The Truth About Waiting to See a Doctor in Canada

SHANOOR SEERVAI: Hi everyone. Welcome to The Dose. I’m Shanoor Seervai, and for the past few episodes, we’ve been talking about health care in developed countries where everyone has coverage, and how their health systems are different from our system in the United States.

Today, we have Christopher Hayes with us. Chris is the chief medical information officer at an academic and research health care organization in Canada. He came to the U.S. in 2013 to study how the workload balance of health care providers affects the quality of care patients receive.

Chris, it’s great to have you with us.

In spite of being neighbors, the U.S. and Canada have dramatically different approaches to health care. Could you start by telling me a little more about how the health care system works in Canada?

CHRISTOPHER HAYES: Sure. So Canada has had universal publicly funded health care since the 1950’s under the Canadian Medicare Act, which essentially said that if you are a resident, citizen, or a permanent resident, landed immigrant, then you have publicly funded, no cost at source to anybody needing health care at any age.

SHANOOR SEERVAI: What services does this cover?

CHRISTOPHER HAYES: So medications, physician services, nursing, equipment, transplant, implant, those are all covered. The only things that wouldn’t be covered would be a private room, if we have any private rooms, or television services. Other than that, your in-hospital care is covered. And your primary care physician services are covered. So visiting a primary care physician in their office, there is no cost to the patient.

SHANOOR SEERVAI: I’m interested in the history behind this. I read that the Canadian Medical Association was opposed to publicly funded health care in the ’60s, and the American Medical Association had exactly the same approach at that time. How did Canada manage to get universal coverage in spite of that opposition?

CHRISTOPHER HAYES: Sure. Well it all began actually in one province, Saskatchewan, who decided they would offer their citizens universal or free health care, publicly funded. And there was lash back from the medical profession then. The thought was that it would restrict what services were provided, it would govern how physician’s relationship with their patient, it would govern their autonomy, and which none of those things are really true.

SHANOOR SEERVAI: Like in the U.S., most physicians in Canada are paid on a fee-for-service basis, so each service is paid for separately. One of the key factors that moved universal coverage forward was an agreement that physicians would continue to be paid this way.

Chris, let’s talk a little more about how Canadian physicians get paid. Do they bill the government for the services they provide?

CHRISTOPHER HAYES: For the most part. If I see a patient in the intensive care unit where I work I bill for the day, times how many days I am taking care of that patient, and at the end of the week I submit that to the government and then the government pays me or my billing agency back.

SHANOOR SEERVAI: And when you say you bill the government, do you bill your provincial government or do you bill the federal government?

CHRISTOPHER HAYES: Yes, we bill the provincial government. Far and away the provincial governments are the deliverers of health care services, not the federal government.

SHANOOR SEERVAI: How does the provincial government pay for health care then?

CHRISTOPHER HAYES: It is all taxes. So it either comes through a proportion of the federal taxes that people pay out of their employment income. So the federal government gets their proportion of income, and then there is an agreed-upon health services transfer to — back to the provinces to partially fund health care.

SHANOOR SEERVAI: Okay. So the provinces deliver care. Do insurance companies help facilitate this? Let’s take your province, Ontario, as an example.

CHRISTOPHER HAYES: So there is the Ontario Health Insurance Plan which is a government-run insurer, and it’s hard to say really insurer because they are not — no one who is buying insurance from them, they’re just paying. So they are not really an insurer.

SHANOOR SEERVAI: So if I were a resident of Ontario, would I have to sign up for the Ontario Health Insurance Plan, or would that just automatically cover me because I live there?

CHRISTOPHER HAYES: If you were a citizen, landed immigrant, permanent resident, you would — I mean, you have to get a health card. So you do have to show up at a government office and prove that you’re you. That involves getting your picture taken, your signature, providing passports or other types of government-issued identification. You are then issued with a health card. That’s what will be asked for when you show up at any health care provider center or office.

SHANOOR SEERVAI: Would that be across Canada, or is that only specific to Ontario? Let’s say you were traveling and got sick and you were on the other side of the country, in British Columbia.

CHRISTOPHER HAYES: So the Canada Health Act, one of its principles is portability. So I as the user, the consumer, will receive health care anywhere in Canada. But that government will bill Ontario for those costs. But for me it’s seamless.

SHANOOR SEERVAI: It sounds like public insurance is fairly comprehensive. But two-thirds of Canadians have supplementary or private insurance. Why is that?

CHRISTOPHER HAYES: On average, Canadians pay 30 percent of their total health costs where the provincial plans cover 70 percent. So in that bucket would be medications, if you weren’t in a program — durable medical equipment, other health disciplines like psychotherapy, physiotherapy, social work outside of the hospital, skilled nursing, or nursing care in your home. It’s not that none of that is covered, but a lot of that is not covered. And so most employed people will have either a group coverage through a private insurer, or individuals can sign up individually for themselves and/or their families to one of these private insurers, but have a private plan.

Because I am an associate professor with McMaster University I have a benefits plan as a McMaster employee. I have my medications covered, I have 80 percent of my dental covered, I have $500 per year for each of massage therapy, psychotherapy, physiotherapy. It’s not that that is free because I do pay into that from my university salary.

SHANOOR SEERVAI: So one of the things that we hear about in the U.S. when our two health systems are compared is that Canada has really long waiting times for health services. How long do people really have to wait to get care?

CHRISTOPHER HAYES: So I guess it’s — it depends on what do you think you’re waiting for. So if you are in a hospital and you need surgery you don’t wait. It gets done in — if it needs to be done in 30 minutes it will be done in 30 minutes. If you need an MRI for care provided in a hospital you will get it whenever — depending on where you are because not every hospital has an MRI, but you will be prioritized and that will happen probably as quickly as it can be done anywhere. It is as the priority drops or is deemed less by whomever that the wait — so the waits are how long will you wait to see a specialist after seeing your family doctor.

I mean, the one that people will talk about is cataracts, hip surgeries, non — not cancer type surgeries, where there — things will get worse if you don’t get treated. And so you can wait months for those surgeries.

SHANOOR SEERVAI: So is there any way that you can speed up your wait times?

CHRISTOPHER HAYES: Well, not unless you know people. Or if there were cancellations and you were on a cancellation list. Then you could. But there is no, can I buy myself a spot closer to the front? No.

SHANOOR SEERVAI: That means that hypothetically, even if I were willing to pay tens of thousands of dollars to get a hip replacement, I couldn’t?

CHRISTOPHER HAYES: Correct.

SHANOOR SEERVAI: All right. How do people feel about this?

CHRISTOPHER HAYES: Well I guess it depends on who you ask, and whether they are in the situation where they do have disposable income that they feel that they should be able to use towards their own, speedier access to health care. Versus the general public belief that this is a right, and if it’s a right then why would we — why should money trump need? There is really no mechanism to buy a spot in the line. And now that doesn’t mean it’s just first-come, first-served. There are priorities, but those priorities for the most part are clinically based.

SHANOOR SEERVAI: Okay, that makes sense. What sort of things are the provincial governments in Canada doing to address this wait time problem?

CHRISTOPHER HAYES: Yeah, so again they are — so data is a huge one. So let’s provide data on specific times in the wait-time process and compare those across sites. So that you can see where you compare to others. And most people would like to compare favorably. They have put in technological solutions to try and bridge the gap between — we are a big country and a big province, and so sometimes wait times can be travel-limited, or travel-impacted. So we have virtual care through our telemedicine service.

SHANOOR SEERVAI: Given that wait times are an ongoing challenge, how do people feel about the health system and the taxes they pay?

CHRISTOPHER HAYES: Nobody likes taxes, and I wouldn’t say that we are any different than anyone else. So people don’t appreciate paying a large sum of their salary towards that — towards taxes, but they will also say, you don’t touch my health care, right? So we have just — politicians just don’t go after publicly funded health care, they just — I think they would lose very quickly because the citizens really believe that this is a major value. And as much as we don’t want to pay high taxes we love our health care system from its accessibility perspective, even if it is we wait more than our American colleagues do.

SHANOOR SEERVAI: It’s true that most people don’t like paying taxes, but then are they happy with the care they receive?

CHRISTOPHER HAYES: Yeah, so the care that they receive versus the health care system at large are probably big differences. So the care that you receive is local, and so how you feel about the care you receive comes down to who is taking care of you on that day.

SHANOOR SEERVAI: There is obviously variation in terms of the patient experience because of the physician and the surgeon you see on a specific day. But are there some provinces in Canada where generally health care is much better than others?

CHRISTOPHER HAYES: So it’s hard to say that one province’s outcomes are better than the other. I think that would be just as hard to say that one state’s outcomes are better than the other, because the determinants of health and regional variability are highly variable across the country. I would say though that if you live in the territories, which are the two — three northern territories that are in pretty sparse and challenging lands, access to health care is very, very different for them. And the cost per person in those remote areas is like three times what it is in an urban — southern Canada, southern Ontario.

SHANOOR SEERVAI: Could you talk about what is so challenging about providing care in remote northern areas like the Yukon or Northwest Territories versus around Toronto?

CHRISTOPHER HAYES: Yeah, so the populace per square inch in the territories is immensely lower than it is in downtown Toronto. So to put the services in there for the catchment population but to have those people accessible to those is a big challenge. Secondly, it would be hard for — a lot of those remote areas are not — don’t have a physician, they have a station nurse practitioner at a nursing post who has connection to larger centers. And then as far as our indigenous peoples, there is — the proportion of indigenous peoples in the territories are more than they are in most other parts of the country. And so you’ve got cultural barriers for those populations. And then geographical barriers, specialty skill barriers, and then things like climate. I mean, if you can’t — how do you get to these people?

SHANOOR SEERVAI: So it must be very expensive to ensure that people in these remote parts of the country have access to medical services. On the point of cost, how much of Canada’s GDP is spent on health care?

CHRISTOPHER HAYES: Around nine something percent. And we’re sort of in keeping with all others that are in the OECD.

SHANOOR SEERVAI: Right. Which aspects of the health care system are most expensive? And what is the government doing to control costs?

CHRISTOPHER HAYES: Well again I would say that from a — what is most expensive in remote areas, remote northern areas, is travel and moving people. Where you don’t have that as a factor — most — it’s like 80 percent of money for health care is spent on people, not on equipment, not on medications, it’s spent on people.

SHANOOR SEERVAI: What makes people anxious about their health in Canada?

CHRISTOPHER HAYES: I think — again, I think it would be wait times. That I would need services and I couldn’t get them. I definitely think that. But I also think some of it is cost, because if you leave the hospital — if you need a nursing home that provides skilled nursing care, and you can sort of have a government subsidized or funded one which you don’t want to put your loved one there. And — but you want them to go — they’ve always said they want to be in this place, and that place is super expensive. So in that respect I do think money is — it’s not that money is not an issue because as soon as you leave the hospital, and there’s — you still need care or therapy, it’s going to cost you.

SHANOOR SEERVAI: How does this compare to the anxiety people have around costs in the U.S.?

CHRISTOPHER HAYES: Well my aunt and uncle and cousins live in the U.S., they have for years. So when I visited my cousin actually during my Harkness Fellowship her newborn son was eight months. So she actually showed me her — I wouldn’t say bill, but it was the itemized list of cost of her delivery. So she received — I think she got an intravenous, and I think some Pitocin drip to augment labor. She didn’t really stay much longer, she didn’t have a C-section, and she was sent an itemized list of costs of $40,000. I mean, my jaw dropped, you know? I could not believe that’s what it cost to have a baby in the U.S.

SHANOOR SEERVAI: Yeah. Many people in the U.S. are unhappy about how much health care costs here, but since we don’t have a universal public insurance program, neither political party has been able to fix this this cost problem. Do you think a political change in Canada could lead to a different sort of health system in the future?

CHRISTOPHER HAYES: Well I think its publicly funded nature is something that politicians would venture very carefully into coming up with different models.

SHANOOR SEERVAI: Why?

CHRISTOPHER HAYES: I just think it’s a belief that it will then become an unregulated market-driven product. And I think that’s because of our naivety in what is happening in the world versus what is happening in the U.S. Because if you look at France and Germany, and many European countries, they are — a lot of them are very privatized, but they’ve been — the government plays a strong role in regulating costs and mandating that people sign up. Anything to reduce the overall cost, because we cost the same as they do, but there is third-party insurers in there. So it’s not just private versus public. I think it’s private equals U.S. health care system.

SHANOOR SEERVAI: To close, Chris, if you had to choose between the health care system you have in Canada and what the U.S. has, which would you pick?

CHRISTOPHER HAYES: So that’s not a simple question, and therefore not a simple answer. I think there are — so some of the downsides to having a publicly funded, government-run health care system is that it’s hard to innovate in that space. I truly believe that there are some places in the U.S. that have absolutely amazing health care that we could only dream of in Canada, and are innovating faster than we would ever. Because there is a market forces aspect to what is driving these leaders. And we don’t have that. And so I think that — I think that we have pretty great health care here, now again I am a practicing physician doing quite well. And I would feel for my kids who I hope that they would be as fortunate to be able to not worry about health care, the cost of health care.

So I would want somewhere in between — I think we need to spend more on market-driven innovation forces in the Canadian health care system that don’t come with — necessarily come with market-driven economics.

SHANOOR SEERVAI: Thanks for listening.