Canada's single-payer healthcare system - a system in turbulence, but beloved nonetheless

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The war on doctors

Milan Korcok investigates the real cost of ‘free healthcare’ in Canada, the impact on employment within the healthcare sector, and the effect this has on access to care

For a nation that prides itself on its universal healthcare system, Canadians become ambivalent when faced with headlines proclaiming that their wait times for emergency room (ER) services are not only punishingly long, but among the ‘worst in the Western world’ as has been reported in the media by Robert Salois, a former Quebec Healthcare Commissioner, referring to conditions in his own province.

Citing data from 2016, Salois claimed that 35 per cent of Quebec’s ER patients had to wait five hours or more for care (with 10 per cent leaving without having seen a doctor), as did 19 per cent of Canadians overall. That compared – not too well – to only five per cent of Americans, Germans or Australians; or two per cent of Swiss, who hit the five-hour delay mark. 

Fast forward to December 2019: The Canadian Press reported that on the weekend before Christmas, the Montreal Jewish General Hospital (one of the city’s core healthcare facilities) was working at 157-per-cent capacity; the Montreal Children’s Hospital at 217-per-cent capacity; and hospitals and their ERs in outlying areas were just as overloaded. To put that into perspective, the international standard for optimal hospital occupancy has long been 85 per cent – with anything below 75 per cent being wasteful, and 100 per cent being too tight, with no room left for error.

Only 43 per cent of Canadians reported that they were able to get a same- or next-day appointment at their regular place of care

According to the Canadian Institute for Health Information (Canada’s primary source of healthcare data), in 2018-2019, Canadians nationwide spent a median of 3.2 hours in the ER per visit. But for 90 per cent of those visits, patients were there for 10.9 hours or less. In 2017-2018, the median time was 2.8 hours per visit, while for 90 per cent of visits, it was 7.9 hours or less. 

According to the US-based Commonwealth Fund, a respected monitor of international health trends, Canada continues to perform below the international average for timely access to patient care: only 43 per cent of Canadians reported that they were able to get a same- or next-day appointment at their regular place of care the last time they needed medical attention. And, when compared to those in Australia, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the UK and the US, Canada was rated the worst in terms of the ability to get a same- or next-day appointment when sick; waiting for treatment in the emergency department; waiting to see a specialist; or waiting for elective surgery. In terms of the ability to get after-hours care without resorting to an ER, it was second worst.
Fortunately, however, Canadians are a forgiving people. Most surveys indicate that once they get into the care of their doctors, they rate it as ‘excellent’ or ‘very good’. 

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Canadians actually do pay, a lot, for a system that is supposedly ‘free’ – they pay every time they fill their SUV with gas, buy a sweater, skates, or a bag of legal cannabis.

Hurry up and wait

Dr Kevin Smith, President and CEO of Toronto’s University Health Network (a consortium of five downtown university-affiliated hospitals), wrote in a Globe and Mail op-ed in November 2019: “Expecting high performance and the best patient experience in this condition is impossible. Overcrowded emergency rooms, long waits for inpatient beds or delays in getting care at home are the norm. Across Ontario, more than 5,300 people are in the wrong environment for their care or recovery. Most often, they are in acute care hospitals when they would be better cared for at home, in long-term care or rehabilitation.”

To attribute Canada’s healthcare access problem to sparseness of hospital beds or a low ratio of physicians to population would be to ignore the elephant in the room

Dr Smith urges a ‘renewed contract for healthcare’. “We must see a significant investment fueled by our federal government if we want universally accessible, medically necessary care to remain part of our national identity,” he said. He also warned that the challenges facing Canadians have an ‘extensive history’. “Those privileged to provide care have long sounded the foghorn. But never before has there been such a perfect storm. We are seeing an ill-timed collision of several factors: a growing population, clinician burnout, mental health and addiction issues, high occupancy rates of hospitals, crumbling infrastructure, funding that doesn’t keep pace with inflation, increasing need to help vulnerable patients, and rising expectations about the use of technology from patients and providers,” he said.

Dr Smith concluded that although many have spent entire careers working to improve the system through efficiency and redesign – and that many, including himself, will continue to do so – without increasing capacity in the health and social services systems, Canadians cannot enjoy the kind of care and innovation they deserve and have paid for.

And Canadians do pay – a lot, for a system many boast about as being ‘free’. It may be free in that Canadians don’t pay the high private insurance premiums that their neighbours in the US pay, but in 2019, total health expenditure in Canada was estimated to reach CAN$264 billion, or $7,068 per person. And overall, health spending will represent 11.6 per cent of Canada’s gross domestic product (GDP)*. And they pay every time they fill their SUV with gas, buy a sweater, skates, or a bag of legal cannabis. 

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Healthcare bureaucracies often shackle doctors with regulations that keep them from doing their work. 

It’s not all in the numbers

Certainly, Canada’s hospital bed count is not rich: only 2.8 beds per 1,000 people, about the same as the US (2.6) or the UK (2.9); but far below Germany’s 4.3 and Austria’s 5.2. But numbers such as those don’t tell the whole story. They don’t reflect how those resources are used. More beds or more physicians don’t necessarily reflect better care. And to attribute Canada’s healthcare access problem to sparseness of hospital beds or a low ratio of physicians to population would be to ignore the elephant in the room: a chronic maldistribution of physicians in many communities throughout the country, as well as persistent underfunding by both provincial and federal governments and regulatory hurdles that keep physicians from doing what they were trained to do. That’s as pertinent in Canada as it is in the US, the UK or France.

In Nova Scotia, for example, maldistribution is endemic, and shortages of physicians – whose earnings are below those of colleagues in other provinces – have led to frequent closures of hospital emergency rooms. There just aren’t enough doctors to cover them all. 

In one television interview, Dr Brian Ferguson – a family practitioner in Amherst, Nova Scotia – noted that when he recently closed his practice due to his own health problems, he had to leave 3,000 patients to seek out other practices. And he admitted that he has also had to advise young potential recruits to move to other provinces where they would get paid more and taxed less.

We are in the midst of the worst healthcare crisis that Ontario has ever seen

No shortage of health bureaucrats

But there is one healthcare ranking in which Canada excels: healthcare bureaucrats.
Canadian healthcare blogger Dr Shawn Whatley has starkly underlined what many doctors see as a major impediment to patient access: bureaucracies and their tendencies to shackle doctors with regulations and useless requirements that keep them from doing their work. He writes that Ontario closed 17,000 hospital beds between 1990 and 2013, yet has not cut a similar number of bureaucrats. In fact, it has allowed their numbers to blossom. 

Citing data compiled in 2015 by healthcare analyst Matthew Lister, Dr Whatley notes that Canada has 32,000 healthcare bureaucrats (these are government appointed managers and directors of local or regional boards, networks charged with evaluating and facilitating the work of doctors, nurses and physicians’ assistants who are the hands-on healthcare providers). That number, reports Lister, equals 0.9 healthcare bureaucrats per 1,000 population. To compare this to other regions, Sweden has 0.4 bureaucrats per 1,000 population; Australia, 0.255; Japan, 0.23; and Germany only 0.06 bureaucrats per 1,000 population. From a different perspective, Japan has 30,000 healthcare bureaucrats for 130 million people. Canada had 32,000 bureaucrats for 35 million people (in 2015). 

Jeff Yurek, Environment Minister and Conservative party MPP for Ontario, wrote in 2017 that the Ontario College of Family Physicians listed some 10,500 family physicians in the province (in most of Canada, certified family physicians provide the core of primary care doctors). At the same time, the Ministry of Health and its various agencies, consultancies and partnerships were charged with employing an additional 13,000 employees to administer within the system. 

Is the ship tilting?

If there seems some imbalance here, that may account for the fractious relationships not only between doctors and their Health Ministry paymasters, but within the organisations that have been representing physicians in their dealings with the health ministries that fund hospitals, direct and channel healthcare resources, and determine how much of the public purse can be devoted to physicians’ costs. 

Though the great majority of Canadian physicians are private practitioners responsible for paying their own facility rents, staff salaries, equipment and all other components of their businesses, their incomes are tightly controlled through Schedules of Benefits negotiated between Health Ministry number crunchers and provincial physician associations. These schedules list the allowable fees for thousands of medical services, and they are not guidelines. They are firm and procedure-specific. No ‘balance’ or extra billing of patients is permitted, and private insurance for those services is banned, although two-thirds of Canadians have some private insurance for supplemental services such as drugs, eyeglasses, dental services and some elective items such as cosmetic services.

For over 139 years, the Ontario Medical Association (OMA) has represented doctors in the province, but for five years has been unable to win a Schedule of Benefits contract from either the previous Liberal government or the current Conservative one. And the troops are restless.

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Dr Brian noted that he has had to advise young potential recruits to move to other provinces where they would get paid more and taxed less.

In 2017, the executive committee of the OMA was pressured into resigning after a no-confidence measure against its proposed contract with the provincial government was passed by the association’s 260-member governing council. That contract offer would have provided an annual 2.5-per-cent increase to Ontario’s physician services but was criticised as not sufficient to keep up with inflation and other physician attrition issues.

In the meantime, several groups have splintered off from the OMA, among them the Concerned Ontario Doctors – composed mostly of frontline, primary care and family physicians advocating a reduced bureaucracy, a stripping down of the health system to a more lean and efficient mechanism that puts patients first and addresses the problem of physician burnout (early retirements are rampant) and high suicide rates.
Said Dr Kulvinder Gill, President of Concerned Ontario Doctors: “Today we are in the midst of the worst healthcare crisis Ontario has ever seen... this did not happen overnight. It is the result of years of complete and utter neglect and gross mismanagement of our once great healthcare system.”

Specialists too have torn away from the OMA to form their own Ontario Specialist Association, believing they can do a better job of representing their interests vis-a-vis government negotiators.

the average Ontario doctor billed $348,000 in the 2017-2018 fiscal year

Negotiations turn ‘hardball’

In 2018, partly to bolster its assertion that Ontario’s physicians’ wages were more than adequate, the Health Ministry released earnings data on the top 100 physician billers to the Ontario Health Insurance Plan (OHIP), and then followed up with the names of 518 physicians who billed more than $1 million. 
The reaction of physicians (and their advocacy organisations) was predictably curt – emphasising that many of those individual bills actually covered group-type practices billed under lead physician’s names – however, the doctors and other professional and clerical staff weren’t listed on these. Such billings also accounted for the cost of facility rents, equipment, pensions, and all of the overhead operating costs of running a business serving thousands of patients.
The OMA emphasised that the Schedule of Benefits needed to be totally updated, that they were complex and confusing with more than 7,000 different, often arcane, billing codes.

To roil the storm waters even more, the politically left-leaning Toronto Star – Canada’s largest circulation newspaper – won a freedom of information action against the Health Ministry, gaining online access to the billings data for all 30,167 doctors who received fee-for-service payments from OHIP in 2017-2018, and made them accessible through its website (just please contribute to the paywall first). All that Star subscribers have to do is punch the doctor’s name into their laptop and there it is, bold as brass: how much their friendly obstetrician or family physician ‘made’ last year.
To give it its dues, the Star did mention that the total billings shown were not the same as income, that there were overhead costs such as rentals and staff to consider. But despite that footnote, the damaged was done,
and even reinforced, when Ontario Health Minister Helena Jaczek confirmed to media that the average Ontario doctor billed $348,000 in the 2017-2018 fiscal year**.

Ever since medicare was enacted in Canada in 1966, when federal legislation pledged that the financing of provincial healthcare plans would be cost-shared by the provinces and Ottawa on a 50:50 basis (a pledge long since abandoned by the feds in favour of a contorted system of tax point trade-offs), tensions between the care providers on the front line and their paymasters have continued to intensify, becoming ever more turbulent. But, quite astonishingly, even as those tensions proliferate and access becomes more limited, poll after poll shows that the vast majority of Canadians love their medicare. In fact, 94 per cent consider it a source of national pride***. Go figure.  ■