Presentation on universal healthcare in Canada and how psychiatry benefits. Portland, Maine, October 20, 2009, Psychiatry Grand Rounds at Maine Medical Center

1. Canadian Psychiatry:
The Case for Universal Health Care and How
Psychiatry Benefits
Carlo Carandang, MD
Assistant Professor,
Dalhousie University Department of
Psychiatry
Attending Child Psychiatrist,
IWK Health Centre
Halifax, Nova Scotia
Canada

3. Canadian Quiz
• How many provinces and territories?
• 10 and 3
• What are the 2 main languages?
• English and French
• Which States border Canada?
• WA, ND, WI, MI, NH, VT, ME
• Capital of Canada?
• Ottawa
• Name the 3 largest Canadian cities
• Toronto, Montreal, Vancouver

6. The Health-Care Crisis Hits Home - TIME
Source: www.time.com
When my brother got sick and his insurers
refused to pay, he needed help. After a
dizzying, infuriating trip through the system,
here's how we found it

7. Facebook Debate
• Carlo - Move to Canada...all Canadians
have health coverage, just like the rest of
the First World Nations. The USA is the
only Western nation without
comprehensive health coverage for all its
citizens...what a travesty. Health care is a
basic human right, not a commodity to be
traded on Wall Street.

8. Facebook Debate
• S - I guess the current debate here is
whether healthcare is a fundamental right
or a privilege. There are strong opinions
on both sides. I don't even think that all
doctors agree.

9. Facebook Debate
• B - A right? Really? That's a pretty slippery
slope. I think freedom is a basic human
right, freedom to make choices in your life
that result in your ability to secure your
own health care, housing, fine dining and
plasma TV...if you are in dire need, there
are organizations out there to help you
avoid dying due to lack of resources to
pay for the basics but no one has a right to
comfort. It something you earn...

10. Facebook Debate
• T - Got to agree with B on that one!

11. Facebook Debate
• Carlo - Been on both sides of this debate,
on one side as an American doc and now
the other as a Canadian doc. What's a
right for Canadians may be a priviledge for
Americans. S, where do you stand on
this? I see the Porsche on your profile
may be giving your answer!

12. Facebook Debate
• J - Unfortunately, we know all too well
from our experience that even the basics
are sometimes not available....right, Dr. S?

13. Facebook Debate
• S - It's wonderful to have a group of Facebook
friends that are on such opposite sides of this
debate. Credit my conservative upbringing in
East Texas and my liberal education at UT-
Austin. Unfortunately, human beings don’t make
the best healthcare decisions for themselves or
financially. Even if they are insured. There are
people who smoke, drink, do drugs, eat too
much, and don’t exercise. Human beings by
nature are very short term thinkers. I don’t think
that society or insurance should cover those who
choose to make those choices in life.

14. Facebook Debate
• S (continued) - There are some days that I want
to (and sometimes do) tell patients to come back
to me only when they choose take care of
themselves. Would make my job much easier.
My hospital is overwhelmed with the uninsured.
Most of the uninsured work. Parkland, as a
safety net hospital, we are supported by Dallas
County Hospital District taxes. Part of my
property taxes goes to this. There are other
Texas counties that don’t have the safety net.
People there struggle.

15. Facebook Debate
• S (continued) - Scandinavia has some of the
best health system in the world but they are
taxed at a highest rate in the world. China has
little or no public system, if you have cancer in
China and can’t afford treatment, oh well, you
die. I agree that healthcare shouldn’t be a right.
We shouldn’t stifle our innovations in healthcare
with socializing our capitalist system. But I think,
we should have mandated universal coverage.
Private vs. public? Doctors would prefer neither.

16. What are the real issues for not having
universal health coverage in the States?
• Capitalism vs. Socialism
• Individual vs. Group
• Private vs. Public
• Self-interest vs. Sharing
• Laissez-faire vs. Regulation
• Innovation vs. Stagnation
• Haves vs. Have nots
• Oppression vs. privilege

17. Canadian and American Psychiatry
• Similar training
– 5 years vs. 4 years, residency training
• Similar professional associations/journals
– APA/AJP-CPA/CJP
– AACAP/JAACAP-CACAP/JCACAP
• Similar practice standards?

18. Canadian and American Medicine
• Last decade, Canadian docs move to USA
for more money
• Canuck docs now returning to Canada for
better salaries and more clinical autonomy
• Managed care did save money and
improve efficiencies when 1st rolled-out
• But the money saved was not placed back
into the actual clinical care of patients...

19. Socialism
• Statism (State)
• Government plays central role in basic services
(health, social security, welfare) and economic
production
• Sharing
– Eliminate concentration of wealth and power
• Whole more important than individuals
• Egalitarianism
• Communism- Karl Marx
– “From each according to his (her) ability, to each
according to his (her) need”

20. Capitalism
• Corporatism (corporate)
• Private ownership (as opposed to public)
• Deregulation
• Minimal government interference
• “Trickle-down” economics
• Profit motive and the right to make a profit drives
innovation, efficiencies
• Milton Friedman
– Chicago School
– Free market

21. Socialism Capitalism
Basic services under
state control
Privatized basic services
Protected worker rights
(unions, minimum wage,
pensions)
‘Flexible’ workforces (no
benefits, highly mobile,
layoffs when recession)
High social spending Low social spending
Civil servants have duty
of loyalty to greater
good- to the
state/collective
Corporate workers have
duty of loyalty to their
shareholders

22. Social Democrats
• Canada and many European countries are
considered Social Democrats
• Mixed Economy
– Mixture of Socialism and Capitalism: selective
public ownership of key national industries,
while maintaining private ownership of capital
and private business enterprise
– Social democrats also promote tax-funded
welfare programs and regulation of markets

23. Free Market and U.S. Managed
Care
• Mid-90’s…First Lady Hilary Clinton pushes
for universal health care in USA
• Free market advocates jump on
bandwagon and believe the market is the
solution to health care crisis
• Private coverage (managed care) now the
dominant form of health coverage
• Has it led to improved care for
Americans?

24. Socialized Medicine
• Socialized medicine
– Public coverage, public delivery
– UK, France
• Doctors are government employees

25. Socialized Services
• Socialized services not new in the States
– Postal service
– Police
– Fire fighters
– Public education (K-12)
• This is already being privatized- Charter Schools
– Military
• Also already being privatized- Iraq war, private security
companies, mercenaries
– Jails
• Also being privatized
– Medicare/Medicaid/VA
• Only covers a small segment of Americans

26. Universal Health Care:
Single-Payer System
• Canadian Health System
– Not fully socialized
– Public coverage, private delivery
• Federal government provides funding to
provinces for health care
• Provinces in turn fund regional health
authorities or private boards

27. Canadian Medicine
• Health care in Canada is delivered
through a publicly-funded health care
system
• Canada's regionally based Medicare
systems are cost effective because of
administrative simplicity

28. Canadian Medicine
• Costs are paid through funding from federal and
provincial income taxes.
• There are no deductibles on basic health care
• No termination of coverage when individuals are
sick
• No restrictions on pre-existing conditions
• No lifetime limits on treatment
• Private supplemental insurance pays for
medication, dental, eye care

29. Canadian Doctors
• Fee for service, Salary, or blended
• In Halifax, Nova Scotia, Dept of Health
contracts with Dalhousie Department of
Psychiatry to deliver psychiatric services
to Haligonians
• Halifax Psychiatrists are independent
contractors, free to set-up medical
corporations

30. Canadian Universal Health Care
• Tommy Douglas
– Saskatchewan, 1940’s
• Health care as a basic human right
• For many decades, Canadian Health Care
was also privately financed
• With public financing, most Canadians do
not go bankrupt nor suffer from no
treatment

31. Universal Health Care and
Medications
• If meds too expensive, then will bankrupt
universal health care system
• Drug costs in Canada and Europe much
less than in USA

32. Canadian Psychiatry
• Treatment decisions made by clinician
• Psychiatrists determine which treatment
modality to use: psychotherapy and/or
pharmacotherapy, social interventions
• Length of stay determined by psychiatrist
on inpatient unit
• No authorizations needed
• Focus on biopsychosocial

33. Canadian Psychiatry
• Drawbacks
– Medications not covered
– Wait lists are long
– Mental health clinicians not as efficient as
American counterparts
– Expensive
• 40% of Nova Scotia budget spent on healthcare
• $3.2 billion CDN
• 6.6% annual growth

37. US vs. Canada
• Canada spends less per capita on health
care and still covers all of its citizens
• Canada spends roughly half as much as
the States, $3,165 vs. $6,102 per person,
year 2004

41. Managed Care
• Originally brought into U.S. to control
spiraling health care costs in late 1990’s
– Cynical view: Capitalism at work
• U.S. Physicians have less clinical
freedoms than counterparts in Canada
and Europe
• In psychiatry, managed care has led to
split treatment

42. American Psychiatry
• Has led world psychiatric ideology over the 2nd
half of the 20th
century
• Managed care eroding the expertise and value
of American psychiatry
• Too pharmaco-centric
• Where’s the psycho-social in biopsychosocial?
• Canada and Europe have always ascribed to the
biopsychosocial model for psychiatry

43. Integrated Treatment and
Comprehensive Formulations
• In psychiatry, no biological test to tell us if we
are right or wrong
• Other medical disciplines are humbled by these
tests
• As such, psychiatrists need to have full analysis
and systematic, logical thinking to assess a case
• Split treatment and being medication only
psychiatrist impacts patient care
• Managed care erodes clinician autonomy

45. What does a graduating Canadian
psychiatry resident see?

46. What does a graduating Canadian
psychiatry resident see?
• Work load
• Work environment
• Salary
• No worries about malpractice/liability when
compared to American grad
– Lower malpractice insurance
• Able to practice psychiatry
• Clinical autonomy

47. Canadian Physician Compensation,
2003-2004

48. My Psychiatric Practice in Canada
• Increase in income
– $CDN on par with $US
• Independent contractor
– Medical corporation
– Decreases tax liability
• Hospital provides infrastructure
– 0.5 FTE admin assistant
– Clinical space/IT support
• Clinical autonomy
– I determine my time devoted to clinical care
• No authorizations
• Malpractice insurance around $1,500 per year
– Liability risk in Canada low

51. Canadian Patient Experience
• MSI card is all you need for medical
services…no co-pays
– Income taxes pay this

52. Canadian Patient Experience
• Supplemental insurance available
(privately) to cover extra medical
expenses
– Private room, medications, dental, eye care
– Around $600/year to cover whole family

53. Canadian Patient Experience
• Patient: Anne
• My wife, Anne, had acute URI
– 8 hour wait in ER
– Admitted to hospital bed (private room)
– Immediate follow-up with ENT specialist
– Acute URI resolved

55. Canadian Patient Experience
• Patient: Mimi
• My infant daughter, Mimi
– Biweekly prenatal classes with public health nurse
– Regular visits to GP for prenatal medical care
– High risk assessments in Fetal Assessment Unit
– Admitted to birthing unit (private room)
• 3 days
– Immediate follow-up with GP for check-ups
– Public health nurse visits at home

56. Canadian Patient Experience
• Patient: Carlo
• My family physician
– Regular visits for various checkups
– Referrals to specialists usually within 1 to 2
months
– If acute (i.e. MI), then referral is immediate
and jump the queue
– Only out of pocket expense is my $600/year
supplemental insurance premium
• Pays for meds and extra medical services

58. So what is the ideal health care
system?
• Health care should not be determined by the
market
• Health plans should not imposed restrictions on
pre-exiting conditions nor have lifetime caps
• Health plans should not terminate coverage
when individuals are sick
• Money saved on efficiencies should be placed
back into the health care system
• But universal health care is expensive
• Probably a hybrid of private and public financing
and delivery (accessibility, efficiency, innovation)

59. Parting Words
• If the U.S. is illiberal, intolerant and
aggressive, then Canada is liberal,
tolerant and passive
• Since President Obama elected, this has
reversed somewhat
• Listen to President Obama regarding
universal health care…one of the great
minds in the world today
• “Yes We Can”