The Health systems of Canada & the USA презентация

Ph.D.
Division of Management, Policy, and Community Health
UT Houston - School of Public Health
Pauline.Rosenau@uth.tmc.edu

for
Doctor of Nursing Practice students
Room 706
University of Texas School of Nursing
Thursday, February 17, 2011

myths
Compare the two countries on Costs
How patients experience it
How hospitals and doctors experience it
Judging Canada and the USA on performance
Strengths and Weakness of each
Try to figure out why

worry about incurring health care expenses.
Nor do Canadians have to submit claims to insurers.
Providers have ONE payer to submit claims to: the provincial government.
Canadian system is largely funded by general tax revenue - 25-50% federal.

is 10 payer provincial health systems with “portability”
Each province is like one big HMO: True
The Canadian health system is “socialist”:
False, most providers do not work for the government but are rather paid by a piece rate system and hospitals are not owned by the government

system top – down
False: federal – provincial authorities negotiate the basics ; for example privatization
In Canada the bureaucracy wastes precious health care resources?
False:
The % of $ used for administration is much lower in Canada than in the USA
Billing is straightforward and electronic with 95% of requested reimbursements completed.

The government sets a budget, the doctors set the payment rates in most provinces
Canadians ration care by age, need, and SES
False: there are no policies that restrict care on the basis of age, need, or socioeconomic status. Such discrimination is illegal
Canada allows euthanasia.
False: Some US states have laws permitting euthanasia but none of the provinces in Canada do.

States spends almost two-and-a-half times the OECD Average

2007

1. Health expenditure is for the insured population rather than resident population.
2. Current health expenditure.

Source: OECD Health Data 2009, OECD (http://www.oecd.org/health/healthdata).

Experiences in seven Countries, 2007 – for methodology

($US PPP)

Total expenditures on health as percent of GDP

Source: OECD Health Data 2010 (June 2010).

Experiences in seven Countries, 2007 – for methodology

for the largest share of this difference (39%),
Payments to MDs and hospitals accounted for (31%) of the next most important variables explaining difference
More intensive provision of medical services accounted for the was the third most important variable in explaining the difference (14%).
Research by professors from Harvard and Un. Of California in summer 2010; Inquiry

complexity = high transaction costs and overhead costs
McKinsey estimates adds $90 billion per year*
Insurance and providers
Variation in benefits; lack of coherence in payment
Time and people expense for doctors/hospitals

* 2006
Source: 2009 OECD Health Data (June 2009).

Spending on Health Insurance Administration per Capita, 2007

* McKinsey Global Institute, Accounting for the Costs of U.S. Health Care: A New Look at Why Americans Spend More (New York: McKinsey, Nov. 2008).

have “good government”
Americans distrust their government
Canadians are comfortable with price controls in the health sector
Price controls in the health sector yield lower costs
Unlike other economic sectors unfettered market competition does not lower costs

OF LIVING

Source: OECD Health Data 2009 (June 2009).

* 2006

*

PATIENT’S POINT OF VIEW – ABOUT THE SAME

Care Physicians, 2006– for methodology

Care Physicians, 2006– for methodology

Care Physicians, 2006– for methodology

Care Physicians, 2006– for methodology

USA

- bills sent to the province
Extra-billing of patient is NOT permitted
No individual bills are prepared for patients
Hospitals (largely private nonprofit) are paid on global budget system with funds sent by the province; some regional health authorities obtain population-based funding (west) (HiT 2004)
Payment for pharmaceuticals varies by province and formularies are set up at the provincial level
What Canadian doctors are paid for treatments and procedures: ex. Gynecologist paid $45 for visit in B.C.

http://www.health.gov.bc.ca/msp/infoprac/physbilling/payschedule/index.html
http://www.health.gov.bc.ca/msp/infoprac/physbilling/payschedule/pdf/26.%20obstetrics_gynecology.pdf

across provinces as each takes care of its on billing
Doctor must be registered as a practitioner in the province
Doctor must have a billing number – and not automatic
Doctor must be eligible and qualified to bill for the specific code indicated: ex. neurologist won’t be paid for doing an appendectomy.
The amount billed must be for the amount allowed by the fee schedule (Medical Services Plan)

online through the web or via a direct connection to the MSP office – daily or weekly- and 98% reimbursed
The provincial payer organization sends payment twice monthly directly to the MD and pay interest on reimbursements that are delayed more than 30 days.
Ease of billing is a big plus in Canada and doctors who have billed in both Texas and Canada are in agreement on this : “One insurer, one fee schedule, rarely any question of eligibility and no incentive to withhold payment – its heaven compared to the US”.

are in poorer health than their Canadian counterparts
Wealthy Americans and Canadians – equally healthy
Little difference between insured Americans and Canadians as a whole -- on access to health care and health status
Americans without health insurance are – different, with low access to health care and more “unmet health care needs”

Alexis Pozen, David M. Cutler (2010) Medical Spending Differences in the United States and Canada: The Role of Prices, Procedures, and Administrative Expenses. Inquiry: Summer 2010, Vol. 47, No. 2, pp. 124-134.

Bhaloo, & Rosenau; “Health Lifestyles in the U.S. and Canada: Are We Really So Different? “Forthcoming Social Science Quarterly, December 2009

Mortality Amenable to Health Care, 2008– for methodology

transplants
One disease favors the U.S.
Breast cancer

Hussey, P. et al, “How Does the Quality of Care Compare in Five Countries?” Health Affairs 23(3) May/June 2004

Canada (CI 0.92 to 0.98)
Results quite heterogeneous
No explanation for heterogeneity

Guyatt, G. et al, “A Systematic Review of Studies Comparing Health Outcomes in Canada and the United States”, Open Medicine 2007;1(1):E27-36

system
Result of budget cuts 1990’s
Today the situation is much improved
But the U.S. also has a “waiting times” problem, but for different reasons
In the US we wait because of cost…..
In Canada patients because of scarcity

Experiences in seven Countries, 2007 – for methodology

Experiences in seven Countries, 2007 – for methodology

is a workable compromise
Access is best when it is universal
Choice is ok – one big HMO
Primary care emphasis is important
Electronic medical records are not essential

as “supply side” control mechanisms even if the MDs are in charge.
“Costs in Canada are too high.” Really? I guess it is always relative to your perspective.
Tolerance of a private sector “safety valve” may be essential if universal access is to be preserved
http://www.oecd.org/dataoecd/51/48/41925333.pdf

always better” when it comes to healthcare
But many patients don’t understand this or believe it.
Medical technology is available…
if you are well insured…
if not insured or underinsured… ?
No waiting if you pay out of pocket.

other industrialized country with little to show for it.
Accessibility – may get better after 2014 ?
Administrative costs are high and this is unlikely to change after health reform is implemented.

– maybe but USA and Canada are converging; media, proximity, culture diffusion, geographic mobility and immigration
History – Yes
More distrust of government in US
More emphasis on individual liberty
Form of government – yes
Presidential system in the USA
Roots in the constitution
Designed to require incremental policy rather than comprehensive policy
Parliamentary system in Canada
Good at implementing comprehensive change quickly and efficiently
Responsible party model
Important role for party leadership

Diagnosis: Rathke’s Cleft Cyst on pituitary gland -- a benign cyst
Wait time in Canada would have been three months with no copay, no deductible
Cost for removal at Mayo Clinic = $97,000

"I knew in my gut that I had to see someone and could not wait five to six months," she says. So she called Mayo Clinic and got an appointment the same day.

Featured on the Mayo clinic website .http://www.mayoclinic.org/patientstories/story-339.html

http://www.youtube.com/watch?v=cahvnCBVXXU&feature=related
http://factcheck.org/2009/08/dying-on-a-wait-list/ same as above with Fact Check information
Mayo clinic charged 100,000$ - Shona’s story is no longer posted at Mayo Clinic’s website
Dr. Jason Huse, a pathologist at the Sloan-Kettering Cancer Center, in the USA . Factcheck.org says: “He told us something different.” "By strict definitions it’s not even a tumor," he said, but a remnant of embryological structures that eventually develop into the pituitary gland. Huse stressed that without having examined Holmes, he couldn’t know the prognosis of her RCC: "It is not out of the realm of possibility," he told us, "that this could have been impeding her hormone secretions to the extent that it was a life-threatening situation." And of course, we don’t know what Holmes’ American doctors told her. However, Huse said, RCC "is not typically a malignant lesion and it is not typically life-threatening." 

SERIOUSLY MISTAKEN IDENTITY” AMER. REV. OF CANADIAN STUDIES – SPRING 2006, PP 27-58

Objective: This study assesses the fairness, accuracy, and comprehensiveness of U.S. newspaper coverage of the Canadian health system in two of the most influential newspapers published in the U.S.
Methods: Quantitative methods, interpretative assessments, and thematic analyses are employed to evaluate coverage of the Canadian health system in the New York Times and the Wall Street Journal between 2000 and 2005

the Canadian health system is found to be poor. Points of misinformation are indicated, misrepresentations are specified, and inadequate explanations are denoted.
Overall, ongoing themes and controversial issues regarding the Canadian health system receive almost as much notice in U.S. newspapers as actual news events.
Anecdotal information plays nearly as great a role in coverage as facts and evidence.
U.S. newspaper reports about the Canadian health system are found to be oversimplified.
Information, all too often, is presented out of context and sources are not always sufficiently identified.
Coverage is incomplete: all provinces are underrepresented in the U.S. newspapers studied, except Ontario.
Some articles are confused and a few were found to contain errors.
Conclusions: These inadequacies in newspaper coverage mean that the U.S. public is sadly misinformed with regard to the Canadian health system.

Health Care System Need Fixing? 10 August 2009” NPR http://www.npr.org/templates/story/story.php?storyId=111721651 
Read: Ross and Detsky “Health Care Choices and Decisions in the U.S. and Canada”; JAMA 10/28/2009 ; 2009;302(16):1803-4, http://jama.ama-assn.org/cgi/reprint/302/16/1803
Read; Sanmartin, et al “Comparing Health and Health Care Use In Canada and the United States,” Health Affairs, vol. 25, July/August 2006 “ (Abstract ) http://content.healthaffairs.org/cgi/content/abstract/25/4/1133
View : “Sicko” by Michael Moore; Scene Selection # 7 Only “Canada!”: about 10 minutes that begins at minute= 40. Seabout 10 minutes that begins at minute= 40. See especially the Conservative party member (golfer interview) at Minute 48 http://freedocumentaries.org/teatro.php?filmID=133&lan=undefined&size=undefined
Listen: Audio Interview and Review of “Sicko” by Jonathan Oberlander – University of North Carolina; for ‘NPR’s program, Fresh Air” 2007. only the first 15 minutes are relevant - about Sicko’s presentation of Canada http://www.npr.org/templates/story/story.php?storyId=11826524
And investigate other countries such as Britain, Germany, Japan, Taiwan, Switzerland at: http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/view/

SEVEN COUNTRIES, 2007

Survey of comparing Adults’ health care experiences in Australia, Canada, Germany, New Zealand, the Netherlands, the United Kingdom and the United States.
Method:
Interviews with representative sample of adults, Age >17years, 2,500 in the United States and 3,000 in Canada. Funded by the Commonwealth Fund, partnered with the Health Council of Canada to expand Canadian Sample.
Interviews conducted by telephone between 6 March and 7 May 2007 by Harris Interactive and Country affiliates
Conducted in different languages; French and English for Canada while Spanish and English in US
The margin of sample error for country averages is approximately + 2 percent for the US and Canada and + 3 percent for other five countries, at 95% confidence interval.
Peer Reviewed Publication Citation: Schoen, C., Osborn, R., Doty, MM., et al. Toward Higher-Performance Health Systems: Adults’ Health Care Experience in Seven Countries, 2007. Health Affairs (2007) 26(6) w717-w734

2006

Countries involved are Australia, Canada, Germany, New Zealand, the Netherlands, the United Kingdom and the United States
Methods:
The survey consists of interviews with representative samples of primary care physicians in seven countries using common questionnaire.
Harris Interactive; country affiliates and in the Netherlands, the Center for Quality of Care Research, Radbound University Nijmegen, conducted interviews by mail and telephone from late February through July 2006
Survey was conducted in English in the US and Canada.
The margin of sample error ranges from +3 percent to +5 percent, at 95 percent confidence interval.
Peer Reviewed Publication Citation: Schoen, C., Osborn, R., Huynh, P.T., et al. On the Front Lines of Care: Primary Care Doctors’ Office Systems, Experiences and Views in Seven Countries. Health Affairs 25 (2006) w555-w571

Canada
Meta-analysis of outcome studies
38 studies meeting most criteria for high quality (only one missed criteria allowed)
Publish or unpublished prospective or retrospective observational studies comparing health outcomes data for patients with any age with same diagnosis in US and Canada
Sources included: EMBASE (1980-Feb 2003), MEDLINE (1966- Feb 2003), healthSTAR (1975-Feb 2003), EBM (2003) and dissertation abstracts ondisc (1969- Feb 2003).
Results were pooled using a random-effects model
Cochrane’s Q-test was assessed to check heterogeneity and relative risk was used as a summary statistics

Guyatt, G. et al, “A Systematic Review of Studies Comparing Health Outcomes in Canada and the United States”, Open Medicine 2007;1(1):E27-36

2008

Comparison of trends in deaths considered amenable to healthcare in the US, Canada and in 17 other industrialized countries.
Data and Analysis:
Mortality and population data extracted from WHO files
Data include deaths coded according to ICD-9-CM and ICD-10 by sex and five-year age band. The general Age limit was set at 75 years.
The causes of death considered are bacterial infection, diabetes, CVD, treatable cancers, cerebrovascular disease and complications of common surgical procedures.
Age-standardized death rates (SDRs) per 100,000 population by sex was calculated for years 1998 and 2003.
Peer Reviewed Publication Citation: Nolte, E., & McKee, C. M. (2008). Measuring the Health Of Nations: Updating An Earlier Analysis. Health Affairs, 27(1), 58-71
Previous Publication Citation: Nolte, E., & McKee, C.M. (2003). Measuring The Health Of Nations: Analysis Of Mortality Amenable To Health Care. BM, 327, 1129-34

International Competitive Rates and a Level Playing
Field.” C.D. Howe Institute Commentary. No. 295. Toronto: C.D. Howe Institute. September