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Canada's Health System Draws Mixed Reviews From Psychiatrists

Although Canadian psychiatrists generally express satisfaction with their government-run health insurance program, not all are happy with the impact of the government's control over hospitals and medical education.

Suppose you awakened one morning and discovered that you could care for your psychiatric patients in whatever manner you deemed best—even by providing lengthy psychoanalysis—and that you would be reimbursed for your efforts by simply submitting a bill. No managedcare exclusions or precertification hassles.

You might think that you had died and gone to heaven, but what's more likely is that you simply relocated to Canada where such seemingly luxurious perks of the government-run universal health insurance program are routine.

The name of the program is "medicare," although it differs dramatically from the U.S. program with the same name (see A Tale of Two Medicares).

The Canadian health system covers all citizens and works well in some areas in which the U.S. system has problems.

"I hear stories of patients being turned away from hospitals in the United States or being afraid to go to the emergency room because they can't afford the care," Padraic Carr, M.D., an associate clinical professor of psychiatry at the University of Alberta, said in an interview. "In Canada that really doesn't happen. When people come to the emergency room, or for an appointment, or to be assessed, no one is refused treatment because of inability to pay."

"Even if psychiatric patients start off rich in their lives, many drift down to a low socioeconomic level because of their illness," Dhanapal Natarajan, M.D., a Saskatchewan psychiatrist who also practiced in Great Britain, reported. "So for them, a universal health care system is extremely important. Even after they are discharged from the hospital, they are looked after."

"Another thing I like about the Canadian system," Carr said, "is that the doctor decides what treatment is appropriate, and it does not have to be approved by any insurance company or third party."

Jacques Bouchard, M.D., a psychiatrist in St. Lambert, Quebec, concurred. "I don't have to justify anything I do. I can treat patients as much as they need."

Outpatient drug coverage mandated by Canadian provinces is also a plus, Arlie Fawcett, M.D., an associated professor of psychiatry at the University of Calgary, stated. "I have patients whose medication costs would be $1,000 or $1,500 a month [if the costs weren't covered by Alberta's mandated drug-coverage plan]," she said.

Still another positive feature of Canada's universal health insurance program, Bouchard reported, is he bills "a single payer, and it is always paid."

Robert Notkin, M.D., a Toronto psychiatrist in private practice who also lectures at the University of Montreal, had good things to say about the health care billing system in Canada. "I have a cousin, a gastroenterologist, in the United States, and I remember being in his practice and seeing four different staff members collecting money from insurers. Most Canadian physicians operate with one staff member or even no staff. Billing is straightforward. You just submit a bill, and generally a month or so later you are paid for the vast majority of claims."

And if that isn't enticing enough, "[r]eimbursement for doctors is based on an honor system," Carr noted.

Psychiatrists Point Out Downsides

But this universal health insurance program that seems too good to be true does have some downsides, Canadian psychiatrists contend.

One disadvantage, Carr indicated, is that having a single-payer system means that there is only one party with whom physicians can negotiate fees. Another downside, he added, is that universal health insurance costs taxpayers a lot of money.

Still a third drawback is that the philosophy underlying Canada's universal health insurance program—delivery of all necessary medical care to all citizens at no charge—cannot always be met because of a dramatic shortage of hospital beds, Alfred Margulies, M.D., a Toronto psychiatrist with a private forensic practice, reported. "As long as I've been in the field of psychiatry, there has been a shortage of psychiatric beds. But the shortage is even worse now," he stressed.

The program's philosophy is further being eroded by a dearth of physicians and nurses, said Jack Brandes, M.D., an assistant professor of psychiatry at the University of Toronto. "Psychiatry in Ontario and Quebec is really suffering. The rates we get paid per session are very high, but there are not many psychiatrists around."

"An independent research institution called the Fraser Institute surveys the status of Canadian medical delivery every year," Notkin reported. "Their most recent survey found that the average wait time across Canada for outpatient appointments with 12 different types of specialists was more than 18 weeks.... I'm not sure where psychiatry fits in.... But in my experience, in different parts of Canada, a patient might wait four months or longer to get to see a psychiatrist as an outpatient."

'Crazy Hours' the Norm

"Doctors are working crazy hours," Margulies added. "So are nurses. There are horror stories about patients dying while waiting to be seen in the emergency room. Some patients are even being shipped to the United States for care. For instance, a man north of Toronto had a ruptured aneurysm, and since he was unable to be admitted anywhere for appropriate care, he was transferred to Buffalo, N.Y., to have the aneurysm clipped."

One reason for the dire shortage of hospital beds and medical staff, Notkin believes, is because demand for medical care increased once Canada adopted universal health insurance; and as demand increased, so did cost; and as cost increased, the government started trying to rein in those costs. Another reason for the shortage, some Canadian psychiatrists contended, is government control over health care finances and delivery.

For example, all hospitals in Canada are publicly funded, and many do not have sufficient money to hire enough nurses, Margulies said. "In the hospital I used to be affiliated with, there was for years an empty floor of unoccupied beds. It was used for movie sets. The hospital didn't have the funding to support the floor with nurses."

Canadian medical schools, Margulies pointed out, are also largely dependent on the government for funds. Eighteen years ago, the government decided to slash medical school slots by 10 percent to save money. The result: a dramatic shortage of Canadian physicians today. "To fill the gap, to meet standards, we would need 26,000 more physicians across the country."

A few years ago, Brandes recalled, "There was a poster that said, 'If you like the post office, you'll love government-run medicine,' which is essentially what Canadians now have. Yet people forget that whereas governments are good at regulating, they are terrible at managing things. So basically what we have here is an experiment that is sort of going down the tubes."

So can it be saved, and if so, how?

One possibility, Brandes proposed, might be to allow people to pay for some of their health care privately. In fact, private clinics have sprung up in Quebec even though they are not officially allowed in Canada, said Brandes. "People don't want to wait four years to get a hip replaced; they are fighting back."

Another possible solution, Brandes ventured, is to use incentives to lure the many young Canadians who have studied medicine in the United States and Europe back to Canada. However, the Canadian government has shown no interest in this idea, he said.

So with some 47 million Americans lacking health insurance, should the United States adopt Canada's universal health insurance concept—that is, transform Medicare with a large "m" into medicare with a small one? Canadian psychiatrists hold varied opinions.

"I could not recommend it," Brandes declared. "I think the concept of national health insurance is admirable in principle, but how do you go about making it work?"

"I would certainly recommend it for mentally ill patients since most are not able to afford a private health care system," Natarajan asserted.

"I have colleagues from medical school who work in the United States," said Fawcett. "They like it very much. However, they say that while excellent medical care is available to some Americans, it is not available to others. So I think the United States would be a lot better off if it adopted a health insurance program similar to Canada's."

"Overall, I am happy with the Canadian system and really can't imagine an industrialized country not having universal coverage for its citizens," said Carr. "It must be heartbreaking for families not to be able to access the health care they need or for families to become destitute because of medical bills."

"If you can avoid some of the pitfalls we have fallen into with our national health insurance program," Margulies said, "I think the United States should adopt it, because when the system works, the patient is the one to benefit."

"Since Americans tend to favor free enterprise to government control, I would recommend that they consider adopting a system that is both public and private—not Canada's totally public one," Bouchard said. "I think private and public can live together if it's well done."

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