A Canadian’s Reflections on American Psychiatry

In the wake of an approaching general election and further partisan divide over hot-button issues, healthcare has re-emerged as a subject of great debate. Contemporary Americans are increasingly faced with skyrocketing prescription drug costs, co-pays, premiums, and deductibles with little signs of relief, resulting in a culture of resentment and anger towards medicine. As a senior psychiatry resident and Canadian from a border city, my recent time spent doing an elective in mental health policy had me reflecting on the mental health disparities in this country. It felt significant for me to reflect on being a Canadian working in the United States. In the United States, the health care system is not universally accessible and consists of a fragmented network of public and privately funded programs that do not widely cover the entire population, leaving upwards of 8.5% of Americans uninsured. Throughout my training I have found myself comparing one system to another and becoming disillusioned with both systems. Now, as I quickly approach the end of residency and the decision of where to work, I have noticed a pervasive sense of ambivalence over where to practice.

In contrast to the United States, the Canadian “Medicare” system ensures that every resident has guaranteed access to benefits through provincial insurance plans supported by tax-payer dollars , eliminating the need for premiums, co-pays, deductibles, and allowing access to clinics, emergency departments, hospital stays and surgical procedures . However, looking at mental health services, eighty-five per cent of Canadians say mental health services are among the most underfunded services in the health-care system, and despite recent unprecedented mental health funding commitments made by the federal government, over 1.6 million Canadians report unmet mental health care needs each year. In Ontario (where I am from), the Ontario Health Insurance Plan (OHIP) does provide full coverage for psychiatrists (for their ability to prescribe) but exclude coverage for psychologists and other mental health providers except if they are imbedded in primary care clinics. In contrast, there is a less clear definition of mental health coverage in the United States, where insurance coverage largely dictates which services patients can access, and services covered by Medicare, Medicaid, and other state-specific plans are saturated with clients due in part to low provider-to-patient ratios. In turn, there has been greater emphasis from US providers to opt out of insurance plans due to lower reimbursement rates and opt instead for fee-for-service models in order to ensure adequate compensation for their services, leaving a majority of patients unable to access these providers and services.

As a psychiatry resident in an urban setting, I have witnessed the impact of the United States medical system on the delivery of mental health care. Despite being instructed about using of billing codes and diagnostic labels, residents are largely insulated from the economics of medicine. Given a patient's insurance, I have seen discussions about potential discharges due to a lack of reimbursement for a hospital stay, even in cases in which a patient might benefit from further treatment. Clinicians often sought to petition hospital administration to subsidize hospital stays for poorly and uninsured individuals, ultimately creating a fraught dynamic between administrators, clinicians, and the patients. I have also struggled with the need to use billable diagnoses when documenting patient encounters. Significant institutional pressures on ensuring full reimbursement for patient encounters often have clinicians working at odds between diagnostic labels and attempting to make sense of patients’ clinical presentations.

In transitioning to my outpatient year of training, I encountered numerous patients at the residents’ outpatient clinic at Sheppard Pratt—a fee-for-service clinic providing psychotherapy and medication management at significantly reduced rates—stating that they had been in the clinic for years due to the cost effectiveness of the services and their ability to obtain quality services that they otherwise would have never been able to access due to lack of financial means and/or insurance. As residents, we have also spent countless hours on the phone with insurance reviewers in the hopes of obtaining necessary services for patients that we knew were in such desperate need of treatment. Oftentimes we were left frustrated and demoralized, as if we needed to beg and plead for services to individuals who were more focused on their bottom line than the patients’ well-being.

It is important to note, however, that there is good that comes from the American medical system. I have found it striking how advanced the technologies and treatments are in the United States— where there seems to be a richer “menu of options” even in the most basic centers—as compared to my observations of Canadian counterparts. As such, I’d like to reflect on a different model that I was exposed to as a PGY-4 resident at Sheppard Pratt. The Sheppard Pratt Retreat (a self-pay residential inpatient treatment unit) allows providers the freedom and flexibility to provide individualized care to both patients and their families in order to support longstanding recovery out in the community. Though expensive, The Retreat provides a unique model for psychiatric treatment that encompasses many of the different modalities that are essential towards recovery. In the United States, it seems as though these types of programs are more likely to thrive as there is already a cultural understanding around paying for medical services that does not exist in Canada. Though I realize that this is not the standard of care for most mental health patients, programs like The Retreat illustrate the opportunities for diverse and specialized care in the US that would be more difficult to sustain in the Canadian system if only by virtue of the different methods in which both countries are reimbursed for services.

Both systems seem to struggle with providing adequate and quality services for the countless patients that require medical assistance, along with an overall insufficient number of mental health providers. However, whereas the Canadian system falters in being able to deliver quality, well-rounded subspecialty mental health services in a timely and consistent manner, the American system struggles with providing the same quality of care and breath of services to similar individuals by virtue of their insurance coverage and financial background. For me, the latter seems to emphasize an already prevalent divide within social classes and reinforces ideas that those with the most resources deserve the best care in this country. This becomes problematic for psychiatric patients, specifically those with severe mental illness, who tend to fall in the lowest rungs of the social ladder, but who often require the most intensive and costly services. Under a universal model of care, theoretically these individuals would have better access to those services without fearing the repercussions of being unable to pay upfront costs.

I believe what struck me most about practicing in the American medical system was the overall emphasis on cost and business models rather than on the patient as a person. Having come from a system that focuses on providing basic needs to everyone, seeing patients struggle to pay for treatment should not be occurring in this modern time—it should not be a privilege for certain members of society.

As a Canadian, it is difficult to see patients struggle with physical and mental health issues when there are other places in the world where its citizens do not have the same worries. Though the Canadian system itself is not perfect and provides its own unique challenges, there is solace in knowing that every Canadian resident (citizen or immigrant) has the ability to seek out medical services without fear of financial ruin or feeling socially ostracized. There is a fairness in the Canadian system in that by providing health care for each and every resident, everyone is given some level of equity in a greater social structure. Conversely, I do acknowledge the American healthcare system has many more sophisticated and advanced treatment options and services that are not as readily accessible in Canada. Despite the opportunity to reflect on these personal experiences, I remain unsure about where the next chapter lies in my career. Despite my upbringing and knowledge of the Canadian system that had been ever present for me prior to moving to the United States, having trained in the American system, the Canadian healthcare system seems like a foreign place altogether to practice as a physician. However, to stay in America under the current health system would mean having to continue to confront these longstanding inequities, along with the struggles with insurance companies and institutional bureaucracy. Perhaps the most fundamental questions I had asked myself was, in our current system, how do we better allocate and provide services to the “underinsured”? If we were to move to a more universal model of care, as many of the current 2020 Democratic candidates are proposing, how do we begin to allocate services, particularly given our understanding of the struggles of Canada and other countries with “universal health care”? These are complex questions without clear answers and continue to create much debate in our society. I struggle to answer them. Despite believing in a universal model of care, it will not be something so easily achieved as some policy makers suggest. What seems clear is there will need to be a shift in public social consciousness before any meaningful change can occur, including shifting from individualist thinking towards valuing equality. Part of the burden will ultimately fall on providers to assume a greater sense of advocacy in health policy in order to begin changing the conversation at all levels—from individual patients to the top levels of government. ■

I would like to extend my sincerest thanks to Dr. Steven Sharfstein, whose invaluable mentorship and guidance throughout my three-month mental health policy elective helped shape this paper. I would also like to extend my thanks to Dr. Christopher Miller, who assisted with multiple revisions of this paper and helped to achieve this final product.