1. An Interview with Tom Barnard.

2. Health & Wealth, a statement by Stephen Bezruchka, a Seattle physician. Download here in pdf.

From 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

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.