Despite their geographical proximity, their similar cultural milieux, and their comparable per capita economic standings, health care in Canada and the United States are vastly different. Is Canada too cost-conscious, putting the inevitable but seemingly insurmountable needs of the many over the immediate needs of the few? Has the United States become too client-centered, putting the needs of the privileged or particularly litigious few over the needs of the many? Which is better for patients?
Let’s contrast some examples. I just returned from a month-long elective at a large Trauma centre in the United States. My usual training centre is in Canada. These are real cases I have encountered, with the demographic details altered for patient confidentiality.
An Example of Healthcare in Canada
A 55 year old man presents to the ED with increasing depressive symptoms for the past week. He hasn’t been eating, he can’t get himself out of bed, he’s shut himself in his room and shut his family out, and is beginning to have vague passive suicidal thoughts. He runs his own business, but has been unable to do so recently. He has never seen a Psychiatrist, and despite being on a waiting list for the last year, does not have a GP. Sound familiar? He is not a candidate for psychiatric admission in the Canadian system, and is instead referred to the Urgent Psychiatry referral service, who are booking appointments in 4-6 weeks. He is given information for the Crisis Line and told to return to the ED if his suicidal thoughts become more tangible in the interim.
Why does this man, who is a responsible small business owner in an urban centre, not have a GP? Is it really acceptable to tell a patient who feels he is in crisis, that we feel he is low risk for successfully committing suicide, and that he has to wait 4-6 weeks to see someone? If he comes back with more developed suicidality, how suicidal does he really have to be before he hits that critical threshold that makes us refer him to Psychiatry the same day? Will that mean he gets admitted to hospital?
An Example of Healthcare in the United States
A 40 year old woman is brought in by EMS because she had a seizure and fell from standing. She is a known epileptic. She has no obvious external signs of trauma, but is intubated in the ED for a low GCS with a sky-high EtOH level; she is extubated shortly thereafter and has no neurologic deficits and has a GCS of 15. FAST is performed and is negative. Despite her witnessed seizure and fall, and lack of obvious trauma, she receives a pan-scan, which is the standard of care in almost all traumas and “traumettes” alike at this centre. An incidental subsegmental PE is found on her scan, with the remainder of the scan being normal. She is admitted to the hospital for head injury monitoring despite her lack of intracranial pathology, and receives an IVC filter that night.
Did the American epileptic really need anything more than a head & neck scan? Did we do her more harm than good, irradiating her and incidentally finding and treating a PE that is of no real clinical consequence? What about the cost of admitting a patient for concussion monitoring? Would she have been treated the same if she didn’t have private health insurance?
Which is better for patients?
First let me start off by saying there is no answer to this question. In the Canadian example, our patient likely was very low risk for successfully committing suicide. He had to wait 4-6 weeks for an Urgent Psychiatry appointment because there are limited staff on that service, but I am quite confident that staffing that centre costs a fraction of what an American centre with shorter wait times would cost. In the American example, the standard of care perceived by patients and physicians alike seems wasteful – clinical judgment is thrown out the window in favor of unnecessary imaging and hospital admission, and a clinically insignificant finding is treated with potential iatrogenic harms. However, I saw time and time again on that Trauma rotation, clinically significant findings on pan-scans I was not expecting and would have missed with our standard of care in Canada. And cost aside, is this propensity to admit people for observation in the United States really such a bad thing? If it saves even one patient, is it not worth it?
When you examine health care spending, the United States is in a league of their own. In 2008 they spent US $7,500 per capita, or 16% of their GDP, on health care. The country with the second-highest spending was France at 11%. Canada ranks 6th on the list of OECD (Organization for Economic Cooperation and Development) countries when ranked according to proportion of GDP spent on health care, spending 10% of our GDP, or US $4,079 per capita in 2008, on health care. The United States also has the highest proportion of private health care expenditures, and is the only OECD country with more of its health care spending coming from private than public funds.
Ok, so all that spending must lead to better health outcomes, right? Wrong. The United States comes dead last in terms of life expectancy, infant mortality rates, and potential years of life lost, when compared to other OECD countries. Canada doesn’t fare much better, ranking 7th/17 in terms of life expectancy, but 16th/17 in terms of infant mortality rates, and 12th/17 in terms of potential years of life lost. Interestingly, Japan, who spends the least per capita on health care, ranks #1 in terms of life expectancy.
This is all to say that spending more does not equate with better health outcomes. Again I’ll ask you, what is better for patients? Is it giving them what they want, as in the US system, even if it contradicts medical recommendations and sometimes common sense? Or is it better to give them improved health outcomes and reduced spending, but at the expense of resource accessibility? How much should we allow a medical standard of care to be shaped by the expectations of our patients and the culture of our society, as opposed to the objective health outcomes we observe?
Unfortunately there are more questions here than answers. Health care systems are monstrous and dynamic networks, and among the most complex systems in the world. If there were an easy answer, everyone would be doing it. I think what’s important to glean from this is that there’s more than one “right” way to do things, and saying that one system is “better for patients” than another centers around a flawed paradigm. What we can say for sure though, is that throwing money at the system does not fix its complex problems, but shifting a societal set of expectations is a monumental task indeed.
1. The Conference Board of Canada. Health spending: do countries get what they pay for when it comes to health care? (2014). Accessed from http://www.conferenceboard.ca/hcp/hot-topics/healthspending.aspx on June 10, 2014.