What Hillary could learn from Canada and Germany - national health care - includes related article

Washington Monthly, March, 1994 by Susan Fitzgerald, Mark Jaffe

In the foreign systems, the responsibility for evaluating patients rests solely in the hands of doctors, who must decide who receives treatment immediately and who will wait. In Ontario, for instance, non-emergency waits for coronary bypasses can last up to three months. In the United States, nonemergency bypass surgery can usually be arranged in one day to two weeks. But there is no evidence that heart patients fare any better in America than they do in Canada.

A 1993 University of Sherbrooke, Quebec, study published in the New England Journal of Medicine found that American doctors were more apt to admit a patient with chest pains to the intensive care unit, more likely to prescribe drugs, and more likely to order X-ray angiography to look for clogged arteries. The study also found that U.S. heart attack victims were three times more likely than Canadians to be operated on.

Yet despite the less aggressive treatment, Canadian heart patients were no more likely to die or suffer a second heart attack than their U.S. counterparts. The only disadvantage was that the Canadians had a slightly greater chance of experiencing chest pains.

In fact, a 1987 Rand study found that 17 to 35 percent of American bypasses might be unnecessary. Still, the number of Americans receiving bypass surgery doubled during the 1980s to 265,000 in 1991. The explosion may have been spurred by the market as well as by medical need; heart bypasses are extremely lucrative. Indeed, fully one-quarter of all U.S. hospital revenues come from cardiac-related business. Of that, more than 80 percent comes from four procedures--cardiac catheterization, angioplasty, bypass surgery, and heart valve surgery, according to the Advisory Board Company, a Washington-based consulting firm. A financial officer at Philadelphia's Lankenau Hospital-one of the area's leaders in bypass surgery--describes the procedure as an economic "winner."

In Canada and Germany, budget caps and uniform insurance coverage remove any question of financial incentive for prescribing surgery. For example, Bernard S. Goldman, the chief of cardiovascular surgery at Canada's Sunnybrook Hospital, had a budget in 1992 to do 635 bypass operations. There was little doubt that he would find enough candidates. His only objective was to start with the most serious cases and work his way toward the least serious. Goldman sees no problem or crisis in this approach. "Hysteria is built into the U.S. system with patients being rushed into surgery," he says. And the numbers back him up.

German Engineering

It was only lunchtime, but Katherine Neubach, a family doctor in the Munich suburb of Neuaubing, had already seen 32 patients for ailments such as the flu, high blood pressure, and pancreatitis. But her day was far from over.

At noon, she drove her blue Volkswagen Rabbit to the apartment of a patient who was too sick to go to a nearby oncologist for a chemotherapy appointment. The patient, a middle-aged woman with bowel cancer, was bedridden with nausea and diarrhea. Hooking a coat hanger to a chandelier, Neubach hung plastic bags of saline solution to begin the intravenous treatment the oncologist had prescribed. Neubach made sure the patient was comfortable and told her she'd be back later that day. If needed, she'd give the woman a shot of morphine.