Saturday, May 22, 2004

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Wow, my second health care post in less than a year

Loyal readers of are aware that while I'm aware that health care is important, I find it difficult to maintain focus when the issue comes up.

I am dimly aware, however, that Canada's single-payer system is frequently cited by liberals as their preferred form of health care reform. Which is why I found the following Brad Evenson story in Cananda's National Post so interesting:

As many as 24,000 patients die in Canadian hospitals each year, while tens of thousands more are crippled, injured or poisoned in association with medical errors that could have been prevented.

A new landmark study of 20 hospitals in five provinces found one in 13 patients suffers an adverse event, more than double the rate found in studies of U.S. hospitals.

"I think this is pretty explosive data," said Alan Forster, a health services researcher at the Ottawa Hospital Research Institute.

"When you start looking at these numbers, you really see the problem in a graphic way."

The study, to be published in the Canadian Medical Association Journal, found 185,000 patients a year suffer adverse events....

In 1999, the U.S. Institute of Medicine published its report on medical errors, "To Err is Human," an effort to bolster patient safety. It cited studies in Colorado and New York that found adverse events ranged from 2.9.% to 3.7% of hospital admissions.

By contrast, the new study found 7.5% of the 2.5 million patients admitted to Canadian hospitals each year suffer adverse events. Dr. Baker says the American studies were focused mainly on major events that could attract lawsuits, not minor problems.

When compared to similar studies in the United Kingdom, New Zealand and Australia, Canada fared well, especially when preventable errors were considered. For example, a study of 28 Australian hospitals in 1992 found 51% of adverse events could have been avoided. A study of two teaching hospitals in the U.K. found 48% were preventable. The Canadian figure of 36.9% was virtually identical to a New Zealand study in 1998.

This may be an example of correlation and not causation. Still, a common assumption among the cognoscenti is that Canada's health care system is superior to America's -- and this study points out that this is not necessarily so.

posted by Dan on 05.22.04 at 08:31 PM


What exactly does ...

"I am dimly aware, however, that Canada's single-payer system is frequently cited by liberals as their preferred form of health care reform."

... have to do with the cited study?

And why did you not quote this rather critical sentence from the article?

"Researchers say 37% of events could have been prevented, noting Canada lags behind the United States and other countries in confronting medical errors."

So, in other words, US malpractice laws have made hospitals safer for patients. Or would you interpret this sentence differently?

Also, I would be interested in a study of "adverse effects" (or the equivalent thereof) among uninsured Americans who couldn't pay for medical care.

posted by: gw on 05.22.04 at 08:31 PM [permalink]

Also, let's not forget the 48 million in the US who have no health insurance - about 1/6 of the US population. Most of them kids. In 2002, it was estimated that 18,000 people in the US die each year because they cannot afford private health care.

I think if you're going to make comparisons between the US and Canada, you should include the whole system, not just what the rich and lucky get.

posted by: Hal on 05.22.04 at 08:31 PM [permalink]

Whoops, 43.6 million, not 48 million. My mistake.

posted by: Hal on 05.22.04 at 08:31 PM [permalink]

Someone should check the statistics for states along the border. It would be interesting to see if anyone is keeping statistics on the number of Canadians who come to the U.S. for procedures/tests. We had Canadian doctors in my home town. There is anecdotal evidence which suggests that we are a safety valve for the Canadian system.

posted by: allison on 05.22.04 at 08:31 PM [permalink]

Really, this post seems meaningless to me. How can you compare rates of "adverse events" without knowing what that means? If the article points out that US studies focus a major events that could result in law suits, is the implication that Canadian studies include a broader range of happenstances under this rubric? 2.9% to 3.7% versus 7.5% of what? If Canadian hospitals admit 2.5 patients annually, that's roughly 8% of the population. How does that compare with US in-patient statistics? What about length of stay? Types of treatment? We certainly need some serious discussion on the pros and cons of public versus private healthcare but the information provided here does nothing to advance it.

posted by: cs on 05.22.04 at 08:31 PM [permalink]

cs and hal are right:serious discussion is needed.
I have lived half my adult life in both countries.Americans would find the relative shortage of advanced equipment like MRIs and the consequent waiting lists unacceptable. So do many Canadians who cross the border to pay for quicker service. I waited seven weeks for a moderately urgent CAT scan, a wait that caused me some anxiety.
BUT I would like to point out to Allison that even though treatment delayed is sometimes treatment denied, the moral horror of poor people and their children(and apparently some well-paid working people too) being discouraged from seeking early treatment by lack of ready insurance is another example of America's devil take the hindmost attitude. I was recently in a pediatric centre observing, while my own boys were being served, dozens of young babies and toddlers being brought in for checkups. Some were obviously very poor: there were immigrants speaking broken English; there were native peoples; there were well-to-do white Canadians. All were served EQUALLY by the same pediatricians who treated my boys. No one was talking about money for these visits. We all simply showed(only on first visit) our provincial health cards. NO one was embarrassed or sent somewhere else because they could not pay. The people who rule the United States(make its laws) and those who vote for them, even in those poor red states, simply would not understand what happened in our pediatrician's office that afternoon. Even conservative people in Canada(and in some ways I am one) would consider it outrageous and disgraceful that the parents of children would worry about taking their children to the pediatrician. Americans are unique in the industrialized world for imposing those cruel contrasts in service.

posted by: gb on 05.22.04 at 08:31 PM [permalink]

To understand the crisis in the Canadain health care system all you need to do is speak to a resident of Canada. We are faced with 10 and 12 hour waits in emergency, sleeping in hallways, 6 month waits for non elective surgery etc. Our systen simply does not work as it exists today,not sure if it is underfunded, poorly managed or the structre itself but it is certainly not a model for any countty to follow.

posted by: David Isaacs on 05.22.04 at 08:31 PM [permalink]

Hal mentioned 43.6 million people do not have health insurance in this country. However, 13 million of those make over $50,000 per year, and half of these 13 million make over $75,000 per year.

If we say that $50,000 per year is enough afford health insurance, we're down to about 30 million who can't afford it. Some of these may be eligible for subsidized programs, but simply didn't fill out all the paperwork.

Now, I'm not trying to downplay the fact that there are millions of people out there who can't afford health insurance. The simplest way seems to me to make more people eligible for subsidized programs, not moving to a single-payer model.

I'm just making the point that there are a lot of people who don't have health insurance for reasons other than being too poor. If you want these people to be insured, you may need a law to enforce it. Maybe we shouldn't have the freedom to be uninsured, while still enjoying access to emergency services.

posted by: Eshan Shah-Jahan on 05.22.04 at 08:31 PM [permalink]

Single payer does not have to be coupled with purely public forms of delivery.As in European countries, you can have multiple forms of delivery, including some private delivery of medical services. Sweden has found real efficiencies by encouraging competitive private delivery even with uniform fees for all forms of delivery.
Subsidized programs can do much, but are also vulnerable to cutbacks when state budgets are badly pinched. That is why a public commitment to equality of access through single payer is important. Delivery can vary.

posted by: gb on 05.22.04 at 08:31 PM [permalink]

Dr. Baker says the American studies were focused mainly on major events that could attract lawsuits, not minor problems.
That reads to me as though the Canadian studies were focused on major events and minor problems. That would mean that the fact that the Canadian rate is double the American would not be surprising, since the Canadians would be counting more errors.
Textual support: The next sentence goes on to mention studies in other countries. It looks to me as though the point of saying "The American studies" is to mark a difference from the others; but it's also possible that Baker was making a different point that was lost in transcription.

posted by: Matt Weiner on 05.22.04 at 08:31 PM [permalink]

I'd say america hospitals are designed around not getting sued, so yeah, they have better stats.

posted by: c. on 05.22.04 at 08:31 PM [permalink]

Who are those who aren't insured in the US? Not who you think they are, search The Heartland Institute.

The Fraser Institute in CA just came out w/an interesting study, too.

Also, if you were a Canadian dog or cat, you'd get an MRI faster at least in one part of Canada.

There's a dr. brain drain to the states.

A lot of those not covered are small business owners and college kids who are actually covered under their parents' policy. AND what about those who choose money over HC bennies, like a firm whose hispanic employees made that decision?

We don't need to toss over the best medical system in the world for what is really no more than about 7% of the population. We can fix that. Don't all 50 states have coverage for poor children?

Look at what happened to TenCare (?) Tennessee's attempt at "National health care." Look at Oregon, even they weren't crazy enough to vote for it in 2003. Voted down 80-20ish, IIRC.

Besides, w/the new MSAs, change is a-coming.

And nothing will happen until we get tort reform. CA's had it for over 20 years.

posted by: Sandy P. on 05.22.04 at 08:31 PM [permalink]

Perhaps an interesting question to ask is how many of those events were caused by the patients themselves lying to the doctors. I am sure that a doctor will misdiagnose a patient if he/she lies about the problem, or reasons behind it.

posted by: Martin on 05.22.04 at 08:31 PM [permalink]

I have to agree Dan. I have to say that Canada's system is over-rated. It does give universal coverage which is a good thing, but it also has serious signs of sacrificing quality in order to do so.

So the question becomes, which would you rather have? A health-care system that covers everybody and is nationalized, but you get not as good treatment options and fewer choices ... or a healthcare system where large portions of the population have no or sub-standard government subsidized healthcare but has the best technology and treatment options in the world?

It's not such an easy choice.

posted by: Oldman on 05.22.04 at 08:31 PM [permalink]

Any discussion of healthcare that does not acknowledge how inefficient the US system is is worthless. We spend 14% of GDP vs. less than 10% for Canada. If Canada wanted to spend that additional 4% on healthcare then I 'm sure they could have all the whiz-bang technology, shorter wait lists, AND universal coverage. As to whether adverse events would decrease, until some common definition is arrived at this post is pretty worthless in evaluating whether Canada is better, worse, or the same as the US in that respect.

posted by: elliottg on 05.22.04 at 08:31 PM [permalink]


We will one day have manadated universal coverage that will probably resemble the Canadian system. If folks want better care, they will be able to purchase a policy similar to Medigap. And the pressure for this system will come from the US Chamber of Commerce, and large corporations, who are very tired of having to invest time and resources figuring out the type of medical policy and benefits best suit their employees and won't wreck their budgets.

And once it happens, the American people will remember the days of evil HMOs in nostalgic sepia tones, as government care will be underfunded, dingy, and have all the doctors that couldn't lure the well off who bought the medigap policies.

It won't be much better, unless you are one who had no health insurance at all. But it will ease healthcare inflation, and folks probably won't detect a similar easing of the rate of healthcare innovation.

posted by: Appalled Moderate on 05.22.04 at 08:31 PM [permalink]

Even those who are "uninsured" may have one, two, or three possibilities of help. Many states' auto insurance includes medical care for injuries resulting from auto accidents. Workers compensation pays for medical care for injuries and illnesses which are job-related. And if one is injured by another party's negligence, lawsuits are sometimes useful.
Between auto insurance and workers compensation, some young folks think they're covered for what is the most likely kind of problem. They won't get sick, they're too young. This being a free country, we don't force them to believe that they are not invincible.

posted by: Richard Aubrey on 05.22.04 at 08:31 PM [permalink]

While I have no statistics to bring to bear on this issue, I can provide a personal andecdote that I always find quite illuminating when discussing health care in the great Canada v. U.S. debate.
Several years ago, I had to have an emergency appendectomy. I was making a lofty $21K/year at the time (just out of college), but I did have benefits (HMO). I showed up at an emergency clinic complaining of pain in my gut, was immediately seen by a doctor, was, within the hour, wheeled over to an adjacent hospital by that same doctor in wheelchair, placed in a semi-private room, and had the surgery early the next morning. For my recovery, I opted to pay an extra $50 bucks a day for a private room. I stayed for 4 days, a received very good if not excellent care in a great surgical hospital, all for the price of a co-pay ($10) and my optional private room fee.
In contrast, a relative had a similar incident, about 6 months previous to mine. Except he lived in Canada. He owned his own business (with about 20 employees at that time), owned a horse farm, took fabulous vacations, etc. In other words, this guy had a lot more money that I did. Well, he was rushed to an emergency room for his appendectomy, which surgically went fine, but he had the pleasure of spending his 3 day recovery in a gurney in a hallway, wearing only a surgical gown, and had access to the public men's room to wash up. Needless to say, as soon as he was able, he was out of there, happy to recover in his own home, thanks. For this, he paid nothing (other than taxes).
Make of the above what you will, but I'll take the U.S. system 99 times out of 100.

Now, I am not saying that American Health care is perfect. But I am happy to pay a portion of my salary to ensure that I get it. It's a sacrifice I willingly make. And we do have programs to support the poorest of the poor, free immunizations and insurance for children, which are mostly local/state and not federal. Also, as treatment of last resort, if you show up in an emergency room, you must be treated by law. The point I am getting at is that is pretty hard to not get health care in the U.S. You have to be either isolated somehow (I am thinking elderly shut-in types), ignorant of the programs, or just choose to not do it.

posted by: Don on 05.22.04 at 08:31 PM [permalink]

Matthew Yglesias has commented on your post, which in my view, is OBVIOUSLY lame. Don't waste your breath people...Dan has not thought this through. You gotta ask yourself:

What's his opinion worth?

posted by: Jeo on 05.22.04 at 08:31 PM [permalink]

Hal: How many of those 43.6 million uninsured are illegal immigrants? (And yes, they are included in the count.) Who, by the way, are guaranteed an emergency room visit for a bad cold - at least here in California.

Which I submit as an anser to CB's charge of "cruel contrast".

Appalled Moderate: ("One day we'll have the Canadian system") Today, Canadians can come here for acute medical care. When we fall into that trap, where will either we or they be able to go? Certainly not Mexico.

Jeo: Yglesias' argument seems to be "Is not - is not", which I find pretty unpersuasive.

posted by: Mike on 05.22.04 at 08:31 PM [permalink]


Either employers will apply the pressure for national health directly, through their lobbyists, or they will do it indirectly, by dropping medical insurance from their package of benefits, and growing the ranks of the uninsured. The auto industry, and other large manufacturing outfits periodically form coalitions demanding universal medical care. As health insurance prices soar at 11, 12% per year, large corporate america wants to put some predicatability into their payroll budgeting.

Where will people go for acute care? There will be places for people with money. There always are. My guess is that the Japnese system will end up evolving here...where the government provides a minimum level of care,and private insurance bought by individuals provdes the rest.

posted by: Appalled Moderate on 05.22.04 at 08:31 PM [permalink]

I work with Canadian doctors who came to the states for a better opportunity. I wonder how large the doctor brain drain actually is, since in my relatively small town I know of 6 Canadians out of maybe 50 doctors. And over 1000 miles to the border!

If the US ever gets tort reform, expect many more Canadian docs to cross the border.

posted by: Bradford on 05.22.04 at 08:31 PM [permalink]

If we're trading anecdotage, I once sprained my thumb badly playing Frisbee. When I called the HMO's assigned provider to be referred to immediate care, the medical secretary refused to refer me because the doctor had never seen me. I had to wait till the weekend when that doctor's office was closed in order to get a referral from the office that the insurance company had on call. I don't quite remember the subsequent sequence of events, but I had to get myself to an emergency room--after not being treated for two days, with my hand purple and about the size of a baseball--where the ER nurse took a look at me, heard my story, marched up to the doctor's office, and brought the secretary down to apologize to me personally.

THEN I had to see a specialist for follow-up--according to the original doctor 3-7 days. The HMO gave me a referral to a doctor who, when I called, was on vacation for two weeks. His partner was in, but the HMO wouldn't approve a referral to the partner until the HR officer at my company called them up to yell at them. I wound up having to squeeze my appointment in on the day I was moving out of town.

So I'm not too receptive to stories about how Canadia is awful and the US system is hunkadory. Anyone figured out whether the US and Canadia numbers are actually comparable yet?

posted by: Matt Weiner on 05.22.04 at 08:31 PM [permalink]

Well matt, we don't have to deal with HMO's so seeing a general practitioner is as easy as a phone call to make an appointment. If I've felt I needed an appointment on the same day I've always received one. Anything non urgent like a knee problem 2 days at most in my experience. There have been reports in the media that some people have problems finding a GP that is taking new patients but I don't know how widespread the problem is. (I have two GP's to go to myself) Referral to a specialist will require a long wait, apparently (maybe sports doctor in your case?), but I don't know how long in comparison to the US. The media has been making a stink about waiting times e.g. the long MRI waiting list, which is why the Ontario government levied a new 1.2 billion tax last week to buy new equipment and other investment to decrease waiting times and improve suboptimal health outcomes for some surgeries (check torontostar, globeandmail for recent coverage of ontario budget). I commented with some quotes about average health outcomes on yglesias post on this topic, which suggests that outcomes arent significantly worse, and are in some cases better, so I don't think the article drezner links to and right wing insinuation from pejman, jane galt, et al. are a sign of the imminent collapse of the health system of their ideologically desire.

I did read that average (of type 1 to type 5 ailments) ER wait to see doctor is around 3 hours in calgary, alberta and 7.5 hours in edmonton, alberta. Supposedly edmonton has an older, more sick population - some will see this as a sign of inefficient allocation of resources - I don't know what it suggests myself. The following web page:

suggests toronto is closer to edmonton, but I'm having a little trouble decoding the information. Anecdotally, I've been to the ER three times with a type 5 lowest priority ailment (all bone fractures - hand, rib, leg), each time in the afternoon and waited between 4 and 7 hours.

posted by: Shai on 05.22.04 at 08:31 PM [permalink]

Don't buy these comparisons. Please be realistic about the subjective process involved in identifying medical errors. I’m a physician who has worked in the UK, Canada and the US (in different eras). They do occur; more often than they should. The famous Libby Zion died after she was given meperidine (a dangerous opiate) by a hospital doctor who had never seen her. Unbeknownst to him, she had recently taken an MAO inhibitor and more remotely cocaine, both of which make the likelihood of a catastrophic reaction to Meperidine rather high. No doctor should prescribe meperidine for any patient whom he doesn't know, and certainly not for an unknown patient on the other end of the telephone. What was decided? That the problem was caused by excessive work hours for doctors in training. Reducing training hours has done more good than harm, but lack of sleep was not the culprit.

When experts review a case protocol with the conclusion "the patient died" they are twice as likely to conclude that negligence was present than if “the patient recovered” – in other words, outcome influences professional judgment about quality of care. You can adjust for this factor by giving some experts the protocol saying that the patient recovered, others the same facts with the report that the patient died. This is very costly- hardly ever done.
You'd have to mix protocols from US and Canadian hospitals, conceal the country involved, and be sure that they are "representative of the population"- nobody has the money to study even 10% of hospitals. It's ridiculous to say that one country takes medical errors more seriously than the other because there are so many different levels of people involved. Global warming is simple compared to trying to get a true estimate of the incidence of medical errors.
We can reduce medical errors by banning telephone prescriptions- making all prescriptions be PDA-generated. However, it would be a nuisance (what about community hospitals with no in-house MDs at night?)- few doctors or patients are ready for this until their ox is gored.
I guess that British and Canadian physicians make fewer errors related to failure to even see the patient and they use fewer drugs, which is good. Hospital medical records seem to be somewhat better in the states. You do wait longer for routine care in Canada, but you are much worse off in the states if you are poor. Both countries have mediocre healthcare systems, with some outstanding and dedicated physicians and nurses.

posted by: drained.brain on 05.22.04 at 08:31 PM [permalink]

I thought of a reason why health care might be something you have trouble paying attention to: you've never had to worry about it, maybe?

posted by: chun the unavoidable on 05.22.04 at 08:31 PM [permalink]

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