Category: System

In 2014, 53,513 Canadians got healthcare in the USA. That’s half the city of Thunder Bay, or all of Cornwall, heading south to get better access to care.

Please read the original article, Leaving Canada for Medical Care, from The Fraser Institute as well as media from CBC, Global News and The National Post. The Globe and Mail and Toronto Star haven’t commented yet.

Canada must ration healthcare. With first dollar coverage, Medicare cannot ration by cost, so it must ration access to care by limiting services with wait times. When waits become intolerable, suffering forces patients to purchase care outside Canada.

Paying privately for medical care is illegal in Ontario yet 26,252 patients went to the United States to purchase care last year.  In light of this, should we:

• Refuse to provide follow-up care for treatments rendered in the USA?
• Set up American clinics on Canadian soil so we can tax the services?
• Revamp the Canada Health Act?
• Close the border?

Denialism

Many argue that Canadians do not go south for care:

• 5 myths about Canada’s healthcare system
• Phantoms in the Snow 
• “Myth of Canadians Going to USA for Healthcare”Google Search

Who’s right? Most physicians know of at least 1 patient who had to go to the USA for care. There are 75,000 physicians in Canada. Even if multiple doctors know about the same patient, it seems to make sense that thousands of Canadians head south for care.

A rose by any other name…

Those with the power to change the system do not tolerate waits. They get care in the USA or purchase routine services at executive medical clinics in big cities.

People talk about Medicare and Canadian identity. Perhaps our Canadian Medicare legacy has tarnished a little? Maybe we should start talking about how to help patients suffering on wait lists?  Maybe we should start figuring out ways to provide access to the multi-tier care that already exists in Canada?

photo credit: cbc.ca

“I just have to order more tests,” a senior physician said.

“No one will support you if you don’t order a CT on someone no matter how trivial the pain. If they find an aortic dissection later, and see that you documented any pain at all…you’re in trouble!”

Fifteen years ago, CT scans were slow, expensive and required special permission from a radiologist. Today, head scans take less than a minute, require no special permission and are still expensive.

As technology improves, we use more of it. Faster, accurate scans, with less radiation, play a bigger role in routine clinical care every year.  But beyond technology, do doctors just order more tests?

Medical Test Epidemic

To get around the impact of new technology, we could look at a test that’s been around for decades. Dr. Robert A Bruce first published on exercise stress testing in 1949.  The modern Bruce Protocol came out in 1963. It’s still a cornerstone in cardiac workup. Most Doctors order dozens of them.

Treadmill technology and computerized readouts improved stress testing but have not changed the basic nature of the test. Just like plain X-Rays still produce images even with computerization, cardiac stress testing gives essentially the same results as 30 or 40 years ago.

Stress Test Volumes (x10) vs. Population (‘000). Ontario 2000-2014

Stress Test vs. Population, % Change

While population increased 15.9% from 2000 to 2014, stress tests increased 84.6%.

Expectations

System planners would love to find one cause for the medical test epidemic. They cannot. The explosion of medical tests could stem from one or a combination of:

• Patient requests
• Aging Population
• Physician habit/peer pressure
• Consultants’ referral requirements
• Fear of regulation
• Fear of litigation
• Guidelines
• Expert opinion
• New technology
• Advertising
• Trends in other countries
• Fashion

Expectations change and usually grow. Doctors can no longer get away without a knee MRI before saying, “There’s nothing surgical.”  Telling someone their knees look worn out on plain film X-Rays will not satisfy a sophisticated patient.

• Consultants expect certain tests before they see a referral.
• Colleagues expect peers to include specific tests in ‘routine’ workups.
• Regulation drives doctors to think less and follow guidelines more.

“Standard of care” is a collage of patient expectations, peer pressure, medico-legal threats, time pressures, expert opinion and one thousand other things.

Two Options

As much as we hate it, water always runs downhill, and supply always links with demand. Free medical testing creates unlimited demand.  Politicians can either:

1. Ration. Limit test availability. Long wait-lists ration care, but politicians hate the risk. Expect more class action law suits like the one in BC as patients suffer avoidable harm from rationing.

Or

2. Introduce Costs. For example, patients could direct funds from their government sponsored health savings accounts, or they could spend their own money on tests.

Escalating expectations for a free service guarantees exponential growth in demand for that service and further growth in expectations. It’s vicious.

For now, the Ontario government decided to fund growth by slashing doctors’ fees. After docs wake up to the 20-30% cut to their net incomes, and patients realize what’s happened to access, Medicare will be in tatters.

What do you think? Is the medical test epidemic a portent for Medicare, evidence of medical progress, or both?

Data source: OMA Economics, Research & Analytics; Photo credit: fda.gov

Video Bonus:

Dr. Donohue shared this brilliant 5 minute video “Bridge Over Diagnosis – A parody of Bridge Over Troubled Water”. Enjoy.

“She’s in the pool from 5 to 7 every morning and for another 2 hours after school,” Mom said. “She trains six days a week and has straight A’s. I think she studies too much.” Mom frowns and smiles with concerned pride.

Top athletes structure every detail of their lives around improving performance with physical development and mental toughness.

• An investigation of Elite Sport Performers 
• Perceptions of Elite Performers
• Which Character Should Sport Develop?

Medical training shapes physicians’ character as much from ‘The Hidden Curriculum’ as what gets taught formally.  The Hidden Curriculum includes all the assumptions and beliefs that define the culture of medical care. Inevitably, the medical profession, including physicians’ attitudes, gets shaped by the medical system.

Medicare changes doctors in ways that may or may not benefit patients. For instance:

• When government pays the medical bills, docs tend to focus on what government wants, not patients’ wants.
• When government controls healthcare, doctors care less about the system, how it runs.
• If medical care is ‘free’, it becomes only correct or negligent. ‘Value added’ holds less meaning.
• Doctors insulated from patients’ ability to pay tend to worry less about costs.
• With increased regulation, doctors avoid regulators’ wrath by ordering more tests. Doctors worry less about costs and more about avoiding trouble.
• Medicare makes doctors appreciate payment from government instead of requests for care from patients. Doctors become thankful to government, less beholden to patients.
• Medical need is what gets reimbursed. Patients’ needs come after need as defined by providers and bureaucrats.
• Third parties define when and where patients should seek care, and from whom. Patients’ opinions are devalued.
• When government pays for all care, reimbursement becomes an expectation from government instead of a payment from grateful patients.

Medicare impacts medicine like spice changes sauce. It tastes different but does not change marinara to alfredo.

Most doctors hate thinking about a patient’s ability to pay during a clinical encounter. Physicians see cost insulation as a major reason to love Medicare. At the same time, Medicare supporters campaign for doctors to take responsibility for spending, to take accountability for healthcare costs. They want doctors to feel the financial pain of their decisions and focus less on churning patients through the clinic.

Built on the Past

Athletes can cheat for a few days and still perform better than the rest of us. But eventually lifestyle influences performance.

The first 10 years of Medicare made Canadians proud. Politicians claimed success for great legislation. Socialists claimed a win for collectivism. But as Medicare crumbles, politicians blame everything other than legislation and political outlook.

The golden years of Medicare brought outstanding results because of the character and culture into which it was placed. Like giving an athlete a new training program, Medicare introduced a whole new set of assumptions about need, value and who is the real customer.

To use another analogy, introducing Medicare in the 1960s is like a toddler placing her teddy bear on top of a stack of blocks. Her tower looks amazing for a second. However, her destabilized creation inevitably crushes all her work.

Looking around for reasons why Medicare under performs is like asking why the teddy bear fell or why an athlete fails after years of not training. Medicare stood on the success of character built over years before. Medicare introduced a new element into a complex system that modified the fundamental character of the whole.

Medicare changes doctors and patients. It altered the medical profession. Does it still bring the change that patients need?

photo credit: telegraph.co.uk