Suppose you awakened one morning and discovered that you could care for
your psychiatric patients in whatever manner you deemed best—even by
providing lengthy psychoanalysis—and that you would be reimbursed for
your efforts by simply submitting a bill. No managedcare exclusions or
precertification hassles. FIG1
You might think that you had died and gone to heaven, but what's more
likely is that you simply relocated to Canada where such seemingly luxurious
perks of the government-run universal health insurance program are
The name of the program is "medicare," although it differs
dramatically from the U.S. program with the same name (see A Tale of Two
The Canadian health system covers all citizens and works well in some areas
in which the U.S. system has problems.
"I hear stories of patients being turned away from hospitals in the
United States or being afraid to go to the emergency room because they can't
afford the care," Padraic Carr, M.D., an associate clinical professor of
psychiatry at the University of Alberta, said in an interview. "In
Canada that really doesn't happen. When people come to the emergency room, or
for an appointment, or to be assessed, no one is refused treatment because of
inability to pay."
"Even if psychiatric patients start off rich in their lives, many
drift down to a low socioeconomic level because of their illness,"
Dhanapal Natarajan, M.D., a Saskatchewan psychiatrist who also practiced in
Great Britain, reported. "So for them, a universal health care system is
extremely important. Even after they are discharged from the hospital, they
are looked after."
"Another thing I like about the Canadian system," Carr said,"
is that the doctor decides what treatment is appropriate, and it does
not have to be approved by any insurance company or third party."
Jacques Bouchard, M.D., a psychiatrist in St. Lambert, Quebec, concurred."
I don't have to justify anything I do. I can treat patients as much as
Outpatient drug coverage mandated by Canadian provinces is also a plus,
Arlie Fawcett, M.D., an associated professor of psychiatry at the University
of Calgary, stated. "I have patients whose medication costs would be
$1,000 or $1,500 a month [if the costs weren't covered by Alberta's mandated
drug-coverage plan]," she said.
Still another positive feature of Canada's universal health insurance
program, Bouchard reported, is he bills "a single payer, and it is
Robert Notkin, M.D., a Toronto psychiatrist in private practice who also
lectures at the University of Montreal, had good things to say about the
health care billing system in Canada. "I have a cousin, a
gastroenterologist, in the United States, and I remember being in his practice
and seeing four different staff members collecting money from insurers. Most
Canadian physicians operate with one staff member or even no staff. Billing is
straightforward. You just submit a bill, and generally a month or so later you
are paid for the vast majority of claims."
And if that isn't enticing enough, "[r]eimbursement for doctors is
based on an honor system," Carr noted.
But this universal health insurance program that seems too good to be true
does have some downsides, Canadian psychiatrists contend.
One disadvantage, Carr indicated, is that having a single-payer system
means that there is only one party with whom physicians can negotiate fees.
Another downside, he added, is that universal health insurance costs taxpayers
a lot of money.
Still a third drawback is that the philosophy underlying Canada's universal
health insurance program—delivery of all necessary medical care to all
citizens at no charge—cannot always be met because of a dramatic
shortage of hospital beds, Alfred Margulies, M.D., a Toronto psychiatrist with
a private forensic practice, reported. "As long as I've been in the
field of psychiatry, there has been a shortage of psychiatric beds. But the
shortage is even worse now," he stressed.
The program's philosophy is further being eroded by a dearth of physicians
and nurses, said Jack Brandes, M.D., an assistant professor of psychiatry at
the University of Toronto. "Psychiatry in Ontario and Quebec is really
suffering. The rates we get paid per session are very high, but there are not
many psychiatrists around."
"An independent research institution called the Fraser Institute
surveys the status of Canadian medical delivery every year," Notkin
reported. "Their most recent survey found that the average wait time
across Canada for outpatient appointments with 12 different types of
specialists was more than 18 weeks.... I'm not sure where psychiatry fits
in.... But in my experience, in different parts of Canada, a patient might
wait four months or longer to get to see a psychiatrist as an
"Doctors are working crazy hours," Margulies added. "So
are nurses. There are horror stories about patients dying while waiting to be
seen in the emergency room. Some patients are even being shipped to the United
States for care. For instance, a man north of Toronto had a ruptured aneurysm,
and since he was unable to be admitted anywhere for appropriate care, he was
transferred to Buffalo, N.Y., to have the aneurysm clipped."
One reason for the dire shortage of hospital beds and medical staff, Notkin
believes, is because demand for medical care increased once Canada adopted
universal health insurance; and as demand increased, so did cost; and as cost
increased, the government started trying to rein in those costs. Another
reason for the shortage, some Canadian psychiatrists contended, is government
control over health care finances and delivery.
For example, all hospitals in Canada are publicly funded, and many do not
have sufficient money to hire enough nurses, Margulies said. "In the
hospital I used to be affiliated with, there was for years an empty floor of
unoccupied beds. It was used for movie sets. The hospital didn't have the
funding to support the floor with nurses."
Canadian medical schools, Margulies pointed out, are also largely dependent
on the government for funds. Eighteen years ago, the government decided to
slash medical school slots by 10 percent to save money. The result: a dramatic
shortage of Canadian physicians today. "To fill the gap, to meet
standards, we would need 26,000 more physicians across the country."
A few years ago, Brandes recalled, "There was a poster that said, 'If
you like the post office, you'll love government-run medicine,' which is
essentially what Canadians now have. Yet people forget that whereas
governments are good at regulating, they are terrible at managing things. So
basically what we have here is an experiment that is sort of going down the
So can it be saved, and if so, how?
One possibility, Brandes proposed, might be to allow people to pay for some
of their health care privately. In fact, private clinics have sprung up in
Quebec even though they are not officially allowed in Canada, said Brandes."
People don't want to wait four years to get a hip replaced; they are
Another possible solution, Brandes ventured, is to use incentives to lure
the many young Canadians who have studied medicine in the United States and
Europe back to Canada. However, the Canadian government has shown no interest
in this idea, he said.
So with some 47 million Americans lacking health insurance, should the
United States adopt Canada's universal health insurance concept—that is,
transform Medicare with a large "m" into medicare with a small
one? Canadian psychiatrists hold varied opinions.
"I could not recommend it," Brandes declared. "I think
the concept of national health insurance is admirable in principle, but how do
you go about making it work?"
"I would certainly recommend it for mentally ill patients since most
are not able to afford a private health care system," Natarajan
"I have colleagues from medical school who work in the United
States," said Fawcett. "They like it very much. However, they say
that while excellent medical care is available to some Americans, it is not
available to others. So I think the United States would be a lot better off if
it adopted a health insurance program similar to Canada's."
"Overall, I am happy with the Canadian system and really can't
imagine an industrialized country not having universal coverage for its
citizens," said Carr. "It must be heartbreaking for families not
to be able to access the health care they need or for families to become
destitute because of medical bills."
"If you can avoid some of the pitfalls we have fallen into with our
national health insurance program," Margulies said, "I think the
United States should adopt it, because when the system works, the patient is
the one to benefit."
"Since Americans tend to favor free enterprise to government control,
I would recommend that they consider adopting a system that is both public and
private—not Canada's totally public one," Bouchard said. "I
think private and public can live together if it's well done."▪