Ian Morrison

Health reform has largely been about expanding coverage to the previously uncovered and regulating unsavory health insurance practices. Now the hard part starts. We have to make the health care delivery system work better, so it is of higher quality and is more affordable than today; otherwise we will bankrupt ourselves in the long run. We need good ideas from anywhere we can get them.

International comparisons, such as the wonderful surveys conducted by Harris Interactive for the Commonwealth Fund, illustrate the substantial and rapid progress that countries such as Australia, Holland and the United Kingdom, in particular, have made in improving the performance of their health delivery systems and embracing many of the tenets of superior health care performance that most U.S. policy experts hold to be self-evident: ubiquitous use of electronic health records in primary care, pay for performance, chronic care disease registries and so on.

But even in the face of such fresh and compelling evidence, most Americans quietly do the nudge, nudge, wink, wink thing and say to each other: “Well, Britain or Holland might be OK for routine primary care, if you like waiting rooms, but where would you or your loved ones want to go when you needed complex, high-technology interventions such as pediatric cranio-facial reconstructive plastic surgery? You would want your child in a fancy American hospital, not in Canada or Britain. Right?” Well, maybe not.

The Story of Dr. T

Dr. T is an Ivy League–trained, sub-specialist reconstructive cranio-facial plastic surgeon who, after completing long years of training at the world’s greatest academic institutions (you institutions know who you are—all 300 of you—so I will not name them to honor Dr. T’s request for anonymity), spent a year in Canada at a large, prestigious pediatric academic health center.

I was lucky enough to be introduced to Dr. T and, based on my interviews with her, I offer a few of her key observations from practicing her craft on both sides of the border:

Quality of nursing care. Dr. T stressed the amazing quality of nursing care in Canada, compared with the most prestigious hospitals where she had worked in the United States. As she put it: “Nurses in Canada seemed more dedicated, more professional, more specialized, more vested in the care of the patients and more empowered, than their American counterparts.” She attributed the differences to leadership, specialization, preparedness and continuous training of staff.

For example, when Dr. T conducted a complex reconstructive plastic surgery operation in Canada that took several hours, she never once had to ask for a specific instrument to be handed to her, because the nurses knew, and had carefully documented, a workflow protocol for each surgeon that the chief OR nurse had developed. In contrast, in the prestigious U.S. academic medical center where Dr. T now practices, she had to spend hours orienting the team to the complex procedure they were about to conduct. In the American hospital, no dedicated RN scrubs for the case; instead, a floating surgical technician is assigned to that OR for that day. Like ships passing in the night.

Working at the tip of a very large referral pyramid. Dr. T is among the most specialized, highly trained, sub-specialty surgeons on the planet. When she was practicing in Canada, she and her colleagues were referred virtually all the complex cases of their type in the region, if not the entire country. In Pennsylvania alone, there are four pediatric cranio-facial plastic surgery centers, each competing for the same patients, and presumably operating with reduced volumes of truly specialized cases.

The benefits of a large concentrated referral pyramid are that outcomes improve through specialization of skills. This is the classic volume-outcome effect. The surgeons, OR team and nursing teams have dedicated staff that work on nothing but these complex cases.

In the United States, we have way too many facilities doing way too many complex cases, mixed in with the run-of-the-mill moneymakers. American specialists are often “amateurs” in the sense that they practice their true sub-specialty craft less than half the time. Because there are fewer specialists per capita and a nationwide health plan, Canadian referral hospitals can build large referral pyramids, create significant volumes, and organize dedicated high-performance teams to conduct complex procedures.

Administrative waste motion. When I talked to Dr. T, she was weary at the end of the day working in her American hospital. She was weary, not because she had just finished a long day in the OR. No, she was weary and frustrated, because she had spent three hours after the case was done googling for CPT codes to make sure she billed correctly for the complex multi-part procedure she had conducted that morning.

Her anxiety was not about maximizing revenue for herself or her institution. (I’m sure the institution would prefer her to be anxious about revenue cycle management, as the CFOs call it.) No, she was anxious that she would “commit heinous fraud on the insurer for billing inappropriately.” Although she spent seven years in surgical training, she admits she is a novice at coding, which can now dominate much of her time. What a complete waste of precious human capital.

Economic discrimination in clinical care. In Canada, if Dr. T received a patient referral, the first thing she would do would be to figure out the best way to take care of the patient. She would never even give the patient’s financial or insurance status a second thought because it is irrelevant to clinical decision-making in most of Canadian health care.

On her return to practice in the United States, Dr. T has been unpleasantly surprised by her clinical colleagues who perform “economic triage of patients,” in which specialists avoid taking cases because the insurance coverage is lacking. Dr. T spends two to three hours every day “fighting the system” (with insurers, her clinical colleagues and hospital administrators) to secure the approval for services that her patients need, whether it be an operation or simple therapy.

Rogue warrior practitioners. In Canada, Dr. T felt she was part of a team with her physician colleagues, the nursing staff and the hospital leaders. On her return to the United States, she feels more like a fellow combatant among the “Rogue Warrior Physicians.”

Pointless pluralism. In her Canadian hospital they had a “clunky electronic health record,” but at least it was standardized across the institution. (Canadians are behind even Americans in their pathetic deployment of EHRs). In her American hospital, though, they have 30 different health record systems, with each specialty service organizing its own clinical charting systems, none of which talk to each other. “I cannot even share my notes with the doctors across the hall,” she told me.

High performance in shabbier surroundings. When Dr. T went to Canada, the OR rooms and clinical corridors were a bit dingier, and she had to walk down the hall to access a shared printer. This is frustrating when you are trying to crank out research papers, on top of a full clinical load. (I can relate to the printer part at least. When I was a young health services researcher at the Vancouver General Hospital in Canada, I shared a subterranean, converted broom closet with two other colleagues. It was at the end of a former secure prison ward, converted to care for long-term geriatric patients. We had to drive 12 miles out to the university campus to access a computer, let alone a printer.)

While the built environment of some Canadian hospitals may be a little shabbier than the Shanghai Like Crane Fest that is the American academic medical center.  (Academic medical centers have been on a decade long orgy of new construction analogous to the Chinese office building boom).  But, don’t assume marble atria lead to superior clinical performance. Dr. T is nostalgic for the shabbier, high-performing Canadian setting. And instead of just sitting back and accepting it, she has joined her hospital’s quality improvement committee, and will dedicate even more of her precious time and skill to making her hospital a better place for patients. She doesn’t know whether to laugh or cry when she hears her educated colleagues insist we have the best health care system in the world.

Time to Lose the Ancient Anecdotes

Dr. T’s experience represents, as far as I can tell, the closest thing to a real-time, double-blind trial of cross-border, comparative high-tech, superspecialty care. Most pundits who opine on the good or bad of other countries’ systems are usually relying on ancient anecdotes about how their Aunt Betty in Winnipeg had to wait nine years for a hip replacement and that wouldn’t happen in Wisconsin. Yawn, yawn.

I am as guilty of this as anyone. But at least Canadian health care for me is not some obscure policy abstraction: It is the system where my sister and all of my wife’s family get their health care, and we have countless Canadian baby boom friends. All of our friends and family on both sides of the border are dealing with the same breast cancer, prostate cancer, knee replacement, hip replacement, heart attack and chronic care issues on a cross-border basis. So I live with the stories and the realities of the good and the bad on both sides of the border.

As I have written in this column before, all health care systems are an ugly compromise among cost, quality and access. There is no perfect system. But what is pretty clear is that we in the United States get about the worst bargain compared with most developed countries.

Canadian health care remains an annoying comparison to American health care because it is so close:

• All Canadians live in American media markets. Canadians are subject to all the Viagra ads on American TV channels, even though the ads are illegal in Canada.

• Canadian doctors are equivalent to American doctors. They pass the same exams and have pretty similar training. Although, Dr. T did point out to me that the Canadian system paid more attention to actually educating their medical residents and fellows rather than exploiting them as under-compensated service providers.

• Canada now spends 7 percent of GNP less on health care than America does. Yes, you do have to wait a bit for a recreational MRI of the tennis elbow in Canada. But Canada could buy a lot of MRIs with 7 percentage points of GNP. At a 10 percent per annum lease rate, Canada could lease 84,000 MRIs with the difference, enough for every hockey team in the country. They wouldn’t do it of course, because they view it as a complete waste of money.

• Canadians drive the same cars, eat the same cheeseburgers and eat even more doughnuts than Americans.

• Canadians are different in values, however. They describe themselves as unarmed Americans with health insurance.

Lessons for American Health Care Organizations

In closing, I asked Dr. T to use her cross-border experience to synthesize her advice for the American health care system. Here’s what she told me:

Refuse to accept that medicine is a business like any other. For one, there is no other business where the customers don’t know what they are getting and for how much. If treating medicine as a business worked best, then why should governments interfere? Yet most countries, including all those that score much better than we do, accept that the best care comes from some government oversight. If we give in to the notion that the market knows best, even in the absence of a true health care market, we lose the ability to prioritize what really matters to us as citizens and physicians.

Get the incentives right. Dr. T has seen salaried academic surgeons and fee-for-service surgeons, on both sides of the border, and she believes that some combination of salary and performance incentives tailored to the specialty is essential to enhance quality, productivity and outcomes. I couldn’t agree more.

Build high-volume regional referral pyramids. Dr. T believes that large regional referral pyramids reduce costs and improve quality, with all the attendant benefits of specialization at the physician, nursing, OR team level. As a former regional planner, I admit she had me at “hello.”

Empower nurses. Dr. T believes nurses need to have a real stake in the organization and feel empowered that they are the central caregiver for the patient. In too many American hospitals, nurses are treated as just a cog in the wheel, or they diminish their own professional status by focusing on collective bargaining issues rather than on clinical leadership and professional development. I am married to a Canadian-turned-American former ER triage nurse-turned-nursing administrator who, when she first practiced in America, said to me: “Boy, do nurses ever kowtow to doctors down here.” Enough said.

Fix the financial matters. Dr. T needs to be relieved of the administrative nuisance and financial rationing that is plaguing American medical practice. Much of it, as Dr. T points out, is self-inflicted pluralism. Doctors need to accept standards, compromise on choices of systems and tools of the trade, and participate actively and enthusiastically in the kind of heavy-duty clinical re-engineering so effective at the Mayo Clinic, Cleveland Clinic and Kaiser Permanente, among others.

Be driven by outcomes… Canadian physicians in Dr. T’s experience embraced evidence-based medicine far more than her American colleagues. She was admonished after her first case in Canada for administering prophylactic antibiotics because it was not an evidence-based practice. As a consequence, patients with multiple resistance to antibiotics were rare in her Canadian hospital, but ubiquitous in her American hospital.

…Not just by incomes. Tommy Douglas, the former Saskatchewan premier who was the father of the Canadian health care system, was recently voted as the Greatest Canadian Ever in a national poll in Canada, beating out in a landslide: Wayne Gretzky, Bobby Orr and some pretty decent figure skaters. Tommy’s great quote was: “When people say, ‘It’s not the money, it’s the principle’ … it’s the money.”

Let’s hope there are lots more young Dr. Ts out there for whom medicine is about bringing compassion to the care of the patient, not just worrying about the money.

Ian Morrison is an author, consultant and futurist based in Menlo Park, Calif. He is also a regular contributor to H&HN Weekly and a member of Health Forum’s Forum Faculty Speaker Service.