Download Stitches in Time - Michael Rachlis MD

What can the US learn from
Canada’s health system
Michael M. Rachlis MD MSc FRCPC
www.michaelrachlis.com
Progressive Democrats of America June 16, 2009
Outline
• Introduction to Canada and its
health care system
• Canada’s health system’s problems,
diagnosis, and solutions
• What can the US learn from
Canada?
Tommy Douglas
(All data from Canada
CIA World Fact
Book 2009)
USA
Population
33 million
307 million 82 million
Area
9,984,670
km2
9,826,630
km²
357,021
km2
GDP ($US PPP)
$39,300
$47,000
$34,800
Gini coefficient
32
45
27
(Lower = more
equality) 2005 data
Germany
(All data from Canada
CIA World
Fact Book
2009)
USA
Germany
Infant
mortality
5.0/1000
6.3/1000
4.0/1000
Life
Expectancy
F 83.91
M 78.69
F 80.69
M 75.65
F 82.42
M 76.26
Migrants
5.6/1000
4.3/1000
2.2/1000
Birth rate
10.3/1000
13.8/1000
8.2/1000
% > 65
15.2%
12.8%
20.3%
Canada: Political Organization
• Westminster model of government
• Ten provinces and three territories
• The federal government is responsible
for foreign affairs, defense, and
criminal law
• The provinces are responsible for
health care, education, and social
services
• Quebec has special status
Canada: Political Organization
• The federal government
and the provinces share
authority over public
health, the environment,
and other key policy
areas
• Canadian governments
fight constantly
– Have you seen us play
hockey?
Canada’s Health Insurance
• Federal health insurance legislation sets
standards for provincial insurance coverage
for physicians and hospital care only
• Mandated first dollar coverage for hospitals
and physicians’ services
• Mixed public private coverage for
pharmaceuticals, long-term care, home care,
and durable medical equipment
• Mainly private coverage for dental, optical
• Except for hospitals and doctors, coverage
varies substantially from province to province
Canada’s Health Insurance history
• 1947 Saskatchewan legislates hospital insurance
• 1957 Federal government legislates national hospital
insurance mandating provincial plan principles
• 1962 Saskatchewan legislates doctors’ insurance
• 1968 Federal government legislates national doctors’
insurance mandating provincial plan principles
• Late 1970s and early 1980s doctors and hospitals in
several provinces begin to extra-bill patients beyond
the public insurance tariff
• 1984 Federal government legislates the Canada
Health Act banning extra-billing
Canada Health Act principles
• Universality
– All Canadian residents must be covered
• Comprehensiveness
– All “medically necessary” physicians and
hospital services must be covered
• Accessibility
– No user charges for insured services
• Public Administration
• Portability
Canada’s Health Care System
• Not “Socialized Medicine”
• Canadian health care, like other aspects of our
social policy, is “mid-Atlantic”
• Canadian Medicare is characterized by “Private
Practice: Public Payment” (CD Naylor. 1986)
– Most doctors are self-employed and bill provincial
health plans on a fee-for-service basis
• In most provinces, regional health authorities
own and run hospitals, long-term care, home
care, mental health, and public health
OECD Health Data Canada USA
2008 (Most data from 2006/7.
Germany
http://www.irdes.fr/EcoSante/Do
wnLoad/OECDHealthData_Freque
ntlyRequestedData.xls)
Health $ (GDP %)
10.0%
15.3%
10.6%
Public % of HC $
70.7%
44.5%
76.9%
Health US $/capita $3678
$6714
Practicing MDs
2.1/1000 2.4/1000
$3371
3.5/1000
Practicing RNs
MRI Units/million
8.1/1000
10.5/1000
9.8/1000
6.2
26.5
7.7
Acute care beds
2.8/1000 2.7/1000
6.2/1000
General Gov't Outlays
(From http://www.fin.gc.ca/frt/2008/frt08_e.pdf)
Percent of GDP
60
50
40
30
20
10
0
Canada
US
Canada vs. the US: No contest!
• In the 1950s, Canada & US had the same health
system, the same costs, and the same health
• Now all Canadians are covered but 47 million
Americans are uninsured, and tens of millions
more are under-insured
• Canada spends much less than the US
• Canadians get only slightly fewer services overall
• Canadians live 3 years longer than Americans and
our infant mortality rate is 20% lower.
• Our Medicare boosts Canadian business
– Health care costs are 1.5% of Canadian
manufacturers’ payrolls vs. 9% in the US
Health Exp as % of GDP
18.0
(From: http://www.oecd.org/document/16/0,3343,en_2649_34631_2085200_1_1_1_1,00.html )
16.0
14.0
% GDP
12.0
10.0
8.0
6.0
4.0
2.0
0.0
Canada
USA
S Woolhandler Int J H Serv 2004;34:65-78.
Canadian health care
costs, especially
public costs are not
out of control
Canadian Health Exp as % of GDP (NHEX 2008)
12
8
6
4
2
0
Total HC as % of GDP
Prov/Terr HC as % of
GDP
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
% of GDP
10
Canada’s health system’s
problems, diagnosis,
and solutions
Canadian Medicare was designed for
another time and was a compromise
1. It was designed for acute illness and
Canada’s acute care system compares
well internationally
2. But now the main problems are
chronic diseases and Canada does
poorly with these and with waits and
delays.
3. Political compromise slowed the
development of a more effective
delivery system
AUS
CA
DEU
NZ
UK
US
3.5
5
2
3.5
1
6
Quality of Care
4
6
2.5
2.5
1
5
Right care
5
6
3
4
2
1
Safe care
4
5
1
3
2
6
Coordinated care
3
6
4
2
1
5
Patient-centered care
3
6
2
1
4
5
Access
3
5
1
2
4
6
Efficiency
4
5
3
2
1
6
Equity
2
5
4
3
1
6
Healthy Lives
1
3
2
4.5
4.5
6
$2876
$3165
$3005
$2083
$2546
$6102
Overall Rank
US$/Capita (PPP)
Chronic Disease Care.
K. Davis et al Commonwealth Fund pub no 1027 May 2007
K Davis.
Commonwealth
Fund April 2006
% Long Waiting Times
(Germany, Canada, USA)
Elective surgery
wait > 4 months
Specialist wait
times > 4 weeks
ER wait > 2 hr
PHC appt > 5 d
0%
20%
40%
60%
Political compromise slowed the
development of a more
effective delivery system
The original Saskatchewan vision -- Swift
Current in 1945 – similar to the Group Health
Cooperative of Puget Sound in 1948
• Prepaid funding Services available on a universal
basis, with little or no charge to users.
• Integrated health care delivery including acute care,
primary care, home care, and public health.
• Group medical practice with doctors working in
teams with nurses and other providers. Overall
public health view of the system.
• Democratic community governance of health care
delivery by local boards.
What happened to the vision?
• Despite the Swift Current Region’s success,
Saskatchewan MDs in the 1950s wanted
independent practice paid on fee for service
• 90% of doctors strike when the province simply
legislates public insurance in 1962
What happened to the vision?
• The federal government only covered hospital and
medical care leaving coverage incomplete
• Dr. John Hastings’s 1972 Report recommended reorganizing the delivery system but it’s mainly
ignored
– The models that were implemented prove to be fonts of
innovation
• Canada inspires other countries’ health policies but
not our own
What happened to the vision?
• 1990s cutbacks harm a vulnerable system
• Waits and delays worsen
• The 2005 Supreme Court Chaoulli case reopens the debate about private health care
• Reforms are being implemented and some
places have made significant progress
We need to change the way we deliver
services
“Removing the financial barriers between
the provider of health care and the
recipient is a minor matter, a matter of
law, a matter of taxation. The real
problem is how do we reorganize the
health delivery system. We have a health
delivery system that is lamentably out of
date.”
Tommy Douglas
“Only through the practice of preventive
medicine will we keep the costs from
becoming so excessive that the public
will decide that Medicare is not in the
best interests of the people of the
country.”
Tommy Douglas
Canadians could have quicker access
• Saskatchewan is aiming for 30% of family
practices on same day service this year and 100%
by 2010
• The Hamilton Shared care Mental Health Program
increased access for mental health patients by
1100% while decreasing referrals to the
psychiatry outpatients’ clinic by 70%.
• The Alberta Bone and Joint Health Institute
reduced the delay for joint replacements from 82
weeks to 11 weeks from GP referral to
implantation of the new joint
What can the US learn from Canada?
• Only public health insurance can control costs AND
provide universal access
• Public health insurance is business’s best friend
• Public health insurance improves equity and
efficiency but does not automatically lead to
improved quality
• Primary health care is the most important part of
any health system. Canada’s poor international
performance for chronic disease management and
waits and delays is due to inadequate PHC
What can others learn from Canada?
• Canada’s system has slowly evolved since
the 1960s
• Canada’s health care policy-making is more
complicated than pre-World War I European
diplomacy!
• Be careful about news from abroad
Summary
• Canada has 14 health care systems
• Canadian Medicare greatly outperforms
the US system
• The US can learn from Canada:
– Single payer systems control costs while
providing universal access
– But you need to re-organize the delivery
system to improve quality
Courage my
Friends, it is
Not Too Late to
Make a Better
World!
Tommy Douglas