Healthcare
in Canada and Elsewhere |
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This is an interview
with Tom Barnard, M.D., who has practiced in both the United
States and Canada.
Tom Barnard, MD, talking to Esther
Wanning, 3/5/05
Dr. Barnard practiced in Petaluma, CA, for one year in 1994-1995.
He then returned to Canada |
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TB: I’m originally from the
states and I was trained at Cornell and Rochester, and I finished
my training in family medicine and anesthesia. …I was
married to a woman whose family was from Ontario, and she
and I were both interested in working in poor and underserviced
places. We moved to the north of Ontario, and I ran an ambulance
program in the remote part and took care of people in native
reserves. I did anesthesia; I delivered babies; I was a coroner.
That was really the golden age of the Canadian system, before
the conservative economics in health care really took hold
and prior to the time when very expensive medical technologies
and increasingly expensive drugs became such an issue in terms
of affordability. It was a totally marvelous experience compared
to what I had seen in the US. We’d see a sick kid in
a remote town and fly her out and take her to where she could
get the best care. Completely without a fee. People had everything
available to them.
Since then, the Canadian system – as many other health
care systems around the world -- has come under a lot of financial
pressure, in part because of the conservative fiscal economics
over the last couple of decades, and in part because medical
technology and pharmaceuticals have become so horribly expensive.
But one of the real advantages of each province’s having
its own mandate is that they have a good ability to regulate
drug costs. By and large the costs are much less here than
in the states, though of course it depends on the particular
drug.
EW: I read an article by Malcolm
Gladwell in the New Yorker saying that the generic drugs cost
as much or more in Canada as they do here.
TB: That’s crap. I live so close to the border that
I see some patients who come over here. A couple of weeks
ago, I saw a woman with breast cancer, who was on a five-year
protocol of post-surgery tamoxifen. She was living on $6 or
$800 a month, and her drug was costing her something like
$150 US for a two-month supply. I wrote her a prescription
and at the pharmacy in my building it cost $10. This was a
generic tamoxifen, made by the same country that produced
the tamoxifen she used in the United States. Metforman, which
is a commonly used drug for diabetes has been available in
Canada as a generic for a long time. In the States it’s
still under patent, and the difference in cost is at least
ten times. I have a pharmacist friend who sees patients who
come over by the busload here and for the most part the drugs
are at least 30% cheaper here. On an individual basis, sometimes
you have a really cheap generic drug in the states.
You know you pay for the drug research through your taxes.
The basic research is done by the Candace Perts of the world
at the NIH, perhaps at universities. Not to say that the drug
industry is all bad, but what they tout as costs of research
are probably widely inflated. And I can tell you as a physician,
the drug companies spend a whole lot of money on marketing.
But the television ads aren’t allowed in Canada. I think
the private industry can have a role in educating people,
say about diabetes, etc., what the possible treatments are,
but never mentioning specific drugs.
In Canada, the industry itself has created a pretty stringent
set of guidelines. They don’t take you and your wife
out to dinner anymore. It’s very carefully controlled.
And any dinners they put on are oriented toward education
rather than any particular product. The other night for instance
they had Paul Richter from Harvard on a teleconference. He’s
a sterling researcher. He certainly wasn’t promoting
a drug.
My office is completely computerized and every exam room has
a computer connected to a high-speed line. I had a lady the
other day who said, well, I have this Rothman-Thompson syndrome,
and I said “What’s that?” So right then,
I looked it up and got a whole printout.
I’m involved in a study at the University of Toronto,
where they’re taking docs in the field and teaching
physicians how best in a time-efficient way to do evidence-based
medicine. It’s a struggle you know, because you don’t
have an infinite amount of time. I think of docs working for
HMO’s in the states where there’s a certain amount
of pressure to see a lot of patients. The fee for a visit
to a family practitioner is not huge, and also there’s
a large shortage of doctors. in Ontario alone there are probably
a thousand or so family physicians lacking for this population.
So our practices tend to be quite large.
While there are always downsides to any approach, I think
it makes a lot of sense to have one insurance company that’s
not for profit, run by the state or some non-political organization.
When I worked in Petaluma I had to give my credentials to
33 insurance companies. Here, the billing part of medical
practice is such a dream. I see a patient, I write a little
code onto a piece of paper, I leave it on my secretary’s
desk, and she does the billing right there. At the end of
the day it goes directly from the computer to the ministry
of health and we get paid once a month, direct deposit in
the bank . It takes like—no time.
EW: So you never have to have a conversation about whether
they’ll pay for it?
TB: Oh no, that virtually never happens. If it’s a medical
emergency. I may call a consultant or a cat scan radiologist
or the MRI guy and say, “Hey Joe, can I get Sally in
right away?” But that’s really a courtesy call.
EW: But that’s not saying
who’s going to pay for it, which is the first question
here.
TB: No, no question about that. Never an issue. The only issue
is that publicly funded systems like this may have a problem
in capacity. For example, there may be an MRI scanner on every
street corner in San Francisco. In Canada, on the other hand,
there are several MRI scanners in a city the size of Windsor.
So when you need an immediate scan you have to push some buttons.
If it’s not urgent you might not get it the same day
or even the same week. A system that’s built around
trying to conserve medical resources doesn’t have that
redundancy in the equipment. If you need a hip replaced because
you broke your hip, you can get that done today or tomorrow.
If you need a hip replaced because you’ve got osteoarthritis,
it may take a few months. And that’s because there are
relatively fewer operating rooms, etc. There isn’t a
medical arms race, where you can get the surgery done at any
clinic as long as you’re willing to pay for it. But
sometimes I think procedures are done in the US for reasons
of remuneration rather than medical necessity.
EW: And here if you don’t
have the insurance, you may not have the necessary procedure
done at all.
TB: Believe me, that year in Petaluma was a real eye-opener.
When I was there docs were going bankrupt. I made an okay
living, but that area, we were practically poverty-stricken.
Here, I have to say honestly, it really is a pleasure to see
people and not to worry about whether they can afford the
care. That said, things come up. Not everybody here has coverage
for medication. And some therapies are covered and some aren’t.
Massage therapy, for instance, you now have to have supplemental
insurance. Many of my patients work for the auto industry
locally. They for the most part have supplemental plans where
you get a certain amount of massage therapy or reflexology.
Some of the experiences I had that year in Petaluma were astonishing.
I worked at a free clinic one night every couple of weeks,
in a soup kitchen kind of place, and I was amazed at the level
of pathology of the people who came into that clinic. And
most of these people were workers with no insurance. They
had the kinds of things that in Canada you would only see
in a textbook, like thyroid disease, that had gone untreated
for two years. And you’d think, “My God, what
year is this?” Or I’d see some poor Hispanic grandmother
who had metastatic breast cancer, and she’d known she
had had this lump for a least a year, but she wouldn’t
go see someone because she didn’t have insurance. God,
it was really heartbreaking, and that stuff would never happen
here. You see a lady with a breast lump here -- and I have
a huge population of migrant workers and people without financial
resources -- and that person here would have all the care
and there would be no question about whether they could afford
it.
There are many positive sides to this system. With a single
insurance system there’s just a huge administrative
saving. It’s not that I don’t have my frustrations.
We all do. But in terms of getting care for people, this system
is marvelous. Honestly, the waits are pretty rare.
Another thing. By and large, malpractice issues are not a
concern for physicians here either. First of all, we have
malpractice insurance from a plan run by physicans called
the Canadian Medical Practice Association. It’s a fantastic
thing, it’s really cheap. Maybe Canadians aren’t
that litigious, but God, I’ve been in practice thirty
years, and I’ve never been sued. Our costs for malpractice
I think are around $2,000 a year; it’s not even on the
radar screen. Here the coverage is completely seamless.
EW: I would assume that part of
the reason that docs are sued so little is that people think
of their physicians as their friends and their advocates,
whereas here, they often think of the doc as the advocate
of the insurance company. And when you feel that your physician
is denying you care when he’s putting money in his pocket,
the relationship suffers.
TB: That doesn’t happen here at all. Ethically, we should
be the person’s advocate for care, and there’s
no reason here that you would be concerned about the cost
of the procedure.
EW: Tell me about something else.
Here, the high-paid specialists are the least likely to go
for a single-payer plan as apparently they suspect their incomes
will plummet.
TB: Here, we had an earning cap for certain classes of physicians
of $450,000 dollars. It was just elimininated in the current
round of negotiations. It would depend on where you worked.
And you might do some surgery outside the cap. But in a city
like Windsor which is relatively underserved for ophthomology
and where there was no cap, it could be $750,000, and this
is without overhead issues. In the states you might easily
have a 50% overhead. My overhead here is 25%. My secretary-receptionist
does all my billing and takes care of it all in a minute.
There are a few things people pay out of pocket for, like
a professional drivers’ physical.
EW: But there’s no copay
for the usual services. People here worry about the idea of
not having copays and envision lines of hypochondriacs filling
people’s offices.
TB: I have to tell you that has not been my experience. Honestly,
most people just don’t come for fun. I have a lot of
people who might be hypochondriacal, but I don’t see
them a lot. That objection I think is based more on somebody’s
personal bias than on reality. If you really look at it, look
at the Rand Corporation studies or whatever, it seems that
what copayments do is to delay reasonable care, and then people
get sicker. I think by and large what you want at a primary
care level is accessibility and affordability. You want that
level of care to be very accessible. And beyond that, ideally,
what you want is to be able to access the secondary and tertiary
levels of care without worry about whether the patient can
afford it. And I think this system does that really well.
It’s not that I don’t complain, and say to myself,
geez, I’m only getting $30 for this visit. But I earn
a few hundred thousand a year, really working very reasonable
hours, and most primary care physicians in the states don’t
have that luxury. I think the system has been very good to
me.
I really like what I do every day. Medicine’s fun, it’s
great, you can really help people, and especially when you’re
not worried about whether the patient can afford a chest X-ray.
EW: I don’t know why more specialists aren’t buying
into the single-payer idea. They hate the system too, the
phone calls, the insurance company clerks.
TB: I think it’s a question of the devil you know. The
big thing with single payer that needs to be emphasized for
a state like California is that it is true that you don’t
want it to be a political football. You want some sort of
free-of-politics person running it who is like a judge or
a czar who the people feel comfortable with and who they can
trust and who isn’t going to be under the hand of some
political party, which will change accessibility. If the Canadian
system has a problem it’s that it’s a bit of a
political football. The Conservatives --who are like the Republicans--
get elected and the next thing you know there is all this
downsizing. Then the liberals elected and it changes. That
part is a little frustrating. But despite all those little
fluctuations, for the most part what people see is pretty
much good access to care, unquestioningly. Your kid gets leukemia,
she gets care, you don’t pay, there’s no question.
There are ancillary costs, driving here and there, but the
system even covers a lot of that. There may be a problem if
someone needs a heart transplant and there may not be a lot
of hearts available, but that’s a problem in the states
too.
My brother died in NY essentially of leukemia because he didn’t
have insurance and couldn’t afford a bone marrow transplant.
He may not have lived anyway of course, but to not even have
access to care….you can’t have a decent society
like that.
EW: Is there anything you miss
about practicing here?
TB: I can’t say I do. You can certainly get MRI and
CT scans in a minute, but you’d have to justify any
of that with the insurance carrier, and that wasn’t
very pleasant. Here, I’m able to get good care for people
and really advocate for them without worrying about whether
they can afford it.
Again, the big thing is you don’t want to feel like
a pawn of the state, an employee of a state system. While
all docs understand that they have to work for the most part
within some kind of insurance system, we want the least intrusive
system possible and one that remains affordable and gives
care to everybody.
It’s really important to support the poor and the children.
We’re learning now that a society that ‘s not
taking care of it’s young and its pregnant moms and
babies will reap the horrible negative returns. Without adequate
care in the first years, they wind up with diabetes and hypertension
and cardiovascular disease later. The more we understand that,
the more we realize that, by God, we have to provide decent
care for them because otherwise we’re going to go bankrupt
taking care of them later. In the U.S., you’re not caring
for the disenfranchised people, who paradoxically you will
get the most savings from.
It’s a simple math problem. George Bush is going to
have to get that. If you’re so bloody conservative,
add up the numbers and see where you should put some resources.
It’s crazy not to be doing that, not to mention the
human tragedy, but even on an economic level it makes no sense.
EW: I don’t know why that
doesn’t penetrate and I don’t know why businesses
won’t buy in.
TB: Businesses here are very comfortable with the idea that
their employees get great health care, and they save a bundle.
That’s a huge advantage for Canadians.
On a human level, this kind of system is tremendously reassuring.
I think California could do a grand job of putting together
a big not-for-profit plan that would take care of everybody
and save a hell of a lot of money. And I think the docs come
out doing better, not worse, financially.
Again, it’s math. Figure out how much you’d save
by not having billing complications. And consider the anxiety
of having procedures halted in the hallway because the insurance
clerk decided it wasn’t going to be covered. I had that
experience, and it was catastrophic. Of course, docs don’t
want to feel that they are going to be poor because the system
changes over. And they won’t be. The cardiologists here
make a damn good living. There was recently a neurosurgeon
here who moved to Michigan, but it had to do with the hospital
not buying him the right equipment, and he was mad. He was
making as much money here as he’s making in Michigan.
That was not the issue. I think a lot of that stuff is more
emotion and hype than reality. I don’t think many docs
move to the US. A lot of docs have moved from Ontario to Alberta,
where they have oil revenues and pay a lot. |
A Chronicle report:
Two women, two cancers, two health-care systems
- Tom O'Brien
San Francisco Chronicle
Thursday, December 29, 2005
After a long time away, you see with new eyes.
I moved back to the United States with my Canadian wife and two
small boys after living 15 years in Toronto and Ottawa. U.S. health
care now looks both expensive and scary, leading me to conclude
that we'd do better with an entirely different system.
Nowhere has this been put in sharper relief than in the story
of two colleagues. Struck in March with cancer, an American colleague
worried about death, insurance loss and bankruptcy. In contrast,
a Canadian colleague and cancer victim had only her disease to
fight.
Susan was on sick leave when I came to work at my new job in August.
She was middle-aged and single with a grown family and well liked
in my office. She was undergoing chemotherapy to treat breast cancer
and not able to work. Our employer supported her beyond the normal
period of sick days and vacation.
But the scary question for anyone but the rich hit with a catastrophic
illness in the U.S. health-care system is: How long will an employer's
support go on if the battle goes far beyond the time allotted for
sickness and vacation? Susan worried about the loss of health-care
coverage and what ensues -- second-rate care, bankruptcy, choosing
between timely drug therapies and even modest necessities. She
died this month before those fears were realized. But had she lived,
she and her family would have confronted the excruciating battle
survivors have to fight with insurance companies, employers and
health-care providers over cost, length and quality of treatment.
In contrast, my former colleague Kathleen back in Canada was gripped
by uterine cancer, which had spread to her intestines. While she
was locked in a life-and-death battle for 18 months, she didn't
have to worry about losing her health care and choosing which bills
to pay. Canadian Medicare covers everyone for everything in hospitals
and doctors' offices, including some elective procedures. This
means no health care-caused bankruptcies. No fights with insurers.
No insurance-driven financial worries. Kathleen could save her
energy for battling her cancer instead. She did recover, and while
her recovery was not necessarily the direct result of differences
in care systems, there is no question that she would have suffered
more with the burden of financial worries related to her health-care
needs.
I hear stories here about Canadians lining up for basic medical
care. But despite plenty of doctor appointments, occasionally bringing
my children to the ER, and having had a heart procedure myself,
I didn't witness any delays for necessary (let alone emergency)
care. In survey after survey, Canadians support public, nonprofit
health care by a wide margin.
And why not? Compared to the United States, Canada has much lower
infant-mortality rates and a longer life expectancy, according
to data from the World Health Organization. Canadian women get
just as many mammograms, for example, as do American women. This
is achieved despite spending far less per person on health care
-- 10 percent of per capita GDP in Canada goes to health care versus
15-plus percent in the United States, according to WHO research.
After 40 years of private health care in America and 15 years
of Canada's Medicare, I'll take the latter. But of course, I can't;
it's not available here. I love my country but not the private
health-care system that abandons many people and worries even more.
Few Americans know that every
other industrial country in the world has a health-care system
more or less like Canada's. I think even fewer realize that we
do, too -- it's called (U.S.) Medicare. The system that boosted
the health of Americans 65 and older is similar to Canada's system
for everyone. They're both "public,
not-for-profit, single-payer" systems with low overhead costs.
So why not extend Medicare to every American?
Our seniors like it. Sure, it will raise the cost of this government
program by billions of dollars, according to even the most conservative
estimates. But it will save money for both individuals and employers
who now purchase private health insurance. After all, it's not
how much of your income you pay, it's how much you keep. You'll
keep more under Medicare-for-all, and every child, woman and man
would get the timely health care they need.
Give people the opportunity to face and fight their illnesses,
not their insurance companies.
Tom O'Brien joined the California Nurses Association (www.calnurse.org)
upon moving back to the United States in August.
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