Canadian Health Care

[ronv]

In the US there is a great debate about government health care (Obama care), even though it hasn't gone that far yet.
Many people on the forum have gov't health care where they live. I am curious about how well it works. Here in the US we just hear bad stories.
Things like cost -- I assume there is some tax
Service
Results
etc.
Thanks!

 

[Mr RB]

Watch the Mike Moore movie on the US health care system. He travels to Canada and the UK and examines their free health care systems in depth, and it's a real eye-opener as to just how bad the US health care system really is. I was shocked.

 

[bryan]

Well Canada healthcare has it's advantages and disadvantages. Yes, healthcare is Gov run and has limitations and negatives like wait lines and huge cost to the taxpayer, but no where near as bad as the news media makes it out to be. There is a lot of chatter about moving to a semi public and private system similar to what some of the European countries have. Only a matter of time.

p.s. When it comes to taxes I think a lot of Americans do not realize or appreciate that they have some of the the lowest tax rates in the world. If you want gov services you are going to have to pay for them.

 

[3v0]

I have been against the government getting deeper into health care.

It has taken a while but I have changed my mind. I want everyone including the congress to live with exactly the same system.

Why: Because I have noticed that Doctors are giving second rate service to people who are on medicare, an existing government health care system for the old and disabled. They can make more money by shorting the medicare patients. Medicare is not welfare but a mandated government system.

If you do have first rate insurance they often exploit it.

Can you tell I am more then a little unhappy with doctors. There is a reason people often say doctors and lawyers in the same breath.

 

[jpanhalt]

I want everyone including the congress to live with exactly the same system.

Couldn't agree more with that. I think exclusion of any group is a fatal flaw and makes the system destined to give second class care to the majority of those covered by it.

Obamacare, as you know, excludes Congress. Prisoners are also excluded. Congress and other high-ranking Federal officials have their own, premium healthcare system. Federal prisoners have a different system that provides access to some of the best medical care available in the US for free. You see, their attorneys can insist on private doctors on the ruse that public doctors are second-rate. The SCOTUS has ruled that providing second-rate care for a prisoner is unconstitutional. The prisoner gets a private jet to the facility, and the government usually pays full price. In the 1980's, Mayo championed the building of a Federal prison in Rochester, MN for that business reason. Of course, it was called a Federal Medical Center, but it is really just a prison. A famous evangelist got sent there. He was healthy. His prayer made the news, "Oh God, I know I have sinned, but what have I done to deserve weather like this."

Why: Because I have noticed that Doctors are giving second rate service to people who are on medicare, an existing government health care system for the old and disabled. They can make more money by shorting the medicare patients. Medicare is not welfare but a mandated government system.

By law, physicians cannot discriminate against Medicare patients. That can have unusual and unintended consequences. One of which is the ordering more tests. That is not good medicine. Another consequence has to do with the frequency of testing, where testing is done, which tests can be done, and even how some tests are actually done. Such decisions used to be based solely (in theory) on medical factors. Now, one must also consult the Code of Federal regulations. Here is just one example. Assays of the concentration of a drug in serum ("drug assays") were/are limited to just once per day per drug. That is fine for some drugs, but for others, you need to assess both the highest concentration after a dose and the lowest concentration after the same dose. That is very difficult to do while complying with the restriction of one assay per drug per day. Now, you say, why not just not charge for the second assay? Well, there is a hospital cost to every assay. Not charging for an assay increases the hospital cost without revenue. Since Medicare reimburses hospitals on a cost basis, increasing cost without creating revenue constitutes fraud. The examples can get very complex. Many, many examples can be given of how dealing with Medicare and other insurance regulations can lead to almost illogical consequences.

As for physicians dealing differently with Medicare patients compared to patients with other insurance, I am sure there are examples. No profession is without its crooks and unethical practitioners, and I hold such physicians in the lowest regard. I do not believe such practices are representative of physicians as a whole. For one thing, Medicare is a good payer compared to some other insurance plans. Physicians still have the option of accepting only some insurance carriers while rejecting others, including Medicare (there are clear exceptions). Insurance carriers also can decide not to accept any individual physician or group. Thus, you will find physicians who aren't "enrolled" with an insurance carrier may reject such patients. Physicians are required to provide emergency services regardless of insurance, and in many hospitals, they must take ER duty on a rotating basis as part of their practice. They are not required, however, to provide follow-up care.

John

 

[KeepItSimpleStupid]

They are not required, however, to provide follow-up care.

That almost looks like it's going to change. Hospitals will now be penalized if there are lots of re-admissions, so to avoid hose charges, the hospital has to make sure the patient is not discharged early and follow-up care is "arranged". Follow-up care can happen easily if the hospital essentially has practicing groups which the major hospital where I am does. In fact, my PCP is a member of the Hospital Network.

I do have Medicare and a zero cost supplement insurance and an extremely nice drug plan. The drug plan is not subject to the Medicare Part D restrictions like you can't have X-drug (barbiturates aren't covered, for instance) and the erectile dysfunction drugs are not covered.
I do know that when I was looking at plans for mom and you had to input all your scripts, there was a discrepancy as to what each plan say called Vicodin. One plan called it Hydrocodone/Acetiminophen and the other called if Hydrocodone/APAP. These are the same, but really apples and oranges to a computer. Pen-needles (used for insulin pens) were not even listed.

I recently had an issue with Allergy testing and Medicare. They didn't initially pay, but my doc said that either way I would not be responsible for the charges. I was not allergic to the mixes for molds, but was allergic to individual molds. So, usually you don't test for mold if the mixes are negative. It did appear that Medicare did pay for the extra tests, about $600.

 

[throbscottle]

In the UK we have the NHS (National Health Service), which used to be envy of the world, but now I'm just embarrassed to mention it, since it now looks more like an exercise in management and administration than in healthcare (I have it on good authority from my wife who works in an NHS office). We pay NI (National Insurance) contributions which are used to fund it (as well as to fund unemployment benefits and the state pension). We also have private healthcare, if you can afford to take out your own insurance. Doesn't mean you pay any less NI though. Whole thing's a shambles if you ask me - we need nurses, not managers. Which reminds me, don't know if it's still common, but a lot of NHS trained nurses used to go and work abroad (in the US for example) where they were (or are) in demand because of the high quality of training they get (or got, anyway). They have managers to manage the paperwork produced by the clerical staff for the managers who want to keep themselves in a cushy well paid NHS job by creating more paperwork... Blegh.

 

[ronv]

Some interesting stuff.

I'm on medicare myself and have no complaints (so far), but like john says there are some interesting ways all the systems get scammed. The best example I have seen is when my wife and my friend both had colonoscopies from the same doctor at the same hospital. His GM insurance (very good) paid $5000 for the same procedure my wife's medicare paid $250 for. Both were billed for more initially.
I do notice it takes more trips to the Dr. than it used to to get a check up. I guess they get paid by the visit.
Like Throbscottle noted my Dr. has more paper pushers than nurses.
Not sure what the answer is.

 

[KeepItSimpleStupid]

Hey, have you ever looked at a bill from a doctor's office with and without insurance? The results CAN be dramatic. Now we don't even see them except once every 6 months or so. If you don''t have insurance the charge is MUCH higher than if you don't. I don't like that.

Same doctor. I had some "corrected" because of "retroactive insurance" and what I saw was staggering.

Mom got a nebulizer and she appears to be "renting" the machine per month for more than the machine costs new. New it's about $40.00. Supplies are about $10/two. Something is wrong here. Not sure of the full details yet.

When I was about 12 YO, I remember a 2.5 day hospital stay (probably 60's) to have 4 teeth pulled. The out of pocket cost was $0.50 USD. The insurance didn't pay for the hospital wrist band. One tooth came in the roof of the mouth, hence the hospital stay.

 

[Inquisitive]

Canadian health care is not totally free. I believe that each participant mush pay a monthly premium. Something like $50.00 -$75.00 per month whether it is used or not. Comes out of their pay check deductions. Children would be cost roughly half that, paid by a responsible guardian.

 

[jpanhalt]

Canadian health care is not totally free.

No health system is free -- not even if the hospitals are in tents and the doctors are slaves. That is obvious and I am sure it is not what you meant.

Medicare was set up as an "insurance." It was then expanded to include a lot of people who hadn't or didn't pay into it. Today, for those who worked a lifetime and paid into it, it is still not free. Elderly on Medicare still pay a minimum monthly amount, which is graduated according to income. The threshold for that penalty is quite low, if the criterion is wealthy vs. median person. It currently is about $85,000 modified, adjusted gross income ("MAGI") for single people. People with good retirement plans plus lifelong SS and a little investment income can hit that limit easily. I know several retired people whose Medicare penalty payments exceed what they could buy equivalent or better insurance for in the open market.

There is no doubt that the American system is expensive. Some very good studies published in the New England Journal of Medicine have documented that. What is often forgotten is that most (more than 50%) of the difference in cost between the American and Canadian systems is due to differences in administrative costs and paperwork. CEO's of the vast majority of American hospitals are not physicians, and their salaries are not uncommonly 7 figures. Rising hospital costs, not physician costs, are the major contributor to increasing costs in the US.

Someone pointed out above that there were more employees pushing paper than caring for patients in a local physician's office. That is not unusual. Before Medicare, two physicians, two nurses/aids (to help patients gets in and out, gather supplies, etc.), and one office person could handle a busy, PCP practice. As long ago as 1992, I visited several rural practices that had just one physician, one helper, and three people in the office.

Back to ronv's question (post#1), I would like to see this thread head in the direction of assessing quality. How is that done? How do lay people perceive quality? How would you measure it for comparison purposes? How would you judge your physician? How would you pick a physician, if you moved to a new town?

John

 

[Val Gretchev]

Health care premiums differ depending on the Province you live in. For example:

In B.C., premiums are payable for MSP coverage and are based on family size and income.
Effective January 1, 2012, monthly rates are $64.00 for one person, $116.00 for a family of two and $128.00 for a family of three or more.

In Ontario, where I live, the rate is based on taxable income for a taxation year. See chart at
https://www.fin.gov.on.ca/en/tax/healthpremium/rates.html

If you are on a pension income or your income is below $20,000 per year, your coverage is free.
For seniors (65 and over), pharmaceuticals are free after a $100.00 per year deductible is paid. The only cost is the dispensing fee, charged by the pharmacy, of $4.00 per drug at the moment.
Seeing a doctor or specialist is free. Getting a yearly flu shot is free. Contrary to many newspaper articles bemoaning the state of hospitals and wait-lists, I find them excellent and all free. Most of the negative comments are politically motivated to embarrass the party in power.

Medical insurance in Canada only covers those services that are not covered by the government plan (e.g. – private hospital room, glasses, dental, etc.). In this way, everyone is treated equally by the same government administered plan and employers can offer special benefits to their employees.


Yes John, nothing is actually free. It’s only perceived to be free by the recipient. The federal government transfers tax dollars to the provinces according to population and their needs. The provinces supplement that through their own taxation including the user fee. The result is a fairly uniform system of health care across the entire country.

 

[panic mode]

Contrary to many newspaper articles bemoaning the state of hospitals and wait-lists, I find them excellent and all free. Most of the negative comments are politically motivated to embarrass the party in power.

Unfortunately, I disagree...

You can blame it on politically motivated bias or what ever you like but I've experienced it first hand on my own skin. Worse, I had to witness my family go through some rough ordeals as well.

Wait times are lower in smaller places but try to get some help in Toronto and you can wait till you turn blue. I know because I was there for years. I moved from Toronto to Mississauga and the situation is just about the same. I am only two blocks away from Credit Valley Hospital but when I need help, I just drive past it, take HWY403 and go to Hamilton because there I get attention way sooner so additional 30-40min drive time is not an issue at all. On a GOOD day ER in Mississauga/Toronto will have someone see you within 5-12h, in Hamilton within 1h. On a bad day, wait times can tripple...

For me the worst case ever was in 2005 just before we moved away. At the time we lived in Etobicoke. My son screamed in the middle of the night complaining of abdominal pain so I rushed him to William Osler Hospital (just across from Humber College). They had him wait and wait, there was no pain killer, only water. After 24h my wife came to be with the kid while I went home to catch some rest. Couple hours later I got a call, his appendix finally popped and that is when they moved him operating room. It is good that this happened while my wife was there and not me. I have never laid a finger on anyone but if I was there at the moment, I would have probably hospitalized someone (and it wouldn't matter who) and end up in jail. My son spent another week there recovering from what was supposed to be routine task but the toxins got into his bloodstream.

I don't give a sh*t who is in power but I am a changed person. Now my blood boils and I see red at a mere mention of Ontario Health system. I don't perceive it free, more like worthless...

 

[KeepItSimpleStupid]

That's what I have heard for Canadian Health Care is that there is no speed to start treatment.

 

[ronv]

In B.C., premiums are payable for MSP coverage and are based on family size and income.
Effective January 1, 2012, monthly rates are $64.00 for one person, $116.00 for a family of two and $128.00 for a family of three or more.

Wow. In the US you can just about add a zero to each of those. Seems like there is room to improve the service if needed.

In the US you pay into the retirement system while you are still working - I think it is about 1.5% of income. Then upon retirement you pay another $100 a month and usually some more for additional insurance to cover what the gov't plan doesn't.

 

[Val Gretchev]

I have never laid a finger on anyone but if I was there at the moment, I would have probably hospitalized someone (and it wouldn't matter who) and end up in jail.
I don't give a sh*t who is in power but I am a changed person. Now my blood boils and I see red at a mere mention of Ontario Health system. I don't perceive it free, more like worthless...

Wow, you are some scary dude! I better stop right there; I don’t want my rep stripes to turn red so soon after the last time.

About 8 years ago, my wife fainted and hit her head on some concrete resulting in a half-inch cut near her right eyebrow. It was bleeding profusely. It was at night and I took her to Oshawa Hospital where we waited for 6 hours before someone could stitch her up. Four years ago, I slipped on some ice and fell on my left arm breaking it in a couple of places and dislocating the elbow. I waited 4 hours at Oshawa Hospital to get a cast put on.

That was not an unreasonable time to wait. I have to agree that 24 hour wait-time for someone to diagnose acute appendicitis is an obscene amount of time. But it happened. Everyone is aware that the ER services are strained and overwhelmed. They are trying to do something about it but the money supply isn’t unlimited.

I had my gallbladder removed by laparoscopy at North York General Hospital and I was in and out in 4 hours. I had my prostate gland removed at Ajax Hospital and I was in and out in 4 days. Both operations were scheduled through the system and went off without a hitch.

The point is that ER is only 10% of the entire Health Care System. It gets a bad reputation for wait-times and many think that’s all there is to health care. Most of the other services that can be scheduled run efficiently with excellent quality of delivery. So don’t throw the baby out with the bathwater.

 

[ronsimpson]

The Mike Moore movie is very political. When it came out friends call and asked me where that hospital is that did not have a wait.

I was raised in Canada, until age 20. I don't mind a less than perfect health care system if I could pay money to get a second opinion or another doctor. That's probably why people fly south with a check book. I don't think the US should be looking at Canada or England. I believe Switzerland and Taiwan are better examples of how to move to a new system.

We don't trust the US government to do the right thing. We do trust the government to through money at the problem and not solve the issues. The insurance companies (don't trust) drive the government and laws in a direction that is not healthy.

My son is gong to a doctor that charges 40 to 50% of the standard cost and does not work with insurance companies. The doctor said insurance only pays 40%. If the cost is 1000 they send him a check for 400 marked paid in full after 3 months and a big hassle. For a 1000 procedure he used to collect 20% from the person. $200 Then send the paper work to insurance which sends him the other $200 if all the paper is right, etc. Now he gets 50% with no one looking over his shoulder. He certainly does not like the government saying which drugs, what procedures, how many in a day, what price, and who is sick/not sick.

 

[jpanhalt]

My son is gong to a doctor that charges 40 to 50% of the standard cost and does not work with insurance companies. The doctor said insurance only pays 40%. If the cost is 1000 they send him a check for 400 marked paid in full after 3 months and a big hassle. For a 1000 procedure he used to collect 20% from the person. $200 Then send the paper work to insurance which sends him the other $200 if all the paper is right, etc. Now he gets 50% with no one looking over his shoulder. He certainly does not like the government saying which drugs, what procedures, how many in a day, what price, and who is sick/not sick.

That illustrates is a very good point that should not be missed. The history of inflated charges compared to actual reimbursement dates back several decades. Some insight into that history may make the crazy system we have in the US seem a little more rational.

One of the biggest clouds hanging over the advent of Medicare (mid-1960's) was the fear by the AMA that it would lead to a national fee schedule. To address that, Medicare paid a fairly high percentage of the usual, customary, and reasonable (UCR) charge made by physicians and hospitals. In the early 1980's, TEFRA (https://en.wikipedia.org/wiki/TEFRA) and related legislation put an emphasis on controlling costs.

The percentage of UCR was ratcheted down to attain that goal. What a stroke of genius that must have been for some bureaucrat. Every time the percentage was lowered, hospitals and physicians ("charges") raised their fees. It did not take very long (1982 to 1990) for charges to go from a realistic amount that was actually paid by self-payers to to a ratio of at least 4:1; that is, a provider had to charge $4 to get $1 in collected revenue.

The silliness of that situation finally became apparent in the late 1980's, which sparked several efforts to rationally derive a reimbursable cost for a particular service (see: RBRVS, Dr. Hsiao, https://en.wikipedia.org/wiki/Resource-based_relative_value_scale). From that point on, there has been effectively a national fee schedule.

However, its history has left a legacy:
1) If one charges less than the fee schedule, you get only what is charged. Sometimes, the provider doesn't know what the Medicare allowance will be, so fees have stayed set high enough to cover any eventuality.
2) It is clearly against the law to charge Medicare one fee and other payers another (lower) fee.
3) Almost all insurance payers have adjusted to the system and set their own, fixed reimbursement schedules. I am not aware of any insurance company that says flatly, we will pay "x" percentage of Medicare, but anyone in practice knows what the average comes out to be. In some specialties, it is more than Medicare, such as 130%; in other specialties it is less than Medicare (e.g., 90%).

Pre-Medicare and the fee explosion, many people were self payers. If one was healthy, why pay insurance premiums, because self-pay could easily be less on an annualized basis. Today, true self-pay is almost non-existent. (The Amish is one identifiable group that actually self-pays.). Self-pay today is basically synonymous with "no-pay." A great many physicians are quite uncomfortable with the ethics of charging such high fees to the few remaining true self-paying patients. That is particularly bothersome in areas of our Midwest that have large Amish populations.

Two solutions exist for that dilemma that are legal or quasi-legal:
1) Charge the inflated fee but don't pursue a patient for not paying the whole fee. (On an individualized basis, patients can negotiate the amount they pay.)
2) Become a cash-and-carry provider.

The problem with a provider following the first method is that, if it were to become a big part of total billed revenue, it might spark an investigation by Medicare for fraud and abuse. The second method is cleaner in that respect. The tables are tipping quickly. In some markets, as much 20% of providers are cash and carry and the percentage is growing rapidly.

John

 

[ronsimpson]

Well said John. Good sources. Thank you.

Paying a doctor 80% is like: Paying (fill in the blank...what ever you do) Like paying you 80% of what you made last year. It causes much unhappiness, low productive, over charging and fraud. If you work slow and get much over time then you get you 20% back. Now we have many laws about fraud and a great amount of intrust on both sides. With 1000s of pages of what a Dr. can/can't do for a government check.....it adds to unhappiness, low productive.

I don't have a answer.

 

[ronv]

Thanks John, I never understood exactly how the charge vs payment thing came about. I watched my neighbor almost go broke when his uninsured son got cancer. The bills were out of sight He couldn't get them to come down either. Probably against the law to undercut the going rate. Standard insurance must use the same system?
So enter Pay for service? That's why my primary care doctor loves me so much.