If America adopts Canada's health care system

[Blackadder1916]

  What I think is totally irrelevant: in the U.S. unlike in Canada, it is illegal for hospitals to refuse care.

My supposition is you are referring to the Emergency Medical Treatment & Labor Act (EMTALA) in the US, however you are only correct as regards a legislative mandate (with the exception of one province).  The Canadian requirement of "duty of care" is based primarily on common law.  It is notable though that the problem of refusing treatment and "patient dumping" was so severe in the U.S. (20 years ago) that Congress felt it necessary to enact legislation as an attempt to curb the practise.  It has not been such an issue (then or now) in Canada.

http://www.emtala.com/faq.htm
http://www.cms.hhs.gov/EMTALA/

In 1986, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay. Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual's ability to pay. Hospitals are then required to provide stabilizing treatment for patients with EMCs. If a hospital is unable to stabilize a patient within its capability, or if the patient requests, an appropriate transfer should be implemented.

The legal duty of physicians and hospitals to provide emergency care (CMAJ • February 19, 2002)

Duty of care

The duty of care is one component of the law of negligence. In order to establish a defendant's liability in negligence, 4 requirements must be met: the defendant must owe the plaintiff a duty of care; the defendant must fail to meet the standard of care established by law; the plaintiff must suffer an injury or loss; and the defendant's conduct must have been the actual and legal cause of the plaintiff's injury.

There are 2 sources of law in Canada: legislation, and common law derived from judicial considerations of legal cases. Case law considering the duty of care in emergency situations is limited in Canada and the rest of the Commonwealth. Although case law in the United States has no binding precedential effect in Canada, relevant US cases have been included in this review, because it is anticipated that, should this issue be litigated, the dearth of Canadian case law will prompt the courts to search for guidance from the US courts.

Under common law a physician has traditionally not been required to undertake the care of someone who is not already a patient. This reflects the position that no person is required to provide assistance to another except in exceptional circumstances.  As summarized in St. John v. Pope (Texas Supreme Court, 1995), "Professionals do not owe a duty to exercise their particular talents, knowledge, and skill on behalf of every person they encounter in the course of the day ... It is only with a physician's consent, whether express or implied, that the doctor–patient relationship comes into being." On the basis of the principle of contract law, that both parties must assent to the creation of a relationship, the right of refusal has been extended to emergency situations even when no other physician is available.

However, the common law has been evolving with respect to the provision of emergency medical services. It appears from recent case law that there is now a positive duty for physicians and hospitals to provide emergency care. The common law has been modified in several ways: first, by using the principles of negligence law, specifically those of proximity and foreseeability, to establish that the relationship between the individual and the physician and hospital is sufficiently close to require a duty of care and by using the principle of reliance to establish that the individual has relied upon the services offered by the physician or hospital; second, as a result of ethical considerations; third, by finding a pre-existing relationship between the patient and the physician and hospital; fourth, through public policy considerations; and fifth, in certain jurisdictions, by legislation.
.....
Legislation

Except in Quebec, there are no currently enforced legislated requirements in Canada for physicians or hospitals to provide emergency care. In Quebec the legislated duty to treat is based on the civil law duty to rescue.  However, section 21 of the Ontario Public Hospitals Act alludes to the special status of individuals requiring emergency care and may be interpreted by the courts as mandating a duty to treat such individuals. The section provides that "nothing in this Act requires any hospital to admit as a patient, (a) any person who is not a resident or a dependant of a resident of Ontario, unless by refusal of admission life would thereby be endangered ... "

The example provided in post #160 concerned an individual presenting to a "medical centre" in Montreal.  Some cursory research indicates that that this "medical centre" is not a public hospital but more likely a private clinic (doctor's office) probably offering some sort of walk-in service (DIAB).

 

[observor 69]

The reason for public catastrophic insurance is simple, and Fred Reed makes it.  Pay particular attention to his admonition in the last paragraph.

But argument by anecdote is barely one step above resorting to personal insults.  Regardless, our provincial health care systems will not prolong life at any cost, and will refuse life-extending treatment in some cases.  In a publicly-funded system, the value of your life is explicitly measured in dollars just as it is by private insurers, and sometimes all you will get is a course of pain management until the end.

But public catastrophic insurance doesn't mean every medical service must be covered, or that nothing may be means-tested, or that medical services should be insulated from a free market.  Canada does not have as good a health care system as is affordable.  Those willing and able to spend more should have every opportunity to do so, in Canada.

Thanks for the column by Fred Reed, very interesting.
I must add that there are many  in Toronto area hospitals like those Fred mentions in his article who don't know or care how to take care of themselves. The norm is to spend thousands to deal with their medical problem and to realease them to repeat it all over again.
While I support our health care system I am always plagued by the comment you make "Those willing and able to spend more should have every opportunity to do so, in Canada." I have watched many very welloff people in line waiting for care for a loved one. Makes you wonder.
Actually I was reminded of this thread by this story in the local paper where I used to live.
http://news.galvestondailynews.com/story.lasso?ewcd=6504490e797f8ba6

 

[a_majoor]

Just back from a trip from the States and saw something that pretty much sums it up: a sign on the Windsor side for their regional hospital saying "No Emergency Services Available"; while on the US side there are no end of huge billboards extolling vast numbers of hospitals and their services.

"Free" service which is simply unavailable is no service at all.

 

[Blackadder1916]

Just back from a trip from the States and saw something that pretty much sums it up: a sign on the Windsor side for their regional hospital saying "No Emergency Services Available"; while on the US side there are no end of huge billboards extolling vast numbers of hospitals and their services.

"Free" service which is simply unavailable is no service at all.

My guess is you saw a sign at the "Western Campus" (closer to main route to/from Detroit) of the Windsor Regional Hospital.

Windsor Regional Hospital is a large multi-site health service organization providing Acute Medical and Surgical Services including Emergency, Family Birthing Centre, Neonatal Intensive Care, Paediatric Services, Critical Care (ICU/CCU/Telemetry), Regional Cancer Services (Inpatient Oncology, Windsor Regional Cancer Centre, Breast Health Centre), Children’s Mental Health, Complex Continuing Care, Long Term Care, Mental Health/Addictions and Physical Rehabilitation Services to 400,000 people in Windsor and Essex County.

The Met Campus of Windsor Regional Hospital provides Acute Care Services in a modern hospital setting that include:

Ambulatory Care
Cardiac Services
Critical Care
Day Surgery  Diagnostic Imaging/Nuclear Medicine/MRI
Emergency
Endoscopy
Family Birthing Centre Intensive Care
Medicine
Paediatrics
Regional Cancer Services
Surgery

The Western Campus of Windsor Regional Hospital is a Centre of Excellence for Rehabilitation, Complex Continuing Care, Specialized Mental Health, and Long Term Care.

I recall (not too fondly) of transporting a patient in the early 80s from NDMC to the psychiatric facility at what was then the Windsor Western Hospital where his release from the CF was to be effective when I turned him over to that facility. 

As regards the billboards extolling the virtues of Detroit hospitals this piece from The Detroit News may be of interest.

Hospitals wage ad war; critics call it unhealthy

By Sharon Terlep / The Detroit News Sunday, May 22, 2005

The latex gloves are off in Metro Detroit, where rival hospitals are spending millions of dollars on increasingly aggressive marketing campaigns designed to lure coveted patients.

It's already hard to turn on TV or radio without hearing health systems tout their skilled doctors and caring staff.

But these feel-good messages increasingly are being overshadowed by harder-edged ads that critics say often scare patients and overhype treatments.

"When we need health care, we are sick and in vulnerable positions," said Dartmouth Medical School instructor Robin Larson, who authored a study of hospital advertising. Patients "don't understand that this information is aimed at generating revenue."

Visit Beaumont Hospital's Web site, and a pop-up window flashes: "Are you at risk for a heart attack? Do you have a Beaumont doctor?"

Pass by any Detroit Medical Center hospital and it's hard to miss flashy ads promising that ER patients will see a doctor within 29 minutes.

A St. John Health System billboard in Roseville counters the DMC pitch: "In an emergency do you want fast -- or good?"

In an era of intense competition and soaring costs, hospitals say marketing is critical to keeping their beds full and patients informed.

The troubling side effect, according to critics, is an increase in ads that can be misleading and even unsafe.

"They make us a bit paranoid," said Thomas Gore, an insurance agent from Clinton Township who says he tries to ignore all types of health-related ads. "They never had this stuff in the past and people seemed to survive."

Hospital marketing that pushes specific procedures and doctors is a national trend that's cropped up recently in southeast Michigan.

Larson's study of 17 top-ranked university medical centers -- including the University of Michigan -- found they often advertise unproven services and use fear to attract patients. "They're contributing to a sense that more care is better, that higher tech care is better," Larson said. "They give an exaggerated sense of how good medical care is."

The study also found that hospital marketing now appeals to the emotions of potential patients more often than it touts the prestige of the institution.

Some hospital marketing specialists say hawking hospital service is no different than selling cola or a car. Others say they try to err on the side of restraint given the high stakes nature of health care.

"We really use the doctors out there in providing input with advertising," said Rose Glenn, Henry Ford Health System vice president of marketing and public relations. "We understand how consumers might get confused."
...

more at hyperlink

 

[I_am_John_Galt]

The U.S. system is not perfect; I suggested below that we should look more along the lines of Singapore's if we are to be committed to universal healthcare (the wisdom of which I am ignoring for now). Our biggest problem might be the mindless "model for the world" mantra/attitude: fortunately, the rest of world realizes just how crappy our system really is (AFAIK, exactly 0 of them have copied our "model").  A recent posting by MarkOttawa/Mark C. on Daimnation (quoted with his approval):

The best health care system in the world...

...is certainly not Canada's. Just Right gives us the guts of a British study:

    ... On most objective measures the Canadian system at best disappoints, and at worst is simply unacceptable in a wealthy, modern nation, particularly when expenditure is considered...

That was as of 2005; things ain't getting any better.

Mark C.

http://www.damianpenny.com/archived/010609.html

And from his source:

Like the NHS to Britons, medicare is a quasi-religion to Canadians. Both systems are regularly subject to the claim that they are the best in the world.
[...]
Comparison with the US is ... understandable, but unfortunate. Firstly because opinion of US health care is largely based on myth (many Americans believe these myths too)...
[...]
Both the NHS and medicare have founding and guiding principles which they systematically fail to meet or abide by. Hence the charge in Canada that everything is free but nothing is accessible".
[...]
... three problems within the Canadian single-payer (government) healthcare model. First, accountability is poor and aggravated by the Federal structure. Second, decision-making is politicised. Third, single-payer government control eads to a lack of innovation. These three lead to a lack of responsiveness to patient needs or wants.

http://jr2020.blogspot.com/2007/12/canadian-healthcare-lessons-for-britain.html

And from an earlier MarkC post:

The time that paramedics spend waiting to hand over patients at Ottawa hospitals continues to get longer, mirroring trends across Canada, despite recent efforts to unplug the bottlenecks that keep ambulances off the road.

Emergency crews in the first half of 2007 waited an average of 57 minutes and 38 seconds to return to service after arriving at a hospital, according to a report being tabled this week at the community and protective services.

[...]

...the Ontario government began funding a pilot project earlier this year at The Ottawa Hospital's Civic and General campuses to alleviate paramedic bottlenecks. Emergency room space is reserved for ambulance patients and extra nurses are on staff to look after those patients.

However, the report states the program "is not proving effective as hospitals still struggle with capacity within their own organization. ... Although solutions to the current hospital wait time is the sole responsibility of the hospital administration, it remains a contributory factor in paramedic availability and therefore negatively impacts service response time."..

http://www.damianpenny.com/archived/010199.html quoted from http://www.canada.com/ottawacitizen/news/story.html?id=652f0a76-4315-4195-8009-41361279530b&k=30455

 

[tomahawk6]

We have seen anecdotal evidence of immigrants in Canada leaving their families to work in the US to take advantage of Canadian healthcare/other benefits,they then send money from the US to their family in Canada.

 

[geo]

We have seen anecdotal evidence of immigrants in Canada leaving their families to work in the US to take advantage of Canadian healthcare/other benefits,they then send money from the US to their family in Canada.

That sounds more like a fairy tale.....
Certainly if he is currently an immigrant to Canada he does not have the papers to legaly work in the US.
If he is a landed immigrant to Canada and applies to immigrate to the US, wouldn't he fall under the "quota" of unsponsored immigrants from Canada - and we're pert far down the list of countries US immigration publishes.

If the gent is working in the US, his company would / could / should have it's own health care package... so what's the point of keeping the wife on this side of the border.... or is it a case of having a wife on both sides of the border?

 

[observor 69]

That sounds more like a fairy tale.....
Certainly if he is currently an immigrant to Canada he does not have the papers to legaly work in the US.
If he is a landed immigrant to Canada and applies to immigrate to the US, wouldn't he fall under the "quota" of unsponsored immigrants from Canada - and we're pert far down the list of countries US immigration publishes.

If the gent is working in the US, his company would / could / should have it's own health care package... so what's the point of keeping the wife on this side of the border.... or is it a case of having a wife on both sides of the border?

Having spent some time in the States Geo the story makes sense.
If he is working there as an undocumented worker then he has no health care, SOL, so it is best to leave his wife in Canada. Plus he is always living in fear of getting kicked out.
If he is legal in the US many companies, small and large find it very expensive to pay for coverage for their employees. So they provide a very stingy amount of plan coverage.  For many Americans the decider on whether to move to a better paying job is the new company health care benefits package.

 

[geo]

Ahh... the undocumented worker!
But, if he is not "landed" in Canada and is working in the US..... then, the fella would be placing even his Cdn citzenship in jeapordy... could find himself thrown out of both countries.

WRT US companies and their HMOs and their stingy health plans.... that's what makes us social democrats different from those capitalist profit mongers i gusee

 

[tomahawk6]

A shocking development from the UK NHS - doctors want to cut off care for the elderly,heavy drinkers and others who have an unhealthy lifestyle.

http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2008/01/27/nhs127.xml

Don't treat the old and unhealthy, say doctors
By Laura Donnelly, Health Correspondent
Last Updated: 11:52pm GMT 26/01/2008

Doctors are calling for NHS treatment to be withheld from patients who are too old or who lead unhealthy lives.

Smokers, heavy drinkers, the obese and the elderly should be barred from receiving some operations, according to doctors, with most saying the health service cannot afford to provide free care to everyone.

doctors say should not be funded by the state.

The findings of a survey conducted by Doctor magazine sparked a fierce row last night, with the British Medical Association and campaign groups describing the recommendations from family and hospital doctors as "outrageous" and "disgraceful".

About one in 10 hospitals already deny some surgery to obese patients and smokers, with restrictions most common in hospitals battling debt.

Managers defend the policies because of the higher risk of complications on the operating table for unfit patients. But critics believe that patients are being denied care simply to save money.

The Government announced plans last week to offer fat people cash incentives to diet and exercise as part of a desperate strategy to steer Britain off a course that will otherwise see half the population dangerously overweight by 2050.

Obesity costs the British taxpayer £7 billion a year. Overweight people are more likely to contract diabetes, cancer and heart disease, and to require replacement joints or stomach-stapling operations.

Meanwhile, £1.7 billion is spent treating diseases caused by smoking, such as lung cancer, bronchitis and emphysema, with a similar sum spent by the NHS on alcohol problems. Cases of cirrhosis have tripled over the past decade.

Among the survey of 870 family and hospital doctors, almost 60 per cent said the NHS could not provide full healthcare to everyone and that some individuals should pay for services.

One in three said that elderly patients should not be given free treatment if it were unlikely to do them good for long. Half thought that smokers should be denied a heart bypass, while a quarter believed that the obese should be denied hip replacements.

Tony Calland, chairman of the BMA's ethics committee, said it would be "outrageous" to limit care on age grounds. Age Concern called the doctors' views "disgraceful".

Gordon Brown promised this month that a new NHS constitution would set out people's "responsibilities" as well as their rights, a move interpreted as meaning restrictions on patients who bring health problems on themselves. The only sanction threatened so far, however, is to send patients to the bottom of the waiting list if they miss appointments.

The survey found that medical professionals wanted to go much further in denying care to patients who do not look after their bodies.

Ninety-four per cent said that an alcoholic who refused to stop drinking should not be allowed a liver transplant, while one in five said taxpayers should not pay for "social abortions" and fertility treatment.

Paul Mason, a GP in Portland, Dorset, said there were good clinical reasons for denying surgery to some patients. "The issue is: how much responsibility do people take for their health?" he said.

"If an alcoholic is going to drink themselves to death then that is really sad, but if he gets the liver transplant that is denied to someone else who could have got the chance of life then that is a tragedy." He said the case of George Best, who drank himself to death in 2005, three years after a liver transplant, had damaged the argument that drinkers deserved a second chance.

However, Roger Williams, who carried out the 2002 transplant on the former footballer, said doctors could never be sure if an alcoholic would return to drinking, although most would expect a detailed psychological assessment of patients, who would be required to abstain for six months before surgery.

Prof Williams said: "Less than five per cent of alcoholics who have a transplant return to serious drinking. George was one of them. It is actually a pretty successful rate. I think the judgment these doctors are making is nothing to do with the clinical reasons for limiting such operations and purely a moral decision."

Katherine Murphy, from the Patients' Association, said it would be wrong to deny treatment because of a "lifestyle" factor. "The decision taken by the doctor has to be the best clinical one, and it has to be taken individually. It is morally wrong to deny care on any other grounds," she said.

Responding to the survey's findings on the treatment of the elderly, Dr Calland, of the BMA, said: "If a patient of 90 needs a hip operation they should get one. Yes, they might peg out any time, but it's not our job to play God."

 

[Brad Sallows]

So a public health care system has become so constrained by finances that it is reduced to perverting triage.  Nowhere in the article did it mention that the uninsured should no longer have to pay insurance (taxes).

 

[Flip]

When Canadians talk about a "two tiered health system" I think this is our future.
The notion that the upper tier won't affect the existing system is specious.
Clearly, in the UK there is a funding issue but in Canada decisions like this are made
quietly every day.  You miss appointments, you get bumped to the bottom of the list.
The article sounds more egregious than it really is, IMHO.

I would suggest that in the US the distortions of uniformity of care are more telling.

The rich guy with a shot liver has a far better chance of receiving care than
the migrant worker or the victim of an HMO.  The insurance people decide
what's possible. If a condition is deemed to be pre-existing, you have a problem.
To that end, I hope the next president of the US shows some leadership with
respect to healthcare.  My vote would go to a republican but it's a fair bet
a democrat gets to sit in the oval office.  Here's hoping.....Cheers all!  ;D

 

[tomahawk6]

The democrats are socialists. They want national healthcare to control people live's and you do that by taking more money to fund the system. We have social security which will be bankrupt in a few years. The politicians cant decide on cutting benefits because to do so may hurt them at the polls so they dont make a decision. Samething would happen to national healthcare.There is no free lunch. At some point there would be rationing of healthcare and waiting lists. There is a trend in the US that if you pay your medical bills at the time of service you get a 50% discount off the bill. Medicare/Medicaid tell doctors what they will charge for any given procedure. I think if we went back to a pure free market system medical bills would be reduced.

 

[Flip]

I think if we went back to a pure free market system medical bills would be reduced.

Sorry T6  - I agree with you on just about every other topic.

I have to disagree here.  Ever walk into a plastic surgeons office?
Not like most doctor's offices - very posh and lots of fashion mags around.

My point is there is a profit motive here and demand is created and not simply
met in this environment.  In a pure private system the object is NOT to fill a need.
The object of an enterprize is to separate people from their money.

Health care is too important to leave to a forces of a free market.

 

[a_majoor]

Flip, in any private or free market system, supply is created to meet demand. This is true for every conceivable product or service, from cars to healthcare.

While there is an element of marketing to create greater demand for products and services, this is also true for any good or service. Think about Coke vs Pepsi or the adds you see for fast food. Perhaps your objection stems from the idea that plastic surgery is a discretionary expenditure, and people could/should make wiser choices. Well who are you or I to say what is a "wise" choice? 

The market can provide the signals for rational allocation of resources to various wants and needs (there is no "Dental Care Crisis" in Canada), so we should advocate for a reduction in the role of governments and bureaucracies in health care.

 

[I_am_John_Galt]

I have to disagree here.  Ever walk into a plastic surgeons office?
Not like most doctor's offices - very posh and lots of fashion mags around.

My point is there is a profit motive here and demand is created and not simply
met in this environment.  In a pure private system the object is NOT to fill a need.
The object of an enterprize is to separate people from their money.

Spare us the propaganda: in any private system, profit is what you are left with when you can produce a good or service for less cost than someone else is willing to pay for it!  Fundamentally, a GOOD thing.  The object is without a doubt to fill a need: if no-one needs or wants what you have to sell, you *have* to produce something else (that people want or need) or you will be out of business.  This is the essence of free enterprise and it's that simple.

Health care is too important to leave to a forces of a free market.

Health care is too important to leave to the whims of the politicians!

 

[Flip]

Health care is too important to leave to the whims of the politicians!

We can at least agree here.

When I contemplate maximizing my profits ( I'm self employed ). I have two choices.

1. Reduce costs - ie. services rendered
2. Increase revenue - ie. push the price up

All business will do a combination of the above.
In a pure business model ( which you are advocating ) The physician is in the position
to avoid expensive procedure and bleed the hell out of people on the simple stuff.
When competition prevents this we would move toward services they cannot.
ie. plastic surgery.
Ultimately, you advocate reducing healthcare to a simple equation in which there is
little motive or room for improving peoples lives.

Add the complication of insurance companies and drug companies and you have
more hands out for a limited consumer dollar.  In spite of flashy adds that promise
more, the game is to actually deliver less. Ever suffer buyer's remorse?
Ever have an insurance adjuster deny a claim? 
Ever find that a drug fails to provide the benefits promised?
I can say yes to all three.
I can also say I don't want to have this happen when I'm in Hospital

 

[Reccesoldier]

1. Reduce costs - ie. services rendered

- or become more innovative and find practical methods of delivering the SAME services.  This makes much more sense from a business standpoint as you will not loose your clientele to someone who does not think with the same pessimism as you demonstrated in the original summation.

2. Increase revenue - ie. push the price up

- again, this is not the ONLY solution as you have implied.  There may be scope to work more, or work smarter to provide the SAME revenue (or higher) without having your business pushed out of the market by demanding an unwarranted increase in price.

 

[Flip]

In the context of insufficient resources and too few physicians, I think my examples stand.

If a GP is payed $35 per visit in a highly regulated system, it's reasonable to assume
removal of regulation will bring about a price increase.  I suggest Alberta's energy
deregulation as an example.  My gas and electricity costs have doubled since deregulation.
These are costs I have to pass along.  Removing regulation in the complex context of health
care is likely to have a cascading effect.

 

[a_majoor]

When competition prevents this we would move toward services they cannot.
ie. plastic surgery.

I don't know where you studied economics, but that statement doesn't make sense.

Monopoly situations attract new competitors who are after the perceived monopoly rents. Monopolies can only persist with the backing of State power to prevent the entry of competitors.

Competition does not prevent the creation of innovative new goods and services (which you seem to be implying), but in fact is the driving force for creating new goods and services. It also brings common goods and services to low income people, since these items become commodities. (Think about the price of computers in 1981 compared to today).

So it would seem that market forces would work to increase innovation available in the medical world and commodify medical practices and services. I'll take the deal.