An American in Oz
Wednesday, August 31, 2011
An American in Oz
Tuesday, August 16, 2011
Monday, August 1, 2011
What Does It Cost -- A Tale Of Two Sisters & Two Systems
One of my great pleasures during the time I spent in Vancouver was reconnecting with my cousin. Brainy, fascinating Cousin Catherine, who left the US after high school to go to Oxford. She never returned to live in the US, spending roughly 20 years in Great Britain and then the past 20 years in Canada.
One drizzly evening she invited me to dinner at her house. "Am I finally going to get to interview you about your health care?" I asked as we sat down at the dining room table in her cozy craftsman style home. "Well, yes, I suppose so," Catherine answered. We had had many conversations about the Canadian health care system, but we’d never gotten into details of her personal experiences.
"Have you had any problems with the Canadian health care system? -- Any waiting list problems?" No, she hadn't. No problems for her husband or kids.
The only complaint she could come up with was that family doctors generally are only willing to discuss one problem per appointment. Since sometimes multiple problems are interrelated, it can get a bit silly at times. "And I've also been coughing --" "Oh, you'll need to schedule another appointment." Even though you're not paying more for the additional appointment, who wants to spend day after day at the doctor's office?
In fact, Catherine is a huge fan of the Canadian health care system. When she goes back to visit family in the US, she often ends up in the exasperating situation of having Americans tell her how bad the Canadian system is. "People who haven't spent one day in Canada and clearly have no idea what they're talking about!"
Catherine is acutely aware of the difference between her health care situation and her sister's. Cousin Jean lives in California and is a booking agent for performing artists. She is in business for herself and therefore has to buy insurance on the individual market.
I decided to give Cousin Jean a call to find out the specifics. "I have no idea what I get," was Jean's first reaction. "I think something's covered and then they change it." Then she began to have second thoughts about talking to me about her insurance. "I'm trying to get new insurance. I don't want to jeopardize my chances." I told her I'd change her name.
In my years of working on health care reform in the US, I have come across lots of people who have these kinds of concerns about being blackballed by health insurance companies. It just goes to show how people fear the life and death control these companies have over their lives, as well as their ruthlessness -- like some sort of organized crime operation.
Once Jean was able to line up a new policy, she told me her premiums were now under $500 per month with a deductible of $6,000.
That's the price Jean pays for going into business for herself. Something her sister Catherine didn't have to worry about in British Columbia when she left her job at the university teaching Middle Eastern History, and opened a small publishing business. "I didn't feel tied to my job at the university because I knew my doctors and hospitalization were covered by the Medical Services Plan (MSP) here."
Monthly premiums for the MSP are $60.50 per month for one person or $109 per month to cover both Catherine and her husband. If their sons were still living at home, the premium would be $114 per month to cover all of them. These are the rates for anyone making over $30,000 per year. There are no deductibles, no co-payments, no guessing at what's covered. For those who make less than $22,000 per year, the premiums are $0 and for those making between $22,000 and $30,000 per year there is a sliding scale on premiums.
But what about those legendary high Canadian taxes, eh?
After doing some research online, for several income levels I added up federal taxes, British Columbian provincial taxes, the Canadian equivalent of Social Security taxes, plus the Canadian version of Unemployment Insurance (which comes out of the taxpayer's paycheck). Then I added up US federal taxes, California (where Jean lives) state taxes, Social Security, Medicare, and California State Disability Insurance. Much to my surprise, the tax rate on income at home is higher than on income in British Columbia. That was true at each income level I tested.
There are higher sales taxes in Canada, although some sales tax is refunded to low-income Canadians. Funding for health care comes out of a combination of Provincial and Federal taxes. There is no specific health care tax in British Columbia but that varies from province to province.
Is providing universal health care enormously expensive in Canada?
Well, let's compare it to the US. In Canada, they spent $4,079 per person on health care in 2008, whereas, in the US, we spent $7,538. In Canada they spent 10.7% of GDP on health care compared with 17.6% of GDP in the US. And of course, everyone is covered in Canada while 17% of Americans are uninsured and almost 20% of Californians are uninsured.
Yes, many Canadians think the amount their government spends on health care is unaffordable. I'm guessing that is the story in every country that has a modern health care system – the tale, as it were, of many cities.
Thursday, July 14, 2011
Waiting Line Reality Check
One of the issues that keeps bothering me is the problem of ending up on a waiting list in Canada with a painful but non-emergent problem. You know, those stories about long waits for joint replacements? Although, knock wood, I don't need surgery, I've gone through enough with my faulty parts to make me identify with patients in pain who don't want to wait for relief.
I was fortunate to be able to interview a Canadian physician whose specialty is roughly like an osteopath -- So he sees people for these painful conditions.
When I asked Dr. King about the problem of wait times, he assumed I meant wait times to get in to see him. In a similar fashion to the prioritizing in hospitals for surgical wait times, Dr. King tries to prioritize the cases that are most urgent. Patients who report being in severe pain can see him within a few days, but it can take a month or two for others.
If one of his patients may need a hip replacement (not a procedure he performs), he tries to anticipate their need for surgery. He'll encourage them to get on a surgeon's waiting list when he thinks a patient is likely to require a hip replacement in the future.
But what about when a patient is having a hard time functioning because of the pain? What kind of flexibility is there with the system? Is a hip replacement simply always low priority if it's not due to a fracture? No, according to Dr. King, it's possible to go to the front of the waiting line if a patient is in severe pain or can't function. Apparently, a specialist can successfully put the pressure on to help out a patient.
I took a look at the handy dandy wait time website for British Columbia: http://www.health.gov.bc.ca/swt/#. For hip replacement surgeries, when I checked the average waits for all of BC, I found 50% are done within about 3 months and 90% are done within about 7 months. There was considerable variation in wait times depending on the doctor a patient chose to see. The website showed some doctors were able to perform 90% of their patients’ hip replacements within a few weeks while other doctors showed 90% receiving the transplant within 14 months.
I also noticed variation in the time to receive some procedures depending on whether treatment was being sought in rural British Columbia or the Vancouver area. Wait times for back surgeries in one of the rural areas were running 90% done within 10-12 months and 50% done in less than 2 months. However, in the Vancouver area, 90% were done within about 4 months with 50% being completed within 3 weeks.
Another complaint one hears frequently is about the wait times for MRIs. Dr. King concurred. "The MRI is a real problem in this country." That is a medical service which can legally be purchased privately, if the patient can afford it. Dr. King said it costs $800-$1,000 to pay privately for a MRI in Vancouver. I spoke to a Vancouver neurologist, Dr. Cashman, who also expressed dismay over the wait for MRIs. When trying to diagnose ALS (Lou Gehrig's Disease), he wants to be able to get a patient in for a MRI right away. But the wait can be impossibly long. On the other hand, when the MRI is being ordered for a patient with a brain tumor, the service is provided promptly.
That being said, both Dr. King and Dr. Cashman like the Canadian health care system very much. In fact, they both came to Canada because they preferred the Canadian system to that of their native countries -- Great Britain and the United States respectively. Clearly, there are trade-offs to be considered with every health care system.
Thursday, July 7, 2011
Dr. Gabor Maté: Healing and Addiction
I knew going into this interview that in some ways, Dr. Gabor Maté viewed all Western medical systems as failures. In preparing for my conversation with Dr. Maté, I found other interviews with him online that clued me in to his perspectives on healing, ADHD, addiction, and chronic disease. And they didn't have to do with whether a government insurer or a private insurer provided benefits or whether a certain high tech procedure was covered.
I arrived at his house at the appointed hour and Dr. Maté invited me to sit down in his kitchen while he fixed some tea. A physician and best-selling author in Canada, I was honored he was taking the time to talk to me.
The major problem with the approach to healing in both Canada and the US, in Dr. Maté's view, is the insistence on separating the mind from the body when considering an individual's health status. He says that if we don't look at the relationship between stress and the immune system, many diseases will never be cured, no matter what the health care system. That doesn't mean Dr. Maté entirely negates the value of Western medicine. He explained that we need to "...get that the medical profession only knows what it knows. When it comes to chronic illness, they really don't know what to do."
Until recently, Dr. Maté was on the staff at the Portland Hotel Society, a Downtown Eastside Vancouver facility that provides housing and professional support for adults suffering from addiction, mental illness, and related problems, and at InSite, a supervised injection site affiliated with the PHS. He treated patients for drug addiction, HIV, and other health problems.
While both the Portland Hotel Society and InSite encourage addicts to seek detoxification and addiction treatment, they do not make abstinence a requirement for obtaining housing and services. They are principally harm reduction oriented. This approach is much more common in Europe, with the United States lagging behind both Europe and Canada. Studies documenting the success of the Portland Hotel Society and InSite have cited benefits including a reduction in the sharing of syringes and an increased use of detoxification services and addiction treatment.
As I steered my conversation with Dr. Maté back toward the subject of Canada's health care system he said, "I know I'm much freer to practice medicine the way I want to in Canada." He emphasized the need to spend as much time as it takes with addicts. This was made more feasible because the Medical Services Plan paid him for the amount of time he spent with his patients and not a set fee per service.
Dr. Maté informed me that the MSP covers all the doctors visits associated with the treatment of addiction. The coverage for residential rehab care is a different matter. Very low-income patients are covered through Social Services. People with private extended health insurance may be covered through their private plan. Some wealthy Canadians pay out-of-pocket for the very pricey Paradise Valley Wellness Centre and similar rehab facilities. Dr. Maté says that although it's a patchwork, "if somebody wants rehab, they'll be able to get in."
Dr. Maté is a fascinating and passionate healer. If you'd like to learn more and take a look at his books, check out his website: http://drgabormate.com/ .
Monday, June 27, 2011
Tuesday, May 31, 2011
The Attorney in 12A
As I sat down in 12C on my flight from Vancouver, my seatmate looked up from the flight magazine and gave me a friendly, “Hi!” By the time we were in the air, he had revealed he was a personal injury attorney traveling down to LA with his buddies to spend a long weekend at The Peninsula, the chief objectives of the trip being dinner at the Belvedere, Spago, and Melisse. Guess business in the personal injury field is doing all right in British Columbia. Before we moved on to more important subjects like my list of hidden restaurant treasures in LA, Mr. P.I. Attorney seemed happy to give me his take on the BC health care system as a patient, as an employer who provides extended health insurance (see Definitions) to his employees, and as a personal injury attorney.
As an individual, Mr. P.I. says his health care has all been good. When he had to have an ankle ligament tightened after an injury, he waited two days to see his family doctor and two months to have the surgery to repair it.
Interestingly, the main reason his wife works 25 hours per week is because her employer pays the premiums for their private extended health insurance as well as their Medical Services Plan (MSP) premium. This got me wondering how much the premiums are for the private, as well as the public insurance. Searching the Internet for extended health insurance coverage quotes, I found a pretty comprehensive policy for a 40something couple with 2 kids for about $320 per month and the MSP monthly premium for families earning more than $30,000 per year is $121. A savings of $441 dollars per month will certainly buy a few dinners at Spago.
Mr. P.I.’s law firm provides some help to their employees for purchasing extended coverage. Similar to the way employers in the US can choose whether to provide any level of health care coverage for their employees and can choose how much of the premium to cover, employers in British Columbia may provide different levels of extended coverage benefits. And some employers do not provide any extended health benefits at all. Also, different policies have different covered benefits, for example, medications, vision care, dental care, chiropractic care, physical therapy, private hospital rooms, and travel health insurance.
As in the US, more large employers provide health benefits than small employers. In Canada it also seems there is some correlation between higher paying jobs and employer-provided extended health insurance coverage. In Vancouver I’ve spoken to employees in clothing stores, the car rental agency, and the nail salon that don’t receive extended health care from their employers.
So it is commendable that Mr. P.I.’s rather small firm pays about half of the premium cost for their employees. Mr. P.I. raised another interesting point: When an employer covers these benefits in Canada, they are taxable. This has been a point of contention in the US health care debate.
Since Mr. P.I. is, well, a personal injury attorney and deals with clients needing health care, I decided to ask him about his cases. As it turns out, basic auto insurance is obtained through a government plan, ICBC, which all BC drivers are required to obtain. So Mr. P.I. ends up bringing cases against the ICBC to get health care costs covered.
This led me to ask whether the Medical Services Plan ever gets sued for not covering services or because a delay in receiving services results in a bad outcome. I’m not talking about personal injury cases, but you know, the way HMOs and PPOs in the US get sued? He said he hadn’t heard about any individual suing the MSP for delayed treatment but he had heard about a case involving the MSP denying coverage for a course of treatment for autism. Seems to be uncommon, though.
He did say there are medical malpractice lawsuits. I guess since doctors are reimbursed to provide all medically necessary care, if someone doesn’t get the care they need, it’s not because of a government insurance plan’s decision. It’s the result of a doctor’s decision so the doctor is to blame.
When I was just about done with my questions, I asked Mr. P.I., “ If you got to vote on it, would you vote to have more privatization in the health care system?” I figured, this guy makes good money, if spending money on private health insurance could eliminate wait times for his family, wouldn’t he be in favor of that? He looked out the window and said with some hesitation, “Yeah, maybe I would…” Then he looked back at me, “But only if physicians were very limited on the amount of time they could spend practicing in private clinics vs. the time they spent in the public system.” In a follow-up email he wrote to me, “Our system is far from perfect, but I do think that it is pretty good, and is a good model for other similar countries to follow in principle.”
These Canucks are darned proud of their health care, eh?
Wednesday, May 18, 2011
Vancouver General Hospital
"Is Vancouver General Hospital mainly for low income Canadians?” I asked. I was reminded my friend Rosie had been living in Canada a long time by the confused look on her face. She explained to me that essentially all hospitals are available to all British Columbians with their government coverage, the Medical Services Plan. There aren't separate hospitals or health plans to treat poor people.
We took a walk over to Vancouver General and I saw a facility that looked more like Cedars Sinai than LA County -- modern, attractive, nice art on the walls. Rosie did clue me in that not all Canadian hospitals look like Vancouver General. In fact, "third world" was the phrase she used to describe the look of the hospital in Montreal where she had given birth to her children twenty years ago. She hastened to say that the care she was given there was excellent nevertheless.
Although all the full service hospitals are public, there are a growing number of private clinics and surgical centers for which people pay out-of-pocket. This is quite controversial because British Columbian law (as well as the law in 5 other provinces) prohibits health care providers and facilities from charging patients for the medically necessary procedures that are covered by the government system. These private facilities for the most part provide cosmetic surgery, MRIs and other diagnostic procedures, arthroscopic surgery, and other simple orthopedic surgeries. Some of the care taking place does fall in the category of medically necessary and this is the subject of a case currently being fought out in the courts.
The scale of the private surgery centers is pretty small -- 5-10 beds per center for overnight stays. For the most part, the government insurance doesn't pick up the tab at private clinics and private health insurance is only allowed to cover supplemental services like optometry, dental, physical therapy, chiropractic, and some cosmetic services. Understandably, the public isn't exactly flocking to spend their own money at private clinics.
Some people who can afford to pay out-of-pocket are willing to in order to avoid waiting. However, many Canadians are deeply resentful about folks "jumping the queue". I've noticed a strong sentiment in favor of equal access for all Canadian residents.
The private centers sometimes are successfully billing the government Medical Services Plan, which is a matter of great concern to those wanting to defend the present health care system against privatization. When Canadians talk about privatizing health care, they are referring to allowing provincial government health plan payments to cover procedures in private hospitals. They are also referring to allowing private insurance payments and private individual payments for the medically necessary care that is covered by their provincial health plans.
For those of you who would like a better understanding of the privatization controversy in Canada (and you wonks know who you are) here are a couple of links:
The first article is an editorial opposed to privatization and the second is an article in favor of privatization by one of the pioneers of private clinics in Canada.
This is a bit like the issue in the US of public money subsidizing vouchers for private schools – It tends to undermine the public system. In addition, the siphoning off of doctors into private clinics will only exacerbate the problem of waiting times for the general public.
Will Canada go down the road of a two-tiered health care system? Not without a fight.
Friday, May 13, 2011
My Visit to the British Columbia Cancer Agency
Through the miracle of Facebook, I have reconnected with a friend of mine from my high school days in Kentucky, who has become a nurse practitioner here in Vancouver. Rosie is employed at the BC Cancer Agency and she was kind enough to show me around the facility, answering my questions about cancer care in this government health care system.
Rosie works with the oncologists assessing how brain cancer patients are responding to treatment (like chemotherapy or radiation). She reads brain scans and has the authority to reorder treatments, prescribe medications, and is also involved in triaging to make sure patients are seen as quickly as possible. The BC Cancer Agency has 6 major centers throughout the province. When somebody has cancer in British Columbia, this is where they come. So Rosie is really at ground zero in the treatment of cancer here.
OK, I could talk about the beautiful modern facility and the roof garden with the lovely view but I'll cut to the chase. What we all want to know is when folks here are diagnosed with brain cancer, do they get the same quality of care through their government health plan as we do in the US? The answer is yes. The first line of treatment is just the same here as it is for people in the US who have good insurance. Patients with brain cancer and other serious illnesses are seen and treated right away. The initial therapies for brain cancer are just the same.
The difference may arise after the tumor grows back, and it generally does at some point with the types of brain cancer (mostly glioblastoma multiforme) that Rosie treats. There are no known cures for glioblastoma multiforme and there is no standard treatment for glioblastoma when it recurs. The number of clinical trials British Columbian cancer patients have the opportunity to participate in are limited in number compared to the number of trials in the US. But given that the population of the US is almost ten times the population of Canada, there are not adequate numbers of patients for enrollment in the same number of trials. According to Rosie, “Canadian oncologists are strategic in their choice of trials, opening only the ones they consider to be most promising for a specific disease.”
I checked this out with my friend Jennifer, who is an oncologist in the US. Her reaction was, "Basically the system in Canada doesn't allow doctors to do completely crazy things." According to Jennifer, doctors in the US sometimes decide to try courses of treatment outside of clinical trials for which there is no evidence of benefit. I was surprised at this because US insurance companies are not noted for being overly generous in covering experimental treatments. Jennifer said, "Sometimes insurers understand what they are covering, sometimes they don’t, and sometimes they decide not to cover it after the fact." Which, of course, leaves the patients to pick up the tab.
I asked Rosie for examples of treatments (effective ones) that patients often want but are not covered by their system. She mentioned Avastin (bevacizumab), which is a drug that can slow the regrowth of the cancer for some months and improve the quality of life for some patients. In the US, the FDA approved Avastin two years ago for treatment of glioblastoma. For those who can afford it. It costs something like $117,000 per year, although patients rarely live that long. As it turns out, in the time since my visit to the Cancer Agency, Avastin has, in fact, been approved now in British Columbia for the treatment of glioblastoma.
Another example of a procedure some patients want that isn't covered is having a brain scan after just one cycle of treatment. This isn't really so useful, but patients often want a scan immediately because they think they are going to be able to tell how the tumor is doing. Typically scans are done after two cycles of treatment in BC. If a patient wants a scan done after just one cycle, they can pay to have it done in a private clinic. Upon consulting Jennifer, I found that doing scans after two cycles is also standard in the US.
So what about the Canadians who want to come to the US for cancer treatment? There are sometimes treatments that the Canadian health care system is willing to pay for but are unavailable in Canada. Under those circumstances a Canadian's treatment in the US is covered by their Provincial health plan. Once again, keep in mind that Canada is a much smaller country than the US. And remember, here in the US, sometimes people travel to another state to see a doctor who is considered the foremost authority on a particular condition.
There are also some folks who simply decide they are going to get better treatment in the US. And maybe some do...