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Canadian Psychiatry: The Case for Universal Health Care and How Psychiatry Benefits


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Presentation on universal healthcare in Canada and how psychiatry benefits. Portland, Maine, October 20, 2009, Psychiatry Grand Rounds at Maine Medical Center

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Canadian Psychiatry: The Case for Universal Health Care and How Psychiatry Benefits

  1. 1. Canadian Psychiatry: The Case for Universal Health Care and How Psychiatry Benefits Carlo Carandang, MD Assistant Professor, Dalhousie University Department of Psychiatry Attending Child Psychiatrist, IWK Health Centre Halifax, Nova Scotia Canada
  2. 2. Canadian Quiz • How many provinces and territories? • 10 and 3 • What are the 2 main languages? • English and French • Which States border Canada? • WA, ND, WI, MI, NH, VT, ME • Capital of Canada? • Ottawa • Name the 3 largest Canadian cities • Toronto, Montreal, Vancouver
  3. 3. The Health-Care Crisis Hits Home - TIME Source: When my brother got sick and his insurers refused to pay, he needed help. After a dizzying, infuriating trip through the system, here's how we found it
  4. 4. Facebook Debate • Carlo - Move to Canada...all Canadians have health coverage, just like the rest of the First World Nations. The USA is the only Western nation without comprehensive health coverage for all its citizens...what a travesty. Health care is a basic human right, not a commodity to be traded on Wall Street.
  5. 5. Facebook Debate • S - I guess the current debate here is whether healthcare is a fundamental right or a privilege. There are strong opinions on both sides. I don't even think that all doctors agree.
  6. 6. Facebook Debate • B - A right? Really? That's a pretty slippery slope. I think freedom is a basic human right, freedom to make choices in your life that result in your ability to secure your own health care, housing, fine dining and plasma TV...if you are in dire need, there are organizations out there to help you avoid dying due to lack of resources to pay for the basics but no one has a right to comfort. It something you earn...
  7. 7. Facebook Debate • T - Got to agree with B on that one!
  8. 8. Facebook Debate • Carlo - Been on both sides of this debate, on one side as an American doc and now the other as a Canadian doc. What's a right for Canadians may be a priviledge for Americans. S, where do you stand on this? I see the Porsche on your profile may be giving your answer!
  9. 9. Facebook Debate • J - Unfortunately, we know all too well from our experience that even the basics are sometimes not available....right, Dr. S?
  10. 10. Facebook Debate • S - It's wonderful to have a group of Facebook friends that are on such opposite sides of this debate. Credit my conservative upbringing in East Texas and my liberal education at UT- Austin. Unfortunately, human beings don’t make the best healthcare decisions for themselves or financially. Even if they are insured. There are people who smoke, drink, do drugs, eat too much, and don’t exercise. Human beings by nature are very short term thinkers. I don’t think that society or insurance should cover those who choose to make those choices in life.
  11. 11. Facebook Debate • S (continued) - There are some days that I want to (and sometimes do) tell patients to come back to me only when they choose take care of themselves. Would make my job much easier. My hospital is overwhelmed with the uninsured. Most of the uninsured work. Parkland, as a safety net hospital, we are supported by Dallas County Hospital District taxes. Part of my property taxes goes to this. There are other Texas counties that don’t have the safety net. People there struggle.
  12. 12. Facebook Debate • S (continued) - Scandinavia has some of the best health system in the world but they are taxed at a highest rate in the world. China has little or no public system, if you have cancer in China and can’t afford treatment, oh well, you die. I agree that healthcare shouldn’t be a right. We shouldn’t stifle our innovations in healthcare with socializing our capitalist system. But I think, we should have mandated universal coverage. Private vs. public? Doctors would prefer neither.
  13. 13. What are the real issues for not having universal health coverage in the States? • Capitalism vs. Socialism • Individual vs. Group • Private vs. Public • Self-interest vs. Sharing • Laissez-faire vs. Regulation • Innovation vs. Stagnation • Haves vs. Have nots • Oppression vs. privilege
  14. 14. Canadian and American Psychiatry • Similar training – 5 years vs. 4 years, residency training • Similar professional associations/journals – APA/AJP-CPA/CJP – AACAP/JAACAP-CACAP/JCACAP • Similar practice standards?
  15. 15. Canadian and American Medicine • Last decade, Canadian docs move to USA for more money • Canuck docs now returning to Canada for better salaries and more clinical autonomy • Managed care did save money and improve efficiencies when 1st rolled-out • But the money saved was not placed back into the actual clinical care of patients...
  16. 16. Socialism • Statism (State) • Government plays central role in basic services (health, social security, welfare) and economic production • Sharing – Eliminate concentration of wealth and power • Whole more important than individuals • Egalitarianism • Communism- Karl Marx – “From each according to his (her) ability, to each according to his (her) need”
  17. 17. Capitalism • Corporatism (corporate) • Private ownership (as opposed to public) • Deregulation • Minimal government interference • “Trickle-down” economics • Profit motive and the right to make a profit drives innovation, efficiencies • Milton Friedman – Chicago School – Free market
  18. 18. Socialism Capitalism Basic services under state control Privatized basic services Protected worker rights (unions, minimum wage, pensions) ‘Flexible’ workforces (no benefits, highly mobile, layoffs when recession) High social spending Low social spending Civil servants have duty of loyalty to greater good- to the state/collective Corporate workers have duty of loyalty to their shareholders
  19. 19. Social Democrats • Canada and many European countries are considered Social Democrats • Mixed Economy – Mixture of Socialism and Capitalism: selective public ownership of key national industries, while maintaining private ownership of capital and private business enterprise – Social democrats also promote tax-funded welfare programs and regulation of markets
  20. 20. Free Market and U.S. Managed Care • Mid-90’s…First Lady Hilary Clinton pushes for universal health care in USA • Free market advocates jump on bandwagon and believe the market is the solution to health care crisis • Private coverage (managed care) now the dominant form of health coverage • Has it led to improved care for Americans?
  21. 21. Socialized Medicine • Socialized medicine – Public coverage, public delivery – UK, France • Doctors are government employees
  22. 22. Socialized Services • Socialized services not new in the States – Postal service – Police – Fire fighters – Public education (K-12) • This is already being privatized- Charter Schools – Military • Also already being privatized- Iraq war, private security companies, mercenaries – Jails • Also being privatized – Medicare/Medicaid/VA • Only covers a small segment of Americans
  23. 23. Universal Health Care: Single-Payer System • Canadian Health System – Not fully socialized – Public coverage, private delivery • Federal government provides funding to provinces for health care • Provinces in turn fund regional health authorities or private boards
  24. 24. Canadian Medicine • Health care in Canada is delivered through a publicly-funded health care system • Canada's regionally based Medicare systems are cost effective because of administrative simplicity
  25. 25. Canadian Medicine • Costs are paid through funding from federal and provincial income taxes. • There are no deductibles on basic health care • No termination of coverage when individuals are sick • No restrictions on pre-existing conditions • No lifetime limits on treatment • Private supplemental insurance pays for medication, dental, eye care
  26. 26. Canadian Doctors • Fee for service, Salary, or blended • In Halifax, Nova Scotia, Dept of Health contracts with Dalhousie Department of Psychiatry to deliver psychiatric services to Haligonians • Halifax Psychiatrists are independent contractors, free to set-up medical corporations
  27. 27. Canadian Universal Health Care • Tommy Douglas – Saskatchewan, 1940’s • Health care as a basic human right • For many decades, Canadian Health Care was also privately financed • With public financing, most Canadians do not go bankrupt nor suffer from no treatment
  28. 28. Universal Health Care and Medications • If meds too expensive, then will bankrupt universal health care system • Drug costs in Canada and Europe much less than in USA
  29. 29. Canadian Psychiatry • Treatment decisions made by clinician • Psychiatrists determine which treatment modality to use: psychotherapy and/or pharmacotherapy, social interventions • Length of stay determined by psychiatrist on inpatient unit • No authorizations needed • Focus on biopsychosocial
  30. 30. Canadian Psychiatry • Drawbacks – Medications not covered – Wait lists are long – Mental health clinicians not as efficient as American counterparts – Expensive • 40% of Nova Scotia budget spent on healthcare • $3.2 billion CDN • 6.6% annual growth
  31. 31. US vs. Canada • Canada spends less per capita on health care and still covers all of its citizens • Canada spends roughly half as much as the States, $3,165 vs. $6,102 per person, year 2004
  32. 32. Managed Care • Originally brought into U.S. to control spiraling health care costs in late 1990’s – Cynical view: Capitalism at work • U.S. Physicians have less clinical freedoms than counterparts in Canada and Europe • In psychiatry, managed care has led to split treatment
  33. 33. American Psychiatry • Has led world psychiatric ideology over the 2nd half of the 20th century • Managed care eroding the expertise and value of American psychiatry • Too pharmaco-centric • Where’s the psycho-social in biopsychosocial? • Canada and Europe have always ascribed to the biopsychosocial model for psychiatry
  34. 34. Integrated Treatment and Comprehensive Formulations • In psychiatry, no biological test to tell us if we are right or wrong • Other medical disciplines are humbled by these tests • As such, psychiatrists need to have full analysis and systematic, logical thinking to assess a case • Split treatment and being medication only psychiatrist impacts patient care • Managed care erodes clinician autonomy
  35. 35. What does a graduating Canadian psychiatry resident see?
  36. 36. What does a graduating Canadian psychiatry resident see? • Work load • Work environment • Salary • No worries about malpractice/liability when compared to American grad – Lower malpractice insurance • Able to practice psychiatry • Clinical autonomy
  37. 37. Canadian Physician Compensation, 2003-2004
  38. 38. My Psychiatric Practice in Canada • Increase in income – $CDN on par with $US • Independent contractor – Medical corporation – Decreases tax liability • Hospital provides infrastructure – 0.5 FTE admin assistant – Clinical space/IT support • Clinical autonomy – I determine my time devoted to clinical care • No authorizations • Malpractice insurance around $1,500 per year – Liability risk in Canada low
  39. 39. Canadian Patient Experience • MSI card is all you need for medical services…no co-pays – Income taxes pay this
  40. 40. Canadian Patient Experience • Supplemental insurance available (privately) to cover extra medical expenses – Private room, medications, dental, eye care – Around $600/year to cover whole family
  41. 41. Canadian Patient Experience • Patient: Anne • My wife, Anne, had acute URI – 8 hour wait in ER – Admitted to hospital bed (private room) – Immediate follow-up with ENT specialist – Acute URI resolved
  42. 42. Canadian Patient Experience • Patient: Mimi • My infant daughter, Mimi – Biweekly prenatal classes with public health nurse – Regular visits to GP for prenatal medical care – High risk assessments in Fetal Assessment Unit – Admitted to birthing unit (private room) • 3 days – Immediate follow-up with GP for check-ups – Public health nurse visits at home
  43. 43. Canadian Patient Experience • Patient: Carlo • My family physician – Regular visits for various checkups – Referrals to specialists usually within 1 to 2 months – If acute (i.e. MI), then referral is immediate and jump the queue – Only out of pocket expense is my $600/year supplemental insurance premium • Pays for meds and extra medical services
  44. 44. So what is the ideal health care system? • Health care should not be determined by the market • Health plans should not imposed restrictions on pre-exiting conditions nor have lifetime caps • Health plans should not terminate coverage when individuals are sick • Money saved on efficiencies should be placed back into the health care system • But universal health care is expensive • Probably a hybrid of private and public financing and delivery (accessibility, efficiency, innovation)
  45. 45. Parting Words • If the U.S. is illiberal, intolerant and aggressive, then Canada is liberal, tolerant and passive • Since President Obama elected, this has reversed somewhat • Listen to President Obama regarding universal health care…one of the great minds in the world today • “Yes We Can”