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• W2149063887 abstract "With political momentum seeming to build toward some sort of system that will extend health coverage to everyone, doctors in the US might be expected to be curious about how it might affect them. Though what form such “reform” might take is anyone's guess, emergency physicians in the US have a universal coverage model close by that might offer some comparisons and contrasts. Everyone in Canada is covered by health insurance, paid for by the government, or more properly, the federal, provincial and territorial governments jointly. But what effect does the system of reimbursement have on clinical practices, diagnostics, pay, work frustrations and other areas? The answer—based on interviews with several prominent doctors familiar with emergency medicine on both sides of the border—seems to be: not so much. In Canada, it all depends on where you work; but the same is true across the US. The payment mechanism is different, but the pay for emergency physicians seems to be similar. In Canada, most doctors submit bills for services to an insurance payer, and the bill is usually paid without much of the hassle seen in the US. But in some provinces, such as Ontario, they are salaried, at a rate that has to be periodically negotiated with the provincial government. “Most Canadian emergency physicians do not contract as a group to a hospital,” said Alan Drummond, chair of public affairs for the Canadian Association of Emergency Physicians and emergency department (ED) director at Ontario's Perth and Smiths Falls District Hospital. “They are basically individual practitioners. They form a group for billing purposes and for educational purposes, but that would be a major difference. There are not a lot of companies in Canada that are involved in staffing emergency rooms, where you'd work for Company A and Company B and be contracted out.” While emergency physicians in Canada might be paid somewhat less, he said, most are comfortable with their compensation. “You're sort of looking at about $110-120 an hour in the small rural hospitals to $135-140 to a tertiary center on the east coast, to $200-$220 in more urban areas of Canada.” Barry Diner, an emergency physician in Atlanta's Grady Hospital System and professor at Emory University medical school, agrees. “I don't think that overall there is a huge difference in the pay structure. People might argue with me, but I have been on both sides. I was an academic up in Canada, and I made as much up there as I do here in the US. If I was a non-academic and spent more time in the clinical arena, I probably would have had made as much, give or take, as I would have made here in a full clinical environment as well. It depends on where you're practicing.” There are pluses and minuses on both sides, said Brian Rowe, professor and research director at the University of Alberta's Department of Emergency Medicine. “The Canadian advantages are: almost everyone pays (or their government does), we have a universal medical malpractice protection system (I pay about $1,000/year for malpractice), strong provincial and national physician unions, and universal coverage for all Canadian patients. The US advantages: more often a blended salary position for ED physicians which rewards diversity, so, far more clinicians will select an academic track in the US.” A possible difference between the 2 countries is crowding in Canadian hospitals, a problem that backs up traffic in EDs, though the same criticism is made in the US, particularly in urban settings. In its position statement on the issue, the Canadian Association of Emergency Physicians, says, “Canada has only 3 hospital beds per 1,000 Canadians, ranking 26th out of 30 OECD (Organization for Economic Cooperation and Development) countries. Our lack of acute care beds means that most Canadian hospitals frequently operate at unsustainable occupancy rates of higher than 90%, a level at which regular bed shortages, periodic bed crises, and hospital overcrowding are inevitable.” However, according to the OECD, the number of acute care hospital beds in Canada was 2.9 per 1000 population, better than in the US (2.7 in 2005), but lower than the OECD average of 3.9 beds per 1000 population. “If you're admitted to the hospital, that's when the delay starts,” said Michael Murphy, chair of anesthesiology and a professor of emergency medicine at Dalhousie University in Halifax, Nova Scotia. “That's when you'd end up spending 20, 30 hours on a stretcher in the emergency room. Not that that's not going to happen in the US” The lack of beds affects the intake side of a Canadian emergency department. “The No. 1 issue in emergency medicine in this nation, I'm sure, is access to care for the non-life-threatening emergencies because you've got admitted patients blocking the emergency department.” But Dr. Rowe said the same problem occurs in many US hospitals. “In New York, where I visited last week, the private ED was clean, technologically sophisticated, not too crowded and was well staffed. Across the street, the same ED group ran a ‘county’ hospital, and it was worse than anything I've seen in Canada.” The differences in wait times—and the similarities—can be traced to the 2 countries' payment mechanisms. “People in the US are treated very differently depending on whether you have insurance or you don't,” said Dr. Diner, “When I work down at Grady, the wait times are ridiculous. They could be 12, 14, 18 hours to see a doctor…” On the other hand, he said, “at Emory University, which has mostly an insured patient population, our wait times are probably only several hours.” Wait time, Dr. Diner said, also depends on the patient's condition. “In Canada, if you have a minor problem you're going to wait, you could wait 6 to 8 hours, but if you have a real emergency you're going to be brought back right away. … In the US if you're uninsured you usually go to places that accept uninsured patients and that means going to county or city hospitals which are usually less efficient.” Minor and less serious problems should, ideally, be treated by a primary care physician, and most of the doctors interviewed said Canada has a much better system of primary care. “There's a well–developed system of primary care in Canada,” said Dr. Murphy. “In 10 years in Canada, I think I saw one case of a vag discharge emergency,” but they were routine at the hospital he practiced at in Charlotte, NC. “People with high blood pressure and diabetes and those kind of disorders are well-managed. I was amazed when I moved to the States to see diabetics in their teens and 20s that were blind because they had retinal disease because they'd been under treated, or are hypertensive and on dialysis because their kidneys had failed. You never see that up here.” “I find that primary care in the US is drastically lacking compared to Canada,” said Dr. Diner. At Alberta University, where he practiced at in Canada, “I am sure that over 75% of (emergency department patients) had primary care doctors,” he said, whereas in Atlanta's Grady system, “which is a city-county hospital, very few people have primary care doctors. I would think that maybe a third—maybe, and that would be at best—would have primary care doctors.” Dr. Rowe demurred. “In, Canada, the primary care network is virtual or nonexistent in almost the entire country. The PCPs don't actually work together to make things better for patients; they are private businesses driven by volume, not quality. Moreover, there are many patients in urban locations that can't get a PCP. In Edmonton, where I work in one of Canada's wealthiest provinces, approximately 25% of the ED patients now don't have PCPs. The national average is around 18 percent, so Canada has not planned well in primary care.” There was also some disagreement among the doctors about the availability of diagnostic equipment and procedures in Canadian EDs—things such as MRI, CT, bone scans and stress tests. “In the province of Ontario,” said Dr. Drummond, “with 11 million people, as of 2004 there were only 105 CAT scanners, of which only 5 are available to communities with hospitals with less than 100 beds. So most of them were grouped in urban settings, which means there is a lot of activity in the prehospital sector diverting patients from community hospitals or rural hospitals to tertiary centers to get something as simple as a CT scan. So that is a major problem.” Dr. Rowe said a lack of access to CT is probably true in rural centers, but “is now pretty universal in large volume EDs.” He was more concerned about access to MRIs, which “is limited by radiologists who don't want to perform scans through the nights and on weekends. So, one solution is to have these things running 24-7 … This is a huge problem in Canada, and some practices would be considered unethical.” Dr. Diner said the availability depends on urgency: “You could probably get everything you need to get if it's an emergency, but if it's clearly not, and it's something that can wait, then it will wait. …” “In the US, a lot of times it's like, ‘Oh well, so you're already here in the emergency department, we have the resources, we have the MRI, we have the CT scanners, so let's just get the tests now.’ That would be unacceptable in Canada because the resources are just not available.” But he again compared the situation to that of the uninsured in the US, if you go back into the county system it would take that long for someone who was uninsured to get that MRI. … I think people have bad outcomes in the US all the time, and it's because they're waiting, and it's not the person who has stellar insurance. It's the person who has no insurance and has no primary care.” Murphy agreed that “if I need an MRI or CT, I'm not going to have a problem getting an MRI or CT” in Canada. In the US, however, “the indications for an emergency MRI are driven by a wallet biopsy, not by the medical necessity by and large. There is so much stuff that we did in labs in the US that if they were insured they got it, if they weren't they didn't. In Canada everybody's insured.” He added, “the way we control access in the US is by the ability to pay. The way we control access in Canada, and costs, is by creating queues, which is a different approach to the same problem.” As to the single-payer system, all the doctors agreed that Canada is not going to change. Some limited fee-for-service private clinics are being provided, and some firms are brokering for treatment in the US, but as to universal access to health care, Dr. Drummond said, “It's a core value, it's in their soul.” So, should the US go to such a system? Murphy said the US should do something to provide primary care to the uninsured and catastrophic health care coverage for all. But beyond that, he said, the US could not afford single-payer—“not because you don't have the money, you have lots of money, but because you would put millions of people out of work that are in the insurance business.” He said payment hassles—for both doctor and patients—that are a routine annoyance in the US are virtually nonexistent in Canada. In 2 comparable-sized clinics he has practiced at in Canada and the US, the former had “one-point-five billing clerks,” the latter had 40. Dr. Diner said he does not support universal coverage in the US because it would simply mean “that insurance companies are going to get richer and richer than they already are.” But he does support single-payer, because “around 22% of health care expenses come from the insurance companies, and if you compared that to the Ontario government, it's 1% for administration. That's a single-payer system.” Dr. Drummond pointed to a personal example, when he and his wife had triplets 12 weeks premature and they had to spend 4 months in neonatal intensive care. “It cost me not one thin dime.” Well, in cash maybe, but how about taxes? “I pay a lot of 'em, but nobody gets denied care on the basis of an inability to pay.”" @default.
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• W2149063887 date "2008-07-01" @default.
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• W2149063887 title "The Maple Leaf Model: What Canada Can Tell American Emergency Physicians About Practice With Universal Coverage" @default.
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