While almost everyone agrees that US health care delivery needs to be reformed, there is much argument about which system would be the most effective. There is clearly no simple answer. While some favor market-oriented solutions, others would like to see this country adopt universal health coverage. But how well do these plans work? Neurology Today asked five neurologists practicing across the globe to help us understand the practice of neurology under single-payer systems in their nations. Their individual impressions provide a glimpse into medical care under a variety of designs.
Health care funds in Canada are supplied by the government and disbursed by the provinces. With the exception of Quebec, physicians are not permitted to charge private fees for insured benefits – all care must be delivered in the public health system. For patients, this means that the majority of hospital and physician services are covered. Janis Miyasaki, MD, a member of the AAN Practice Committee, has worked in Canada for fourteen years as a movement disorders specialist. Because there are fewer than five hundred practicing neurologists in Canada, she said that access is often a serious problem. The waiting time for a new patient at her center is between four months and two years.
“I closed my practice to new consultations for about two years since I could not accommodate the follow-up visits for my existing patients,” she said. “Very few communities have neurological emergency care because there are too few physicians able or willing to take call,” she added. Availability of hospital beds is also quite restricted, according to Dr. Miyasaki.
“In the Greater Toronto area with a population of approximately 5 million, we have the lowest bed-to-population ratio in the country, so the pressure on emergency departments and hospitals is immense,” she noted. “The lack of specialty emergency care outside of teaching hospitals results in huge strains on academic centers to provide care for emergencies in essentially the entire province,” she explained.
But access to procedures, unlike the hype, is actually not a problem. “Despite news articles and the perception that patients cannot get tests,” she said, “if one of my patients requires a scan, I can obtain it within the day.” Drug coverage is also better under the Canadian system, said Dr. Miyasaki, who explained that the Ontario Drug Benefits program supplies drugs free of charge to those sixty-five years of age or older, on family benefits (welfare in the US), or disability. In her experience, the drugs covered are extensive and well vetted. She said, “When colleagues in the US were unable to prescribe dopamine agonists for patients, all provinces covered these drugs.”
Dr. Miyasaki explained that salaries vary depending on whether Canadian doctors work in the private sector or as academics. While in private practice, her highest net income (after rent and secretarial expenses and before taxes) was $175,000 (Canadian), whereas her first contract with the university in 1999 was for $105,000. “I was considered a low biller among community neurologists due to my concentration on neurodegenerative diseases,” she added.
But insurance denials are far fewer than in the US. According to Dr. Miyasaki, a new consultation in Ontario reimburses $127.50 (but she is paid for nearly 100 percent of claims), $175 for a first follow-up within a year, and $68 for the next two visits for certain chronic illnesses. Likewise, hospital fees are typically reimbursed for the majority of claims submitted. Concurrent care by specialists is not restricted, allowing neurologists to continue their involvement in emergency cases.
Dr. Miyasaki said that Canadian physicians face many of the same pressures as those in the US, including mounting drug costs, an increasing older population, and smaller percentages of citizens entering the workforce resulting in fewer future taxpayers. “But I am very happy with my profession and my position in Canada,” she concluded, adding that she never has to decline patients requiring care due to coverage or worry that they would be unable to afford their prescribed medications.
Spain offers both public and private care options. Its National Health Insurance (NHI), financed through taxes, covers all Spaniards. Joseph C. Masdeu, MD, PhD, practiced in the US for 24 years, before becoming the Chair of Neurosciences at the University of Navarra Medical School, the only private medical school in the country. Its hospital physicians are all salaried. The hospital has modern equipment, including PET and functional MRI with a 3 Tesla unit and a large research lab area for neurosciences.
“The caliber of most physicians is very good in Spain, where medical school is competitive, and the overall quality of hospitals is similar to that in the US,” said Dr. Masdeu. Dr. Masdeu's colleagues in the public sector tell him that they like the fact that all patients can receive care, but that because the system is budgeted, services can be limited.
“With the government as the payer, fiscal responsibility can be less strict than in private institutions, which, if run inefficiently, risk closing,” noted Dr. Masdeu. He reflected: “Since patients do not have to pay for services, some tend to insist on unnecessary testing, causing those who really need them to wait, and risk worsening.” Dr. Masdeu has seen delays of up to six months for procedures and elective surgery. “Patient care decisions are often dictated by politics and can be wasteful,” he added.
Physicians' incomes in the public system are fixed. Salaries are about one-third of those in the US, according to Dr. Masdeu. He speculated that the reason for that disparity could be that there are few new openings in the hospitals and physicians tend to stay at the same place for their entire lives. It is not unusual for physicians to work in the public system from 8 AM – 2 PM, and in their private practice (reimbursed by HMO-like payers), in the afternoons and evenings.
George C. Ebers, MD, a multiple sclerosis specialist, worked in the US for six years before practicing in Canada for 21 years; he has been at the University of Oxford since 1999, having recently completed a term as department head. He said, “Universal publicly funded health care is clearly the best overall, but it has to be funded adequately.” Dr. Ebers said that he sees better value for expenditures in the United Kingdom (UK) where the system is far less hampered by medicolegal problems, overutilization, and ineffective procedures.
“The mindset of British patients largely matches that of their physicians,” he said. “They don't want to take medications unless there is clear evidence of benefit and they are more concerned about iatrogenic illness.” He contends that in the UK and Canada there is more skepticism about effectiveness of neurological treatments. The approach to therapeutics is more sober but it is not independent of cost considerations. He also noted that in the UK doctor shopping is at a minimum and patients are more accepting of their illnesses and of medical advice.
However, he pointed out that governments in the UK and Canada seem unable to accept that the cost of health must necessarily rise because the demographics mandate it. Financial decisions regarding health care are politicized and long-term planning is difficult to sustain. Although he admits that there have been long waits for procedures in the UK, he has seen a considerable improvement in this regard with the increase in expenditure from 6 percent to nearly 9 percent of the gross domestic product.
Although Australia has universal health coverage, private health insurance covers almost half the population. In this country, privately financed plans allow individuals to select providers and care options that work in parallel with the public system. Pediatric neurologist John Lawson, BMed, PhD, was trained as an epilepsy fellow at Miami Children's Hospital and now practices on staff at Sydney Children's Hospital. He explained that while Australia's multi-payer system entitles all residents to the universal health care system (Medicare) and treatment at public hospitals without cost, some Australians purchase private policies. Many child neurologists are employed by the state or provincial government at a fixed salary, but a portion of their income can be enhanced by a percentage of their private billings, Dr. Lawson explained. “Approximately half of the nation's child neurologists are employed in private practice and bill Medicare; the difference between the fee schedule and what physicians charge – ‘the gap’– is paid by patients,” he said. This is often the equivalent or more of the Medicare rebate, said Dr. Lawson, who added that procedures such as electroencephalography and electromyography are rebated in a similar manner. “The Medicare rebate would be insufficient to compensate for the costs of private practice without the gap,” Dr. Lawson explained.
Dr. Lawson admits that the waiting time to see a neurologist, or to obtain an MRI scan requiring general anesthesia for a child, is an average of three to six months, but can be up to 12 months in some regions. But he likes the fact that ultimately even residents who are impoverished can afford to see specialists for free.
Health insurance in France is administered by a branch of the Social Security system; it is funded through workers' salaries (60 percent), taxes on tobacco and alcohol, and personal income taxes. Government health expenditures are segregated into three groups of the population: salaried workers and their families, farmers, and the self-employed. The expenditures for each group are divided by region and type (physician fees, prescriptions, nursing, hospitals, clinics, etc.).
Care is free or reimbursed 100 percent for disabling chronic and serious disorders; in more benign conditions reimbursement is only 70 percent, the difference being covered by supplemental insurance, most commonly provided by employers. Supplemental insurance also pays for procedures and equipment not wholly covered by governmental insurance. French citizens may select their own physicians, including specialists, and may go to any hospital – public, private, or university. Because of good cooperation between government-financed medical care and private medicine, there are no waiting lists for surgery. Access to care is unlimited and referrals are not necessary to see neurologists.
“Full-time neurologists are at times able to admit patients to the hospital more easily than neurologists who work solely in private practice,” said Gérard Said, MD, Chief of Neurology at the Centre Hospitalier Universitaire de Bicêtre, Université Paris-Sud. “They also have somewhat better access to modern imaging and to collaboration with experts in different fields,” he noted.
Dr. Said, who specializes in disorders of the peripheral nervous system, works full time in the hospital and university and a half-day in private practice in the hospital. “Most patients with neurological disorders have to pay very little in the hospital and all expenses related to their disease are fully covered by national health insurance,” he pointed out. “Whereas the system provides a good salary for those with an academic position – two salaries: one from the university and one from the hospital – and there is time to do research, after retirement, income is low,” he added.
As this tableau of programs describes, there is much diversity among nationalized health care programs, many of which preserve a private practice option. While inadequate funding appears to be a criticism of some systems, quality of care does not. With the wealth of experience in the provision of universal health care from other nations, perhaps expert health economists and policymakers in this country will be able to design a system for the US that will one day be implemented.
The last In Practice column, “US Neurologists Argue for a Universal Health Plan But Differ on the Details” (August 15, page 17), featured the input of neurologists on the US health care delivery system.