WCHL Your Health Radio, Nov. 16, 2011
The following text is an unofficial transcript of a radio broadcast titled “Demystifying the Canadian Health System” featuring Dr. Khati Hendry. She appeared on “Your Health Radio with Dr. Adam Goldstein and Dr. Cristy Page” on WCHL 1360 AM on Nov. 16. The program is produced weekly by the Department of Family Medicine at the University of North Carolina. A link to the podcast of this broadcast is available here.
Dr. Cristy Page: I’m Dr. Cristy Page and I’m joined today by guest host Dr. Rob Gwyther from the Department of Family Medicine at the University of North Carolina. On our show today we are going to talk with family physician Dr. Khati Hendry about “Demystifying the Canadian Health System.” She practiced in the United States for many years, but now she’s a practicing family physician in Canada.
Dr. Hendry is a U.S.-trained family physician like me and Rob but she has worked in British Columbia in a private family practice since 2004, so she has experienced both sides of the health care systems in the United States and Canada.
Dr. Rob Gwyther: So I’d like to start by figuring out just what you’ve done in the United States and what you’ve done in Canada so our listeners will understand what your references are.
Dr. Khati Hendry: Thanks for having me. I actually spent more time in the United States than in the Canada. I am an American, a U.S. citizen, and I did my training in the U.S. Then I got my dream job working in a community health center in Oakland, California, oh, way back when. I was there for almost 25 years.
Dr. Page: Wow, that’s real service.
Dr. Hendry: Yes, that was quite a bit, actually. So while I was there, the clinic grew, I had more responsibilities, I was the medical director there, and then I was the medical director of a whole network of community health centers in that area. I got pretty heavily involved in administration, and when other opportunities came up, and personal things like getting married and so on, I had a chance to move to Canada. So I worked in the Oakland area for 25 years and I’ve been working here for the last seven years or so as a family doctor.
Dr. Page: So you’ve really had experience that is more than just a glance at each of the health care systems.
Dr. Hendry: Yes, I feel like I’ve had a quite intimate look at a number of issues that people are concerned about on both sides.
Dr. Gwyther: So I’d say in this country people who are physicians are pulling their hair out because they’re not satisfied with the system. Lots of patients don’t have access to this system and are not happy about that. It’s about to bankrupt the country and everybody in Washington is screaming and yelling. The Canadians, by repute in this country, have a pretty good system. People have access to the system and they seem to be more content. Is that your experience?
Dr. Hendry: That is exactly my experience. Actually, I have to say that when I moved up here and started working it felt a little bit like I had finally stopped banging my head against the wall. It felt really good to stop. [Laughs.] So, no, it’s quite a relief to be working in a system where you’re not spending most of your energy essentially fighting to make things better for your patients — fighting the insurance companies, fighting the rules and regulations, things changing underneath you all the time, worrying about patients who you can’t get what they need. It’s been an amazing journey, one that I’ve been really happy to be able to make.
Dr. Page: How does it relate to primary care being a family physician or being a patient receiving primary care. How would you summarize the major differences between the two systems?
Dr. Hendry: Well, as far as the medical care goes, it’s really hardly different at all. In other words, I might see someone in my office – they’re going to have same colds, they’re going to have the same problems, and I’m going to be bringing my same expertise there, be ordering the same tests for investigation, and I’ll be making my referrals. So in terms of day-to-day seeing patients, it’s not that different. What’s really different is the context in which it’s happening. It might be helpful just to give a little example. I’m right now in my office and saw patients all morning. So what happens is that they come in the door, they say hi, they have their card, their number, whatever. No one has to check for whether or not it’s still valid, or whether they changed from one plan to another, or if they have co-pays that they need, or anything. They just come in for the visit. They go down the hall and I see them. I do whatever is necessary. I don’t have to fill out any extra forms. I go to my EMR, my electronic medical records, I put down what I did, and it gets sent off by the one, part-time bookkeeper, who serves the six-physician practice, and I get money.
Dr. Page: Hm. That sounds really heavenly.
Dr. Hendry: It’s amazing. It’s amazing what you don’t do in all of that, you know? You just cut right through it. You’re taking care of patients and being concerned about their medical issues. I’m practicing medicine, not paperwork.
Dr. Gwyther: So if you talk to people in this country they sort of in knee-jerk fashion say, “Oh, we couldn’t have socialized medicine here.” We have to have our system, which is in incredible disarray. So here’s my questi
on: You, as a Canadian physician, are told what you’re going to earn and how things are going to go by the government, they become the single payer, and if you’re going to have a contest between the medical establishment and the government, that’s how things are going to be ironed out. In this country, most physicians are working for a bunch of insurance companies, and if they wanted to take them on, they’d have to take them on one a time. So which is the one that you think enables you and your patients to benefit the most?
Dr. Hendry: Well, I have to say that it’s really nice not to be spinning your wheels, dealing with a multiplicity of people to fight against, for starters. And the thing that the government tells you what you’re going to get is kind of an oversimplification. I think a lot of people don’t realize that medicare – and this is kind of ironic, but the name of the system in Canada is medicare …
Dr. Gwyther: We stole it. [Laughter.]
Dr. Hendry: So, you know, people who have Medicare in the U.S., for the most part, even though there are of course things that they might want to improve, it’s generally been a pretty popular program and it’s incredibly popular here in Canada. People give it very high marks and say they don’t want to get rid of the system, just like people don’t want to get rid of Medicare in the States. In terms of the government telling you what to do, it’s a little more complicated. There’s a Canada Health Act, and there’s a federal level in which there are certain things that need to be included in the health care systems in the provinces (provinces are our states). Each province actually has the authority to modify what that plan looks like, they just can’t go below the basic requirements. So they can add other things, tweak them, and in addition, each province negotiates with the medical association for how they’re going to pay the physicians. So physicians have quite a say in it, there’s a back and forth as these negotiations go on, and it’s not the same from province to province, but there’s an agreement on a fee structure. And I know people in the U.S. are familiar with fee structures from all the different insurance companies, but we have one fee structure.
Dr. Gwyther: And everybody goes home at the end of the day and that’s what you’re going to get, you don’t have to negotiate with five different vendors.
Dr. Hendry: Yes. If you’re going to get X amount of money, that’s what you get. And the other thing is that you get it. Or you almost always get it, I mean unless you did something egregious. They way it used to be in the States, I remember, you would submit your bill and maybe you’d get it and maybe you wouldn’t. Maybe they would have changed the goalposts, maybe you would have spent six months trying to get paid. But here, essentially, you have an agreement about what you’re going to get paid and they pay you. They don’t micromanage.
Dr. Page: It sounds like it’s cutting out a lot – you mentioned the paperwork before, and you mentioned that you have this one part-time person who’s helping to submit this for six different doctors.
Dr. Hendry: Right.
Dr. Page: Whereas in the United States we pay all this money to try to keep our practice open to have all these people who are helping with paperwork, signing for the bills, working with the insurance companies, and all this. And it sounds to me like it’s simplified a lot in your office. And has that borne out to be true for you?
Dr. Hendry: Oh, unbelievably so. And it’s much simpler also for the patients, because if I want to send someone to the hospital or a specialist I don’t have to worry about what plan they’re in, whether we have an agreement with it, or whether it switched from one day to the next. You know, you probably have this – one of those handheld Epocrates-type programs … the applications.
Dr. Page: Yep.
Dr. Hendry: You know, you have the 50 different formularies that you can use, special apps. There’s no need for an app here, because everyone basically has got pretty much the same plan.
Dr. Page: You can prescribe a medication and it will be paid? Or do you only have certain medications that are on the plan that you can choose from?
Dr. Hendry: Well, actually, that’s an interesting point, because the Canada Health Act provides for medically necessary services, which includes doctor visits, hospital visits, and the supporting tests and examinations. Pharmaceuticals were actually not part of that original plan. Some of the provinces, all of the provinces, have made different efforts to try to include that. But that’s one of the things that needs to be reined in, in terms of costs in Canada, is how we deal with pharmaceuticals because there isn’t a federal plan for payment. However, we don’t have a lot of different plans that tell you what you can and can’t prescribe. There’s a share of costs for most places, a few provinces do have pharmaceutical coverage, but it’s not quite as straightforward as medical services.
Dr. Gwyther: We need to take a short break, but when we return we’ll continuing talking to our guest, family physicians Dr. Khati Hendry about demystifying the Canadian health care system. We’ll be right back with Your Health.
Dr. Page: Welcome back. You’re listening to Your Health. We’ve been talking with Dr. Khati Hendry about demystifying the Canadian health care system. Dr. Hendry is a U.S.-trained family physician who spent 25 years working in the United States and has spent the last seven working in Canada. But we were talking a little about socialized medicine, or this fear that having a single-payer system is socializing medicine. And one of the things I hear a lot from people in my family and peopl
e who are concerned about any talk of that in our country is this perception that people are waiting in lines, that care is getting rationed out, and that if you want a transplant you can’t get one because of the long lines. Tell us how that bears out, or is that true?
Dr. Hendry: Well that is certainly not my experience at all. One of the things is that people have their own ideas of what it looks like. It’s very ironic. I moved to Canada and immediately I am working in a private doctors’ office. I have much more say over how I take care of my patients – more than I ever did while working in the States, where I was an employee and I had people micromanaging me, almost on a daily basis, from all the different insurance companies to the government agencies and everything else. I have to say there is much less intrusion by government or any kind of insurance agency here in Canada than there is in the United States. That’s No. 1. The other thing is that a lot of people think we are all employees of the government, and that is absolutely not true. Most of the doctors are in private practice. We have a fee scale we have agreed to through negotiations with our medical associations. So that is a single-payer source so it is publicly administered, but it’s not government officials that are running it. It’s the doctors who are running the medical system in terms of defining what we want our patients to have, and so on. The questions of lines, it really just has to do with supply and demand. If you’re in a rural area – we’re a big country, so you have a lot of rural areas – you’re not going to have immediate access to some specialists if you’re up on the Northwest Territories, for example. So obviously…
Dr. Page: That’s true for rural America as well, right?
Dr. Hendry: Exactly. And the other thing is that there are some issues with overtreatment when you have too many specialists. Because if they’re there, they’re going to want to work, right?
Dr. Page: Yes.
Dr. Hendry: So there is a better distribution I would say throughout the country. The places where people run into trouble are either where you just have a shortage of doctors – and again that is mostly in a rural areas, not unlike many other parts of the world – or in places where you have not as many specialists as you need. And in elective areas.
Dr. Page: So what about the concern that, you know, I want my knee replacement, it’s not emergent, but I’m going to have to wait forever to get one?
Dr. Hendry: Well you won’t wait forever. I mean, you might get it next year instead of this year, but you don’t wait forever. But people are still concerned. You know, everyone is very involved in their medical care because we’re all part of the system, so people are quite vocal about it, so you certainly hear about it, but in fact if people need a knee replacement, they will get it, and they will not go bankrupt from it, and they will have it done at a reasonable time. So what have they done to deal with that — they have developed a wait-list system throughout the country, and each province has a different way of dealing with it. They’ve worked on different ways to expedite some of these elective procedures that people want to go faster. In British Columbia, for example, they have a website where you can go and see who has shorter wait times and then ask to be referred to a physician who has a shorter wait time. So people are working on it. But it’s only the elective stuff, not the emergent thing.
If you can bear with me for a second, for orthopedics — I often had a hard time getting services for my patients when I was in the States. I don’t know if that’s your experience, but it turns out that it’s not always that easy to get exactly what you want when you want it in the States either, especially in the safety-net. But here, if I have someone who really needs something, they get it. There is an orthopedist 24/7 at my hospital.
If someone has a fracture or an acute injury they go there and they’re seen that same day, and again, no one goes broke for that because they don’t have to pay extra for it. I have never, ever been in a situation here that I was in in the States where I had to have a patient make a decision about a life-threatening situation versus financial disaster.
Dr. Page: That’s a common scenario in our country.
Dr. Hendry: And you have a million examples of that. But I had a patient I thought was having a bleed into his brain, a subarachnoid hemorrhage, and was trying to convince him to go to the emergency room. He was terrified because he had no insurance and it would be expensive.
Dr. Page: That would be the United States.
Dr. Hendry: Yes, in the United States. I’ve never have that problem here. It wouldn’t be thinkable.
Dr. Gwyther: I remember seeing a movi
e where the question was asked of a couple of Canadian citizens who wanted to come to the United States for a wedding and their family and that they bought some kind of insurance for a couple of weeks so that if anything happened here they’d be taken care of. They were that afraid to come here because of the possibility of that happening.
Dr. Hendry: People are terrified of that. Absolutely you need insurance when you go. We do have snow up here, you may have heard of that [laughter], so quite a few people are snowbirds and they go south, many go to the States, and they always have insurance. And I get people coming back who had things happen in the States and still end up with thousands and thousands of dollars of debt, even after their insurance paid. If it had happened in Canada they wouldn’t have had any of that.
Dr. Gwyther: That’s absolutely amazing to me. So do family doctors play the gatekeeper role in Canada?
Dr. Hendry: Well, actually we do, in part because it’s much more family-practice friendly. Everyone is used to that’s how you get care, you see your family doctor, which, as a family doctor, I love. It’s not overly specialized in that way. But if someone wants to see a specialist, then I refer them. So yes, I’m a gatekeeper. Now you could go and see a specialist on your own if they would see you, but most of the specialists won’t do that, because they don’t get a specialist consultation fee that doesn’t come from the family doctor, so there’s nothing prohibiting them from doing it, but they prefer the family doctor send them. The other thing which is kind of interesting is that not only is it family-doctor friendly, but the pediatricians and internists in Canada are specialists, meaning that people don’t go there for their primary care, they’re referred there by the family doctors for a specific issue.
Dr. Page: Interesting. What about a medical home? Are people attached to you and your practice as a place that they receive primary care?
Dr. Hendry: Oh, completely.
Dr. Page: That’s wonderful.
Dr. Hendry: Yeah. You go to your doctor, that’s your doctor, right? And so that’s your medical home. Now there is a lot of interest in Canada in improving the medical home and making sure everyone has one, because we still do struggle with that, making sure that everyone has their own family doctor and that’s a really big issue for people. It’s being done differently in different areas. So in Ontario, for example, they’ve used a lot of multidisciplinary clinics, settings, and in that city usually there is some combination of salary and fee for service, and then in other areas, no so much. So it’s being experimented with differently across Canada. Absolutely, that’s the idea – for everyone to have their own family doctor, have a place that they go, have their medical home.
Dr. Gwyther: Do you have what’s called “pay for performance” down here up there, where if you do certain things you’ll make more money because your payers are telling you it’s the right thing to do?
Dr. Page: Or a way they monitor the quality of care?
Dr. Hendry: Not exactly the way that they have it in the U.S. There’s a lot of discussion about whether there might be some role for some of that. In my office, the closest thing I could say is that we get to that is the incentive program for family doctors to encourage us to take care of people with chronic illnesses and do maternity care and people in nursing homes, and so on. So there are special fee codes that we can submit for doing full-service family practice, essentially, which is more financially attractive than just doing walk-in clinics, or something like that. That’s not exactly pay for performance, but it is getting paid more for doing certain types of services. It’s certainly not punitive in any way. There is also some experimenting for increasing the elective surgeries in which hospitals get more money the more surgeries that they do, which is a little bit of a twist on what they’re currently doing.
Dr. Page: We are going to have to wrap up our conversation, but Dr. Hendry thank you for taking the time to talk with us and really you did demystify some of our questions and what I hear a lot of concerns about the Canadian health care system. It doesn’t sound perfect, but, gosh, the idea that you can see patients and take care of them without 12 different arguments about how to get paid sounds pretty dreamy.
Dr. Hendry: Can I just say one parting shot? And that is that one of the things I’m most impressed with is that you don’t lose your insurance. In other words, no worries about pre-existing conditions, if you lose your job, you don’t lose your insurance. If you have dependents, are married or not, or whatever, you still have the insurance. So you don’t lose it. You always have that sense that you’re taken care of and that you belong and people aren’t going to leave you in the dust or make you bankrupt. People are worried about their health and getting better. They’re not worried about the bill they’re going to get at the end of the day.
Dr. Page: Thank you for making that extra statement. It’s hard to end the conversation because there are so many questions about how it works over there, but you are good neighbors and we appreciate your taking a moment with us to demystify the Canadian health care system.
Dr. Hendry: Thank you.