Healthcare difference part II……….Rationing in the US

Anticipating the differences between the US and Canada, I focused on the rationing of healthcare. When most folks I know talk about the difference between the delivery of health care in the two nations, rationing and quality are two differences that stand tall among the potential pitfalls of a nationalized system. Rationing occurs in both systems, the prime difference is the transparency with which it occurs in each system.

Rationing in the United States
Many people are surprised to learn that rationing of healthcare resources does in fact take place within the United States, and the absence of transparency is why most American do not recognize the rationing. The rationing of healthcare in the US occurs in two forms- insured and uninsured.

Uninsured
If you are unfortunate and lack health care insurance in the United States, then by definition you ration the health care that you receive from the system. You ration your healthcare because you have no choice, it is simply too expensive to be sick, and even more expensive to purchase insurance. So like most folks when money is short, you do without things that seem to be luxuries. This means that you do not enter the healthcare complex until you have no choice, and enter the system when your health has deteriorated to such an extent that you must enter the system because you are simply too ill to do otherwise. This illness may be something seemingly innocuous such as a bad case of the flu, or something more complicated. In the end, it means a trip to the emergency room/urgent care/walk in clinic for the help. Often the choice of where to enter the system is dictated by the available cash on hand, with those who have the fewest resources shunting to the emergency department for their care. Unfortunately this means that they are entering the system at the most expensive point.

This makes little sense economically but it is one of the only ways people can be guaranteed that they will be seen and treated, and it is the Emergency Medical and Active Labor Act that makes this possible. This obliges the emergency department to make sure that the patient does not have any life threatening illnesses and that they are medically stable before sending them home. This does not mean that everyone has to be treated, but in a practical sense, everyone is. The line between diagnosis and stabilization to treatment is very small, so it makes little sense not to just finish the work. This is in part why so many people arrive for prolonged waits in the emergency departments across the US. Patients who have more discretionary spending often go to the Urgent Care or Walk In clinics to be seen for their minor ailments. These clinics are far more efficient than the Emergency Departments, but payment is expected at the time of service. In both cases, the treating provider has no obligation to care for the patient beyond their encounter, that is, they have no obligation to look after the long term chronic health care needs of the patients they treat. In essence they are rationing the care they deliver; they do not deliver the long term care.
If you need hospitalization and you lack health insurance, then this prospect is a nightmare. The EMTALA obligates the hospital to admit you to the hospital, stabilize you condition, and then look toward discharge. Hospital costs are such that even an overnight stay in the hospital may cost you over $1500 which for a family of four with two working parents earning $50,000 a year will find difficult. Additionally most folks without insurance work in jobs where there is little if any paid sick time, so there is the burden of lost income for the period of time you are hospitalized as well as any time spent recovering after you leave the hospital. In fact recent studies (prior to the economic slump) indicate that health care expenses contribute to bankruptcy in 50% of the cases and when looking at housing problems (failure to pay rent or mortgage payment), 25% are due to healthcare expenses.

The Insured
If you are one of those fortunate enough to have insurance, you are still subjected to health care rationing, but unlike the uninsured, it is often a more complex form of rationing that takes place. It is not called rationing in the usual sense; it is couched in terms such as “covered services”, “preferred provider”, “pre-existing condition”, and “denied claims”. Here is how it plays out from the perspective of a physician inside a very organized integrated health care network.

When a patient presented to be seen in the clinic everything went very well as long as I did not ask the system do more than it was prepared to accomplish. In other words, if I saw the patient, diagnosed the condition, and treated it then there was no particular problem. However, if I wanted to involve other providers, provide more than one type of service on the same day, or provide care that was outside of the usual scope the rationing began. As an example, if I a patient can to me with a mole on their skin that was concerning and I determined that the mole should come off, then proceeded to remove this mole during the same visit, it was often not paid. What this meant to the patient was inconvenience, in that I would diagnose them and have them come back on another day for the procedure that should have taken place at the same time as the initial visit. If I wanted more specific testing it often required additional paperwork to be completed in order to justify the service. Often this would involve a phone call to someone who would approve the service. These same steps were required when medications outside of the formulary were required, or when a referral to a specialist was indicated. These additional steps increased the time line for a patient to obtain the services, and each step provided an opportunity for the insurance company to decline the coverage. Often after a claim had been submitted, additional paperwork would come through that would essentially be asking if the condition being covered might have been a pre-existing condition. If you are unfortunate enough to be found to have received services for a pre-existing condition, then the claims will be denied and you will be stuck with the bill for any services that can be related to that condition, after the fact.

An additional component to the rationing of health care for the insured patient is the conditions and services covered as well as the amount of coverage for these conditions. The fact that you have insurance is not a guarantee that you will receive treatment. If you need treatment for a condition that is not covered by your plan then you are out of luck. Likewise, the type of treatment that you may be eligible to receive will depend on the terms of you plan. These terms may change without your notice, and you may be left holding the bag. Finally, if the cost of your care exceeds the threshold of the plan, then you insurance runs out and ceases to pay for any additional costs. This is in fact rationing. If you have insurance and you do not need much then you get what you want without any real trouble. If you have significant needs, then it is likely that the insurance company will ration your access until you run out of coverage or they find a link to a pre-existing condition that allows them to decline payment for the claims. If you are uninsured you really only get acute treatment and nothing more, at great cost.

In the case of the US, the rationing that occurs is done in a manner that is not transparent and is without any recourse. You cannot vote out the people who have rationed your healthcare, you cannot sue the insurance company that has decline your care, and the majority of people cannot afford to get sick. In a system where healthcare is nationalized transparency is a key element to the rationing of care…..more to come.

Comparison Shopping for your Health Care System Part 1

In the end you are still taking care of the patient

Since I have been in practice in Canada for six months I thought it might be time to reflect on the similarities and the difference s between the US and Canadian system of health care. As a reminder, I am a Family Physician. This means that I take care of whomever walks through my office door to the best of my abilities regardless of age, sex, or ability to pay. I see everything, and refer to specialists when I am out of my comfort zone, or have run out of good ideas. So a good place to begin our review would be in the typical clinic day.

The View From Texas

When I practiced in Killeen for Scott and White my day started in clinic around 8:30. I would see a patient basically every 15 minutes until 12pm, break for lunch, and start at 1pm and continue until 3:45pm. This resulted in seeing about 26 patients a day give or take (depending on how many physicals I had that day).

I usually arrived earlier in the morning to try and answer all the patient messages, look over lab results, complete forms, and answer e-mail prior to the first patient of the day. I dictated my charts as I went and that usually took 2-3 minutes per patient so I spent roughly 10-12 minutes of each visit with the patients. During that time you would try to complete all the work that needed to be done for this patient. The presence of the electronic medical record allowed me to review all the visits since the last time I had seen them as well as all the specialty visits. It also let me look and see if they were up to date on their labs, preventative care, and such. Some days the computers worked well and this did not take much time, other days they were slow and it became difficult. In general, my patients were older with my average patient being late 60s early 70s with the occasional child thrown in for variety. If a patient needed a procedure done often it happened during their visits, or was quickly scheduled for my dedicated procedure day.

The days felt very busy and I usually returned home feeling fairly worn down. I usually left the clinic in Killeen after 4:30 or 5 pm and then headed to the house. As part of my practice in Texas I did the occasional delivery usually in the wee hours of the night, and one week of every six was spent working in the hospital taking care of the hospital service. On the whole, the patients that I took care of in clinic and in the hospital were older sicker folks.

The View From Prince Edward Island

My practice in Canada is usually starts around 7 am with hospital rounds at the Alberton hospital where I see my one or two patients, then I drive to O’Leary for hospital rounds on my one or two patients. I arrive at the clinic between 8:30 and 9 am to begin my clinic day. I see a patient every 15 minutes from 9 am through 11:45 and then from 1 pm until 3:45 pm give or take I see between 23 and 25 patients a day depending on the number of work-in patients.

During the visit you work on many of the same issues as I did in Texas, catching up on preventative health care, reviewing labs and such to monitor chronic illnesses, and cajoling patients into changing their lifestyles. Since the notes are handwritten, there is no time spent dictating the chart (and thus no time spent signing off on dictation). Since it is a paper chart, there is a bit of work to keep the flow-sheet organized so that you do not have to dig through the chart each time you want to review preventative care. Because of the manner in which the clinic is arranged, it is difficult to perform procedures in the clinic, so I often send those to myself when I am going to be working the urgent care clinic. You still have the usual lab to sign off on, as well as the consults to review and such, but the paperwork that seemed to be such a large part of my practice in Killeen is not here. I do not have any pre-approval insurance forms to complete, and I cannot think of the last time that I had to complete a Pharmacy Assistant form for anyone. The patients do not seem as ill either. I have some terribly sick patients (i.e. the renal failure alcoholics with diabetes) but they are not as big a part of my practice as they were in Texas. The pharmacy does not fax forms to me for refills, they either refill the medications for one month and have the patient make an appointment to be seen, or they call me directly during the day and I give them the go ahead. This relieves all the pharmacy paperwork that I had from Texas and it was a huge chunk of my paperwork.

There are some distinct differences in the prevalence of certain medical conditions, specifically thyroid disorder, crohn’s disease, celiac disease, and cancer, but I think that these represent the effect of a small isolated population (after all there was no direct connection to the mainland until 20 years ago). I usually complete all my work by 4:30 or 5 pm and head home. I am no longer delivering babies so I do not have those night-time calls. There are two duties that I did not have in Texas that are part of my practice, the Urgent Care Clinic and the Emergency Room. On average I have one call in each location weekly. Usually they are back to back where I work the UCC one day and the ER the next. The hours for the UCC are from 8 am to 8 pm and the volume is variable. The ER is a 24 hour shift, and volume is steady but manageable. As influenza has arrived in our part of the island, the UCC and ER have become very busy places. Despite the addition of daily hospital work and the shifts in the ER and UCC I do not feel as tired as I did when I was in Texas.

Quelle est la différence?
The question in my mind is why am I less fatigued than when I was in Texas. I have been giving this a great deal of thought over the last weeks and I have come to a couple of conclusions.

First, the ever present push in Texas to see more folks all the time felt like a weight on you back. The addition of 3 patients a day meant an additional 15 people a week really seemed to increase the work load (especially when you translate that into the additional dictations, labs, and pharmacy faxes).. Where I feel like I have the time to talk to folks here, I never really felt that previously.

Second, the patients have a different level of expectation in Canada. In the US I always had the feeling that patients wanted everything done all the time whether they needed it or not. I felt like I was always counseling patients about why they did not need antibiotics, an MRI, or a CT scan. The sense of entitlement that I felt form the patients in the US was always present as was a continuing concern that someone was going to file suit for the care that you provided. I am not saying these are rational feelings, but they reflect the feelings of the day when I was practicing. As well, my conversations with my colleagues during lunch confirmed that others felt the same way. The patients here do not demand that everything be done, and if you are sending them for extra tests, they do not fret if these tests take a couple of weeks to get accomplished. With the malpractice laws in Canada, the frequency of litigation is low, and patients do not seem to view it as a lottery like chance for a big win.

Finally, paperwork here is not nearly as onerous as it was back in the Texas. I know it goes against what I initially expected from a government run system, but the amount of paperwork that flows through the clinic is not nearly as copious. This burden was one I did not really appreciate until it went away, and I do not miss it one bit.

Well that is the first view of the similarities and differences. I will post more on this subject over the course of February and try to continue to fill in the gaps so you get a good feel for what is working and not working in both systems. Stay tuned.