Editor's Note: This article appeared in the September 2009 issue of our sister publication, Renal and Urology News.

President Obama's initiative to reform the American health care system has stirred vigorous debate about the best way to accomplish the objectives of reining in costs and expanding coverage to the uninsured and underinsured. Some individuals believe the country should emulate Canada and adopt some type of single-payer system of universal coverage. Opponents claim such a system would result in long delays for care. Is this the case? And how do the American and Canadian systems compare with regard to the quality of patient care and the effect on medical practice? To find out, Renal & Urology News interviewed Canadian urologists and nephrologists who have practiced on both sides of the border. Overall, they indicated that although the Canadian model is not perfect, it is a good system in which patients generally receive timely and competent care and physicians have fewer practice hassles compared with their American counterparts.

“I think universal coverage works,” said Hesam Farivar-Mohseni, MD, of Ontario's Brampton Civic Hospital, a Canadian citizen who spent nearly 11 years in the United States. Following a two-year fellowship at Memorial Sloan-Kettering Cancer Center in New York, he spent time working in New York and at West Virginia University Hospitals in Morgantown.

Misconceptions on both sides

“Patients in Canada are not being denied anything,” he said. “People in the U.S. think that patients here [in Canada] are waiting outside the hospital, they have no access to the hospital, and they're dying because this is government-sponsored health care. That's not true at all. If there's a serious disease the family doctor calls a specialist and the person is seen right away. If a patient has a kidney stone or something similar, they may wait for eight hours, but that's true in the States, too. Such patients don't get seen in the emergency room there right away, either.

“And the funny thing,” he continued, “is that people here think people in the States are dying on the street corner because they have no insurance, and that's not true, either. They go to a university hospital and get the same treatment that most patients get.”

Dr. Farivar-Mohseni said he believes the Canadian health-care model could be successfully implemented in the United States. “I have no doubt in my mind,” he said. “The good thing about the Canadian system is it's much cheaper and provides the same quality of health care in general. In the U.S. there are middlemen: You have the insurance companies and the hospitals, which need to make money. Here, only the physician and the pharmacy need to make money. So that's a totally different attitude, and the cost is definitely lower because there's no profit there.”

Because Canada's coverage is not only free but portable, there is no such concept as going out-of-network. “You can go anywhere in the country and should not be denied any treatment by any doctor,” Dr. Farivar-Mohseni said. “You can ask to be referred to a particular doctor or location. For example, if you are from Toronto, you can go to London, Ontario, or to Ottawa if you want. That's one of the advantages here.”

Despite the disparities in the Canadian and U.S. medical infrastructures, “there's not much difference between the two systems,” Dr. Farivar-Mohseni said. “We treat the patients exactly the same way—the same medications, the same surgeries, the same instruments.”

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.

Media messages

Canadian-born urologist Joel Teichman, MD, who became a naturalized American citizen, believes people have been getting distorted views of both countries' health care systems from the media. He described a recent Canadian television ad sponsored by a political action committee. It featured a woman from Ontario who had a rare brain tumor that required her to seek treatment in the United States. According to the commercial, the woman would have died from lack of treatment in Canada. The message: Americans should avoid adopting the Canadian system.

“Meanwhile, the Canadian media offer stories of hardworking, tax-paying Americans who end up requiring some necessary medical treatment that bankrupts them,” Dr. Teichman told Renal & Urology News. “Americans learn to fear our ‘incompetent' system, and Canadians learn to fear the ‘unfairness' of the American system.” 

Dr. Teichman was an Associate Professor at the University of Texas Health Science Center at San Antonio from 1994 to 2003. He moved back to Canada after being unable to resist a recruiting offer in Vancouver, where he is a professor at the University of British Columbia.

Streamlined billing

Dr. Teichman mainly sees patients suffering from kidney stones and interstitial cystitis, but he sees more patients in Canada than in Texas. According to Dr. Teichman, this may be attributable to the fact that there are fewer specialists per capita in Canada than in the United States or that he was not focused on competing for business in the United States. Moreover, in Canada, the much more streamlined billing process helps free up time and resources. “In Texas, my urology group at the university employed multiple billing people full-time to preauthorize insurance claims, file claims, chase down insurance companies for failure to pay, and handle insurance denials,” Dr. Teichman said. “Here in British Columbia, I file all my claims electronically to the province insurer and am reimbursed within two weeks. It occupies five to 10 minutes per day. I employ no billing person.”

Lawsuit paranoia in the U.S.

Dr. Teichman may also be able to see more patients because he does not have to spend as much time conducting elaborate informed-consent discussions. “For my American patients, I spent more time detailing all the potential adverse outcomes for drugs, therapy, or surgery. In Canada, I feel more comfortable telling patients they do not need a certain test than I would have in the U.S. There's a greater paranoia in American medical practice because of medicolegal ramifications.” Physicians are concerned that “if you fail to dot the I's and cross the T's and go absolutely obsessively over every last possible complication, a patient will turn around and say, ‘You failed to give me appropriate informed consent,' and sue you,” he explained.

As a result, Dr. Teichman said, physicians working in the United States have to spend a lot more time and money than their Canadian counterparts ordering irrelevant and costly tests “merely for the sake of covering themselves.”

Dr. Teichman has a working theory about why some Americans fight the prospect of what seems like a great deal—free health care: “Canada was founded around stability and good governance, and America on principles of individual freedom, liberty, and pursuit of personal happiness,” he said. “An extension of the American sense of liberty is that many Americans distrust government and abhor lack of choice. A single-payer system conjures up the possibility of lack of choice and a heavy-handed, government-run boondoggle. I think most Americans would be surprised to learn that the majority of Canadians receive quality health care from their own physicians and without government intrusion. Some American insurance companies pose much more significant intrusion and interference on patient care, and limits choice, more than exists here in Canada.”

All in all, Dr. Teichman said, “The Canadian system covers everyone quite well, so no one is left behind—but a deluxe model of enhanced health care for purchase is not really available here. I believe the U.S. system is the best health care available anywhere—if you have insurance. Both systems work reasonably well as long as you have access to health care.”

Paucity of primary care docs

Barbara Ballermann, MD, who spent a large part of her career in the United States and who now is the President of the Canadian Society of Nephrology, said she appreciates the peace of mind that Canada's universal health coverage brings to all constituents. “For Canadian people and physicians, the basic principle that everyone has equal access to health care without worrying about payment is an enormous advantage that cannot be overstated. I believe this could be achieved in the U.S., even without a single-payer system.”

The Canadian system, however, is not without its problems, said Dr. Ballermann, Professor of Medicine at the University of Alberta in Edmonton. One is that the provincial government system basically still pays more for procedure-based and specialty-based medicine than it does for primary care. “So we have a huge shortage of primary-care physicians.”

This is a familiar complaint in the United States as well, where a lack of insurance frequently prevents people from obtaining primary care services. In Canada, the problem stems from the fact that there simply are not enough general practitioners available. Consequently, Dr. Ballermann said, “People without a primary-care physician don't see anyone for preventive care. When they feel ill, they usually come to the emergency room. Of course, the cost for treatment goes up. So, as in the U.S., access to primary care is not available to everyone.”

In addition, people get put on long waiting lists for primary care. “We're trying to shrink that wait list,” she said.

Delays in specialized service

Delays also extend to more specialized services, an issue that became personal for Dr. Ballermann when her then 82-year-old father faced a three-year wait for hip replacement surgery. Knowing that the lag time could lead to severe neuromuscular degeneration that would impede her father's recovery, Dr. Ballermann considered taking her father out of the country where she could pay for faster service. She eventually found a way within the Canadian system to get her father his surgery within six months, but she can understand why small factions of practitioners and patients throughout Canada have lobbied for the right to provide and obtain private health care, even though such actions go against the spirit of the Canada Health Act.

At the University of Alberta, Dr. Ballermann and her colleagues have established a triage system. Patients requiring urgent care might be seen that same day or within a week, and a person with a non-urgent condition might wait up to two months for an appointment. “But you would never wait longer than three months. We have limits built in,” she said.

Another problem with the Canadian system, she said, is that it stifles innovation and removes “some of the incentives to do better.” Compared with Canada, the U. S. provides more opportunity to conduct innovative research, supported by both government and industry. “There's a greater innovative spirit. It's just part of the U.S. culture.”