How our healthcare stacks against the best worldwide

Canada’s healthcare system has deteriorated in the past three decades. We had been rated second or third in the world in the 1990s and now the Commonwealth Fund rates our system as 10th of the 11th richest countries in the world—the US being worst. The ratings go: Norway, the Netherlands, Australia, UK, Germany, New Zealand, Sweden, France, Switzerland Canada, US. Other studies published rate Denmark, South Korea and Taiwan as top three. What happened in Canada began in 1991 with the Seaton Royal Commission, which was established to determine causes of, and cure for, rising healthcare costs. It accepted the advice of three healthcare economists who said the problem was too many doctors, treating too many patients, requiring too many nurses, filling too many hospital beds. Read: Rising complaints on healthcare quality: Ontario patient ombudsman A member of this team is quoted: “A central cause of the problem was an oversupply of physicians which generates greater use of services and a hospital-bed-built was a hospital-bed-filled.” The commission stated that immigrant doctors had no right to work in Canada, and that foreign trainees must agree to return home after completing their training. Medical school admissions were cut by 10-30%. Hospital-based nurse training programs were cut across the country. And so now we have 2.44 doctors per 1,000 population—51st in the world, and not enough nurses or hospital capacity. Various organizations—The Commonwealth Fund, Fraser Institute, Statista and others—have rated international healthcare systems. I will present their summaries to show where we succeed, and where we fail. Read: Are team-based healthcare clinics that serve one geographic area the answer? Much of this data is from 30 countries in the OECD. The Commonwealth Fund rated some of the richest 11 countries. The following areas were analyzed: Cost of delivery of healthcare. Availability of resources: i.e., physicians, nurses, hospital beds, CTs, MRIs, PET scans, LTC. Use and access to these resources: physician consultations, wait lists, specialist referrals and surgeries. Clinical performance and quality. Health outcome statistics. In some areas where all countries are doing well, the differences are very small but are magnified by ranking. Cost of healthcare Among the 11 richest countries in the world Canada spends the most: 13.3% of GDP (gross domestic product), with an annual per capita spend $5,900. Our geography plays a role in this statistic. The next top spenders are Norway (11.8%, $6,800), the Netherlands (10.9%, $6,000) and Australia (11.5%, $6,000). The average for countries in the Organisation for Economic Co-operation and Development (OECD) is 10% of GDP, with a $4,627 annual per capita spend. However does Canada stack up regarding healthcare resources compared to the OECD average? Per 1,000 people, Canada has 2.44 doctors, 10.3 nurses, 2.2 hospital beds, 0.38 psychiatric hospital beds and 54 long-term care beds. The OECD average beats out Canada on some but not all, with an average per 1,000 people of 3.8 physicians, 10 nurses, 3.5 hospital beds, 0.7 psychiatric hospital beds and 49 long-term care beds. Canada also lags behind the OEDC average on technical equipment and diagnostic tools. Per million Canadians, the country has 10.3 MRIs, 15 CTs, 1.6 PETs and 18.1 mammography tools. Meanwhile the OECD average is 19 MRIs, 30.1 CTs, 2.6 PETs and 24.4 mammography tools. Compared to the top 11 OECD countries, Canada also lagged on timely access, according to 2021 data. In Canada, 41% of people can make a same-day appointment to see a doctor when sick, compared to 57% for the OECD 11 average; 39% of Canadians found it very/somewhat easy to access after-hours care, compared to 48%; 38% of Canadians waited less than four weeks for an appointment with a specialist, and 62% waited less the four months for elective surgery, compared to 53% and 79%, respectively. But Canada is right in line with the OECD 11 average with 14% of Canadians =having experienced costs as a barrier to care. In terms of clinical performance and quality, Canada is more of a mixed bag on key indicators compared to global peers. 93.1% of Canadians got hip-fracture surgery initiated within two days of admission to the hospital, compared to an OECD average of 81.2% 4.6% of Canadians died within 30 days of hospitalization for acute myocaridal infarction, compared to 6.2% 23.1% of Canadians admitted for hemorrhagic stroke died within 30 days, compared to 22.3% and 7.5% of Canadians for ischemic stroke, compared to 7.4% Both Canada and the OECD average saw 0.06% of hospitalized psychiatric patients attempted suicide while in hospital. Comparing five-year survival rates, 88.6% of Canadian survive breast cancer, compared to 85.1%, 67.3% survive cervical cancer versus 66.5%, and 67% of Canadian survive colon cancer, compared to 63%. When it comes to life expectancy data, Canada ranks 16th out of 30 among OECD countries, with a life expectancy at birth of 81.7 years, compared to the average 81.4. What does this all mean? We don’t have enough doctors, nurses, hospital beds, equipment or homecare or long-term care facilities. Inadequate home and long-term care aggravate longer wait times for hospital care because of plugged up hospital beds (25%), filled with patients who could be treated with adequate long-term or homecare facilities. Blocked beds block emergency rooms already stressed by hallway medicine. Minor problems could be looked after more appropriately if there were more family doctors and community facilities. Blocked beds cause delays of elective surgery, but the data shows that once we do wait and get into the system, we seem to do all right. What Canadian Medicare covers (70% of all costs) All essential physician visits Hospital services, inpatient, prescriptions Laboratory and imaging procedures What Canadian Medicare does not cover Outpatient prescriptions, dental, and partial vision care Other professional care: PT, OT, alternative medicine Appliances (e.g., crutches, wheelchairs, CPAP, audiology) What provinces cover (varies per province) Many aspects not covered by Medicare, (as above) as well as varying levels of Home Care and Long-Term Care 65%-75% of Canadians have supplementary insurance for uncovered expenses (e.g., Blue Cross) Healthcare systems rated “The Best” NORWAY Universal National Health Program, funded federally, administered by municipality Annual deductible of $210, then almost everything is covered Government reimbursement of prescribed medicines Permanent illness tax deduction Financial qualification coverage for jobless, poverty Private insurance is held by 9% of the population: it may be provided by employer, and assures quicker access and coverage for uncovered equipment and procedures. Considered unnecessary by most Cost: 11.8% of GDP—$6,800 annually per citizen AUSTRALIA Established originally like Canadian Medicare but evolved Mix of funding Federally, State, Private insurance Covers most of MD fees, hospitalization and testing Private health insurance rebate from federal government Reduced cost of drugs Disadvantages: no dental program or coverage medical devices Occasional long wait times Private insurance: 50% of Australians, provides shorter wait time (for insured), choice of doctor, choice of hospital and accommodation Cost: 10.9% of GDP—$6,000 annually per citizen NETHERLANDS Universal, private, compulsory health insurance; companies are required accept all applicants Uninsured are fined, insurance premiums taken from income; less than 2% uninsured There is a Means Test and subsidy for low income. Government responsibility: monitoring quality, cost, access, safety, quality efficacy of medicines, assurance of evidence-based decisions, evaluation of new technology, health care and public health and cost effectiveness Finances: insurance premiums cover 45% of cost of healthcare costs, with the remainder coming from income tax There is an annual $500 deductible Coverage: doctors, hospitals, prescribed meds, ambulance, transportation, dental surgery in hospital, dental care and physio to age 18, homecare nursing Supplemental insurance for prescription glasses, physiotherapy and dental care Cost 10.9% of GDP—$6,000 annually per citizen DENMARK Considered the best in one survey Federally funded by taxes: health care for all citizens, administered by 5 regions Coverage: all physician fees, hospitalization, free home care and long-term care, health visitor service, pediatric dental care, mental health Online national medical records accessible to MDs and pharmacists Not covered: adult dental, cosmetic surgery, physiotherapy, occupational therapy, alternative medicine Prescribed meds: variable subsidy. Private insurance: 42% of Danes; often employer provided, for everything not covered. Also reduces wait times and ability to choose private doctors, specialists, hospitals. Requires consultation summary from general practitioner. Cost: 10.3% of GDP—$6,000 annually per citizen Compare our system to the best When you look at these top systems and coverage provided, ours is not really much different. We all provide basic care and a variation in the peripheral aspects with differences in funding and options for supplementary insurance. Private insurance shortens wait times for the insured, but in Canada—with our deficiency of doctors, MRIs and CT scanners—this would increase wait times for the rest of us. Thus, our system is not broken, it is fundamentally as good as the best but has potentially correctible issues, mainly with wait times because of insufficient personnel, lack of equipment and hospital under-funding Possible solution for Canada’s healthcare problems Increase the number of Doctors Increase medical school enrolment Institute a national registry of physicians Increase the number of residency spots Accelerate the program for foreign medical graduates Create a special program for recognition and acceptance of Canadians graduating from foreign medical schools (there are hundreds in accredited Irish, Scottish, Australian schools who are unable to obtain residencies in Canada, and end up in the US) Increase number of GPs Create more realistic fee schedule for Family Doctors Create more family practice residencies Institute program of Rural Family Practice preceptorships Increase the number of nurses Return to 3-year, hospital-based RN programs. Increase funding for more Nurse Practitioner programs. Resume Home Visiting Nurse programs. Build effective home care and long-term care facilities This keeps patients out of hospital and decreases the ER load. Increases availability of hospital beds Decreases wait times for elective surgery Improves care for patients with chronic disease Is much Less expensive than hospital care Add more Urgent Community Care Centres Establish “Super Walk in Clinics” with basic lab, radiology, doctor and nurse practitioner,” for non-life or limb” emergencies. There should be several in large metropolitan areas. These would decrease ER congestion and provide prompter service for minor illnesses and injuries. Eliminate Hospital Global Budget System Few developed countries, other than Canada, use global budgets for hospital funding Many did previously but evolved to other blended systems with payment for performance and bundled payments. The main advantage of the global system is to provide policy makers with predictability. Increase effective Telehealth Programs for remote areas Add a National Electronic Medical Records system Subsidize physicians to convert to EMR Develop low-cost housing beside hospitals and care homes Nurses and care aids can then afford to live near their workplace At present in Canada if you are in the right place at the right time and you wait, and get into the system, you do well. I do believe that our healthcare system is not broken and would improve if these suggestions were instituted promptly. Dr. Morley Lertzman, is based in North Vancouver, B.C. He is a retired professor of Medicine at the University of Manitoba and honorary professor of Medicine at the University of British Columbia. He is also a past president of the Canadian Thoracic Society.

How our healthcare stacks against the best worldwide

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