U.S.-trained Doctor Demystifies Canadaís Health System

WCHL Your Health Radio, Chapel Hill, NC.† Aired Nov. 16, 2011.

[The paragraphs in large type are the most cogent parts of the text, They duplicate the most important points of the entire interview.† JAF]

The following text is an unofficial transcript of a radio broadcast titled ďDemystifying the Canadian Health SystemĒ featuring Dr. Khati Hendry. She appeared on ďYour Health Radio with Dr. Adam Goldstein and Dr. Cristy PageĒ on WCHL 1360 AM on Nov. 16. The program is produced weekly by the Department of Family Medicine at the University of North Carolina: http://yourhealthradio.org/2011/11/16-with-dr-khati-hendry/

Dr. Cristy Page: Iím Dr. Cristy Page and Iím joined today by guest host Dr. Rob Gwyther from the Department of Family Medicine at the University of North Carolina. On our show today we are going to talk with family physician Dr. Khati Hendry about ďDemystifying the Canadian Health System.Ē She practiced in the United States for many years, but now sheís a practicing family physician in Canada.

Dr. Hendry is a U.S.-trained family physician like me and Rob but she has worked in British Columbia in a private family practice since 2004, so she has experienced both sides of the health care systems in the United States and Canada.

Dr. Rob Gwyther: So Iíd like to start by figuring out just what youíve done in the United States and what youíve done in Canada so our listeners will understand what your references are.

Dr. Khati Hendry: Thanks for having me. I actually spent more time in the United States than in the Canada. I am an American, a U.S. citizen, and I did my training in the U.S. Then I got my dream job working in a community health center in Oakland, California, oh, way back when. I was there for almost 25 years.

Dr. Page: Wow, thatís real service.

Dr. Hendry: Yes, that was quite a bit, actually. So while I was there, the clinic grew, I had more responsibilities, I was the medical director there, and then I was the medical director of a whole network of community health centers in that area. I got pretty heavily involved in administration, and when other opportunities came up, and personal things like getting married and so on, I had a chance to move to Canada. So I worked in the Oakland area for 25 years and Iíve been working here for the last seven years or so as a family doctor.

Dr. Page: So youíve really had experience that is more than just a glance at each of the health care systems.

Dr. Hendry: Yes, I feel like Iíve had a quite intimate look at a number of issues that people are concerned about on both sides.

Dr. Gwyther:  So Iíd say in this country people who are physicians are pulling their hair out because theyíre not satisfied with the system. Lots of patients donít have access to this system and are not happy about that. Itís about to bankrupt the country and everybody in Washington is screaming and yelling. The Canadians, by repute in this country, have a pretty good system. People have access to the system and they seem to be more content. Is that your experience?

Dr. Hendry: That is exactly my experience. Actually, I have to say that when I moved up here and started working it felt a little bit like I had finally stopped banging my head against the wall. It felt really good to stop. [Laughs.] So, no, itís quite a relief to be working in a system where youíre not spending most of your energy essentially fighting to make things better for your patients -- fighting the insurance companies, fighting the rules and regulations, things changing underneath you all the time, worrying about patients who you canít get what they need. Itís been an amazing journey, one that Iíve been really happy to be able to make.

When I moved [to Canada] and started working it felt a little bit like I had finally stopped banging my head against the wall. It felt really good to stop. So Ö itís quite a relief to be working in a system where youíre not spending most of your energy essentially fighting to make things better for your patients -- fighting the insurance companies, fighting the rules and regulations, things changing underneath you all the time, worrying about patients who you canít get what they need.

Dr. Page: How does it relate to primary care being a family physician or being a patient receiving primary care. How would you summarize the major differences between the two systems?

Dr. Hendry: Well, as far as the medical care goes, itís really hardly different at all. In other words, I might see someone in my office Ė theyíre going to have same colds, theyíre going to have the same problems, and Iím going to be bringing my same expertise there, be ordering the same tests for investigation, and Iíll be making my referrals. So in terms of day-to-day seeing patients, itís not that different. Whatís really different is the context in which itís happening. It might be helpful just to give a little example. Iím right now in my office and saw patients all morning. So what happens is that they come in the door, they say hi, they have their card, their number, whatever. No one has to check for whether or not itís still valid, or whether they changed from one plan to another, or if they have co-pays that they need, or anything. They just come in for the visit. They go down the hall and I see them. I do whatever is necessary. I donít have to fill out any extra forms. I go to my EMR, my electronic medical records, I put down what I did, and it gets sent off by the one, part-time bookkeeper, who serves the six-physician practice, and I get money.

Dr. Page: Hm. That sounds really heavenly.

Dr. Hendry: Itís amazing. Itís amazing what you donít do in all of that, you know? You just cut right through it. Youíre taking care of patients and being concerned about their medical issues. Iím practicing medicine, not paperwork.

Dr. Gwyther: So if you talk to people in this country they sort of in knee-jerk fashion say, ďOh, we couldnít have socialized medicine here.Ē We have to have our system, which is in incredible disarray. So hereís my question: You, as a Canadian physician, are told what youíre going to earn and how things are going to go by the government, they become the single payer, and if youíre going to have a contest between the medical establishment and the government, thatís how things are going to be ironed out. In this country, most physicians are working for a bunch of insurance companies, and if they wanted to take them on, theyíd have to take them on one a time. So which is the one that you think enables you and your patients to benefit the most?

Dr. Hendry: Well, I have to say that itís really nice not to be spinning your wheels, dealing with a multiplicity of people to fight against, for starters. And the thing that the government tells you what youíre going to get is kind of an oversimplification. I think a lot of people donít realize that medicare Ė and this is kind of ironic, but the name of the system in Canada is medicare Ö

Dr. Gwyther: We stole it. [Laughter.]

Dr. Hendry: So, you know, people who have Medicare in the U.S., for the most part, even though there are of course things that they might want to improve, itís generally been a pretty popular program and itís incredibly popular here in Canada. People give it very high marks and say they donít want to get rid of the system, just like people donít want to get rid of Medicare in the States. In terms of the government telling you what to do, itís a little more complicated. Thereís a Canada Health Act, and thereís a federal level in which there are certain things that need to be included in the health care systems in the provinces (provinces are our states). Each province actually has the authority to modify what that plan looks like, they just canít go below the basic requirements. So they can add other things, tweak them, and in addition, each province negotiates with the medical association for how theyíre going to pay the physicians. So physicians have quite a say in it, thereís a back and forth as these negotiations go on, and itís not the same from province to province, but thereís an agreement on a fee structure. And I know people in the U.S. are familiar with fee structures from all the different insurance companies, but we have one fee structure.

Dr. Gwyther: And everybody goes home at the end of the day and thatís what youíre going to get, you donít have to negotiate with five different vendors.

Dr. Hendry: Yes. If youíre going to get X amount of money, thatís what you get. And the other thing is that you get it. Or you almost always get it, I mean unless you did something egregious. They way it used to be in the States, I remember, you would submit your bill and maybe youíd get it and maybe you wouldnít. Maybe they would have changed the goalposts, maybe you would have spent six months trying to get paid. But here, essentially, you have an agreement about what youíre going to get paid and they pay you. They donít micromanage.

Dr. Page: It sounds like itís cutting out a lot Ė you mentioned the paperwork before, and you mentioned that you have this one part-time person whoís helping to submit this for six different doctors.

Dr. Hendry: Right.

Dr. Page: Whereas in the United States we pay all this money to try to keep our practice open to have all these people who are helping with paperwork, signing for the bills, working with the insurance companies, and all this. And it sounds to me like itís simplified a lot in your office. And has that borne out to be true for you?

Dr. Hendry: Oh, unbelievably so. And itís much simpler also for the patients, because if I want to send someone to the hospital or a specialist I donít have to worry about what plan theyíre in, whether we have an agreement with it, or whether it switched from one day to the next. You know, you probably have this Ė one of those handheld Epocrates-type programs Ö the applications.

And itís much simpler also for the patients, because if I want to send someone to the hospital or a specialist I donít have to worry about what plan theyíre in, whether we have an agreement with it, or whether it switched from one day to the next.

Dr. Page: Yep.

Dr. Hendry: You know, you have the 50 different formularies that you can use, special apps. Thereís no need for an app here, because everyone basically has got pretty much the same plan.

Dr. Page: You can prescribe a medication and it will be paid? Or do you only have certain medications that are on the plan that you can choose from?

Dr. Hendry: Well, actually, thatís an interesting point, because the Canada Health Act provides for medically necessary services, which includes doctor visits, hospital visits, and the supporting tests and examinations. Pharmaceuticals were actually not part of that original plan. Some of the provinces, all of the provinces, have made different efforts to try to include that. But thatís one of the things that needs to be reined in, in terms of costs in Canada, is how we deal with pharmaceuticals because there isnít a federal plan for payment. However, we donít have a lot of different plans that tell you what you can and canít prescribe. Thereís a share of costs for most places, a few provinces do have pharmaceutical coverage, but itís not quite as straightforward as medical services.

Dr. Gwyther: We need to take a short break, but when we return weíll continuing talking to our guest, family physicians Dr. Khati Hendry about demystifying the Canadian health care system. Weíll be right back with Your Health.

Dr. Page: Welcome back. Youíre listening to Your Health. Weíve been talking with Dr. Khati Hendry about demystifying the Canadian health care system. Dr. Hendry is a U.S.-trained family physician who spent 25 years working in the United States and has spent the last seven working in Canada. But we were talking a little about socialized medicine, or this fear that having a single-payer system is socializing medicine. And one of the things I hear a lot from people in my family and people who are concerned about any talk of that in our country is this perception that people are waiting in lines, that care is getting rationed out, and that if you want a transplant you canít get one because of the long lines. Tell us how that bears out, or is that true?

Dr. Hendry: Well that is certainly not my experience at all. One of the things is that people have their own ideas of what it looks like. Itís very ironic. I moved to Canada and immediately I am working in a private doctorsí office. I have much more say over how I take care of my patients Ė more than I ever did while working in the States, where I was an employee and I had people micromanaging me, almost on a daily basis, from all the different insurance companies to the government agencies and everything else. I have to say there is much less intrusion by government or any kind of insurance agency here in Canada than there is in the United States. Thatís No. 1. The other thing is that a lot of people think we are all employees of the government, and that is absolutely not true. Most of the doctors are in private practice. We have a fee scale we have agreed to through negotiations with our medical associations. So that is a single-payer source so it is publicly administered, but itís not government officials that are running it. Itís the doctors who are running the medical system in terms of defining what we want our patients to have, and so on. The questions of lines, it really just has to do with supply and demand. If youíre in a rural area Ė weíre a big country, so you have a lot of rural areas Ė youíre not going to have immediate access to some specialists if youíre up on the Northwest Territories, for example. So obviouslyÖ

I moved [to Canada] and immediately I am working in a private doctorsí office. I have much more say over how I take care of my patients Ė more than I ever did while working in the States, where I was an employee and I had people micromanaging me, almost on a daily basis, from all the different insurance companies to the government agencies and everything else. I have to say there is much less intrusion by government or any kind of insurance agency here in Canada than there is in the United States.

Dr. Page: Thatís true for rural America as well, right?

Dr. Hendry: Exactly. And the other thing is that there are some issues with overtreatment when you have too many specialists. Because if theyíre there, theyíre going to want to work, right?

Dr. Page: Yes.

Dr. Hendry: So there is a better distribution I would say throughout the country. The places where people run into trouble are either where you just have a shortage of doctors Ė and again that is mostly in a rural areas, not unlike many other parts of the world Ė or in places where you have not as many specialists as you need. And in elective areas.

Dr. Page: So what about the concern that, you know, I want my knee replacement, itís not emergent, but Iím going to have to wait forever to get one?

Dr. Hendry: Well you wonít wait forever. I mean, you might get it next year instead of this year, but you donít wait forever. But people are still concerned. You know, everyone is very involved in their medical care because weíre all part of the system, so people are quite vocal about it, so you certainly hear about it, but in fact if people need a knee replacement, they will get it, and they will not go bankrupt from it, and they will have it done at a reasonable time. So what have they done to deal with that -- they have developed a wait-list system throughout the country, and each province has a different way of dealing with it. Theyíve worked on different ways to expedite some of these elective procedures that people want to go faster. In British Columbia, for example, they have a website where you can go and see who has shorter wait times and then ask to be referred to a physician who has a shorter wait time. So people are working on it. But itís only the elective stuff, not the emergent thing.

So what have they done to deal with [waits for certain elective procedures] -- they have developed a wait-list system throughout the country, and each province has a different way of dealing with it. Theyíve worked on different ways to expedite some of these elective procedures that people want to go faster. In British Columbia, for example, they have a website where you can go and see who has shorter wait times and then ask to be referred to a physician who has a shorter wait time. So people are working on it. But itís only the elective stuff, not the emergent thing.

If you can bear with me for a second, for orthopedics -- I often had a hard time getting services for my patients when I was in the States. I donít know if thatís your experience, but it turns out that itís not always that easy to get exactly what you want when you want it in the States either, especially in the safety-net. But here, if I have someone who really needs something, they get it. There is an orthopedist 24/7 at my hospital. If someone has a fracture or an acute injury they go there and theyíre seen that same day, and again, no one goes broke for that because they donít have to pay extra for it. I have never, ever been in a situation here that I was in in the States where I had to have a patient make a decision about a life-threatening situation versus financial disaster.

If someone has a fracture or an acute injury they go there and theyíre seen that same day, and again, no one goes broke for that because they donít have to pay extra for it. I have never, ever been in a situation here that I was in (sic) in the States where I had to have a patient make a decision about a life-threatening situation versus financial disaster.

Dr. Page: Thatís a common scenario in our country.

Dr. Hendry: And you have a million examples of that. But I had a patient I thought was having a bleed into his brain, a subarachnoid hemorrhage, and was trying to convince him to go to the emergency room. He was terrified because he had no insurance and it would be expensive.

Dr. Page: That would be the United States.

Dr. Hendry: Yes, in the United States. Iíve never have that problem here. It wouldnít be thinkable.

Dr. Gwyther: I remember seeing a movie where the question was asked of a couple of Canadian citizens who wanted to come to the United States for a wedding and their family and that they bought some kind of insurance for a couple of weeks so that if anything happened here theyíd be taken care of. They were that afraid to come here because of the possibility of that happening.

Dr. Hendry: People are terrified of that. Absolutely you need insurance when you go. We do have snow up here, you may have heard of that [laughter], so quite a few people are snowbirds and they go south, many go to the States, and they always have insurance. And I get people coming back who had things happen in the States and still end up with thousands and thousands of dollars of debt, even after their insurance paid. If it had happened in Canada they wouldnít have had any of that.

Dr. Gwyther: Thatís absolutely amazing to me. So do family doctors play the gatekeeper role in Canada?

Dr. Hendry: Well, actually we do, in part because itís much more family-practice friendly. Everyone is used to thatís how you get care, you see your family doctor, which, as a family doctor, I love. Itís not overly specialized in that way. But if someone wants to see a specialist, then I refer them. So yes, Iím a gatekeeper. Now you could go and see a specialist on your own if they would see you, but most of the specialists wonít do that, because they donít get a specialist consultation fee that doesnít come from the family doctor, so thereís nothing prohibiting them from doing it, but they prefer the family doctor send them. The other thing which is kind of interesting is that not only is it family-doctor friendly, but the pediatricians and internists in Canada are specialists, meaning that people donít go there for their primary care, theyíre referred there by the family doctors for a specific issue.

Dr. Page: Interesting. What about a medical home? Are people attached to you and your practice as a place that they receive primary care?

Dr. Hendry: Oh, completely.

Dr. Page: Thatís wonderful.

Dr. Hendry: Yeah. You go to your doctor, thatís your doctor, right? And so thatís your medical home. Now there is a lot of interest in Canada in improving the medical home and making sure everyone has one, because we still do struggle with that, making sure that everyone has their own family doctor and thatís a really big issue for people. Itís being done differently in different areas. So in Ontario, for example, theyíve used a lot of multidisciplinary clinics, settings, and in that city usually there is some combination of salary and fee for service, and then in other areas, no so much. So itís being experimented with differently across Canada. Absolutely, thatís the idea Ė for everyone to have their own family doctor, have a place that they go, have their medical home.

Dr. Gwyther: Do you have whatís called ďpay for performanceĒ down here up there, where if you do certain things youíll make more money because your payers are telling you itís the right thing to do?

Dr. Page: Or a way they monitor the quality of care?

Dr. Hendry: Not exactly the way that they have it in the U.S. Thereís a lot of discussion about whether there might be some role for some of that. In my office, the closest thing I could say is that we get to that is the incentive program for family doctors to encourage us to take care of people with chronic illnesses and do maternity care and people in nursing homes, and so on. So there are special fee codes that we can submit for doing full-service family practice, essentially, which is more financially attractive than just doing walk-in clinics, or something like that. Thatís not exactly pay for performance, but it is getting paid more for doing certain types of services. Itís certainly not punitive in any way. There is also some experimenting for increasing the elective surgeries in which hospitals get more money the more surgeries that they do, which is a little bit of a twist on what theyíre currently doing.

Dr. Page: We are going to have to wrap up our conversation, but Dr. Hendry thank you for taking the time to talk with us and really you did demystify some of our questions and what I hear a lot of concerns about the Canadian health care system. It doesnít sound perfect, but, gosh, the idea that you can see patients and take care of them without 12 different arguments about how to get paid sounds pretty dreamy.

Dr. Hendry: Can I just say one parting shot? And that is that one of the things Iím most impressed with is that you donít lose your insurance. In other words, no worries about pre-existing conditions, if you lose your job, you donít lose your insurance. If you have dependents, are married or not, or whatever, you still have the insurance. So you donít lose it. You always have that sense that youíre taken care of and that you belong and people arenít going to leave you in the dust or make you bankrupt. People are worried about their health and getting better. Theyíre not worried about the bill theyíre going to get at the end of the day.

Dr. Page: Thank you for making that extra statement. Itís hard to end the conversation because there are so many questions about how it works over there, but you are good neighbors and we appreciate your taking a moment with us to demystify the Canadian health care system.

Dr. Hendry: Thank you.

Permission to reprint this on my website was requested in January 2012.† (JAF)