Sometimes, fewer options
Still, the medical system in Canada can be more restrictive than in the United States, he said. “Here [in Canada] the government decides that this hospital does this, that hospital does that,” he said. “In the U.S., if you want to do something, and you're capable of doing it, nobody stops you. And I think that makes things more accessible to the patient.”
Lithotripsy is among the procedures that are more readily available in the United States than in Canada, he noted. In New York State, for example, lithotripters are available in more cities compared with Ontario, and some hospitals that do not have the devices can have mobile lithotripters come to the hospital on certain days, according to Dr. Farivar-Mohseni. “In Ontario, however, patients can undergo lithotripsy in only one of two places throughout the entire province: downtown Toronto or London, Ontario,” he said. “And I think that's bad for the patient and also bad for the physician, because then you're only letting certain physicians do [the procedure],” Dr. Farivar-Mohseni said. “That's, in fact, a major problem.”
In addition, Dr. Farivar-Mohseni, who also is in private practice, said it is not easy in the Canadian system to introduce a new technique or obtain a new technology, such as robotic prostatectomy or brachytherapy for prostate cancer. “You have to go through a lot of hoopla, and eventually the response is, ‘No, we don't have the money,' or, ‘We're not the place to do this. The government says another place has to do it.'”
Patients never see a bill
The major distinction in patient care between the United States and Canada is the fact that Canadians incur no charges for services. Patients never see a bill in this taxpayer-funded system. The Canadian system gives a per-person allotment to each province, and then each province decides how it is going to pay for health care. In Canada, every patient has a family physician who serves as the conduit between all patients and specialists. Rulan Parekh, MD, MS, a nephrologist at the University of Toronto and who formerly worked at Johns Hopkins University in Baltimore, noted that in Canada, all patients need to be referred to specialists by their family physician. “So everybody has a gatekeeper, and that gatekeeper takes care of them from a general point of view,” said Dr. Parekh, who is on the Editorial Advisory Board of Renal & Urology News. “Canadians are willing to wait to see the specialists and just see their family physician instead. They want to try to do as much as they can with the family physician. As a result, in Canada, you have many more family physicians and fewer consultants. In the States, it's the opposite.”
Dr. Parekh returned to Canada after 20 years of practicing adult and pediatric nephrology in the United States. Although Dr. Parekh has not been in private practice in either country, she said she can still relate to the obstacles faced by American patients. “I feel that the burden to the patient in dealing with all the health-care bureaucracy in the States is enormous,” she said. “[In Canada], you walk in, you give your health card, and that's it. Nobody asks you to sign your life away, nobody asks you to make sure you pay for the bill, nobody asks you about co-pays, nobody tells you that your insurance won't cover this so you have to pay for it. I don't think Canadians realize how much stress there is in the United States for patients who are really ill.”
Dr. Parekh said she doubts that the Canadian model would translate easily to the United States because of inherent differences between the two systems. “For example, U.S. medical students graduate with a huge burden in loans, so they have to become specialists,” she said. “How else are you going to pay off those loans unless you join a medical field which is procedural based to obtain an adequate income? You have to opt out of Medicare because if you're in general practice or an internist, you can't make the money to support your practice with only Medicare patients.” In contrast, most medical students enter family medicine and thus provide general medical care to patients. In Canada, “the reimbursement to family physicians and to specialists may be lower but the fact that you get 100% reimbursement and not a discounted amount allows you to plan your practice,” Dr. Parekh said. “[All] physicians can do very well financially regardless if your clinical practice is procedural based or not.” Reimbursement amounts in Ontario in general seem small because services cost less, particularly without the overhead and markups associated with American medical care, she added. At the same time, however, all types of physicians in Ontario have heavy patient loads because of a shortage of both generalist and specialist physicians.
Another major feature of the Canadian system is the regionalization of medical care. Certain facilities serve as centers of excellence to which patients are referred for particular types of specialty care, she explained. By caring for large numbers of patients with specific medical problems, these centers develop an expertise in certain treatments that might not be possible at smaller centers caring for fewer patients.