Americanization of health care in Canada

This is an article about a Canadian's sister's treatment for colon cancer in California. I edited it together for an easier read [hopefully] , there is more if you read it all [link].

At the end, I didn't include it, she makes a statement about Canada's private clinics and a slippery slope where insurance companies make the call in choosing your treatments. Its not a lock-solid connection, nobody knows if we will cross that line in allowing private clinics.
I like, and have enjoyed the benefits of, our Canadian health care system where we all recieve the same treatments for a given illness regardless of ability to pay. Longer waiting periods are better than nothing at all!! As a student and later as unemployed temporarily, I could have needed care I could not have afforded. I want my grandsons to have that too.


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Dateline: Friday, December 16, 2005
What Americanization of health care really means:
Insurance companies truly drive every aspect of "care".

It is important for Canadians to understand the full dimensions of "Americanization of health care".

Most Canadians are not aware of how bad it is in the States.

In America, the bottom line of the insurance companies is truly the driving force in health care. It drives everything from diagnostics to treatment to palliative care. At every point, the companies squeeze patients and doctors in ways Canadians would find incomprehensible.

Lengthy waits for consultations, referrals, appointments, diagnostics and, most critically, approval for all these things from the insurance companies. The delay in approvals often led to setbacks in treatment.

The doctors and hospitals clearly passed off less lucrative procedures to one another. Certain hospitals would only do certain procedures. American hospitals give priority to patients with higher-price insurance premiums.

Unlike in Canada, no homecare is available except from cancer society volunteers. Courses of treatment that run counter to the insurance company's ability to save money are vetoed.

[T]he palliative care they offer is dismal, volunteers and the occasional nurse , [no] morphine pump. The insurance companies control that.

I think that Canadians should take every reasonable step to inform our Members of Parliament (once the 39th Parliament has opened, of course) to protect the Canada Health Act and the principles that the Act stands for. We should not be disouraged by the ruling in Québec authorizing private health care clinics — the ruling concluded that our public health care system needs to be improved, not abandoned.

It is important that all Canadians have equal access to health care. Financial situations should not make anyone privy to better or more timely care, nor should the poor be discriminated against. We're talking about peoples' lives here — Canadians' lives. Our lives.

i support a national public system for basic and emergency services. Beyond that, i am quite happy to pay for options not offered under a single insurer service because they have deemed not to cover something.

Canadians deserve better than a single serve system.

Perhaps a model like car insurance in BC where basic is required through public but extended systems are available from other insurers.

I like my private healthcare, thank-you. I am not going to give it up so that everybody can recieve LCD service.

You'll be sorry, Caracal. That's okay though, 'cause I'll be there to kick you in the kidneys and say, "TOLD YA SO!"

private health care already saved my life where the screwy public system screwed up, so if not for what you hate, i would not be here for you to try and kick!

But how, in Canada, could private health care have yet had a chance to save your life? Unless of course you live in Alberta, or perhaps Québec, in which case I apologize; but in the rest of Canada, private health care is widely unavailable.

BC.... widely unavailable, but still available. it just is not advertised.

The public system has saved my life a few times. I think that unless you've ever been laying in the back of a pick-up truck puking blood because somebody dropped a tractor on you, you might want to back off here.

Just a guess. Of course, under the private system I would have bled to death while they were dicking with my insurance, so what the f*ck. That's what the Conservatives count on...that you'll die before you can talk back.

well, rev, i don't want a complete private system. I think a public base is great. I just want the ability to choose and purchase whatever i want on top of the basic (which i think needs to be basic and emergency only).

Look at how auto insurance runs in BC. The core stuff everybody has to buy comes from ICBC, but you can choose what you want and who you want it from beyond that.

Nah, look at a guy who has been puking blood because a tractor fell on him. I'm here to talk back because you didn't get your way. I'm alive because of Tommy Douglas and thousands like him.

They got my wallet out of my pocket after a bit. If it wasn't for our health care system, I'd be dead. I was insured enough at the time that they might have expressed regret. Or maybe not.

Make up all the **** you want. If you want to tell me how we shouldn't have healthcare, come on over. I'll be more than happy to drop a tractor on you.

under my approach you would have had the same coverage!

the caracal kid, with all due respect, your approach would be extremely difficult to implement, namely because there would be a huge debate on what would be considered "emergency" and "essential" services, and what would be considered "extended" to the extent that one would be required to seek out and pay for private care.

Note Edited to correct a typo.

People make such broad and untrue generalizations about public and private care....

I work in the US. No, you wouldn't bleed to death while we dick with your insurance. I have a lot of problems with the way the medical system is run (if I get sick I'm coming back to Canada!), but we don't let people die because of finances. EVER.

some things are worth the effort!

better to put in the effort for a better system than settle for the status quo.

Okay, you all ready for a dose of reality? I'm going to give you the insider's view of American health care from the POV of the insurer. You may want to have a stiff drink or a toke handy, because you will probably need them by the time you finish reading this.

Perhaps some of you have wondered why I am able to spend so much time on this board during the day. Well, I'll tell you why: I was fired from my job in the American health-care industry, for the simple fact that I made it known that I did not approve of being expected to do unethical things in the course of my daily work in order to save the HMO which employed me money while it was simultaneously soaking the customers for high premiums.

I worked for a major American HMO - a "health maintenance organisation" for anyone who may be unfamiliar with the term. HMO's serve as both insurer and care provider to those enrolled in their program. The insured (the "member") pays a premium just as with other sorts of health insurance, and care is provided by a combination of doctors employed by the HMO, contracted to it, or in rare circumstances, permission may be granted for a patient to see a specialist who is outside the plan and network. If hospital care is needed, it is either provided in a hospital OWNED by the HMO, or else by one contracted to it if the HMO in question does not own a hospital in the area. If a patient who is covered by HMO "X" suffers an emergency somewhere outside of the area in which the HMO operates, s/he may receive emergency care outside the network, but must be moved to the HMO's hospital as soon as is possible, or else face the prospect of having to pay for further care out of his/her own pocket.

HMO's also provide a limited amount of outpatient therapy and usually have a prescription drug benefit as well, but the therapy is generally of very limited duration and the drug benefit is usually limited only to certain drugs, and often excludes the newer, more effective but more expensive medications available.

An HMO will also cover certain items of durable medical equipment used by the patient in his/her home and daily life. However, this coverage is again very limited and the rules governing what is in fact covered are capricious at best.

With me so far? Okay, you've now got a basic idea of the company and the environment in which I worked. Now I'll tell you about my particular job, and about how I came to not have it any more.

My work involved the processing, approval and/or denial of referrals to specialists and claims for procedures, general care, and durable medical equipment. After having been in this position for a while, I noticed that medical equipment, procedures, and even medical conditions themselves were frequently miscoded and misdescribed in the processing paperwork, even when the true condition, treatment and equipment was clearly listed in the original requests. Since a part of my job was to generate and send letters of denial to patients whose claims and requests the company had decided not to honor, I saw quite a lot of this on a daily basis, and I brought what I originally thought were innocent, if rather stupid, errors to my superiors. This resulted in some re-examination of the claim in many cases, and at times in a reversal of the decision to deny, meaning that the patient did in fact receive the care requested.

However, after some time of this, I was taken aside by my superiors and informed that I was being "too detail-oriented" and that I really ought to simply type up what was put in front of me and not bother to look through the files as I did so. As being "detail-oriented" was in fact one of the qualities that had been listed as desirable in a candidate for this job when I applied for it, and as we were dealing with critical issues of people's health, I found it rather odd that I should be criticised for paying attention to detail.

For a while I said nothing, but then I was involved in a series of meetings dealing with how we were to process certain claims and the criteria for approval and/or denial thereof. One specific area addressed was that of durable medical equipment. This includes items such a wheelchairs, back braces, limb braces, oxygen equipment, hospital beds for use in the home, etc. In the course of these meetings I learned that it was routine for us to deny claims for many of these items even when their medical necessity had been demonstrated by one or more physicians responsible for the patient's care! This did not sit well with me, as you can probably imagine.

For example, I remember one particularly glaring example of a teenaged patient with severe cerebral palsy. Having little to no control over his body, this young man was confined to a motorized wheelchair when he was not in his bed. He attended special education classes in school and his family attempted to involve him in normal family activities as much as possible, but he was developing additional physical problems due to his always being either seated or laid flat. Several of our own physicians and specialists had recommended that this young man have the use of a standing frame designed to maintain him in an upright position during part of the day in school and at home, in order that he might develop both the additional core motor skills necessary to reasonable function in the daily world and also to assist his digestive system in processing his food and wastes. The frame isn't cheap, but neither is it horribly expensive. However, it is somewhat expensive for an average family to afford, and this family was already paying high premiums to the HMO in order to provide care for their family - including this young man - anyway. Well, to make a long story short, the standing frame was deliberately miscategorized in processing as a lift-chair - one of those armchairs you may have seen advertised on TV to senior citizens, the type that will tip the seat forward in order to make it easier for the person to stand up and get out of the chair. That's a far cry from a frame designed to hold upright someone who has only minimal control over his body and its motion and functions!

When I pointed out the error, I was told repeatedly to ignore it and simply process the denial.

Same thing happened with a back brace for a 13-year-old girl with scoliosis ($1,200, vs. $40,000 a decade hence for surgery to treat the effects of untreated juvenile scoliosis - ironically we would cover said surgery, provided the patient was still a member of our HMO), a wheelchair for an elderly woman who had lost the use of her legs, and a plethora of other cases. And these were just the durable medical equipment cases. Don't even get me started on surgical procedures, diagnostic testing, and visits with specialists - not to mention pharmaceuticals to treat various conditions. I learned after a while that the primary reason behind many of these erroneous denials was that, while the member could appeal the denial, appeals took up to 30 days or even longer, and it was hoped that many of them would either not wait, or be confused by the language of the denial in the first place, and pay for their care on their own, thus saving the company money.

In any case, it was fairly well-known after a time to my superiors how I felt about these denials, and a variety of things were added to my job - including another person's work - in an attempt to disgust me so much that I would quit... which I was about to when they finally decided simply to fire me.

Now tell me, do you REALLY feel comfortable entrusting all but the most basic of emergency care to for-profit entities? I know I sure as hell don't.

What's the difference between terrorists and HMOs?
You can negotiate with terrorists

Seriously, I switched from an HMO to a PPO plan not long after I moved because the HMO was just ridiculous. The PPO isn't great, but it isn't terrible either. I have seen a lot of stupid insurance stuff happen in our hospital... It doesn't inspire my confidence in the private management of healthcare.

yes. but not an anerican style system. basic coverage means all hospitals remain public for example.

in comparision to your story, i used to know a nurse that quit and went back to school to do something else because holding a masters in nursing still renders you responsible for the patient but unable to question a doctor even if you know they are making an error.

a public only system denies the user choice. it dictates what type of treatment you can and can not get. no thanks. i prefer to have options.

edit:
just to add, the populace was not too supportive of public healthcare when introduced, and now they love it. the same will be true when they have the security of the public system with the freedom of choices of a public layer on top.

Not sure if you're talking to me or to Tracey, but I can tell you that in my area the HMO in question used both publicly and privately owned hopsitals, but that still didn't keep the need/desire to turn a profit from trumping the quality of the patient's healthcare. When the insurer, rather than your doctor, determines what care you "need", something's drastically wrong. And when your degree of medical "need" is determined by your insurance company's willingness to pay or by the amount of money in your bank account, sooner or later you're likely to get screwed.

The private healthcare system allows no more choice (and sometimes less) than a public one, because you can only receive the care that your insurer decides it is willing to pay for, and you can only see the doctors they allow you to see, and use the facilities they allow you to use. That is, unless you are wealthy enough to afford to pay out of your own pocket for your care, which most people are decidedly NOT wealthy enough to do.

a public-private system allows the following:

1) a basic level of coverage to all people guarenteed.

2) the option to "opt out" of specific types of coverages under the public system in exchange for purchasing different coverage under an alternate plan (or not having the additional coverage at all).

3) as you stated, the freedom to pay for services you desire.

we currently (in some locations) already have #3 where you can pay to have testing done to skip cues, and that money goes back into operation of the equipment for those in the cue.

there is a great deal that is not covered by the public system leaving people with the options of pay from pocket or get nothing option.

Public systems in canada have a history of being financial failures. The system needs to be overhauled allowing for more options, and for better use of the public system. The public system is currently abused because people can get away with it. Yet, for this gross ineffeciency, nothing is accomplished.

CK, it would make far more sense to expand the public system to cover those things that are not covered now.

imagine for a moment that you are someone who either cannot afford insurance coverage, or who has opted to decline certain types of coverages because you are certain that you will never need them. And then suddenly you find yourself suffering one of those things that you have opted not to cover, or you are ill or injured beyond the level of what is covered under the "basic" public care, and you have no private insurance.

What then?

then it is called tough ****. sounds cruel, but it is the reality under the current system as well when you hear stories like one i remember of a man being in severe pain and unable to move, laying on his back in his living room for weeks, with some kind of back injury, because there was not room for him.

we have seen time and again how government monoliths end up collapsing under their own weight.

yes, if an expanded system could be done, it would be better for "all", but to do so would require that such a system moved beyond the current scope of "healthcare" and into "lifestyle management" (not just to encourage proper diet and exercise, but to properly encourage proper use of the system. BC sent out a "treat yourself" booklet to every house a few years ago to help alleviate people going to emergency rooms for splinters (for ex). I have never seen any reports on if it was effective. I hope it was.)

But you and I both know that "tough ****" isn't going to cut it. Sooner or later those people will have to be treated. What happens when it is the parent of young children? What if it is a child? No reasonable society is going to be comfortable with the idea of just letting people die or suffer permanent disability without even an attempt at treating them, and so sooner or later they will in fact be treated, and the general public will have to assume the cost through one avenue or another anyway.

That is an everyday reality right now in the U.S. One reason our medical costs are as high as they are is because of all the uninsured people who wait until a problem becomes major and then seek care at an emergency room because they know that is the one place they cannot be turned away (by law). Rather than having had inexpensive preventive care or early care for a problem, they often present at the emergency room when the problem is so severe that it requires major intervention, and this intervention costs far more than the initial care would have earlier on. Yet because these patients did not have the money to pay for that earlier care, they receive the more major care in the ER or are hospitalized, and they then receive a bill that they usually cannot afford to pay. So in the end the hospital absorbs the cost, and in turn jacks up the cost of all services it provides, thus spreading the cost of treating the uninsured out over EVERYONE who uses that hospital. Some of that cost even translates into higher charges from the hospital to insurance companies, who in turn pass them on to their customers in the form of higher premiums. In the end, the general public still, winds up paying for the care provided to those who cannot afford to pay for their own, and yet the outcome of that care is often far worse for those patients than it would be under an outrightly public system, because they wait so long to seek treatment. So basically it's less for the dollar, rather than something reasonable, in terms of quality of outcome.

The other side of the coin, of course, is that sometimes people who do not have health insurance will go to the emergency room for a minor health issue (especially if it involves a child) that really ought to be seen in an office visit by a regular physician. Again, they cannot afford the office visit, and would turned away for lack of insurance were they to attempt to see a doctor in the office, but they will go to the emergency room because they know that they cannot be turned away there, even though the problem they are going there for does not belong in the ER.

the same stuff happens under a fully public system but for different reasons. that is why an expanded health public system would have to move more into "lifestyle care".

I do think the public system (either fully or private-public) requires everybody has a family physician. It also requires people use that physician appropriately! The same need for user awareness is necessary for emergency rooms.

just to play devils advocate, since i have filled up on IAC's rhetoric in the other thread: what is so wrong with letting people die? they are just doing their part to decrease the surplus population! (i am just joking, and remembering the old scroogie movie!)

I for one have no problem with it doing that to some degree. Better lifestyle education could save a lot of people a lot of health problems. Even HMO's in the U.S. try to do a bit toward that, including the one I worked for.

But when people do not have coverage to see a physician for a particular illness and the ER is their only avenue for obtaining care, that is when the problems develop. That's what happens here in the U.S. on a daily basis.

Hmmm.... where'd this handy cream pie come from?

Summer, I swear you are reading my mind. I have to laugh a little when Canadians talk about private health insurers as providing more choice (they don't!) or being more efficient (they aren't!).

On the matter of choice, I was not allowed to see just any doctor with my HMO. He had to be on the HMO's list. I couldn't go to any hospital. It had to be on the HMO's list. I couldn't get any test or treatment because it had to be approved by the HMO. With the PPO, I can at least choose any doc or hospital, but I still have to get their approval for tests and treatment.

On the matter of efficiency, time after time public has shown to be cheaper than private simply because they don't waste nearly as much money on administration (paying people like Summer's friends to refuse your claims) or paying their shareholders (the profit they make does not go back into providing good medical care).

I work neonatal intensive care and see first hand the amount of money wasted on treating emergencies that could have been prevented or minimized with a little early care. Unfortunately only the er has to treat patients, so that's where the uninsured go. No health care workers would ever deny emergency treatment based on the patient's finances, so those emergency room bills are not going to stop any times soon. And those who say they are ok with being refused emergency care are just lying.

Tracy, you and I have both seen it from the inside, as both patient and provider. It's amazing how much there is that really isn't visible from the outside, isn't it? I honestly never had a clue until a few short years ago.

I've got coverage under a PPO now, through my fiance. Costs a bundle, too, but beats being without. I've gone without insurance before, and was hospitalized for three days during that time with something that could have killed me if left untreated (a DVT). So I also know firsthand about how the uninsured use the system in the only way they can.

well, again i must state i am not suggesting an americian system of healthcare, so your HMO issues would not apply.

i am currently in the grey area in our system (unofficial private service and public service). I have 3 doctors, should i need them, the freedom to get whatever care i deem to be the most benefitial to me, the freedom to get tests when i want them (no cues). It is worth it.

Sounds like you're happy within the Canadian system then?

One of my coworkers recently got into a car accident. She will never be able to pay the bills. Over 20K for the emergency room care alone (not including her time in intensive care and general medical). And thanks to the new bankruptcy laws, she can't even do that to get rid of her health care bills. It's pretty sad when a nurse can't afford to be hospitalized in the hospital she works in day after day.

Yep. I couldn't pay my hospital bill, either.