Canadian health care

[Bruce Taylor]

and because of the visual politics I am not allowed to get together with a few other investors and buy one, to rent it out.

True in Ontario, and four other provinces. However, private MRI services are available in Quebec, B.C., Saskatchewan, Nova Scotia and New Brunswick

Americans reading this might not realize that health care in Canada is mainly a provincial responsibility (within guidelines set by the Canada Health Act), and there are regional differences. So, for instance, Quebec has a private-public pharmacare system, Alberta has a limited prescription drug program, etc.

[TomF]

You need a place with enough population density though, to make a private MRI clinic pay. Yes, NB has one such clinic, and no, it's never been especially financially viable.

Not least because the public system out here is positively glowing with medical imaging equipment, so there isn't any incentive for Medicare to contract it out.

[Canoez]

True in Ontario, and four other provinces. However, private MRI services are available in Quebec, B.C., Saskatchewan, Nova Scotia and New Brunswick

Americans reading this might not realize that health care in Canada is mainly a provincial responsibility (within guidelines set by the Canada Health Act), and there are regional differences. So, for instance, Quebec has a private-public pharmacare system, Alberta has a limited prescription drug program, etc.

What happens when citizens are traveling between provinces and need care - is that charged back to the "home" province?

What is the policy for "guests" who are vacationing in Canada and need medical care?

[TomF]

Canadians can get care anywhere in the country as they'd need it, and it's charged back to their home province via negotiated standard rates that are refreshed every year or so by the provinces/territories. One of the Feds' core requirements for accessing the Federal dollars they make available to the provinces/territories is that access to care is "transferrable", wherever in Canada a Canadian happens to get sick. We have to report publicly every year on how much of this has happened in either direction - patients we've served and billed back, and our citizens who've got care while out of the province.

Each province/territory works out its own arrangements and rates for charging non-Canadians who have the misfortune to get sick if they're here. What it usually comes down to is submitting a bill to the person's insurance company, as happens in the US ... though some hospitals have the means to actually receive payment for things like emergency room services directly.

There are probably more formalized charge-back provisions between the Canadian provincial/territorial systems and, say, the British National Health Service - I've never had to work in that area, so I dunno how developed those things are, and how they set the rates.

[CWSmith]

You need a place with enough population density though, to make a private MRI clinic pay. Yes, NB has one such clinic, and no, it's never been especially financially viable.

Not least because the public system out here is positively glowing with medical imaging equipment, so there isn't any incentive for Medicare to contract it out.

This is hard for me to understand. Yes, they are expensive. However, as a diagnostic tool, they are among the best inventions in my lifetime. Their uses are far-reaching. I would think that Canada would invest in these, so what is stopping it?

[Gib Etheridge]

We had our second child while in the US. The CDN healthcare was still valid but we had to first pay US rates then apply for CDN reimbursement which was at what the same procedure(s) would have cost in Canada, about half what the US hospital charged We lost money, but we did gain a daughter so it was worth it.

[TomF]

Oh, while the actual # of diagnostic imaging machines (of various descriptions) varies somewhat from province to province (they're provincial decisions), claims that this means that required imaging is not available isn't strictly speaking accurate.

Anywhere in the country, there are essentially 2 streams of access for imaging - the stream of people who've just had an acute trauma of some description who get imaging usually within 6 hours, and the stream of people who'd benefit from imaging for an ongoing but not presently life-threatening condition.

We don't have national benchmarks for how long folks ought to wait, whether in sub-categories of that second group, or even within the acute group. In NB, the argument has been that the private diagnostic imaging clinic in Moncton (they do both MRI and some ultrasound work) somehow wouldn't exist if there weren't a market. In practice though, they've had a very hard time getting clients even among those with the personal $ to pay, because the wait times in the publicly funded system are pretty comparable with how long you'd wait at the private clinic too.

The only complaint letter I've ever been able to dredge up - and I have to search each year, as part of the work to complete a public report I write - was a woman who needed MRI images of a knee. She was irritated that she was initially told it would be 4 weeks before she could get it done at the hospital, and went on to try and schedule the work at the private clinic - she wanted public reimbursement. She dropped her request when the public system folks, quite unaware of her letter to the Minister, called her a couple of weeks later ... and got her through the hospital's imaging clinic before the private for-profit folks had been able to schedule her.

The issue with employing the ever-improving types of diagnostic imaging for "medically necessary" purposes is that in terms of patient outcomes, the stats don't show that improvements in the tech or resolution between the mid 1990s and today have delivered commensurate improvements in patient outcomes. The physician's actual treatment modalities typically don't change because of a higher resolution or otherwise better view - a better MRI of the soft tissue around a knee typically shows in better detail what damage exists, but the surgical intervention, when you're actually in there cutting or stitching, isn't actually likely to change a whole lot. There are exceptions to this - I'd presume that the better the resolution of a brain MRI the better for a neurosurgeon ... but to tell pre-biopsy whether there's a tumour somewhere? Or something else surgical?

What we've found in our system is that the existence of more instances of a really fine tool frequently means that the tool is utilized more, but not necessarily that the patient's care plan or the statistical benefit in their outcomes track with it. In fact, we find that adding a new high-end tool is liable to result in the patient going through the same # of lower-sensitivity tests first, and then get the gold standard test in addition. Adding to the # of tests, hence the inconvenience to the patient, the length of time to confirm and implement a treatment plan, and incidentally the cost to taxpayers. We're great at adding diagnostic procedures, but crappy at zeroing out those which arguably have become obsolete.

Finally, when there's both a publicly funded and privately funded option for any service, but a limited number of the human resources qualified to do the service ... there tends to be competition for those staff, usually over working conditions rather than wages. The private clinics "cream off" the lower-risk and lower-intensity services, which are more easily put into something like production-line efficiency ... but this leaves only the most complex services in the public system. And a little-appreciated fallout of that is that the expertise and dexterity displayed doing those complex services is usually developed by repetitively practicing, by doing the less complex ones. If you remove the day-to-day less intensive procedures from a clinic's workweek, you've often also removed the pathway where clinicians grow their skills over time to become truly expert. So as a result of reducing overall volumes in a publicly funded clinic, you've inadvertently sometimes reduced the skill level which can be displayed, when it's most critical.

It does come down to what definition of "value" you're looking to manage for.

[stromborg]

This article (from Nerdwallet, 2017) helps explain why you might not have an MRI in your neighborhood. https://youtu.be/1-BpjokHpRg

"Safety features must be built in to protect those right outside from the magnetic field. Add in patient support areas and installation costs, and a suite with just one machine can cost anywhere from $3 million to $5 million."

That's a pretty big capital expenditure to make if you aren't pretty certain about the size of your potential customer base.

All this talk about the Canadian healthcare system has me curious about Canadian (rest of the world?)-vs-American usage rates, health clinic hours and patient expectations. Along with the cries of "keep the government out of my healthcare unless we're talking about women's reproductive health" fears about wait times seems to come up frequently. Good medicine takes time, it isn't like what you see on TV. As a first responder/EMT I rarely get through a 24 hour shift without thinking "Really, you thought that was an emergency?".

[CWSmith]

Guys, I think you are telling me that Canada is not willing to spend the money to have good diagnostics when needed. Both my wife and I have been "in the can" several times. I had a herniated disc in my neck diagnosed that way. She had other issues. Good and timely diagnostics are the best way to schedule or prevent surgery. And $5M may be a lot for a small town, but in any sizeable city there should be sufficient to do the job.

Don't get me wrong. I started this thread because I feel the conservatives in this country are lying about Canadian health care, but the inability to get good diagnostics is a recurring theme that I do hear from Canadians and I cannot understand why. Diagnostics are cheaper than treatment.

[Too Little Time]

Excuse me, but what planet do you live on? People with good health coverage don't dare leave the job they hate because they know it'll cost them untold amounts of money. Most working folks nowadays have mediocre coverage - that still costs them a lot of money. People who work for themselves cannot afford real heath insurance.

I'm on medicare now, but my partner still has to have private insurance (she's a Realtor & therefore self-employed). "Real" health insurance - what one could afford maybe 20 years ago - that has a $500 deductible & covers most everything after that is roughly $1900/month for just her. I'll do the math for you - that's just about $23,000 per year to cover a healthy woman in her early 60's. Instead, she has a plan with a 5K deductible - and that still costs $780/month - $9300/year.

So - please explain to me how we've made poor choices - other than to choose growing older rather than suicide.

In 2005 HSA's became available. Being self-employed and healthy, my wife and I took on a high deductible healthcare policy. It cost much less than your wife's policy. In the next 10 years we paid $68K into our HSA. It was not until 2010 that my wife gave permission to invest that money in a popular index fund. We now have $300K in our HSA. Our insurance prior to retirement paid out over $100K for healthcare. It did that without any complaint. And without raising my premiums. We paid a bit over $10K in out of pocket expenses - and got tax deductions since our business made the actual payments. (Prior to that we seldom had insurance.)

I think there were better choices you could have made.


My son-in-law changes jobs frequently - every 3 years or so. At his last change he insisted that the company health insurance pay for his daughter's doctor - who was out of network. They agreed. He still got a big pay raise to change jobs. But a lot of people have unfounded fears about finding a job.


People in good health have an easier ability to change jobs as insurance coverage based on risk is much cheaper than the group plans businesses have. The big mistake most people made in having health insurance is letting their employer select it and determine how much the employee was going to pay.

[Ron Williamson]

I like our system.
I've had two MRIs since 2017. The first( torn subscap,minor snowboard crash) took a couple of weeks and was required,after I saw my GP,prior to seeing the ortho surgeon.About 6 weeks start to finish, including ortho,who concluded that since I had good motion and strength,and little pain, surgery would be a step backwards

The second (wrist/hand bones deterioration),after the initial GP visit Thursday, they were to book an MRI appointment,prior to ortho, and I asked to be put on the cancellation list as well.
MRI called me Monday,with a cancellation for Wednesday. GP office called Tuesday with a regular appointment for a week later. Ortho(different guy) wanted to fuse my wrist and cut a chunk out of one of the long bones.
Hard no.
"It's pretty simple,and I like surgery,so anytime you want......"
All in,about three weeks.
I have no recent complaints.
R

[bob winter]

I have never had a problem with diagnostics when I needed them. Fortunately, I have not needed them all that often but, when I have, they were readily available in a timely fashion.

[Dave Hadfield]

The wait time in the Barrie area a few years ago for non-threatening MRIs was 9 months. A friend of mine went through it. (Or tried to...)

[TomF]

The wait time in the Barrie area a few years ago for non-threatening MRIs was 9 months. A friend of mine went through it. (Or tried to...)

And yeah, it happens. The waits are different in different parts of the country, depending on the investments that the specific province/territory (or regional health authority within it) have made - because there aren't national benchmarks in place for non-acute diagnostic imaging.

Same with access to a primary health care provider, FWIW. The degree of accessibility (often measured in things like % able to have a non-urgent appointment within 3 days, or 5 days) varies not just from province to province, but in regions within those provinces. Some places, doctors and nurse practitioners really want to live - and others, not so much. There are various tools that governments can use to try to smooth this out, but essentially it's the same kind of issue facing any employer wishing to attract and retain highly skilled and highly mobile workers.

IMO, there are good reasons to add some "sticks" to the "carrots" to help assist accessibility - I remember that when my dad was a freshly minted Clergyman, the United Church at that point required that newly qualified clergy simply go where they were sent for the first 3 years of their careers. It was a cost of doing business. Now, most of those clergy didn't stay past 3 years in North Armpit SK, 1500 miles away from their friends and family in the Toronto region, but the national Church said "tough rocks - they need worship, marriages and funerals in North Armpit too." As the cost of medical education - however enormous for the student - is also about 70% funded from the public purse in Canada ... that kind of short term "return of service agreement" is important. Some jurisdictions have these already for medical students - but allow graduates to simply pay a fee to opt out of the agreement, if they wish. IMO that's wrongheaded, and should stop.

[Garret]

In 2005 HSA's became available. Being self-employed and healthy, my wife and I took on a high deductible healthcare policy. It cost much less than your wife's policy. In the next 10 years we paid $68K into our HSA. It was not until 2010 that my wife gave permission to invest that money in a popular index fund. We now have $300K in our HSA. Our insurance prior to retirement paid out over $100K for healthcare. It did that without any complaint. And without raising my premiums. We paid a bit over $10K in out of pocket expenses - and got tax deductions since our business made the actual payments. (Prior to that we seldom had insurance.)

I think there were better choices you could have made.


My son-in-law changes jobs frequently - every 3 years or so. At his last change he insisted that the company health insurance pay for his daughter's doctor - who was out of network. They agreed. He still got a big pay raise to change jobs. But a lot of people have unfounded fears about finding a job.


People in good health have an easier ability to change jobs as insurance coverage based on risk is much cheaper than the group plans businesses have. The big mistake most people made in having health insurance is letting their employer select it and determine how much the employee was going to pay.

High deductible plans were ~ 1/3 the cost in 2005 compared to now. I'm glad you made enough money to put that much into your HSAs. We did not make as much so were weren't able to put as much in. What is in ours now is being saved for an emergency - not used to make payments on insurance.

I realize our making less money than you makes us stupid, but so be it.

[Hugh Conway]

I realize our making less money than you makes us stupid, but so be it.

you are stupid because you haven’t picked up how much money TLT has made is a constantly changing number, and the numbers don’t work. Minimum annual deductible on a high deductible family plan was $2200. Out of pocket max $11,200. His numbers don’t work.

[Garret]

Gosh - thanks for confirming.

[Hugh Conway]

Gosh - thanks for confirming.

I didn’t mean that as harsh to you as it sounded. We can’t all coast by on our wife’s payroll like he did. We can’t make up numbers either, like contributing more to your HSA than legally allowed

[Garret]

I didn’t mean that as harsh to you as it sounded. We can’t all coast by on our wife’s payroll like he did. We can’t make up numbers either, like contributing more to your HSA than legally allowed

Thanks - appreciated.

[chas]

Cradle to the grave healthcare, no bills to manage. I’m not sure people are refused necessary drugs in this country if they are unable to pay. Smarter people than I are in charge, hope they are handling it well. Good so far. / Jim

[Ron Williamson]

And yeah, it happens. The waits are different in different parts of the country, depending on the investments that the specific province/territory (or regional health authority within it) have made - because there aren't national benchmarks in place for non-acute diagnostic imaging.

Same with access to a primary health care provider, FWIW. The degree of accessibility (often measured in things like % able to have a non-urgent appointment within 3 days, or 5 days) varies not just from province to province, but in regions within those provinces. Some places, doctors and nurse practitioners really want to live - and others, not so much. There are various tools that governments can use to try to smooth this out, but essentially it's the same kind of issue facing any employer wishing to attract and retain highly skilled and highly mobile workers.

IMO, there are good reasons to add some "sticks" to the "carrots" to help assist accessibility - I remember that when my dad was a freshly minted Clergyman, the United Church at that point required that newly qualified clergy simply go where they were sent for the first 3 years of their careers. It was a cost of doing business. Now, most of those clergy didn't stay past 3 years in North Armpit SK, 1500 miles away from their friends and family in the Toronto region, but the national Church said "tough rocks - they need worship, marriages and funerals in North Armpit too." As the cost of medical education - however enormous for the student - is also about 70% funded from the public purse in Canada ... that kind of short term "return of service agreement" is important. Some jurisdictions have these already for medical students - but allow graduates to simply pay a fee to opt out of the agreement, if they wish. IMO that's wrongheaded, and should stop.

Irrelevant to the thread,but SWMBO was born in Uranium City, SK, because of that United Church requirement.
R

[Dave Hadfield]

My daughter has just become a physician. The obstacles that were thrown into her path to become one in Canada were enormous, stupid, useless, bad for the country and NONE of them were related to her abilities or performance.

Eventually she had to go overseas (Ireland), and I had to back her student loan -- with the equity in my house. Canadian banks don't loan for medical training overseas unless there is security. And there at U of Limerick, she shone -- did very well.

Anyway, there's a big long list of events in the process that raised my eyebrows to the stretching-point over the last 5 years. As an airline pilot, I am very used to a rigorous and impartial training and evaluation standard. But what I saw of the medical stream was amateurish and disorganized. That's the reason we have an inadequate number of doctors in Canada. The process doesn't work well.

Sorry for the sidetrack -- not a UHC issue. Just venting...

[Sailor]

Dave, I was listening to CBC on the way into work few months ago and there was a Doctor who was from the UK trying to become licensed to practice here. The hurdles, and hoops he had to go through, the lack of assistance, the confusion at every step of the way. Also why we're short on doctors. We can't even import them and let them work without causing headaches along the way. There should be a process in place (in each province since medical is provincial and not federal but it should be federal in my view) that guides people through the steps. We can't just let anybody practice or someone from an online university with a fake degree could end up, or a real degree from a sub standard school. Either way, we need to ensure our imported doctors are qualified at least equivalent to our own doctors without making them go through medical school or challenging 3 dozen exams. A simple process that adequately ensures we have suitable doctors and that they aren't scared away because of the complexity of our system. Sounds like it works sending them away, but not the reverse. Does your daughter have to practice in Ireland (I could think of worse places to be "stuck" having to work. What would any process look like that would allow her to come home to practice one day?

[Too Little Time]

you are stupid because you haven’t picked up how much money TLT has made is a constantly changing number, and the numbers don’t work. Minimum annual deductible on a high deductible family plan was $2200. Out of pocket max $11,200. His numbers don’t work.

Perhaps you should not use your confusion to draw false inferences.

Our policy had a $10K deductible - the year in which we had over $100K of expense. But since we were healthy, we only paid that one year. But what is paid for insurance and care is unrelated to what is contributed to an HSA.

[Hugh Conway]

Perhaps you should not use your confusion to draw false inferences.

Our policy had a $10K deductible - the year in which we had over $100K of expense. But since we were healthy, we only paid that one year. But what is paid for insurance and care is unrelated to what is contributed to an HSA.

It is quite confusing how often your numbers change almost like you make them up! Spin spin sugar!

[UCanoe_2]

So, if I decided to move in with my cousin in Ontario I would be an expat US citizen living in Canada. Would I still be eligible for the Canadian health care system? Right now my wife and I are paying about $6600 per year for Medicare, Rx coverage, and Medicare supplements. That's just for premiums, not for copays or other out of pocket costs.

[mmd]

So, if I decided to move in with my cousin in Ontario I would be an expat US citizen living in Canada. Would I still be eligible for the Canadian health care system?

Nope. You gotta be a landed immigrant or citizen to be eligible, and there is a waiting period, I believe.

[TomF]

landed immigrant, citizen, spouse of a citizen, refugee ...

The key is that one way or another the person needs the legal status to be a permanent resident. And most provinces (maybe all?) require 3 months' residency first, before one can become a member of that province's plan. (During which time, if the person had simply moved from another part of Canada, they'd be on their prior province's ticket.)

[Too Little Time]

High deductible plans were ~ 1/3 the cost in 2005 compared to now. I'm glad you made enough money to put that much into your HSAs. We did not make as much so were weren't able to put as much in. What is in ours now is being saved for an emergency - not used to make payments on insurance.

I realize our making less money than you makes us stupid, but so be it.

You asked me to explain. I did. My wife looked at the cost of health insurance and made a decision as to which was more cost effective. Either we saved money by doing an HSA or we diverted our IRA contribution to the HSA. It was not about having more income than you did.

But my observation was that we have no idea what the Canadians are comparing to when asked if they prefer their system to the US system. It seems obvious that even those in the the US have seldom thought about their options. There is little reason to believe the Canadians spend much effort on the subject.

[mmd]

Nice insult to an entire nation, TLT...

[TomF]

Nice insult to an entire nation, TLT...

Not worth the reaction.

Canada's health system manifestly has issues, as do any large systems. I'm unaware of ANY developed nation which does not have significant, genuine concerns about this or that aspect of their country's universal health care system. And over the years, part of my job has included looking for such, and for best practices about how some such issues can be addressed.

Dave Hadfield earlier expressed his anger and frustration at the way that Canada's medical school admissions happen, and how many places there are. Prompted by his daughter's experience - I'll echo that. My older son's in a Canadian med school, finishing his second year now, but it took him 3 application cycles. I'm unconvinced that he'd become a sufficiently different person by round 3 to justify why he wasn't in round 1, and I have several ... opinions ... on the selection processes, criteria, application of these in balanced way ... and frankly about the education processes themselves.

This is not unique. This is the farthest thing from unique, in global comparisons.

[CWSmith]

It seems obvious that even those in the the US have seldom thought about their options.

You miss the point again, TLT. The problem is that many (even most) have no options. I have a good job, I get paid well, and my two options are to accept the plan my employer provides (that still costs me) or buy my own at full price. That's not an option.

[P.I. Stazzer-Newt]

Thread Drift

What is a "Landed Immigrant"? - is it related to "Landed Gentry" or is there some other definition.

[mmd]

Thread Drift

What is a "Landed Immigrant"? - is it related to "Landed Gentry" or is there some other definition.

From the Canadian Immigration & Naturalization Dept. website:

"Canadian landed immigrant status, also known as a permanent resident, refers to an individual who has been granted permanent residence, a type of immigration status, after immigrating to Canada"

[P.I. Stazzer-Newt]

Thanks for the explanation