Another way that the Canadian system reins in costs is by limiting physician licensure. The province must sign off on the region in which a doctor chooses to practice. There are restrictions on foreign medical graduates practicing and Canadian medical school enrollment has not kept up with population growth.
For a rheumatologist in private practice, what is life like in Canada? As I noted, the simplicity of the payment structure allows physicians to run their offices with barely any staff. Overhead costs are low. But then so are payments for care. In general, reimbursements appear to be in the range between Medicare and Medicaid. My rheumatology friends tell me that their office waits times are lengthy (just like here). Charts are still handwritten and, of course, barely legible! The ability to order biologic therapies and advanced imaging is restricted. For example, some provincial rules require a three-month trial for each of two to five consecutive disease-modifying antirheumatic drug (DMARD) therapies before accepting a request for biologic therapy for patients with rheumatoid arthritis. Once approved, patients must wait additional time before getting the prescription filled. Since the costs of these drugs are covered by the government, there is a constant pressure to stay within budget. Remember the adage—a slower traffic flow consumes fewer resources.
Practice Challenges
Before my American colleagues get too smug, there are some other practice-related issues that need to be considered. In Canada, I believe that doctors are more widely respected by their patients, and even by the bureaucrats. The bureaucrats need physicians to keep the system moving along. Recall that medical cost containment in Canada is achieved by limiting access to technology and inpatient bed availability and by keeping physician salaries at what they perceive to be reasonable levels. This is a key point. Although internists and “cognitivists” (e.g., rheumatologists, endocrinologists, and infectious disease specialists, to name a few) in both countries earn about the same salary, there is a huge salary gap between “interventionalists” (such as cardiologists, gastroenterologists, and surgeons) on both sides of the border. Their salaries in Canada are about half to one-third of their American counterparts. This means that many Canadian graduates have less of a financial incentive to choose the higher-paying specialties. Recently, some provincial programs have started paying rheumatologists and other internists modest stipends to teach residents in their clinics (Hallelujah!). Inpatient consults performed after hours or on weekends are now rewarded with extra compensation, too. In Canada, the onus of dealing with the denial of coverage is not thrust upon the individual doctor. The patient understands that the doctor cannot do much to change the rules or to hurry up the waiting game. This is very different from what American doctors face. For example, a recent denial of a drug that I requested for a patient with severe, ulcerating Raynaud’s disease resulted in a 14-page fax being sent to me (twice) listing my rights to appeal the decision. Does a 14-page legal document really serve anyone’s interests? In Canada this would never happen because, in all likelihood, this costly third-line drug would not even be listed in the government-approved formulary, so there would be no point applying in the first place.
