problem.   People who are healthy receive an incentive in that, at the end of the year, the money in the MSA can be taken out and used as disposable income - there is positive reinforcement in an MSA system to use your health dollars wisely.

Regarding "How good is Canadian health care".... I don't even want to talk about. That report is so amazingly doctored (no pun intended) that I laughed the first time I read it. Just to mention one thing,   and one of the more important things for them to make their point, they list Canada as number 1 for percent of GDP spent on health care in OECD countries in "age adjusted dollars." Firstly, they've got some of their numbers wrong (not significantly, but still...). Secondly, I find it amusing how they have to "adjust" the GDP spending to make their point. lol. You can "adjust" dollars to pretty much do whatever it is you want them to do (for example, if too many people pass a class a prof will often "adjust" the marks so the proper amount fail....).

It seems to me that if a specific age group relies on the health care system more then other groups, you would want to ensure that this is factored in when you compare costs/capita of states that may have different proportions of various age groups.

And lastly, Kliens "Third Way" fails to deal with the issues I have outlined above with having for profit delivery system. Namely that they are more expensive.

It would be more expensive in terms of actual health care costs, I've agreed with this.   The aim with private delivery is for a more effective system that services people as soon as possible.   As well, if you took out the nickel-and-diming that perverse incentives create, I'm sure that you would get more "bang-for-the-buck" out of health dollars; this is a conclusion Gratzer comes to and supports.

I agree. However it has NOT been proven that private or for profit delivery of health care would be any better at solving these problems. Rather, it appears, at least to me, that we should work within the framework of our system (a publically ran system, which IS a VERY, if not THE, most efficient delivery model....further I might add that in NONE of this literature has the efficiency of a public hospital been questioned, rather it is the system as a whole and it's operation that has been challenged), to try and improve it's effectiveness by using a combination of modest funding increases (already done), minor changes to the structure and operation of the system to improve patient care (such as national treatment standards to ensure proper treatment, and acceptable wait time standards to ensure timely access), and minor changes to the delivery of health care to the patient to decrease abuse of the system (such as a small user fee).

These changes, from my perspective, will result in a lot better care for patients than would switching to a drastically different model who's benefits cannot be proven and who's detractors are far too obvious.

I guess if you are comparing delivery systems (as opposed to coverage), looking at the US and Canadian systems serve a purpose.   From what I can understand, a properly insured patient will get superior services in terms of available treatments, wait times, care and attention, etc, etc in an American system then they would in Canada.   The example that the fellow used earlier on in this thread about his Dad going to the US for successful cancer treatment is a good example.   Sure, Canada payed more by sending him south, but he lived, and that is what is important.

I can see that the fundamental disagreement here is on a free market or a central-command system of delivery.   Proof is in the pudding on how well command economies do in meeting the demand of consumers.   Health Care, like food, clothing, or shelter is a essential commodity that has both supply and demand.   I don't disagree with certain government involvement in providing health care delivery in regions where demand may not be high enough to bring in an essential amount of service, but other then that, private delivery seems to have proved that it is able to give patients better health care in the end - the fact that Canada sends people to the United States for treatment is a testament to this fact.

I agree with a nationally funded and directed system of universal coverage for major services and a publicly or public/private, individually managed account system that is managed by the individual.   Adequate and universal coverage that contains incentives to use Heath Care dollars wisely, when combined with a superior system of private delivery, seems to be the best looking way to ensure that Canada meets the 5 Principles of the Canadian Health Care - quality, timeliness, cost effectiveness, patient oriented, and universally accessible - which aren't being met now to the degree that they could be when you consider that we are a G8 Country.

 

[Brad Sallows]

I fully expect that with a single public insurer - one point of contact for most billing - we should have lower administrative costs.  However, that tells us nothing about the desirability of public vs private delivery.

>The fact that they are illegal immigrants makes me doubt that they would be counted in official US government census data.

The numerator in the per capita fraction is the cost; I assume that when an agency provides services to a non-citizen (as required by law in some jurisdictions) it still bills the US government.  If the denominator - the number of people - excludes illegals, that merely causes the per capita cost to be inflated above its true value.

There are still factors unaccounted which I have not seen explored in any of the many articles and arguments on private vs public health care.  Are the costs of Canadians who seek health care outside Canada included as part of what should be the true cost of health care in Canada?  How do income levels of providers compare; if we had the same per capita numbers of doctors, nurses, etc and paid them approximately the same relative to other professions, what would our costs be?  Is equipment in Canada available on the same scales (ie. per person) and is it more or less up-to-date: what are the comparative costs of having enough, modern equipment?

Absent answers to all these questions, I see no compelling reason to accept the facile suggestion that public delivery is necessarily less costly than private delivery; unless it can be explained why health care is a unique service, it must also be the case that a government monopoly on grocery stores would provide the most food to the most people at the least cost.

 

[Edward Campbell]

Jeffrey Simpson, in today's Globe and Mail at http://www.theglobeandmail.com/servlet/story/RTGAM.20050316.wsimpson16/BNStory/National/ gets it mostly right when he says:

Where's productivity when you need it . . .

By JEFFREY SIMPSON

Wednesday, March 16, 2005 Updated at 1:46 AM EST

From Wednesday's Globe and Mail

Compared with crime, trials, courts and sex, the subject of productivity doesn't sell newspapers. But without better productivity, there won't be as much money to buy newspapers â ” or anything else, for that matter.

So it's worth perhaps pondering a sentence or two from Statistics Canada last week: "Productivity growth in Canadian businesses was a flat 0.0 per cent last year." And this one: "Labour productivity has been virtually flat for two consecutive years."

Those are terrifying sentences, economically speaking. Without productivity growth, there's no real economic growth, no real wealth creation, no improvement in the country's overall standard of living. You'd think that would make news.

For years, federal governments have been nattering on about productivity. And, in fairness, Canada made important productivity strides in the 1990s, eclipsing the U.S. powerhouse six out of eight years from 1993 to 2000. Canada needed those years, because the country had slipped further and further behind the Americans in the previous quarter of a century.

Since 2000, however, the old pattern has returned. Canadian productivity has gone in the tank, with no growth for two years, while U.S. productivity improved by 4 per cent each year.

"Experts" blamed the rising Canadian dollar, but that's not the answer â ” because our productivity slump started before the currency's rise. Indeed, over time, the higher dollar might make Canadian companies more competitive, since they will import more high-technology machinery and rely less on the magic carpet of the low dollar for growth.

When the Statscan report was published, Industry Minister David Emerson said he'd produce some kind of innovation strategy. Heaven only knows how many of these Ottawa has already produced.

At productivity's heart lie innovation and research and human skills. Without these, a country is sunk. So how is Canada doing? In short, poorly relative to others.

A brilliant report emerged recently that underscored that poor performance and knocked the props from beneath some of the much-vaunted tax breaks offered companies by Ottawa and the provinces to encourage research and development.

The Toronto-based consulting firm Impact Group looked at where and how much industrial research â ” a key determinant of productivity â ” was done in Canada from 1994 to 2000. Among the sobering findings: Very few Canadian companies do research and development. Over seven years, only 9 per cent of Canadian firms did R&D every year. The remainder did nothing or were "at best occasional performers."

Here's a sentence from Impact to wake everyone up: "We conclude that there has been no generic increase in the number of companies performing research in Canada between 1994 and 2001." This, despite strong economic growth and a host of government incentives.

What did happen, however, was that firms dipped quickly into the research and development business to scoop up available government tax credits â ” without increasing their overall commitment to R&D. This was particularly noticeable in Quebec, which led the country in R&D relative to its market size.

The Quebec government showered tax incentives on companies and pushed up provincial R&D numbers. Says the Impact study: "Much of the apparent activity was simply companies taking advantage of available government money." Offer essentially free money, in other words, and companies will come. They just won't stay at the R&D business for very long.

Simpson, like his friends in government and the commentariat in Ottawa is, however, afraid to go the final step and to lay the blame where it belongs: Stalinist health care.

Canadians have been conditioned â “ through 30 years of propaganda â “ to believe that our national health care system is something other than a social and financial disaster.   Spending, way too much of it wasteful spending on health care consumes far, far too much public money - money from an already overtaxed population - and politicians are terrified at the prospect of spending less because they know that Canadians, the vast, overwhelming majority of Canadians, know little and care less about health care spending, except that it may not be cut, lest they have to pay something.

Really important programmes â “ the ones which may actually contribute to the future of the country are being cut and even abandoned as governments try to feed the insatiable health care monster, a monster which can never be satisfied.   The productivity gap is only one illustration of a flawed policy and hopeless priorities at 'work'.

We must stop adding to public health care spending; then we must begin to transfer most of the health care spending burden exactly where it belongs: individual Canadians, through competitive private insurance for most, through public subsidies for some, a few, to prevent catastrophic health care bills â “ and catastrophic had better mean that personal bankruptcy is the only alternative, the kids' music lessons and the vacations in Florida had best be long gone, along with the cottage and second car before someone actually gets benefits from the public insurance safety net.

We must aim to reduce public spending on health care to something less than 4% of GDP so that funds can be spent on R&D and education and things that matter to the country, rather than pandering to the groundless fears of too many ill-informed Canadians.   That means stop spending increases now and then begin to cut, deeper and deeper.   As Mrs. Thatcher used to say: There is no alternative.

 

[mariomike]

Hope there is not a DNR on this thread:

"Doctor supply outpaces population: The number of doctors practising in Canada is increasing at a faster rate than the population, according to a new report released Thursday.":
http://www.cbc.ca/health/story/2009/11/26/doctor-supply-canada.html

 

[Antoine]

I found this survey interesting, you can go on the Web site to find more, the PowerPoint presentation is also good.

www.canadaspeaks2010.ca/index.php

Canada Speaks! 2010: Canadians Go for Gold in Health and Medical Research

The Association of Faculties of Medicine of Canada (AFMC), BIOTECanada, the Canadian Healthcare Association (CHA), Canada’s Research Based Pharmaceutical Companies (Rx&D), MEDEC and Research Canada: An Alliance for Health Discovery are pleased to release the results of their public opinion survey on health and medical research.  This survey builds upon two previous surveys undertaken by Research Canada: Canada Speaks! 2006 Research Canada’s First Public Opinion Survey on Health Research in Canada and Communicating Health Research in an Era of Headline News 2007  providing important tracking data on Canadians views of health research and the media and science relationship in Canada.
Canada Speaks!  2010 demonstrates Canadians’ on-going commitment to Go for Gold in health and medical research and their desire to emerge from the middle of the pack even in the face of an economic recession.
Health and medical research is a top Health Care priority for Canadians—84% say health and medical research makes an important contribution to the economy, recognizing that the economy is the most important issue facing Canadians today. Further, 90% of Canadians believe basic research should be supported by government even if it brings no immediate benefit.
Even in recession, a large majority of Canadians would pay out of pocket to improve health and research capacity. Canadians would allocate 23 cents out of every health care dollar to health and medical research. Compared to 2006, a similar majority of Canadians are willing to pay $1 more per week out of their pocket to fund new health and medical research projects in Canada.
While a majority of Canadians consider the country to be a middle of the pack player among industrialized nations contributing to the global pool of health and medical research, 89% believe that Canada should be global leader in this area.
Canadians also see an important role for the private sector. Four out of five Canadians agree that the Federal Government should support tax and regulatory policies that encourage private industries to conduct more medical research.
Health research holds a promise for the future. Canadians continue to have confidence about the ability of health and medical research to bring about continued improvement in patient outcomes: Most believe that breakthroughs for cancer, diabetes heart disease and Alzheimer’s are attainable within 10-20 years.
We are proud to present the results of this survey which demonstrate that Canadians continue to prioritize health and medical research among the nation’s health prerogatives. It provides direction to any government willing to make the necessary investments for Canada to break out of the middle of the pack and become a global research leader.

 

[a_majoor]

Here is an interesting look at how alternative systems work in Sweden. With "health care" spending closing in on 40% of government spending in Ontario alone, change is needed and soon for fiscal reasons. Patients might also apprieciate getting real healthcare as opposed to long wait times.

http://fullcomment.nationalpost.com/2012/06/28/tasha-kheiriddin-think-two-tier-health-care-would-be-a-disaster-ask-a-swede/

Tasha Kheiriddin: Think two-tier health care would be a disaster? Ask a Swede
Tasha Kheiriddin  Jun 28, 2012 – 8:28 AM ET | Last Updated: Jun 27, 2012 9:34 PM ET

Comments Email Twitter Hospital floors so clean you could eat off them. Wait times non-existant. Clinics designed with state of the art technology, much of it home-grown. Welcome to healthcare, Swedish style — which delivers quality universal care without many of the downsides we experience in Canada.

I visited Sweden last week on a study tour of the country’s healthcare system. And I arrived in the country with certain preconceptions. Sweden has a reputation as a socialist welfare state. The government provides generous maternity leave, free daycare, universal health care and free university tuition. It also extracts high taxes, which in the 1970s hit a stratospheric 90% on top earners. Many prominent Swedes, including tennis great Bjorn Borg, relocated to more favorable tax jurisdictions. In the 1980s, the country experienced a real-estate crash, followed by a banking crisis. The nation’s GDP dropped 5% between 1990 and 1993; faced with massive deficits, the government then lowered tax rates, cut spending and implemented a series of reforms to increase efficiency in the delivery of social services.

One of these services was health care. While the Swedish system remains publicly funded, the government opened up the system to private providers, which compete alongside the public system for contracts. According to Marit Vaaren, CEO and founder of Sirona Health Solutions, the involvement of the private sector did more than increase efficiency: it spurred innovation, which in turn resulted in savings to both the public and private sectors.

Innovation is at the core of Sweden’s economy more generally; the nation of merely nine million people is highly export-dependent, and has had to innovate to survive. It has produced companies whose reputation and reach extend far beyond its borders, including Skype, ABB, Ericsson and IKEA. The country devotes 3.7% of national GDP to R&D; in Canada, we spend 2%.

In health care, outside-the-box thinking has resulted in changes as seemingly small as obliging healthcare workers to wear short sleeves, in order to reduce the transmission of infections. Or to install recessed lighting in hospitals, instead of hanging lamps, and angling cupboard tops downward instead of making them flat, both to reduce dust accumulation, which can harbour bacteria. It can also be as sophisticated as designing equipment sterilizers in three zones instead of two, which ensure that surgical equipment is packed in as sterile an environment as possible.

Some of this technology is being imported to Canada; the sterilization equipment, manufactured by Getinge, is currently available in Toronto-area hospitals. But the Swedish attitude toward the private sector, source of many of these innovations, sadly is not, as Canadian politicians still cling to the myth that for-profit companies cut corners when delivering care — despite ample evidence to the contrary both at home and abroad.

Vaaren’s company recently conducted a study on Swedish nursing homes, and found that private institutions delivered better care than their public counterparts. On 11 of 16 quality indicators, the private facilities scored better. Sweden also boasts a fully private emergency hospital, Saint Göran Hospital, which received the highest quality score for all hospitals in the country.

A diversity of providers also helps the bottom line: In 2008, according to the OECD, Canada spent US$4,079 per capita on health care. Swedes live on average one year longer than Canadians, yet they spent $3,470. Within this envelope, they also contribute directly in the form of user fees and copayments.

While the Swedes still debate the extent of the relationship between the country’s public and private delivery models, Vaaren said there is no desire to return to the previous system of exclusively publicly funded care. Innovation has increased, wait times have disappeared, and equality of access is still guaranteed. Sounds like the kind of system that would be great for Canada — if only we could get past our own prejudices.

National Post
tjk@tashakheiriddin.com

 

[old medic]

Here are some rebutals about private swedish companies operating 911 service:

http://www.thelocal.se/40608/20120503/
'Unlike Sweden, when you call an ambulance in the US, it comes'
03 May 2012

After her child suffered a serious injury in Sweden and no ambulance was sent, US-native and parent Rebecca Ahlfeldt was left feeling especially vulnerable........

http://www.thelocal.se/39930/20120327/
Report slams denied ambulance call death
27 March 2012

Health authorities in northern Sweden have come in for scathing critique for the death of 22-year-old Jill Söderberg, whose repeated calls for an ambulance were denied because she was “still talking”...........

alternate news source: http://www.foxnews.com/health/2012/03/28/woman-died-after-being-denied-ambulance-because-was-still-talking/

http://www.thelocal.se/39656/20120314/
Heart attack victim dies after ambulance denied
14 March 2012

A 75-year-old Stockholm man suffering from a heart attack was forced to call three times and wait 13 hours before emergency services operator SOS Alarm finally sent an ambulance. He died in hospital the following day.
The man called Swedish emergency number 112 at 10pm one evening last summer complaining of pain in his arms and breathing problems, but the nurse who took the call didn’t think an ambulance was necessary.

Several hours later, the man called again, telling the operator he felt extremely weak and was still having trouble breathing.

The man was told to lie down and rest.........

http://www.thelocal.se/33350/20110421/
Ignored ambulance call fatality 'a tragedy'
21 April 2011

The nurse who refused to send an ambulance to a 23-year-old Stockholm man who later died had been reported several times prior to the incident.
"Help me," 23-year-old Emil Linnell can be heard saying repeatedly in recordings of his January 30th call to SOS Alarm, Sweden's emergency response service.
According to Sveriges Television (SVT), the nurse who took Linnell's call had several years of experience in the healthcare sector and had worked as an emergency call operator for more than a year.

There are many more to be found in swedish news sites.

 

[a_majoor]

It seems we have to take different poisions; I can get an ambulance and then wait six or more hours in an emergency room (and still end up paying the ambulance fee) or go to Sweden and wait for an ambulance...

I will admit that having access to a car or a neighbour does make it possible to apply a bit of self help to getting to the hospital, but sitting in the ER for six hours with my daughter (who was suffering a breathing emergency) provided powerful motivation to figure out and advocate for something that works better once you get in the door....

 

[Edward Campbell]

I rather like Singapore's system which features, in addition to private insurance, "health savings accounts" into which everyone pays something. In Singapore no medical service is provided free of charge, even within the public healthcare system. This reduces the over-utilisation of services, which is the norm in our fully subsidized universal health insurance systems. Charges vary enormously across the system but, as Tommy Douglas intended:

a. Everyone gets treated, eventually; and

b. No one goes bankrupt because of health care costs.

Outcomes are excellent - better than ours in every single measure last time I looked; hospitals are modern, clean and exceptionally well equipped; costs are low.

It is often said that Singapore's system would be hard to replicate in the liberal West; I suppose that's true because we are, really, neither very smart nor very imaginative.

 

[old medic]

It seems we have to take different poisions.....

No, it's not a different position. My point is / was, no system is perfect. Sweden has
problems like everywhere else. I am just pointing out a logic flaw in Tasha Kheiriddin's
post.

 

[a_majoor]

So there are problems, we address them. Our system is so dysfunctional and such a threat to the public treasury that many people would gladly take the Swedish system if offered (or the Singapore system, which is better yet). The prevailing attitude among the political and chattering class is that to ring up any alternative system or discuss the merits of alternative systems is heresy that should be met with a massive outpouring of public outrage to drown out the speaker (since burning at the stake is frowned upon these days).

If anything, fixing ambulance dispatch would be quite easy, since it is a small and separate "branch" of healthcare, if you will.

 

[mariomike]

I can get an ambulance and then wait six or more hours in an emergency room (and still end up paying the ambulance fee) or go to Sweden and wait for an ambulance...

In Ontario, ( not sure which province you live in ) the fee for ambulance transport is normally $45.00. 
Your extended health care insurance ( if you have it ) will reimburse you the $45.00.

( There is no charge if 9-1-1 is dialed and paramedics respond to perform an assessment and patient care on scene, but do not transport. aka "Treat and Release". )

I will admit that having access to a car or a neighbour does make it possible to apply a bit of self help to getting to the hospital, but sitting in the ER for six hours with my daughter (who was suffering a breathing emergency) provided powerful motivation to figure out and advocate for something that works better once you get in the door....

Not sure if your daughter was in the waiting area or the treatment area of the Emergency Department.

If your daughter was transported by paramedics, and if she had unresolved shortness of breath, Transfer of Care ( patient transferred to an ED stretcher and report given ) would only take place inside the treatment area.

 

[Infanteer]

I rather like Singapore's system which features, in addition to private insurance, "health savings accounts" into which everyone pays something. In Singapore no medical service is provided free of charge, even within the public healthcare system. This reduces the over-utilisation of services, which is the norm in our fully subsidized universal health insurance systems.

Dr David Grazer has written two books about bringing a system like Singapore's to Canada - he sings high praise about the "health savings accounts".  I've ranted on about them here over the years.