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.

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/ .

Wait time for heart surgery?

After a few weeks of vacation time, I’m back to Health Care: On Location with another story from a fellow airplane passenger. I'm beginning to think I should call this blog Health Care: In Flight. This time I was seated next to a Fijian immigrant who has lived in Canada for 18 years.

Mr. Fiji deemed all his Canadian health care experiences...positive.

The most notable of his health care experiences was his heart bypass surgery. This is one of the procedures I’ve had some concerns about with respect to waiting times.

Mr. Fiji told me about showing up one day at his doctor's office complaining of shortness of breath. The very next day, he saw the cardiologist. Day after, angiogram. Two weeks later, bypass surgery. Mr. Fiji hastened to say that had he experienced any pain, he was supposed to call the doctor and he would have undergone surgery immediately. This is the Canadian health care system working just as it is meant to work -- brief wait for a serious but non-emergent conditions, no wait for a true emergency.

The British Columbia Health Ministry actually has a website where you can see the wait times for each physician for each "elective" surgery. http://www.health.gov.bc.ca/swt/ When I think "elective" surgery, I'm thinking tummy tuck not bypass surgery. But for the purposes of the wait time website, it means any surgery that isn't an emergency.

The website shows that according to the most recent 2011 statistics in the Vancouver area, 50% of the patients received their coronary bypass surgery within 3.2 weeks and 90% within 11.1 weeks. These statistics do not include emergency patients. They received their surgeries immediately.

In 2004, the Canadian government committed to the Ten-Year Plan to Strengthen Health Care. This plan included setting medically acceptable benchmarks for wait times for certain procedures including coronary bypass surgery. According to the Canadian Institute for Health Information, in 2010 the provinces were meeting the benchmarks for bypass surgery at a rate of 95%-100%. In British Columbia it was 99%. Here’s a link to a chart showing how each province is doing in meeting the benchmarks for several other procedures: http://www.cihi.ca/CIHI-ext-portal/internet/en/document/health+system+performance/access+and+wait+times/release_21mar11_fig1 .

The more I talk to Canadians, the more persuaded I am that generally people are getting the care they need, when they need it.

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?

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:

http://www.thestar.com/opinion/editorialopinion/article/917635--privatization-is-not-a-quick-fix-for-the-health-system

http://network.nationalpost.com/NP/blogs/fullcomment/archive/2007/10/22/brian-day-s-diagnosis-the-president-of-the-canadian-medical-association-explains-how-to-fix-our-health-care-system.aspx .

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.

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...

An Afternoon of Polishing, Waxing, and Health Care

As I headed toward the waxing room at Granville Day Spa, I debated whether I could successfully question the young Korean woman about her health care. Was it culturally inappropriate? And what happened if she became particularly passionate about some health care injustice while shaping my eyebrows? But I'm rarely deterred by being inappropriate and eyebrows do grow back so I decided to give it a shot.

Yes, she had had problems with the health care system -- finally, a story about those long waits for health care in Canada. She had developed acne for which she saw a GP in a clinic without any waiting time. He prescribed birth control pills and suggested she wait to see if that helped. But she wanted to see a dermatologist and had to wait a few months to get in. When her turn finally came up to see the dermatologist, she couldn't remember the name of the referring GP and thought she would have had to go back to the clinic to find out. So she felt it was too much hassle and never saw the dermatologist. Her opinion was the Korean health care system was better.

I continued the discussion in the nail salon while I waited for my daughter's Royal Manicure/Pedicure to be finished. Since the young Waxing Lady was not a Canadian citizen, I asked both her and the woman working on my daughter whether they had been able to access the government Medical Services Plan right away upon their arrival in Canada. They both answered yes. Then they qualified that saying it took 3 months or maybe 6 months before immigrants were eligible for the program. Having looked into this for my own potential eligibility, I believe 3 months is the correct answer. And only for people lawfully admitted to Canada for permanent residency.

As others in the salon heard what we were talking about, the discussion widened. Some complained about the Medical Services Plan not covering dental and orthodontics. The private extended health insurance (see Definitions) came up again, which can be provided by an employer or purchased individually. But even with private coverage there is a lot of dental work not fully covered. They began discussing the merits of going to Costa Rica for dental care and cosmetic surgery.

Someone else talked about their grandfather who had ended up on a bed in the hallway of a Canadian hospital for 3 days when it was established his cancer was terminal. (In interest of full disclosure, a friend of mine who works for the British Columbia Cancer Agency says there's no way that would actually occur.) If it is true, wow, that is indeed the worst thing I've heard about Canadian health care so far!

It is definitely true there is a serious shortage of hospital rooms in British Columbia. A few months ago there was an incident in which a hospital was so short of beds that they had to briefly accommodate emergency patients in the hospital's Tim Horton's coffee shop. http://www.cbc.ca/news/canada/british-columbia/story/2011/03/01/bc-royal-columbian-tim-hortons.html .

It's kind of the equivalent of seeing patients at Denny's. Every time I pass a Tim Horton's now I think, "I'd like fries and an IV with that."

However, a young waitress/student in the salon had been in the hospital recently and had been quite satisfied. She had had extended coverage through her mother and had been in a private room --said the doctors had been very thorough; every possible test had been done.

Her waitress friend told me she made under $15,000 per year and thus qualified for both free premiums for the Medical Services Plan, as well as free extended health insurance. Another woman talked about the premiums she had to pay for the Medical Services Plan -- $168 quarterly for her and her children.

At one point, they started comparing their system to the system in the US. There was much squealing and wrinkling of noses over the assertion of one of the waitresses that some people in the US go bankrupt paying for care when they have serious illnesses. "Reeeeaally??!!!"

Same reaction when someone said that uninsured cancer patients go untreated -- horrified incredulity. I hadn't brought these subjects up but I clarified that if someone goes to an emergency room, the hospital is obliged to stabilize their condition. However, I gave the example of an uninsured woman who goes to the hospital with a lump in her breast -- The hospital is not obliged to provide follow up treatment.

When Beatrice's nail polish was finally dry, we all parted company with big goodbyes and heartfelt nice meeting yous. We all had learned something at the Granville Day Spa Health Care Seminar.