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$139 Appendectomy : In Canada, Sick Never Turned Away

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Times Staff Writer

An American suffering from a heart condition recently visited a Canadian doctor for a checkup. After a battery of tests, he left with a smile. His health was sound and so was his bank account.

The last time he had received a similar examination from his Los Angeles doctor, the visit had cost $250. This time he paid nothing: There were no checks to write, not even an insurance form to fill out.

So it is for nearly everyone living in Canada. With a few exceptions, patients pay nothing for physician’s costs and basic hospital charges. Nearly all costs are borne by the government. The patient does not even need to send in a claim. The doctor and the hospitals simply bill the government.

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Much Cheaper Than U.S.

And even those bills are cheap, at least when compared to costs in the United States. For an appendectomy in Ontario, Canada’s richest province, the government receives a bill of about $139, compared to the $890 that the California Medical Assn. says is the average fee for such an operation in California.

A $355 tonsillectomy in California is performed in Toronto for $84. And, according to the Ontario Medical Assn., a single coronary artery bypass that might cost $3,000 in the United States costs $535 here.

Because of one of the world’s most complete public insurance programs, there are no stories in newspapers here of the sick and injured being turned away from emergency rooms and hospitals because they are broke or have no insurance. Nor do doctors refuse patients or refer them to charity facilities because they cannot pay. Medical and hospital care is deemed a right here--just as police protection is a right--that is not tied to the citizens’ ability to pay.

Canadian Peace of Mind

The sense of security, not to mention superiority over the U.S. system, that this gives Canadians was illustrated by Barry Callaghan, a Toronto poet and editor, who said in an interview that “America may be the land of the free and the brave, but I wouldn’t want to get sick and die there. That would take too much courage.”

Canada does not have socialized medicine in the way that Britain does, with government-owned hospitals and greater government control over fees and the practice of medicine in general. In Canada, the government’s role is still essentially that of running an insurance system.

Patients are free to go to any doctor and hospital of their choice. Government regulation of the practice of medicine is no more intrusive than in the United States, with the medical profession essentially setting the standards.

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At the same time, as measured by such standards as doctor-patient ratio, available hospital beds and available treatment facilities and techniques, the quality of medical and hospital care in Canada is generally acknowledged by international experts to be first-rate, particularly for a country with only 25 million people.

Doctors Doing Well

Even the doctors--some of whom still have reservations about the program--do as well comparatively as their counterparts in the United States. They have been the top-earning profession in the country for the last 25 years, and their incomes continue to grow faster than those of any other group.

The Canadian system, however, does have its problems. There are concerns about future government financing of the system, particularly for hospital care, and there is a serious dispute between doctors and the province of Ontario over the right of physicians to overbill--that is, to bill the government at a rate higher than the mandated fee schedules.

Furthermore, there are coverage gaps in dental care, the cost of prescriptions and the non-medical or custodial treatment of the elderly.

Nonetheless, there is general agreement from every sector of Canadian society that the system is now as good or better than any in the world.

No Interest in Swap

“I don’t know of a better system,” said University of British Columbia Prof. Robert G. Evans, a Harvard-trained medical economist recognized as an expert in international health systems. “I don’t think I’d like to swap with the United States.”

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Until the 1950s, Canada’s health-care system was the same as the United States’--a mixture of private insurance programs and out-of-pocket payments by individuals without insurance. The provincial governments limited themselves to providing care to indigents and small, special groups.

But as Canada generally began to move from a predominantly private enterprise economy to one dominated by government intervention, the theory took hold across the political landscape that health care should be guaranteed by society.

In 1958, the Conservative government of Prime Minister John Diefenbaker instituted a national hospital insurance program that has evolved into a system under which hospitals can be privately owned and operated but must be nonprofit. Now, 95% of all hospital costs are provided by the provincial governments, with the rest coming through private fund-raising.

Private Coverage Ended

In 1962, the province of Saskatchewan instituted a medical insurance system that eliminated private coverage and guaranteed payment to doctors by the provincial government.

Seven years later, under the Liberal Party of Prime Minister Pierre Elliott Trudeau, the federal government expanded the national system to include doctors and medical care, with fees to be negotiated between the provincial governments and organizations representing the nation’s 50,000 doctors.

Originally, the provinces could allow doctors to overbill, but only Ontario, Alberta and New Brunswick permitted the extra charges. However, because of fears that overbilling was creating a special class of doctors available only to wealthy patients, the federal government in 1984 ruled that any province that allowed overbilling would lose a dollar in federal payments for every dollar a doctor charged above the agreed fee schedules.

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That is a negligible problem for New Brunswick, where overbilling amounted to only $63,000 in the 1984-85 fiscal year. But for the two other provinces, it is a serious matter: Ontario lost more than $40 million in federal payments and Alberta lost more than $8 million in the same fiscal year.

Costly for Ontario

Ontario government sources estimate that the province will lose another $53 million this year and $100 million more by April, 1987 if overbilling is not stopped. So, the province intends to stop it. A bill currently working its way through the provincial legislature would prohibit all extra charges and would levy a $10,000 fine on any doctor who violates the ban.

The Ontario Medical Assn., which represents the province’s 17,000 doctors, has threatened a strike if the bill is not modified. It argues that the measure threatens the freedom of physicians.

“If you allow the government to capture the profession financially, sooner or later it will capture them in a professional sense,” Dr. Edward Moran, the association’s general secretary, said in an interview.

The doctors also say that the real question is not that patients will be denied access to doctors of their choice because of any ban on overbilling, since only 5% of the province’s doctors currently overbill. It is that the government is not funding the entire system adequately.

‘A Lack of Everything’

“We’re talking about a lack of everything,” Moran said, listing new technology, hospital beds and research.

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Arguing that “big government is the greatest single threat to good health care,” he pointed to Quebec and British Columbia, provinces in which the governments try to limit the places where doctors may practice by restricting licenses and reducing fees for those physicians who refuse to go to unpopular areas.

Many doctors also complain that the legislation will turn them into civil servants, reduce their social standing and ultimately restrict their incomes.

However, statistics from Canada’s tax agency, Revenue Canada, indicate that Ontario doctors are quite well rewarded. Average annual pay in 1984-85 ranged from $106,000 for general practitioners to $342,200 for radiologists, although those are gross figures and include office costs. The average net income for all doctors in the province last year was $131,000.

Overbilling Problem

Ontario Health Minister Murray Elston counters that overbilling “is a very serious problem” and presents a particular threat to the elderly. “Financial matters are what limit the access,” he said in an interview. “A study shows that 62% of seniors had been overbilled.

“I am not prepared to see the wealthy get the best of care and the rest get the leftovers.”

Elston added that even threats of strikes by doctors will not change his mind. “We’re going to end overbilling; that’s all there is to it,” he said.

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Actually, the arguments now being made by Ontario’s doctors have been heard since the system was initiated. Yet there has been no real evidence that either physicians or the public have been hurt to any significant extent.

Such controversies aside, the crucial question is whether Canada’s universal health insurance system provides the people with good medical and hospital care. And on that issue, even the doctors generally indicate approval of the current practices.

‘A Bloody Good System’

“It’s a bloody good system, frankly,” Moran said. And a survey conducted last November found that 76% of Canadian doctors believe that Medicare, as it is called here, has been beneficial to the health of Canadians and that half of the physicians feel they have benefited financially from the system.

Canada will spend about $39 billion this year on medical and hospital care, or about 8.6% of its gross national product. Among the world’s industrialized nations, only the United States and Sweden spend more per capita on overall health care.

There is just over one doctor for every 500 people in Canada, and that ratio increases by 1.5% a year in spite of the fact that Canada has little or no population growth. (According to statistics obtained through the American Medical Assn., there is one physician for every 212 people in the United States and one for every 262 in California.)

But the overall figures, including the number of hospital beds available, put Canada among the best in the world in health care, although Canadian officials agree that there is a problem with hospital bed access. Robert Evans, the University of British Columbia economist, blames that on the failure of the system to properly allocate the facilities.

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Alternate Treatments Urged

“Some of the squeeze,” he said, “is the failure to send patients into alternate treatments, for example as out-patients.”

Other flaws concern the cost of drugs and care for the aged.

Canadians must pay for any drugs not provided at hospitals or doctors’ offices. Compared to the United States, however, the cost of medicine is relatively low, particularly since generic drugs--non-brand name drugs--are far more readily available here and at lower prices. One study indicates that Canadians would spend at least $200 million a year more for drugs if they lived under the American system.

The biggest gap in the health care net appears to be in treatment of the elderly. They now receive only the same general hospital and medical care as the rest of the population. Nursing homes and other facilities have to be paid for by individuals.

‘No Pressure to Expand’

“At this time, there is no pressure to expand the system to include custodial costs,” said Ian Shugart, a senior policy adviser at the federal Health Ministry. Instead, he said in an interview, the challenge “is to provide more creative solutions through providing alternative systems and to keep them (the aged) independent longer.”

If the Canadian system is, as federal Minister of Health Jake Epp said in an interview, “as close to 100% as possible,” the only remaining issue is whether the country can maintain current standards.

Nearly everyone agrees here that it can.

“There is no political division over the system,” Evans said. “Everyone is committed to it, and the government is willing to pay for it.”

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