Canadian Medical Association Journal 1996; 155: 1599-1600
[en bref]
© 1996 Charlotte Gray
Dr. Robert Harris had written from Massena, NY, to report that he would happily welcome any Ontarians who crossed the border to find a doctor in the event of job action by Ontario physicians. He told patients that if they consulted a physician in the US they could expect immediate treatment, the latest technology and more care. "We know from talking to our Canadian colleagues at county medical meetings that their instrumentation, material and equipment is often outdated and deficient compared with ours," he wrote.
Pretty smug, eh? The writer appeared to be trolling for more business while pointing out that health care in Ontario was below standard and his Canadian counterparts were underpaid. Harris pointed out that his US fees were four times those paid to Ontario doctors for equivalent procedures and that the current Ontario fee schedule "is one of the all-time great social bargains."
But the story turned out be more complicated than it first appeared. I found it surprising that a New York doctor knew so much about the Canadian system and also read the Ottawa Citizen. So I called him in Massena and learned that he only kept office hours there from 9 to 11 am on Wednesdays. Otherwise, he could be reached in Cornwall, Ont. I subsequently discovered that he lives in Canada, spends 3.5 days a week working here and 2.5 days south of the border. Harris, a plastic surgeon who specializes in hand and reconstructive surgery, has hospital privileges in two Cornwall hospitals, one in Potsdam, NY, and another in Massena.
Harris, in other words, has bifocal vision. He has known both the US and Canadian systems since he first got his green card to practise in the US 10 years ago and decided to commute across the St. Lawrence a couple of days a week. He is also representative of the doctors who feel most besieged these days within the Canadian system: entrepreneurial types who are not attached to teaching hospitals and have watched both their status and their incomes shrink.
The philosophical differences between the US and Canadian systems are less important to him than the need to practise medicine the way he believes and was taught it should be practised. He rarely sees patients in the US who do not have any health insurance (most likely because they are filtered out of the system before they reach specialists). He regards health care as a personal responsibility, not a common good, and argues that the millions of uninsured Americans have made a choice not to buy health care coverage, since those who are too poor to purchase insurance are covered by Medicaid.
In 1986, when Harris first started his cross-border practice, he had no problems with the Ontario system. He had been practising in Montreal until 3 years earlier, but was growing exasperated by restrictions on Anglo-Quebecers and on doctors in the province.
He decided he didn't need the hassle, and initially planned to go straight to the US. However, he received such a welcome in Cornwall, which was in desperate need of a plastic surgeon, that the idea of practising within two different systems took root. "They rolled out the red carpet for me here," he explains. "In those days I was able to practise to textbook standards."
Today, however, "things have fallen apart." Budget cuts over the past 5 years have had a major impact on Harris. In 1983, 30% of his gross revenues went to overhead costs; today, overhead expenses account for 43% of revenues. OHIP fees have been frozen for 6 years. He reckons he takes home somewhere between 15 and 20 cents on each dollar earned in Ontario, "and those are devalued dollars." In contrast, he keeps 30 cents of each dollar earned in the US. Moreover, he can earn far more there. In Cornwall, the fee for a breast reduction is $803. When the same procedure is performed in Massena he earns between $2500 and $4000 (US), depending on which insurance company is paying. Similarly, a simple mole removal in Canada pays $13.60; in the US, the bill will be several hundred dollars.
The decline in his Canadian income offends Harris, who graduated from the University of British Columbia in 1957. "The way we're treated here is disgusting," he says. But that's not the only problem. He is also worried by the constant squeeze on his operating room time and the way procedures that aren't life threatening are bumped from the OR schedule. "Unless a patient is in shock or the bone is sticking right through the skin, I can't get them into the OR for 2 or 3 days."
Yet to treat such injuries properly, he argues, they should be dealt with within 6 to 8 hours. "One weekend I was called in to see a young man who had sustained a jaw fracture. I was bumped from the OR nine times, from Saturday lunchtime until Monday evening."
Similarly, elective-surgery cases now take months to schedule. He says there is a 5-month waiting list for breast-reduction operations in Canada, and he knows there is no hope of using state-of-the-art treatments if they increase costs, even when they have been proven to be more effective.
Harris, of course, is not the only physician voicing such complaints, but the thing setting him apart from the crowd is his knowledge of how such cases are handled across the St. Lawrence River. When he's in the US, breast-reduction surgery can be scheduled for the following day. If he is called to perform emergency surgery, he knows the patient will be in the OR before he has crossed the border. And US insurers are eager for physicians to use proven new technologies if they cut costs by reducing risks and lengths of stay.
"In Massena, I can treat my patients according to the textbook. In Canada, we are no longer practising to standard and the gap between what we should be doing and what we are doing is growing. We're not using the equipment or supplies required [and] we no longer have the trained personnel we need. And the differences between the two systems are rubbed in every time we go to a meeting in the US."
Dr. Ted Boadway of the Ontario Medical Association suggests that Harris's diagnosis of the problems besetting Canadian health care is inaccurate. "Doctors here are practising to standard," he says. "But they're often not allowed to do the job. This is a systemic, not a medical, problem."
A 2-year wait for a total hip replacement is poor service and debilitating for a patient, but it means the health care delivery system is at fault, not the physician. Boadway was not surprised to hear of Harris's open invitation to Canadians to cross the border for health care.
"It is an American tradition to advertise in their health care market," he says. "In a market environment, people always look for the opportunities."
I assumed, when I realized how Harris practised, that he would be shuttling patients back and forth across the border. Not so. Canadian patients prefer to wait several weeks for elective surgery provided under OHIP, or to travel to Ottawa or Kingston, than pay themselves for instant surgery across the border. And his opportunities to bring American patients to Cornwall for procedures like breast reductions, which would earn the hospitals extra revenue, have been curtailed because of OR closures.
Underlying Harris's indignation is another concern. He acknowledges that the Canadian system is based on volume, and that physicians who want to increase their incomes must see more patients. "We're guilty of encouraging overuse," he says. "I've seen younger doctors under great pressure to generate more volume in order to start their practices, or keep them afloat."
Given Harris's position, the most intriguing question is why he has not shifted his practice entirely to the US. "I've thought about it," he admits. At 63, however, and close to retirement, it doesn't seem worth it. "And then there is the allegiance thing -- my family, my United Empire Loyalist roots. . . ."
But entrepreneurial physicians like Harris are feeling less and less welcome in Canada, and their attitude is infectious. His four children all went to college in the US, all have their green cards and, with their father's encouragement, intend to settle there.