Downloaded from www.ajronline.org by 96.38.217.138 on 10/23/15 from IP address 96.38.217.138. Copyright ARRS. For personal use only; all rights reserved
883
Perspective
-,
-
.
Canadian-Style Richard
Health
Care:
Implications
has been considered one of the practical alternatives American system gone awry. The misconceptions and about CUHCS need to be dispelled for radiologists, all cians, and the general public in the United States. This
attempts
to inform radiologists
of diagnostic
imaging
about
and allied workers the advantages
Increasingly, there have been longing looks northward toward Canadian-style health care, a system heartily approved by the vast majority of Canadian citizens and the majority of physicians [1 , 3-6]. Sixty-eight percent ofAmenicans consider the Canadian health system superior [2, 3]. Philosophically, Canadians seem to have extended the guarantees contained
to the myths physiarticle
in the field
in the
American
disadvan-
liberty,
and the pursuit
and
tages of CUHCS. It is not intended to promote the system. The United States had a basically free enterprise system of health care until 1965 [1 J, when the U.S. Congress established the Medicare Program to provide health care for all persons over age 65, with a federal health insurance program financed through Social Security, and the Medicaid Program to provide medical
care for the indigent
Legislators
reasoned
that
via a federal-state most
private, voluntary health insurance. however, this governmental attempt
Americans
rely
Two
Director
of Diagnostic
address:
AJR 159:883-884,
Department
October
Imaging,
Alberta
of Radiology,
Rights
that
entitle
of happiness”
medical
citizens
to include
to
“life,
“and universal
ment.
on
Twenty-six years later, at limited national health
Rather,
by all the Canadian
provinces.
myths
of the Canadian health care system (1 ) Health care in Canada is not predom-
need to be dispelled: inately governed and funded
by the Canadian
it is governed
and
funded
federal by
the
govern-
provinces.
The Canadian government provides funds to each of the Provincial Medicare Programs at approximately the 40% level with the proviso that the provincial health plans be accessible to all citizens,
to province,
trillion dollars [1 ]. As expenditures have increased, coverage has decreased. Medicare now covers only approximately 40% of health care costs for the aged, and the states have drastically reduced Medicaid coverage. Thirty-seven million Amencans (13% of the population) have no health insurance coyerage [1 ], and an estimated 60 million are underinsured. Not surprisingly, the results of a 1991 Hams Poll [2] revealed 92% of Americans to be dissatisfied with the medical care system. In a 1992 Time-Cable News Network poll, 56% of Americans favored national health insurance over the current system. Received December 16, 1991 ; accepted
of
and by 1 971 had been adopted
program. would
Bill
access to adequate medical care” (contained in Canadian Health Care Act, 1971). Historically, the Canadian-style health care system began in 1961 in the province of Saskatchewan
coverage has been disastrous. Total health care expenditures have mushroomed from 6% of the gross national product to approximately 1 2%, an annual expenditure of over half a
Present
for Radiologists
L. Wesenberg1
The American free enterprise system of health care is in crisis. The Canadian Universal Health Care System (CUHCS)
1
.
The provincial service such
be comprehensive,
and be publicly
be portable
managed
from
province
and administered.
medicare systems are not a socialized as the British National Health Service
Rather, they are a form of health insurance. The conglomerate of these multiple provincial medicare insurance systems has been called the Canadian Health Care System. All residents of a particular province are required by law to purchase provincial medicare insurance (e.g., $52/month per family in the province of Alberta in 1991). If a resident is unable to pay the monthly fee, a short form and declaration appeal can be made, and if approved, the province then pays the insurance
after revision April 16, 1992. Children’s University
Hospital,
and Professor
of Radiology
and Pediatrics,
University
of Calgary,
Alberta,
Canada
(1980-1988).
of South Alabama, 2451 Fillingim St., Mobile, AL 3661 7. Address reprint requests to A. L. Wesenberg.
1992 0361-803X/92/1594-0883
C American
(2)
health (NHS).
Roentgen
Ray Society
WESENBERG
884
fee. The practical effect of this policy is that the entire population has health insurance coverage. The provincial insurance plan is the sole health insurance provider (with minor exceptions) and has major funding responsibilities for(1) hospitalsDownloaded from www.ajronline.org by 96.38.217.138 on 10/23/15 from IP address 96.38.217.138. Copyright ARRS. For personal use only; all rights reserved
funded
annually
physician The
latter
between
on
the
basis
services-paid
fee is determined the
provincial
of a global
budget
and
(2)
for on the basis of fee-for-service. annually
medical
through
association
negotiations
and
the
provincial
health care plan. Physicians thus remain independent, rather than being employees of the system (government) as in the British NHS. The Canadian Provincial Health Care System thus is politically and philosophically in the middle, between the British system on the left and the American system on the right. It is no panacea, but it works. What are the implications for radiologists working in the “Canadian” health-care insurance system? University and academic radiologists commonly work for a salary that is negotiated with the department chairman, who negotiates for the university radiology group with the hospital administration. They
in turn include
radiology
salary
and all radiology
depart-
ment operational expenses in the global budget. Private radiologists may operate their own radiology offices, just as in the United States. In this case, the radiologists can bill for both the technical and professional components of the bill, which
is charged
to
the
provincial
health
care
AJR:159,
carriers
and/or
federal
(the best guesstimate
of
the average annual private, full partner radiology compensation was approximately $255,000 to $300,000 in the province of Alberta in 1 991 ; Bullman D, personal communication). Even by American standards, this would be enough to subsist on. Disadvantages for radiologists of the Canadian-style health insurance system center on the system’s tightly controlled expenditures [4, 6-8]. Anything perceived as “high tech” equipment, such as CT and MR imaging equipment, is delib-
erately delayed in funding approval. For instance, in 1991 the province of Alberta, one of Canada’s wealthiest, had only two MR scanners
Alabama,
for a population
with a population
of 2 million
[7]. The state
of
of 4 million, has 25 MR scanners
(1 0 mobile vans) [9]. Access to MR imaging also is greatly restricted because only another specialist, not a general prac-
titioner, can refer patients for MR imaging. Radiologists also may be affected by restrictions on hospitals’ global budgets that delay replacement of old imaging equipment or result in deterioration of hospitals’ physical plants, including radiology departments. Physicians in Canada receive slightly less than their Amenican counterparts [7]. Although Canadian radiology fees are lower per patient, volumes are higherthan in the United States [7]. The cost of both malpractice insurance ($1 722/year,
1991) and medical
insurance
bureaucracy
October 1992
education
is significantly
less in Canada
system. There is a separate interventional procedure schedule that is billed at a significantly higher rate but with direct billing of the provincial health plan. In the system, the basic fee paid per examination is less than fees charged in the United States
[7]. When these factors are considered, the Canadian radiologist has a marginal advantage over the American radiologist in gross income. However, income taxes generally are higher in Canada. The Canadian radiologist, along with his physician
(e.g.,
counterparts, is subject to being periodically “attacked” as earning too much money by provincial politicians. This is particularly tense during election campaigns. However, this pressure is probably no more intense than that experienced periodically by American radiologists and other physicians.
for posteroantenior
and
lateral
chest
radiographs,
the
professional component was $6-$1 0 in 1 991 ; Bullman D, Medicine Hat, Alberta, Canada, past president, Alberta Radiological Society, personal communication). However, all billing is to one insurer,
which
eliminates
much
of the bureaucratic
work and expense of trying to collect from hundreds of different insurers. There are minimized accounts receivable, and as a general rule, the province does not “bounce” checks. Private radiologists working in a hospital have the option of working for (1) an annually negotiated stipend, commonly with a provision to bill the health care plan separately for special procedures, or (2) a negotiated percentage of the gross billings to approximate the professional fees without having to send in charges on each patient (Canadian physicians
consider this percentage (3) a straight fee-for-service of the various fees are then
arrangement
“fee-for-service”),
or
for the professional component examinations performed. The overall radiology buried by administration in the hospital global
budget. Thus, most Canadian radiologists remain independent contractors. The overall fee schedule is negotiated annually between the provincial radiologic association and the provincial medical association. The latter then negotiates with the provincial health-care insurance agency. Fee alterations may come in the form of an overall percentage increase for each
separate
item in the radiology
fee schedule
or selected
changes in the individual examinations or procedures. Fees may vary significantly among provinces. One province, Ontanio, has even [7]. The overall
placed effect
income but involves
a cap on physicians’ of this is to generate
reimbursement less personal
less hassle for radiologists
with insurance
Although
it is unlikely
that a plan identical
to the Canadian
health care insurance plan, particularly as it relates to radiology, could function in the United States, an “Americanized” version [10].
of the Canadian
health
system
merits
consideration
REFERENCES 1 . Tems M. Lessons
from Canad’s health program. J Public Health Policy 1990;11 :151-160 2. Harris L. The Harris Poll (#52): A 79-19 percent majority favors national health insurance for all. New York: Louis Harris & Assoc., Dec. 22, 1991. 3. Woods D. Dissecting Canadian health care. Pa Med 1990;6:40-43 4. Brown JS, Kimberly BP. The look north to the Canadian health care system: possible implications for otology and neurotology (editorial). Am J OtoI 199112:12(5)
5. Starfield B. Primary care and health: a cross-national comparison. JAMA 1991;266:2268-2271 6. Enthoven A, Kronick A. A consumer-choice health plan for the 1990s. N EngI J Med 1989;320:94-101 7. Orford
AR.
Reflections
on the Canadian
and American
health-care
sys-
tems. Mayo Clin Proc 1991;66:203-206 8. Iglehart JK. Canada’s health care system faces its problems. N EngI J Med 1990; 322:562-568
9. State of Alabama, Office of Health Planning Data Bureau, Report SSE6. Montgomery, AL: State Office of Health Planning, 1990 10. Himmelstein DU, Woolhandler 5. A national health program for the United States. NEngIJMed 1989; 320:102-108
883
Perspective
-,
-
.
Canadian-Style Richard
Health
Care:
Implications
has been considered one of the practical alternatives American system gone awry. The misconceptions and about CUHCS need to be dispelled for radiologists, all cians, and the general public in the United States. This
attempts
to inform radiologists
of diagnostic
imaging
about
and allied workers the advantages
Increasingly, there have been longing looks northward toward Canadian-style health care, a system heartily approved by the vast majority of Canadian citizens and the majority of physicians [1 , 3-6]. Sixty-eight percent ofAmenicans consider the Canadian health system superior [2, 3]. Philosophically, Canadians seem to have extended the guarantees contained
to the myths physiarticle
in the field
in the
American
disadvan-
liberty,
and the pursuit
and
tages of CUHCS. It is not intended to promote the system. The United States had a basically free enterprise system of health care until 1965 [1 J, when the U.S. Congress established the Medicare Program to provide health care for all persons over age 65, with a federal health insurance program financed through Social Security, and the Medicaid Program to provide medical
care for the indigent
Legislators
reasoned
that
via a federal-state most
private, voluntary health insurance. however, this governmental attempt
Americans
rely
Two
Director
of Diagnostic
address:
AJR 159:883-884,
Department
October
Imaging,
Alberta
of Radiology,
Rights
that
entitle
of happiness”
medical
citizens
to include
to
“life,
“and universal
ment.
on
Twenty-six years later, at limited national health
Rather,
by all the Canadian
provinces.
myths
of the Canadian health care system (1 ) Health care in Canada is not predom-
need to be dispelled: inately governed and funded
by the Canadian
it is governed
and
funded
federal by
the
govern-
provinces.
The Canadian government provides funds to each of the Provincial Medicare Programs at approximately the 40% level with the proviso that the provincial health plans be accessible to all citizens,
to province,
trillion dollars [1 ]. As expenditures have increased, coverage has decreased. Medicare now covers only approximately 40% of health care costs for the aged, and the states have drastically reduced Medicaid coverage. Thirty-seven million Amencans (13% of the population) have no health insurance coyerage [1 ], and an estimated 60 million are underinsured. Not surprisingly, the results of a 1991 Hams Poll [2] revealed 92% of Americans to be dissatisfied with the medical care system. In a 1992 Time-Cable News Network poll, 56% of Americans favored national health insurance over the current system. Received December 16, 1991 ; accepted
of
and by 1 971 had been adopted
program. would
Bill
access to adequate medical care” (contained in Canadian Health Care Act, 1971). Historically, the Canadian-style health care system began in 1961 in the province of Saskatchewan
coverage has been disastrous. Total health care expenditures have mushroomed from 6% of the gross national product to approximately 1 2%, an annual expenditure of over half a
Present
for Radiologists
L. Wesenberg1
The American free enterprise system of health care is in crisis. The Canadian Universal Health Care System (CUHCS)
1
.
The provincial service such
be comprehensive,
and be publicly
be portable
managed
from
province
and administered.
medicare systems are not a socialized as the British National Health Service
Rather, they are a form of health insurance. The conglomerate of these multiple provincial medicare insurance systems has been called the Canadian Health Care System. All residents of a particular province are required by law to purchase provincial medicare insurance (e.g., $52/month per family in the province of Alberta in 1991). If a resident is unable to pay the monthly fee, a short form and declaration appeal can be made, and if approved, the province then pays the insurance
after revision April 16, 1992. Children’s University
Hospital,
and Professor
of Radiology
and Pediatrics,
University
of Calgary,
Alberta,
Canada
(1980-1988).
of South Alabama, 2451 Fillingim St., Mobile, AL 3661 7. Address reprint requests to A. L. Wesenberg.
1992 0361-803X/92/1594-0883
C American
(2)
health (NHS).
Roentgen
Ray Society
WESENBERG
884
fee. The practical effect of this policy is that the entire population has health insurance coverage. The provincial insurance plan is the sole health insurance provider (with minor exceptions) and has major funding responsibilities for(1) hospitalsDownloaded from www.ajronline.org by 96.38.217.138 on 10/23/15 from IP address 96.38.217.138. Copyright ARRS. For personal use only; all rights reserved
funded
annually
physician The
latter
between
on
the
basis
services-paid
fee is determined the
provincial
of a global
budget
and
(2)
for on the basis of fee-for-service. annually
medical
through
association
negotiations
and
the
provincial
health care plan. Physicians thus remain independent, rather than being employees of the system (government) as in the British NHS. The Canadian Provincial Health Care System thus is politically and philosophically in the middle, between the British system on the left and the American system on the right. It is no panacea, but it works. What are the implications for radiologists working in the “Canadian” health-care insurance system? University and academic radiologists commonly work for a salary that is negotiated with the department chairman, who negotiates for the university radiology group with the hospital administration. They
in turn include
radiology
salary
and all radiology
depart-
ment operational expenses in the global budget. Private radiologists may operate their own radiology offices, just as in the United States. In this case, the radiologists can bill for both the technical and professional components of the bill, which
is charged
to
the
provincial
health
care
AJR:159,
carriers
and/or
federal
(the best guesstimate
of
the average annual private, full partner radiology compensation was approximately $255,000 to $300,000 in the province of Alberta in 1 991 ; Bullman D, personal communication). Even by American standards, this would be enough to subsist on. Disadvantages for radiologists of the Canadian-style health insurance system center on the system’s tightly controlled expenditures [4, 6-8]. Anything perceived as “high tech” equipment, such as CT and MR imaging equipment, is delib-
erately delayed in funding approval. For instance, in 1991 the province of Alberta, one of Canada’s wealthiest, had only two MR scanners
Alabama,
for a population
with a population
of 2 million
[7]. The state
of
of 4 million, has 25 MR scanners
(1 0 mobile vans) [9]. Access to MR imaging also is greatly restricted because only another specialist, not a general prac-
titioner, can refer patients for MR imaging. Radiologists also may be affected by restrictions on hospitals’ global budgets that delay replacement of old imaging equipment or result in deterioration of hospitals’ physical plants, including radiology departments. Physicians in Canada receive slightly less than their Amenican counterparts [7]. Although Canadian radiology fees are lower per patient, volumes are higherthan in the United States [7]. The cost of both malpractice insurance ($1 722/year,
1991) and medical
insurance
bureaucracy
October 1992
education
is significantly
less in Canada
system. There is a separate interventional procedure schedule that is billed at a significantly higher rate but with direct billing of the provincial health plan. In the system, the basic fee paid per examination is less than fees charged in the United States
[7]. When these factors are considered, the Canadian radiologist has a marginal advantage over the American radiologist in gross income. However, income taxes generally are higher in Canada. The Canadian radiologist, along with his physician
(e.g.,
counterparts, is subject to being periodically “attacked” as earning too much money by provincial politicians. This is particularly tense during election campaigns. However, this pressure is probably no more intense than that experienced periodically by American radiologists and other physicians.
for posteroantenior
and
lateral
chest
radiographs,
the
professional component was $6-$1 0 in 1 991 ; Bullman D, Medicine Hat, Alberta, Canada, past president, Alberta Radiological Society, personal communication). However, all billing is to one insurer,
which
eliminates
much
of the bureaucratic
work and expense of trying to collect from hundreds of different insurers. There are minimized accounts receivable, and as a general rule, the province does not “bounce” checks. Private radiologists working in a hospital have the option of working for (1) an annually negotiated stipend, commonly with a provision to bill the health care plan separately for special procedures, or (2) a negotiated percentage of the gross billings to approximate the professional fees without having to send in charges on each patient (Canadian physicians
consider this percentage (3) a straight fee-for-service of the various fees are then
arrangement
“fee-for-service”),
or
for the professional component examinations performed. The overall radiology buried by administration in the hospital global
budget. Thus, most Canadian radiologists remain independent contractors. The overall fee schedule is negotiated annually between the provincial radiologic association and the provincial medical association. The latter then negotiates with the provincial health-care insurance agency. Fee alterations may come in the form of an overall percentage increase for each
separate
item in the radiology
fee schedule
or selected
changes in the individual examinations or procedures. Fees may vary significantly among provinces. One province, Ontanio, has even [7]. The overall
placed effect
income but involves
a cap on physicians’ of this is to generate
reimbursement less personal
less hassle for radiologists
with insurance
Although
it is unlikely
that a plan identical
to the Canadian
health care insurance plan, particularly as it relates to radiology, could function in the United States, an “Americanized” version [10].
of the Canadian
health
system
merits
consideration
REFERENCES 1 . Tems M. Lessons
from Canad’s health program. J Public Health Policy 1990;11 :151-160 2. Harris L. The Harris Poll (#52): A 79-19 percent majority favors national health insurance for all. New York: Louis Harris & Assoc., Dec. 22, 1991. 3. Woods D. Dissecting Canadian health care. Pa Med 1990;6:40-43 4. Brown JS, Kimberly BP. The look north to the Canadian health care system: possible implications for otology and neurotology (editorial). Am J OtoI 199112:12(5)
5. Starfield B. Primary care and health: a cross-national comparison. JAMA 1991;266:2268-2271 6. Enthoven A, Kronick A. A consumer-choice health plan for the 1990s. N EngI J Med 1989;320:94-101 7. Orford
AR.
Reflections
on the Canadian
and American
health-care
sys-
tems. Mayo Clin Proc 1991;66:203-206 8. Iglehart JK. Canada’s health care system faces its problems. N EngI J Med 1990; 322:562-568
9. State of Alabama, Office of Health Planning Data Bureau, Report SSE6. Montgomery, AL: State Office of Health Planning, 1990 10. Himmelstein DU, Woolhandler 5. A national health program for the United States. NEngIJMed 1989; 320:102-108
