Considering Cracks in the Canadian Healthcare System

A Neurosurgeon’s Perspective: Considering Cracks in the Canadian Healthcare System

There was a time when the percentage of gross domestic product spent on healthcare was roughly the same in the U.S. and Canada. In 1965, the year Medicare was signed into law in the U.S., Canada spent 5.9 percent of its GDP on healthcare compared to 5.6 percent spent in the U.S. By 1985, the year after Canada mandated health coverage for its residents, the health GDP percentage had risen to 8.1 in Canada and 10.0 in the U.S. Over the next 20 years the health GDP expenditure in Canada increased by 21 percent, while in the U.S. it ballooned by a comparatively alarming 53 percent. Judging by healthcare GDP expenditure alone, Canada’s health system is quite appealing. Add the benefit of universal health coverage, and its appeal grows. But no system can be perfect. Two widely recognized concerns Canadians have with their health system are overburdened emergency rooms and long waiting periods for patient access to care. The AANS Neurosurgeon asked James T. Rutka, a neurosurgeon practicing in Canada, to comment on these issues with respect to neurosurgery. Dr. Rutka is chair of the Neurosurgery Expert Panel, a group that advises the Ontario Ministry of Health and Long-Term Care, as well as chair of the division of neurosurgery at the University of Toronto.

Health Expenditure as a Percentage of Gross Domestic Product: U.S. and Canada Since 1984 Click to enlarge

“Twenty years ago, the system was more in balance,” said Dr. Rutka. “By and large, Canadians identify themselves with the health plan, but most recognize that it has limitations and problems.”

The “health plan” is the Canada Health Act, which since 1984 has mandated health coverage for Canada’s residents. Healthcare delivery is controlled by the individual health ministries in Canadaâs 10 provinces and three territories. The “13 interlocking provincial and territorial health insurance plans … share certain common features and basic standards of coverage” that are based on the “underlying Canadian values of equity and solidarity,” according to Health Canada, the federal government’s department for healthcare administration.

Dr. Rutka acknowledged that Canada’s health system is experiencing problems both in delivery of emergency neurosurgical care and in long wait times for degenerative and elective spinal cases, but his primary concern was for the patients in need of acute neurosurgical care.

“What happens to a patient with a broken neck when all the neurosurgical beds are filled?” he asked.

He explained the problem as a function of supply and demand. Through the health ministries, the government controls supply, which in this case translates to surgical capacity, intensive care and step-down unit beds, and nurses. While Canada is the second largest country in the world by area, most of its population is concentrated along the border with the U.S. In areas where there is increased demand brought on by population growth, a particular issue along the U.S. border in Ontario and British Columbia, the capacity of the system to deal with the increased volume of patients has remained static.

As in the U.S., when a hospital does not have the capacity to treat an emergency neurosurgical case the patient is transferred to a facility that does. In 2007-2008, 48 percent of urgent neurosurgical cases were transferred, according to a report on neurosurgical care in Ontario released earlier this year by the -Neurosurgery Expert Panel, which Dr. Rutka chairs. In 6 percent of those cases, the patients were transferred to U.S. hospitals.

“We have contracts with U.S. facilities to look after these patients,” said Dr. Rutka. “The government permits transfer and provides appropriate funding to the U.S. hospitals which care for these patients.” He identified Buffalo and Detroit as the sites of most neurosurgical transfers to the U.S. from Ontario.

In Ontario, the patient transfers are handled through the government”funded CritiCall service. A physician or physician designate can call the service. CritiCall staff utilizes a standard protocol for communication of patient information and connects the caller with the “most appropriate consultant.” When a patient transfer is indicated, the service handles all of the details. One of CritiCall’s goals is to “keep patients as close to home as possible.”

Long wait times are comparatively less of a concern for neurosurgeons and their patients, according to Dr. Rutka.

“Neurosurgery just entered the wait time strategy a year ago and is well within the guidelines that are being recommended,” he said. “However, degenerative and elective spine cases will undoubtedly fall outside the expected wait times,” and patients wait longer for these types of procedures.

The “wait time strategy” is the 10-year plan initiated in 2004 to reduce wait times throughout Canada for specific diagnostic and surgical procedures.

Dr. Rutka said that the majority of Canadians are generally satisfied with their healthcare system. “Most are proud that there is universal coverage, and for more than 90 percent of cases the system works fairly well,” he said. “However, there are clinical situations which arise that show the system is strained and needs improvement, especially for patients requiring acute neurosurgical care.”

When asked if some privatization is in the future for Canadians, Dr. Rutka noted that there is a minimal amount of privatization now and said it would not surprise him if Canada heads toward a blend of privatization and public healthcare. Some provinces, such as Quebec and British Columbia, already have private clinics that primarily offer diagnostic services, although their legality under the Canada Health Act has been questioned by some. In 2008 Nova Scotia announced a year-long demonstration project whereby the province would pay for minor orthopedic surgeries performed at a private clinic as part of its strategy to reduce wait times.

Even so, there is not widespread support in Canada for complete health system reform. “One thing is clear, and it is that there is no utopia in healthcare plans,” said Dr. Rutka. “We look at the American system as the one that offers the best healthcare services in the world, and we do not think we should be following the British or the Scandinavian models. All countries around the world will be following the debate on healthcare reform in the U.S. with great interest.”