What it’s really like to practice medicine in the U.S.
Proposed tax changes to limit income sprinkling and changes to incorporation have led to some Canadian physician groups predicting mass migration to the United States.
Is the grass really greener on the other side of the border for physicians? Is the health care in the United States as bad as its Canadian critics say? We asked health care providers who’ve worked in both Canada and the U.S. to share their experiences. This is not a representative nor comprehensive sample, but is meant to give a human snapshot on some of the issues.
A few themes came through: They told us that Canada’s system provides care without burdening patients with as big a bill as the United States– but has long wait times, constraints around technology and innovation and a constant tension between a patient’s needs and the system’s budget. Meanwhile, they said that some parts of the U.S. system can provide excellent care with the latest tools and technologies exactly when it’s needed – but only if a patient is insured – and requires a great deal of effort and wasteful expense from physicians and others when interacting with insurance companies.
Paperwork and malpractice costs are enormous
“Any family physician who wants to move from Canada to the US is probably nuts,” says Lee Green, a family physician and health system researcher. He became the chair of the department of family medicine at the University of Alberta more than five years ago, after a 26-year career as a researcher and family physician at the University of Michigan.
“For the most part, family physicians are paid better and treated better [here] than they are in the U.S.,” he says. “You’re not going to get a better deal going to the U.S.”
While Canadian physicians operate under a relatively uniform health system (albeit one with provincial and territorial differences), American physicians can operate as independent businesses, as part of a privately run hospital, a teaching hospital, a County hospital where low-income and low-coverage individuals seek care, or an integrated health care system, where all the medical services a patient might need — doctor visits, testing, surgery, hospital care — are integrated into one system.
Green says anyone thinking about decamping to the U.S. for financial reasons will get a rude awakening when considering the costs associated with billing. “To try to go set up a private practice in U.S., what folks discover is that the cost of billing and collections would eat up everything you might save in taxes and more,” Green says. “They’d quickly discover themselves up to their necks in a complex and often totally contradictory billing system.”
Green also remembers looking at his malpractice insurance invoice when he arrived in Canada, thinking it was pretty stiff – until he realized it was an annual fee. “If they think taxes are bad, wait until they see their malpractice premium,” he says.
Canada’s system isn’t perfect – our fee-for-service structure isn’t ideal, although Green notes that the type of alternative relationship plan that pays his own salary is a step in the right direction. And he says family physician culture in Canada probably gives doctors too much personal autonomy over things like patient data, making it difficult to study the effectiveness of the system. But he says he would find it very difficult to return to the U.S., mostly because he believes the U.S. system is designed to value profits over care.
More integration and research opportunities
Kaveh Shojania, a general internist and scientist focusing on health quality improvement and patient safety at Sunnybrook Hospital, went to Harvard for his residency, followed by a fellowship at the University of California-San Francisco, where he eventually joined the faculty.
He remembers “an incredible amount of micromanaging from the insurance companies” – such as being asked why a patient was still in hospital or why a certain test or procedure had been ordered – but also felt that physicians took more responsibility for the overall care of their patients, making themselves available on weekends and evenings and wearing a pager to remain available anytime.
He saw more integration in the U.S. system he worked in, with clinics and hospitals tied together by insurers and more use of electronic medical records. That link between clinic and hospital has benefits for patients, he says, since there are incentives for communication between doctors to avoid high-cost readmissions.
The U.S. also holds enormous opportunities for training, he says, since it has a wealth of research hubs and is often on the cutting edge of basic science and funds far more clinical trials.
And there is a certain novelty to seeing insured patients move smoothly through the system.
“You see someone and they need an operation, it’s going to happen within a day,” he says. “When I said I wanted to do something, it was easy to get it done without having to constantly worry about getting on the schedule or getting it to happen in time.”
More than money
Dan Lewis was born in the U.S. but raised in Canada, and he returned to the States to pursue his doctorate in pharmacy at the University of North Carolina. He always intended to return to Canada, but at the time the exchange rate was at an all-time low. That, coupled with a generous benefits package, meant a job in the U.S. would pay nearly double what he could earn in Canada.
He stayed five years, specializing in oncology pharmacy in hospitals in Maine and Vermont. But he found his Canadian values were often at odds with the for-profit motives of the American health system.
He noticed many of the physicians he worked with let finances guide their care decisions, an observation borne out in this 2014 study that found financial incentives significantly influence U.S. physicians’ supply of health care.
“I found that most of them really were mainly concerned with their own bottom line, not to say at the exclusion of providing care, but if there were two different kinds of interventions that they could choose from and both were equally good, they would choose the one that contributed most to their own financial situation.”
(To be fair, Canadians are not immune to prescribing the more expensive option, although in our case, it might be more due to pharmaceutical marketing tactics.)
Lewis also found interactions with patients were cooled by the potential for lawsuits, with care providers choosing their words carefully. “People are more suspicious, patients are more suspicious,” he says. “That creates a barrier between them and the caregivers, the doctors, nurses or pharmacists who work at the bedside. It makes it a little more difficult.”
While he initially stayed in the U.S. for financial reasons, ultimately he realized the money wasn’t enough. He left after five years.
“I had a very good position but I felt that my work quality of life, whatever financial advantage I had, did not outweigh the quality of life that I remembered having in Ottawa,” he says. “There’s more than just money. You can make 20 percent more, but what’s that going to do to your quality of life? Are you really going to like filling out insurance forms? Corporate forces so directly affect the way you practice because the bottom line is, why would these docs want to prescribe treatments that are unnecessarily expensive when they have equally good options? It’s because somehow it’s going to contribute to their salaries.”
Carrying the heartache of the uninsured
Trying to get nephrologist Denise Hart to speak a bad word about the Canadian health system is a losing proposition. After nearly 30 years in San Antonio, Texas, Hart and her neurologist husband, Robert, have found a much happier home in Hamilton, where she works with dialysis patients.
“To a certain extent, we were medical refugees, in that we were not happy with the health care system in Texas,” she says. The usual Canadian complaints about wait times do not faze her, nor talk about the newer, shinier equipment believed to be so readily available south of the border.
“Everything I could need is available here,” she says. “A lot of things that are ‘advancements’ in the U.S. are maybe things that in some situations aren’t needed and are just expensive ways for providers to get in the profit chain, so to speak.”
When pressed, she’ll allow that electronic medical records (EMRs) are not as advanced here as in the U.S. But she’s quick to offer a caveat: “A lot [of U.S. EMRs] are designed as billing documents,” she says, not with patient care as their top priority.
She knows first-hand the frustration of trying to get an insurance company to pay for treatment. (This paper found that for every hour spent with a patient, U.S. physicians spend two additional hours on the paperwork.) It’s not as simple as handing over an insurance card – there’s the “due diligence” of confirming coverage, looking up the deductible and figuring out what drugs are covered.
“For a physician just to get paid, they have to have a whole bank of billers because you’re dealing with probably hundreds of insurance companies and they all have different rules,” she says. “It’s extremely time consuming, even if everything works well and everybody’s covered. The lack of a system impedes quality and it’s very inefficient and expensive.”
“No system is perfect but that said, the Canadian system has the framework and the organization to be able to solve what problems exist and to solve the health care problems for Canadians. That structure doesn’t exist in the US. And that’s a big problem. “What we have in place in the United States is a structure that is chaos. There are multiple insurance companies, multiple payers all acting under different rules that they set for themselves. Also acting under the premise that a virtually unregulated free market can effectively and efficiently health care – and that’s just not true. Health care is just not a field in which a free market works well.”
Worse was the lack of care for the uninsured. (Nearly 15 percent of Texans do not have health insurance, an improvement from the 25 percent who were uninsured prior to the introduction of the Affordable Care Act.)
“It weighed on me a lot,” she says. “Even as a physician who says I’ll take all comers, if they need drugs, how do you get them? If they need to go into the hospital, they can’t, not unless they’re in extremis. The ER only has to take care of them if they’re dying.”
“It also changes what you do. This was really brought home to me when I came to Canada,” she says. “In Canada, it’s more that the hospital sees what needs to be done, wants to do it and then secondarily says, do we have it in the budget, is there going to be a way to pay for it? Whereas in the U.S., the money is number one. The hospitals I worked in were for-profit. Dialysis was for-profit. ‘Dr. Hart, you know, this is a business.’ I can’t tell you the number of times I heard that.”
‘What am I doing in this system?’
When Bob Hart, Denise’s husband, first arrived in Hamilton, he’d introduce himself to patients by telling them he’d just moved from San Antonio, Texas. Their reaction: “Well, why?”
“There’s a perception somehow that I went from first class to second class,” says Hart, a neurologist in Hamilton, Ontario focusing on stroke prevention. “I feel lucky to have come to Canada to finish my career whereas, you know, being a doctor in the U.S., there were some pretty dubious ethics.”
Hart is a global expert in stroke care. But he remembers being told by hospital administrators in the United States that he wasn’t ordering enough MRIs and should order more scans, because that’s how the hospital made money.
“That sort of thing, it’s very discouraging,” he says. “There are things that go on, like putting pressure on doctors for early discharges that make it, well, I didn’t really feel all that good about it. You do your best for individual patients. But in that system, you find yourself asking: what am I doing here?”
While Canada is thought to have long wait times to see specialists, Hart works in a stroke prevention clinic that’s been set up and funded so that all patients are seen within 24 hours, or within three days if they come in on a weekend. “We have no wait list and in fact could beat anyone in the States.”
Canada’s health system, for all its flaws, can still make urgent care happen urgently – an MRI can be done in an hour, if it’s needed, he says. And that’s regardless of income or employment. “Remember, in the States there are a third of people who get nothing at all. If you’ve got fancy insurance, you’ll get it in three days. If you’ve got no insurance, you never get an MRI.”
“I feel more like a doctor here because everybody has access,” Hart says, recalling having to send a patient having multiple seizures home in the United States with a 30-day supply of medication, but knowing they would be unable to afford any more. “That sort of anguish, that’s where doctors call drug reps and beg for donations, where we buy medicines personally. It makes it a bad day, it makes you feel like, what am I doing here in this system?”
(Poor access to medications happens in Canada too, of course, as we’re one of the few high-income countries without universal pharmacare.)
“While we may not get everything we want here, at least the conversation is based on how can we do the right thing? It’s been a joy to be here.”
‘Like walking backwards in time’
Angela Payment moved to Dallas after graduating from nursing college in Winnipeg at a time when no one was hiring nurses. In Dallas, she found work in a private hospital that operated as a step-down facility for patients recovering from care in the ICU. It was demanding, highly specialized care delivered by a close-knit team. She quickly grew to love it.
It was only after an upheaval in her personal life that she returned back to Canada, landing in a small hospital in Ajax, Ontario.
“It was like I walked backwards in time,” she says. “Everything seemed like it was really old, outdated. The machines, everything. It was totally a wrong fit for me.”
Staffing numbers were low, so everyone was overwhelmed and demoralized and no one had a say in their work schedule. “It was a totally different atmosphere from where I came from.”
Payment eventually moved on, and now works as a flow coordinator at Alberta Health Services, helping move patients to available beds. But she’s had little opportunity to really bring the best of what she experienced in the U.S. to her role here in Canada.
“I find that we have too much bureaucracy in Canada,” she says. “If you want to make change, you have to go through four or five committees. That takes up to a year and then by the time the change is made, there’s something else new that we’ve got to get going.”
She also sees more waste in the Canadian system. Knowing that a patient would be billed for every bandage, Payment developed a conservative approach to using medical supplies. During her first few shifts back in Canada, she was shocked to discover how easily staff could blow through hundreds of dollars worth of medical supplies.
Saddling patients with those bills is definitely the downside to the American system, she says. “That’s the part of the American health system that’s robbery. But then again, I had surgery down there, they found cancer, and I had surgery within six weeks.” By contrast, when a routine follow-up test found an abnormality after she returned to Canada, it took six months before she could see a specialist and another six months before she could get surgery.
“That’s the problem in Canada: we do not have access to health care as well as everybody thinks we do,” she says.
Peter Kim, an organ transplant specialist in Vancouver, spent several years working at a large hospital in Dallas. He came away with mixed impressions of the Canadian and U.S. health systems.
In Canada, a surgeon with his kind of specialized training has somewhat limited options – given our population relative to the United States, there’s only so much need for a transplant specialist and the work will only ever be concentrated in urban centres.
But he was initially shocked to discover that, in Dallas, uninsured patients could be turned away from life-saving transplant surgeries. He came to see it as a larger system problem and one not easily solved. (He sometimes saw patients for free, but any diagnostics or testing would need to be paid for out-of-pocket.)
“The main difference is that the philosophy of the health care systems are very different,” Kim says. “In the U.S., especially at a private hospital, it’s driven by profit. They open the hospital to make a profit and they sustain themselves by making a profit. Each system has a very different focus, yet each system has its own advantages and disadvantages.”
Reality check: we’re both near the bottom of Commonwealth Fund rankings
How good is the Canadian system, really? How good is the U.S. system? These are questions that preoccupy Peter Cram, a general internist at Toronto’s Mount Sinai Hospital and a health systems researcher at the University of Toronto.
“It’s really hard to answer that,” he says. There’s not enough empirical data – most studies are confined to one state or one region or one province. Cram points to a 2007 review by McMaster researcher Gordon Guyatt looking at studies comparing Canadian and U.S. health outcomes. “He came to the conclusion that there isn’t that much research comparing mortality, readmission rates or patient satisfaction. Can we really say with any certainty how these countries compare?”
On a personal and professional level, Cram is happy in Toronto. But he’s not wearing rose-coloured glasses.
The most recent Commonwealth Fund report that compared health systems in 11 developed countries put Canada, France and the U.S. in the bottom three spots. While Cram isn’t a fan of their methodology, he points out that what keeps Canada from the absolute bottom of the pack is the lack of insurance coverage in the U.S., something that was rapidly changing due to the Affordable Care Act (at least until recently).
“Why ask for Canadian-style health care, when it’s only a couple rungs above the U.S. in the rankings?” he asks. “We’re both near the bottom [of the Commonwealth ranking], but for very different reasons. There are countries that have a Canadian-style system – where 99 percent of people are insured – but then they’ve actually tackled a lot of other issues. The Netherlands, England, Germany – they spend less than we do and actually seem to have patients who are more satisfied.”
He shares the views of others that the Canadian system lacks experimentation, doesn’t promote entrepreneurship and is sluggish and slow when it comes to new ways of delivering care.
“It’s a government-run health system. It takes a massive degree of outrage or activism to encourage a politician to take a huge risk with revamping a system,” he says.
Still, he’s in no rush to return to the U.S.
“I love Toronto, I love the university, I do think that the health system does deliver a remarkably consistent level of care to the population,” he says. “And I think having the safety net underneath people is remarkable. I do think that there’s a lot to be proud of.”