i was talking recently with Luftmentsch of Vision of the Night about the health care systems in. the UK and Canada, and I thought it would be interesting to take a look at what a patient scenario might look like in particular health care system.
Health care systems overview
First, let’s take a quick look at the basics of the health care systems in Canada, the US, and the UK. Being Canadian, that’s obviously what I’m most familiar with. I have some knowledge of the American and British systems, but I’m fairly clueless about the nuts and bolts everywhere else.
In Canada, medically necessary health care is publicly funded, and patients are not allowed to be charged for services. This is defined under a federal law, the Canada Health Act, but health care is administered by the individual provinces and territories. Federal transfers provide a large portion of the funding. My health coverage is tied to the province where I live, but if I need health care services in another part of the country, they’ll just bill my province.
Each province makes its own decisions about how to administer services. My province is divided up into a handful of health authorities, which run hospitals, public health services, and other assorted services. Physicians, and some other professionals in private practice, bill the government directly in a fee for service model. Private practice means they run their own office, but they still can’t direct bill patients unless it’s for a non-medically necessary service that’s not covered by the public system (such as Botox for cosmetic reasons).
The National Health Service (NHS) is the public system in the UK. It seems… complicated, to say the least. There are local trusts, and there’s a lot of commissioning going on, although I can’t for the life of me figure out what that actually means. From what I’ve heard, I’m not convinced the NHS is entirely sure what any of it means either. The NHS England offers this video to explain how they’re organized, or perhaps just confuse you even further.
The U.S. has less of a system and more of a free-for-all. That’s free as in capitalist free-for-all, not health care that’s freely accessible. Some people have insurance coverage, some don’t. Even if you have coverage, that doesn’t mean you have access. You probably have to be concerned about what’s available in and out of network, as well as whatever co-pay you have to cough up.
About 30% of the population is covered by either Medicare (a federal program for seniors or people with disabilities) or Medicaid (a state-based program for people with low incomes). However, being covered doesn’t mean that providers will necessarily accept that coverage. In 2020, 1% of physicians overall have opted out of Medicare, but the specialty with the highest opt-out rate just happens to be psychiatry at 7.2% (Kaiser Family Foundation). According to a 2019 report (macpac.gov), only 35.7% of psychiatrists accept new Medicaid patients and 62.1% accept new Medicare patients. Compare the to 70.8% and 85.3% respectively as the overall average for physicians.
Throw in for-profit hospitals and the most expensive health care in the world, and you’ve got a not so pretty picture.
A patient scenario
The basic patient journey for this scenario is a patient whose GP has just started them on lithium and has referred them to a psychiatrist. So, let’s begin this journey if it were to happen in my province, British Columbia.
Seeing the GP
While some GPs here work at clinics operated by the local health authorities, most operate independently. For each patient visit, they bill the provincial health plan (here, it’s called the Medical Services Plan or MSP). Doctors don’t set their own billing rates; MSP has predetermined amounts associated with each billing code. If I’m a new patient at a GP’s office, I just need to show them my ID with my personal health number. GP visits are fully covered, so there’s no co-pay or whether or not they take my insurance or any of that American-style nonsense. Some things, like writing sick notes, aren’t billable under MSP, so some GP’s offices will charge for them.
So, I see my GP. He gives me a prescription to start the lithium, and a lab requisition to get a blood test a week later. He says he’ll send a referral to a psychiatrist.
Going to the pharmacy
Canada has been talking about starting a national pharmacare plan, but it hasn’t actually happened yet. While there would be an extra cost associated, having a single national payer would mean much better bargaining power with drug companies than provincial pharmacare plans can manage, so that would bring down drug costs. At least it’s better than the US, where getting screwed repeatedly in very uncomfortable positions by drug companies is apparently preferable to having the government get involved to slow down the money train.
As things currently stand, medications are fully covered for anyone while they’re in hospital, but in community, patients have to pay, and provinces may chip in means-tested coverage. Because my income was low last year, the province covered a portion of my meds all of this year, and last month I hit a deductible, at which point they were fully covered. Some people have “extended health insurance” through their employers that provides drug coverage.
Going to the lab
Basic laboratory services are covered by provincial health plans, but for the most part, they’re privately delivered. The lab closest to me is privately operated, but they bill MSP using my health number. I only have to pay if I’m requesting a particular test that’s not covered because it’s not medically necessary, like pharmacogenomic testing.
I grew up in a small town, and any time bloodwork was needed it was done at the hospital lab, because that was all there was in town.
Referral to a specialist
What happens at this step would depend on who/what I was getting referred to. A run of the mill psychiatrist would run their own show in private practice and bill MSP for each visit with me. The GP would refer directly to a psychiatrist that was taking new patients. If I needed to go to a specialty service or a mental health team that involved case managers and assorted others, I would be referred to the appropriate service operated by the local health authority. Those services are fully covered.
Therapy isn’t covered under the public health care system unless it’s part of a service delivered by the local health authority. If there wasn’t a health authority service that fit my needs in a timely manner, then I would have to pay to see a therapist in private practice. An extended health insurance plan might cover part of that cost.
So there you have it, an example patient journey in my part of Canada. Would things look different under your local health care system?
The Mental Health Resource Directory page has contains a wide selection of useful mental health websites and apps.