Health Care Models Compared:
Canada vs. U.S.

Editors' Note: This thorough report provides a good overview of the relative merits and faults of the U.S. system vs. Canda's single-payer universal health care.

Nurse Donna Riley hurried through the drab halls of St. Michael's Hospital to deliver the bad news.

Eduard Krause, a 71-year-old retired mechanic, had been waiting more than six weeks for heart-bypass surgery. After fasting for 18 hours, he was lying on a gurney, ready to be rolled into the operating room. Now he would have to wait a bit longer: An emergency patient had been rushed into surgery, bumping him from the day's schedule.

"The lady who is having her operation is 34 years old," explained Ms. Riley. "They found a big tumor on her heart." Mr. Krause replied: "I can understand all that. But if I go home, I'm afraid I might not come back."

In Canada's public-health system, which promises free, equal-access care to all citizens, medical resources are explicitly rationed. For the country as a whole, that works -- Canada spends far less on health care, yet the health outcomes of its citizens are generally as good as those in the U.S.

But the trade-offs are steep: Canadian hospitals are slower to adopt the latest technology, meaning patients have more limited access to cutting-edge medical equipment. There are fewer specialists for patients to see.

The riskiest trade-off of all is troublingly long waits. Once patients see a family doctor and get a referral for specialist care, it can take weeks or even months to get an appointment. In some parts of the country, patients waiting for admission to a hospital sometimes find themselves waiting for hours and even days on gurneys in the corridor, and receiving treatment there.

Waiting is the giant flaw in many national health-care plans. A study this year by the Organization for Economic Cooperation and Development found waiting times for elective surgery are a "significant health-policy concern" in about half of the group's 30 members, including the United Kingdom, Australia, Sweden, Canada, Italy, Denmark and Spain. Waiting times weren't a problem in the U.S., the group said.

In Canada, the long waits stirred a public outcry and a government inquiry when a 63-year-old heart patient at St. Michael's died in 1989 after his surgery had been canceled 11 times. While the inquiry concluded the death wasn't caused by the delays, it highlighted the long waiting lists and called for better management of patients in the line.

To tackle this crucial problem, Canada is turning to Donna Riley and others like her. The 51-year-old nurse is one of Ontario's "cardiac-care coordinators." Her job: to make sure waiting doesn't kill patients.

Hospitals across Canada struggling with their own waiting-list woes are now trying to follow Ontario's model. The experience in Ontario, the largest of Canada's 10 provinces, spotlights one of the essential problems with health-care rationing and a possible solution.

In Canada, one way hospitals restrain costs is by trying to always run at capacity. It's more efficient to run a hospital that way, just as it's more efficient to fly an airplane with every seat full. But running at capacity means lines always form. Waits for certain nonemergency surgeries in Canada can be up to two years. In parts of the country, there are long lines for such things as magnetic resonance imaging or children's mental-health services.

Health-care spending accounts for 10% of Canada's gross domestic product, while in the U.S., it consumes about 14%. Canadian patients can choose their own doctors, and they never see a bill for their care. Canadian physicians, who are paid by the government, generally earn much less than their U.S. counterparts.

Despite Canada's lower health-care spending, patient outcomes in a number of areas, including cancer and heart disease, are similar. Overall, life expectancy in Canada is 79.4 years, compared with 76.8 years in the U.S., the OECD says.

Many factors affect longevity, of course. Nearly one-third of Americans are obese, for instance, compared with 15% of Canadians. And since millions of Americans are uninsured, many may not get access to the care they need.

Some U.S. experts who have studied the Canadian system say that waiting lists are a sign that the health-care system isn't wasting money on unnecessary procedures, equipment or personnel. "If you don't wait in a medical system, there's a problem," says Ted Marmor, a health-policy expert at Yale University. The question, Prof. Marmor says, "is whether people are waiting inappropriately."

In Ontario, the cardiac-care network works to strike this balance. The network consists of 17 hospitals, and 50 surgeons who share heart-patient cases. There are government guidelines to follow: At St. Michael's, six scheduled surgeries are allowed each day. Ms. Riley's challenge is to juggle the elective and the urgent cases so that all six operating-room slots are filled every day -- and no one is left waiting longer than the recommended length of time.

To do that, she fields calls about urgent cases from community hospitals that don't do heart surgery and need to transfer patients. Using test results received by e-mail or fax, she fast-tracks urgent cases to the attention of St. Michael's on-call surgeon, who decides who will be treated that day. On evenings and weekends, Ms. Riley's bridge games and outings to her nephew's sporting events are often interrupted by pages from patients waiting for surgery whose pain is suddenly worse.

"Donna's the traffic cop in the middle of a busy intersection," says Dr. William Sibbald, a Toronto expert in critical care and one of the authors of the government report that led to the creation of the cardiac-care network.

Before the network was created there wasn't much coordination between Ontario's hospitals and doctors. Surgeons managed their own list of patients, and waiting times varied greatly from hospital to hospital.

With Ms. Riley and her fellow coordinators working to distribute the patient load, the mortality rate for those on the network's waiting list has been reduced to about 0.39%, from as high as 0.74% in the mid-1990s.

Waiting times, which have been on a downward trend in recent years, increased slightly in the first part of 2003, partly because the severe acute respiratory syndrome outbreak earlier this year forced the cancellation of hundreds of lab tests and elective surgeries.

Eduard Krause, a 71-year-old, walks a mile before breakfast most mornings.

The SARS episode showed Canada's system lacks "surge capacity," according to a report by David Naylor, the dean of the University of Toronto's medical school. With hospitals already full, handling a large number of patients who required isolation overwhelmed the system. At least some of the early infections spread because patients shared emergency-room observation areas separated only by a curtain.

To ensure standardized waiting times for heart patients in Ontario, surgeons assign every patient a score of between one and seven, depending on the severity of their symptoms. The scoring system was devised by heart surgeons and cardiologists. Patients are then separated into four categories: emergency, urgent, semiurgent and elective.

For example, a patient who is rated a 2 should wait no more than 48 hours, according to network guidelines, while a person rated a 3.5 could wait as long as 14 days. A score of between 5 and 7 indicates an elective patient for whom a wait of as long as 120 days is considered safe. Hospitals' waiting times, and the percentage of patients treated within the recommended time frames, are posted on the network's Web site.

"Urgent people get treatment in a timely fashion," says Dr. Lee Errett, chief of cardiac surgery at St. Michael's. Today, most urgent and semiurgent heart patients are treated within two weeks. Non-urgent patients wait an average of 49 days for surgery.

Ms. Riley decided at age 12 that nursing was her calling, after she helped care for a uncle dying of cancer at her family's farm on Prince Edward Island. After working as a cardiac nurse, she rose to the position of head nurse on the surgical ward. By the late 1980s, the Ontario government tightened spending, forcing hospitals to cut beds. Heart patients found themselves waiting up to a year for surgery. "There was no mechanism in place" to triage patients or share them between surgeons or hospitals, says Ms. Riley. "This always bothered me."

These days, Ms. Riley is usually calling the hospital on her cellphone by the time she backs her Honda out of her driveway in the morning. Her first call is often to the intensive-care unit. She needs to know how many patients are well enough to be moved to regular hospital beds. "The ICU is the bottleneck," she says.

Intensive-care beds are the most expensive and scarce in the city. At St. Michael's, 13 ICU beds are reserved for cardiac-surgery patients. When St. Michael's gets hit with several cardiac emergencies, Ms. Riley, in her white gown and well-worn Birkenstock sandals, heads to other floors in search of the beds she needs. "Donna won't sleep well if we cancel a cardiac surgery," says St. Michael's cardiac program director Ella Ferris.

During the day, she reviews her three-ring binder of elective cases, penciling in notes about patients who call to complain about increased pain or scheduling concerns, such as a wedding, vacation or work commitment.

On the spring day Mr. Krause was scheduled to have his long-awaited bypass, Ms. Riley got a call about another patient -- a woman with a benign tumor on her heart that could cause a stroke. To fit her in, Ms. Riley needed to cancel another patient. The only one she could cancel was Mr. Krause, because he was rated the least urgent of the six scheduled surgeries for that day.

While Mr. Krause had been waiting six weeks for his date in the operating room, he had also waited several additional weeks before that for an angiogram and a stress test. "They are always booked," he said. Informed of the last-minute delay, Mr. Krause told Ms. Riley his chest pains had grown worse lately -- to the point where he had almost called an ambulance the night before. "The pain is constant," he said.

Mr. Krause was also worrying about his ailing wife and mother-in-law at home. His wife had broken her leg and was on crutches. His 91-year-old mother-in-law, who has Alzheimer's disease, lives with the couple. Mr. Krause had recruited his brother and sister-in-law to help out while he was in the hospital. A delay would force the whole family to make another set of arrangements.

In pushing for Mr. Krause's admission and surgery, Ms. Riley considered his family situation in addition to his pain. He got the operation the next day.

"She's kind of the patient advocate," says her boss Dr. Errett. "She's always the voice of the underdog." Yet he says the two don't always agree on who should be treated first. "I override her sometimes," he says.

Concern for patients sometimes leads Ms. Riley to an odd role reversal: She finds herself hounding patients who are hesitant to schedule surgery. One patient, who operated a swimming-pool business, refused to be scheduled for his bypass "because of pool season. He was taking a risk by waiting," says Ms. Riley. She called him every few days to check on him. He had his surgery after pool season and did fine.

The hospitals in the cardiac-care network keep a database of patient outcomes to help pinpoint those at highest risk from waiting. A recent analysis of the data showed a disproportionate number of deaths were occurring in patients with a condition called aortic stenosis. Because of the finding, patients with the condition are now seen more quickly. The system still leaves surgeons grappling with questions about how to ration finite resources. On one of the busiest days in recent months, an emergency patient was transferred to St. Michael's with a ruptured valve condition. The survival rate for the procedure, according to the network's data, is just 10% to 20%. Indeed, the man died a few days after his six-hour surgery.

The procedure is frustrating, says Dr. Errett, because it claims many resources and so seldom succeeds. "I've met with our group and said, 'Maybe we shouldn't do them at all,' " he says. In the end, the doctors decided to continue doing the procedures.

Some patients, such as Mr. Krause, say that waiting isn't too bad a price to pay for their free medical treatment. Now recovered from his May surgery, he takes a mile-long walk before breakfast most mornings. "The care, I think, was pretty excellent," he says.

Comparing Health Care

Canada
Who Pays: The government provides coverage for all medically necessary treatments -- 70% of the nation's health-care expenditures. Private insurance is available for prescription drugs, dental, vision, psychotherapy, fertility treatments and private hospital rooms.

Hospitals: Government-funded.

Doctors: Bill the government according to rates set by the provinces.

Prescription drugs: Hospitals pay for drugs they dispense. For other drugs, Canadians pay out of pocket or through private insurance. Some provinces offer public drug-insurance plans. The government regulates prices of brand-name drugs, so prices are much lower than in the U.S.

Advantages: Everyone is guaranteed access to care. Patients can seek services of any specialist.

Disadvantages: Top specialists and many family doctors have long waiting lists.

United States
Who Pays: Individuals are generally responsible for costs, either out of pocket or through insurance. Many have employer-paid or subsidized programs. The very poor are covered by the government's Medicaid program, and seniors and the disabled are covered largely by the government's Medicare program.

Hospitals: Generally compensated by a mix of insurance and patient payments, charitable contributions, government funds and investment income. Some uninsured patients are billed by hospitals.

Doctors: Set their own fees. Many accept public and private patient insurance and receive amounts set by insurers.

Prescription drugs: Drugs dispensed by hospitals are usually included in the cost of treatment. For other drugs, insured patients generally make a co-payment, with insurers covering the rest. Uninsured patients can face extremely high drug costs.

Medicare pays for drugs only during hospital stays.

Advantages: Patients with good coverage get access to one of the world's best medical systems, often at a relatively low cost.

Disadvantages: For the growing number of uninsured, health care can prove enormously costly and difficult to obtain.

©2003 Wall St Journal