Things missing from the health care debate

[tiriaq]

I have experienced the Canadian health care system from its inception. Went from no coverage of any kind, to what exists now.
Have also had a lifetime of experience with the Canadian tax system.
There is lots of opinion, information and misinformation being posted here about both.
50% income tax rate? Gimme a break.
I have heard that actual per capita health care expenditures are actually higher in the US than in Canada. Is the money being well spent? Value received?
Both my wife and I have gone through significant life threatening illnesses. Treatment was efficient and effective. No appropriate treatment was witheld or delayed.
Canadians also have the option of buying services. My son didn't want to wait for imaging - was going to be a few weeks - paid $500, had it done in a couple of days. His doctor offered him the choice.
My wife with did doctor's billings for a regional hospital. Yes, the different provincial plans are honoured. But the payout rates are different, but not all provinces pay claims promptly, or for the full amount. One large province east of Ontario was very bad in this regard. There is also variation in what is covered. Very expensive costs like air ambulance may not be covered by a provincial plan. It is common for Canadians to have secondary health coverage through a private insurer (employment related or privately purchased) to cover things the provincial plans do not.
The colonoscopy story is interesting. When my Dad lived in the US, he observed that as soon as a doctor learned that a health plan covered extensive diagnostics, every test under the sun would be ordered, usually through a clinic or lab. in which the doctor had a business interest. I have never heard of doctor in Canada not ordering tests like colonoscopy when appropriate.

[Louis of PA]

In the free-market system here in the U.S., a doctor or group of doctors can decide to open a facility to perform procedures such as colonoscopies.

They might do this because the hospitals where they are connected might decide to spend their money on other things such as MRIs or CAT equipment.

Or the doctors might simply feel they have better control and faster reaction time by having their own facility.

And yes, they have a profit motive, as they should. There's no reason that a doctor must act as a non-profit entity.

And there is nothing dirty about profits. Profits have helped the U.S. to develop the most advanced medical technologies and the most advanced pharmaceuticals, more than the rest of the world combined. Advances that the rest of the world benefits from.

When a government system is created that dispenses with the profit motive and stifles individual initiative, people end up with situations as described in the article below regarding Canada.

The Canadian doctor who wrote this report says, "It's time to act". To an American, that comes across like a child pleading with his father to make everything right. Such dependency on government largesse is something I'd hate to see here.

To solve such a problem, a government bureaucrat might say, "Let's raise taxes" followed by several years of study, haggling and waiting.

Here, a doctor can simply say, "I'll open my own facility".... and it's done.

Again, if I had been under the Canadian system, I might be dead by now.

from on line sources:

Colorectal cancer screening in Canada: It's time to act

Richard E. Schabas

Dr. Schabas is Chief of Staff at the York Central Hospital, Richmond Hill, Ont.

Correspondence to: Dr. Richard E. Schabas, Chief of Staff, York Central Hospital, 10 Trench St., Richmond Hill ON L4C 4Z3

The National Committee on Colorectal Cancer Screening (NCCCS) and the Canadian Cancer Society have recently endorsed colorectal screening using fecal occult blood (FOB) testing. These documents are the latest links in a lengthening chain of reports that now brings us to a de facto national professional and scientific consensus on this issue. There has been enough talking. It is now time to act.

Colorectal cancer is the commonest cause of cancer-related death among nonsmokers in Canada. In 2002, there were an estimated 17 600 new cases and 6600 deaths from the disease nationally. Although age-standardized incidence and death rates have been declining for decades, the total number of new cases and related deaths is growing steadily because of population aging.

Colorectal cancer has long been regarded as an attractive target for screening: it is a common cancer; its natural history is reasonably well understood; early disease is detectable by means of tests that are acceptable to patients; and treatment of early disease is highly effective.

Cancer screening is intended to reduce mortality. However, good intentions are not enough. Policy-makers must be confident that screening actually does reduce mortality. Very large and lengthy randomized trials are necessary to answer this question.

Fortunately, well-designed randomized trials of screening using FOB testing were begun in the 1970s and early 1980s, and the results of 3 trials were reported in 1993 and 1996., All 3 trials showed a statistically significant mortality reduction with FOB screening.

A follow-up report from one trial also documented a significant reduction in cancer incidence, presumably because of the excision of premalignant adenomatous polyps. The results of the 3 trials are remarkably consistent, when difference in compliance and test sensitivity are taken into account.

Many clinicians are sceptical about using the FOB test. The test is undeniably imperfect: it misses almost as many cancers as it finds. If not done carefully, false-positive results could overwhelm our capacity to provide diagnostic follow-up.

The mortality benefits shown in the clinical trials were modest, but this was due in large part to poor compliance. Individuals who are compliant with FOB screening can expect a more substantial reduction in their risk of dying of colorectal cancer.

Six credible Canadian groups have endorsed colorectal cancer screening with FOB testing. Cancer Care Ontario and the NCCCS conducted comprehensive multiple-stakeholder reviews. The Canadian Task Force on Preventive Health Care conducted a rigorous evidence-based analysis.

Both the Quebec and the national health technology assessment agencies have reported on economic evaluations. The Canadian Cancer Society has based its position on the weight of evidence and expert opinion.

The key recommendation of all these groups is to screen average-risk, asymptomatic individuals over the age of 50 with FOB testing annually or biennially. Cancer Care Ontario, the NCCCS, the Canadian Task Force on Preventive Health Care and the Canadian Cancer Society all stress the need for an adequate infrastructure, quality assurance and timely diagnostic follow-up of positive test results.

Cancer Care Ontario estimated that a well-run program could reduce colorectal cancer mortality by 20%, which translates to about 1500 fewer deaths annually in Canada by 2015.

Colonoscopy and flexible sigmoidoscopy are also options for colorectal cancer screening. Colonoscopy is probably a better screening tool than FOB testing for average-risk people who are prepared to accept the discomfort and inconvenience of the procedure.

Colonoscopy appears to be at least as cost-effective as FOB testing, the higher cost per procedure balanced by lower frequency and higher yield.,

The deal breaker for colonoscopy is inadequate health system capacity. We are far from having enough capacity to offer colonoscopy as primary screening for the more than 7 million people aged 50–75 in Canada.

Cancer Care Ontario calculated that Ontario would have enough colonoscopy capacity to support FOB screening, and then only if an FOB test with high specificity is used. Given our existing health care resources, therefore, confirmation of positive FOB test results should get first call for colonoscopy.

A nation that believes in the principles of equity and distributive justice in health care must start its colorectal cancer screening with FOB testing.

As for flexible sigmoidoscopy, it should not be recommended over FOB testing because the supporting evidence is not as strong as it is for FOB testing and because flexible sigmoidoscopy has the inherent limitation of examining only part of the colon.

The procedure is probably a reasonable alternative for people who are noncompliant with FOB testing and may also prove a useful adjunct to FOB testing.

If FOB screening for colorectal cancer is worth doing, it is worth doing well. Simply issuing clinical guidelines is not enough.

Cancer screening always has the potential for harm, particularly from false-positive test results and complications from diagnostic investigations. The emphasis on adequate infrastructure and quality assurance by several groups who have endorsed FOB testing,,, is well founded.

If we use the results of the randomized trials to justify the intervention, we must be confident that we are providing care that matches the quality of these trials. The specificity of FOB testing and the safety and accuracy of diagnostic colonoscopy will be critical parameters of a quality colorectal cancer screening program. Provincial breast cancer screening programs have already shown that it is possible to provide high-quality cancer screening in the real world.

FOB screening could be an important building block in a comprehensive attack on colorectal cancer.

Organized programs would not only save lives through screening, they could also provide an effective platform for education about the benefits of healthy eating and physical activity in preventing colorectal cancer.

Furthermore, these programs would identify individuals and families at increased risk because of adenomatous polyps, who may benefit from intensive surveillance, genetic testing and, possibly, chemoprevention with ASA or calcium supplements.

Cancer control is a challenging and frustrating business. We get few opportunities to substantially reduce rates of death from common cancers. FOB testing is not an ideal screening tool, but it is an evidence-based intervention that is cost-effective and feasible. It also prevents cancer and saves lives.

Colorectal screening with FOB testing is simply too good an opportunity to ignore.

[Vern Humphrey]

50% income tax rate? Gimme a break.

Do us a favor. Check your pay stub and tell us what percentage is withheld.

[tiriaq]

Withhold is variable. The employee can select how much is to be withheld. It could be as high as 50% IF the employee elected that amount. Some would rather have more withheld, and then get a refund, than have less withheld, and have to pay. Other folks try for a balance. Here are some numbers:
Just checked my tax return for 2008, my gross income from Superannuation and Canada Pension Plan was $57774. Tax deducted at source was $9843.96, approximately 17%. Actual Federal and Provincial tax paid was $7871.31. Just deposited the refund cheque today. The withhold was from my Superannuation only, no withhold from my CPP (although I could elect to have tax withheld).

[DaveHH]

There are millions of people already getting free medical care, our problem is that if you have any tangible assets, you don't get it. When the Dutch invented the system of shared risk in maritime commerce the idea was great; everyone pays a little and when someone needs help, the money is there. In our country, there are what? 20 million illegal Mexicans and their families who pay absolutely nothing for their medical care. They are welcomed into our hospitals with open arms, you and I are not, we just have to pay for it. The programs that provide these services are run by Hispanics, the people who make the decisions are Hispanics and if these people chose to be selective about who gets care and actually try and cut back on the freebies, they'd be out of a job. So it's a self perpetuating problem. These freeloaders are breaking the back of our social services and nobody says a word in protest. Go down to the local Social Security office and look at all of the signs in Spanish, check out the almost 100% Hispanic workers in these offices. Notice how many young people are in there getting free money. Imagine how many SS checks are sent to dead Mexicans every month. The Democrats love these potential voters and if it means we go under as a society, they could care less.

[tiriaq]

Here is a Canadian health care horror story:
Chap from Lindsay, about an hour from where I live, had a seizure, went to the local hospital. Given anti-seizure medication, sent home, imaging was ordered, but was going to be a few weeks. Went to NY State, paid for imaging, out of his own pocket. Growth in brain. Went home with the data. OK, we will follow up, looks benign, it'll be a few weeks. Went back to NY State, its malignant as all hell. Had the surgery there. Went home. Applied to the Province for reimbursement. It was under $25,000 all told, a bargain if you ask me. Province refused to pay, because he did not have prior approval. He is suing them. Have not heard of the outcome.
It is ironic that a Cdn. can literally walk in off the street, and access the same health care that an uninsured, non-indigent US citizen could access.

[Mark in Ottawa]

In response to those who asked about the Canadian Tax Rate, the Fraser Institute, a conservative think tank has recently calculated that the average Canadian family pays a total of 43.9% of its income in taxes to all levels of government. This is up from 33.5% in 1961. The article can be found at: http://www.fraserinstitute.org/comme...xIndex2009.pdf. I don't think that I would mind so much but I spent my career as a federal public servant and saw a lot of waste - much of it due to politicians, political correctness, lack of reasonable political will etc. Oh yeah and some of it from my bureaucratic colleagues.

In any case, there is no doubt that both the US system and the Canadian system have strengths and weaknesses. In many cases, our service is lousy but there are attempts going on to improve it. For example, my wife just had both knees replaced using a new faster approach in our local hospital and felt that the level of service and the quality of the surgery was very good. A few years ago, I had major back surgery carried out and after a long wait for the diagnostics was amazed to find that the surgery was scheduled for only 2 weeks later and that was because the surgeon wanted more tests carried out before he started. Based on the horror stories in the news, I had expected a year long wait.

[oscars]

I have a United Health Care backed PPO. If I don't get prior approval, I don't get coverage - what's the difference who holds the purse stings? By the way, United Health Care has most of the high deductibles. So what if your coverage is 8 mil - rots of ruck getting United to cover.

Health care is in no way related to any market principles (supply and demand or elasticity) and that is way the gov restricts cardiac transplant cites and certain types of medical instrumentation for example.

As far as screening when does cost enter? Lets have all over 40 get CAT scans plus MRI for soft tissue as some cancers might be picked up (a couple of thou here).

All over 35 get stree EKG's plus phase contrast cardiograms - might find silent cardiac problems (1500 here).

Likewise, all over 35 men get ultrsound exams for enlarged prostates and let's not end here - have biopsies to rule any malignant tissue.

Get the drift - all health care is rationed. Again, United Health care and BS/BS will restrict payment for colonoscopies to restrict groups (familial history, age, ethnic background etc>)

[Louis of PA]

The state always seems to get their nose into things when it is different than the usual and when it works. Another small business will bite the dust for being different.

I don't think the reason is "being different". I think the reason is campaign contributions from regular insurance companies to the people who write the laws, in order to stamp out honest competition.

In the old days, we called it "corruption".

Louis of PA

[Louis of PA]

This is part of what a doctor from Colorado recently posted on HughHewitt.com:

"Finally, a word about the "uninsured". These folks, estimated to number ~46 million, are one of the big drivers pushing the nation to a one-payer system.

"Study after study has shown that most of these patients are 1) eligible for gov't programs already,2) transiently uninsured because of job change, 3) making good money but have elected not to buy insurance, 4) illegal aliens.

"The hardcore long-term uninsured only number 10 to 15 million. In a nation of 300 million, this really should not be a big problem. Providing some level of care for the 3-5% that are truly uninsurable should not be a justification for screwing things up for everybody else."