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The great health debate: keeping key facts top of mind

Any debate that doesn’t focus on sheer numbers of hospital beds and physicians is dodging the most obvious point


 

It’s tempting to overcomplicate the debate over health care. There are so many intriguing aspects of the system to examine, from the usefulness of diagnostic imaging (often overrated) to the necessity of timely psychiatric care (often overlooked).

But these subjects, worthy as they are of close attention, are not the reason Canadians fret about their system. The reason is waiting. If we could find a family doc without months of searching, see a specialist without weeks of worry, and visit an emergency room without the prospect of hours of sitting, we’d be satisfied.

So let’s not lose sight of the point. The countries with the best performance on timeliness of care, according to the Commonwealth Fund, a U.S. health research foundation, are the Netherlands and Germany. OECD statistics for the Netherlands are somewhat harder to compare with Canadian data, so let’s take a look at Germany.

There are 3.89 active physicians in Germany for every 1,000 people, compared to 2.27 per 1,000 in Canada. Can there be a more straightforward explanation for why it takes longer to see a doctor here? There are 5.7 acute care hospital beds in Germany for every 1,000 people, compared to 4.3 per 1,000 in Canada. Since any emergency room doctor will tell you the main reason for backlogs in the ER is too few hospital beds upstairs to accept new patients, doesn’t the German edge here tell much of the story?

Any debate that doesn’t focus on sheer numbers of hospital beds and physicians is dodging the most obvious point. Debate the way we pay for care, argue over how it’s managed—fine. But don’t kid yourself that we’re going to see doctors as quickly as they do in countries with more doctors, or run our ERs as smoothly as they do in countries with more hospital beds.


 

The great health debate: keeping key facts top of mind

  1. Failure to properly manage chronic disease in the community produces unnecessary hospitlization, and failure to plan for enough long term care beds means that too many patients are waiting in acute care beds. This means we spend disproportionately on expensive hospital care using up funds that might otherwise mitigate the problems with better chronic disease management at the front end and more long term and community (ie. home care) at the back end.

    Better coordination between the three levels of care would help to prevent additional disease and it really should be a priority to increase spending on community care. It's ridiculous to leave someone in an average $7000 per day hospital bed, exposed to risk of infection or reduced independence, when it costs a few hundred per day in a personal care home.

    It also costs the economy (not to mention the personal cost to families) if caregivers have to leave the work force to care for elderly parents because the waiting list for a personal care home is so long.

  2. Again we go around the health mulberry bush, and again we discover we need more doctors.

    So get more doctors….we have thousands of them waiting behind the wall of job-protectionism put up by the Colleges of physicians and surgeons.

    • I heartily agree. And for some reason, the College of physicians and surgeons never seems to have to come forward and tell us what the problem is! I mean, we know what the problem is, but shouldn't we be making them at least TRY to come up with some nice sounding, misleading spin?

  3. Very good points Mr. Geddes, but I think you do have to factor in population density.

    Building that many more acute care hospital beds will certainly help, but help who and how much? They have to be located somewhere and they are going to be far from more people in need than they would be in Germany. You can't put a cardiac unit in every community or even near every community in Canada. The population density simply doesn't support that level of build.

    Still, when most of us – over 80% – do live in cities, it is an important place to start.

    If only a political party would come along and promise to reduce wait times and make it a priority. Even if it was only one of five priorities. Anyone? Anyone?

    • Good points. I think we do a good job serving remote/light density populations by providing transport to larger centers. This model has the benefit of concentrating expertise, which is an important factor in successful outcomes, making the jobs more appealing to candidate physicians and minimizing costs. It sucks though to have to go the extra distance in terms of family support and the destabilizing element of extra time and wear and tear involved in trasnporting patients. On balance, though, if it increases spaces and doctors at a reaosnable cost, it's not all bad

  4. Germany has a better system because it spends more and citzens pay more out of pocket. It is a point that Dr Brian Day [ previous head of CMA] always somehow failed to mention ever, whenever i heard him promoting the superior French and German mixed systems. For instance my inlaws pay somewhere in the region of 1000-1500 marks per month – and that's for their state contribution, excluding any private insurance. I should mention i have no idea if Germany funds HC out of general revenue or what tax arrangements they have. Still, you get what you pay for and i can't imagine many Canadians being able to fork out that kind of monthly premimum.

    • Do they still have marks in Germany?

      • You're right my info is a bit dated. I believe it's euros now.

    • I currently live in Germany. As Timesarrow noted, Germany has a better system because there is a lot more money going into the system.
      Paying into public health care costs about 300 euros per month (taken automatically off the paycheck). The employer also makes a contribution. If you are unemployed, the government pays. In addition, each time you visit a doctor (whether in the ER or via appt, you pay 10 euros). If you decide to enter the private system (the majority of germans are publicly insured), you cannot return to the public system. Private patients must earn above a certain amount per year.
      The major differences between private and public: private patients pay up front for all services and then are later reimbursed; faster access to specialists (ie same day service vs waiting 2 weeks in public system for appointment); more 'free' services. For example, if someone calls an ambulance for a non-emergency reason, in the public system, they can be held accountable for paying a service fee for this. For private patients, this is never an issue.

      Also important to this equation is the number of doctors in Germany. Getting into medicine does not require a 4.0 CGPA and time spent volunteering with Africa orphans. The government regulates entrance to medicine and the number of study spots (here also to note, university is nearly free of tuition in Germany). Getting a spot requires good high school marks, but it is nothing like the competition in Canada. The correlate to having many more doctors- they are paid substantially less than doctors in Canada.

      • My figures for my inlaws were a bit out, i think? But I remember being quite shocked at the time. Are German Drs also on salary?

        • Yes, they are also on salary- not fee for service.

  5. OK, let's complicate it a little bit.

    Germany has a much broader mix of public and private. If the public lineup stinks, more people will find enough value in "private" to pay for it. If public pays attention (yeah, ok, humour me here), public might learn a trick or two from private about efficiency and trimming unnecessary costs and ensuring patient satisfaction.

    And i don't think it's just how-many-acute-beds-are-there, although that's certainly a big thing. But how many chronic non-acute patients with nowhere else to go are clogging up those acute care beds? The rest is just plumbing — the clog backs things up to the emergency room, …

    • MYL makes an excellent point. Managing the growing number of chronic, non-acute patients is the elephant in the room. The surging number of elderly patients as we baby boomers age will mean that those with chronic non-acute illnesses must be dealt with somewhere else than in hospital emergency rooms.

    • The German model is complex. Private alternatives to the main public insurance plan are available only to some. Many civil servants, for example and perhaps surprisingly, are covered under a private plan. As well, a separate long-term care plan is mandatory for everybody—important to know when considering those chronic care patients you rightly mention. As I understand it, it's not a practical option for the vast majority of Germans to switch from the public plan to private insurance. Excellent overview here:
      http://www.commonwealthfund.org/Topics/Internatio

      • Thanks. Will poke around at your link later this evening.

        It should not be surprising at all that civil servants are blessed with the gold-plated benefits at taxpayer expense. Just have a look around here!

  6. First I will say that I do not know of a hospital bed in Canada that costs $7000/day. They are more in the range of $1000-$2000 in my experience. I am sure that the same problems exist across the country – perhaps not to the same degree in every province. I live in Alberta. 8% of our hospital acute care beds are taken up by people awaiting placement in long-term care (this is up from 2%). It is well known that are ERs in Calgary and Edmonton have been in terrible condition because very sick people are admitted with no beds to go into. We are short of family physicians, we can't open more beds as we are short of nurses – there is actually a global shortage.

  7. So, why are there more hospital beds and more doctors? Here's a tidbit: http://www.nypost.com/p/news/opinion/opedcolumnis

    Hmmm… government controlled health care causes 45 hospitals to stop construction immediately. 40% of doctors plan to drop out of patient care in 1 to 3 years. 60% said ObamaCare will "compel them to close or significantly restrict their practices to certain categories of patients".

    It seems people are willing to create more beds and become doctors if they are not government controlled and government restricted. Of course in Canada, the construction on the new private hospitals never even starts, the beds fail to materialize at any time.

    In a private market, demand is met by supply. In Canada's health care monopoly, demand is met by…. endless whining by people who have no recourse. Demand is met by…. resistance from government to pouring more dollars into an inefficient and non-innovative monopolistic system.

    Demand is met by…… nothing but politics.

    • Heh – a hard-right thinktank funded by Exxon and Koch Industries publishes some anecdotes in the New York Post and scf declares victory and curses the effects of politics on healthcare.

      Why, oh why can't Canada's healthcare system be more like America's (you know, before Obama totally ruined it)?

  8. More Canadian med school students should be accepted each year. It's a joke that one needs straight A's in undergrad to have a chance at med school in Canada.

    Personally, I'm ok with having a doc operate on me even knowing that he got 89 instead of 94 in organic chem 331 (as long as those hands are steady as robots!)

    • The University of Calgary has just opened a program that will graduate only Family Docs, which are in short supply. Part of the problem is that many who attend medical school want to specialize and no one wants to be a family physician. The other problem is that it is very expensive for family doctors to set up business in some places – big cities in Alberta and I am guessing some of the other Provinces being the case. We need to come up with a way for them to make more take home pay.

  9. According to Harvard statistics, 12,000 people die each year because of lack or no health insurance in the United States. There can be many reasons why people do not have it. 1) They think they will never get sick or 2) they cannot afford it. My question is should we remove our public health care system so that we will create a better quality of care of the rest of us? In other words, should we kill off the poor? Essentially that is what we are doing when we are privatizing. People will die because some will not be able to afford it.

    If you think that is a solution, I guess we should also remove our welfare system as well… Kill off the poor so we receive lower taxes and a better quality of life.

    • My solution is to this whole health care crisis is taxing the products that are causing the increase in rise of cost. For example, taxing fast foods and junk food; obesity is one of our major problems which causes strokes and heart diseases. If we tax them, they will cover the cost of our health care and in the short run and long run, it will reduce the demand of consumption because of the increase in price due to the tax. As a result, in the long run, it will make us more healthier.

      I can't believe the government is spending 16 billion on a jet but not inject that in our health care system.

  10. Privatization does not have to result in the 'killing off of the poor". A two tiered health system can actually provide more opportunities for speedier responses in the public system. Those that choose to use Public will have reduced waiting times as those that can afford to go Private will no longer be a burden on the public health care system.
    Australia has a two tiered health system where both public and private complement each other, however, the choice to use Private is still up to the individual. I believe this is also the case in several European countries. Australia may not have the best health care system in the world but after living in both countries, I know that if I ever need anything done quickly that I could fly back to Australia get everything attended to and then fly back to Canada where I would still be on a waiting list.

    Canada also needs to increase the number of places available at University to study Medicine. We have a large number of students with the right grades but who still fail to get in simply because there are not enough spots. We all know that there are not enough Doctors so why would we limit the amount of places available.

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