Would a two-tier system solve the problem of unemployed specialists?

[kitchenlover]

I don't want to start a political debate or anything, but I noticed there are tons of jobs for specialists/surgeons in the US but they seem few and far between in Canada.

Is that a problem inherent in the single payer system and could private healthcare solve that? I feel like this would be the only way to make the job market better for many specialists to have a chance at practicing in Canada. Would it be unpopular with the public (putting your political preferences aside) to pursue this policy?

[who_knows]

Jobs is only a fraction of the problem. Patients wait for 3 years for a knee replacement, 6 months to see a gastroenterologist, or a year for an ENT surgery. I lived in a country with the two-tire system and the wait times are negligible. Also, in that country, it's unheard of a surgeon switching to family medicine because he can't find a surgeon job.

Opening up private clinics will solve not only the job issue, but also ridiculous wait times.

[Edict]

On 7/14/2022 at 12:17 PM, kitchenlover said:

I don't want to start a political debate or anything, but I noticed there are tons of jobs for specialists/surgeons in the US but they seem few and far between in Canada.

Is that a problem inherent in the single payer system and could private healthcare solve that? I feel like this would be the only way to make the job market better for many specialists to have a chance at practicing in Canada. Would it be unpopular with the public (putting your political preferences aside) to pursue this policy?

Yes, in the sense that theres less money in the system. The bottleneck isn't surgeons wanting to operate, its OR time, which is limited by the government because the government covers the costs for nursing, techs, equipment. In the US, if someone is willing to pay i.e. insurance via corps/private citizens, someone is willing to build it. In a sense, in a single payer system, you need to convince the government to let you have your surgery, in private healthcare, you need to show them the money. 

However, the problem of unemployed or underemployed specialists is much easier solved by reducing the number of trainees as opposed to dramatically increasing OR time. The challenge of single payer is that its expensive and its very expensive to give people surgery with short wait times. There are of course ways to reduce costs at little expense to other outcomes, but politically wouldn't look great (i.e. reducing staff pay, reusing equipment etc.) The government is always trying to balance costs with patient outcomes, i.e. the greatest good for the greatest number. In a private system, there likely would be over-treatment because physicians would be incentivized to convince patients they need more treatment in order to make more. 

 

[futureGP]

On 7/17/2022 at 5:53 PM, Edict said:

Yes, in the sense that theres less money in the system. The bottleneck isn't surgeons wanting to operate, its OR time, which is limited by the government because the government covers the costs for nursing, techs, equipment. In the US, if someone is willing to pay i.e. insurance via corps/private citizens, someone is willing to build it. In a sense, in a single payer system, you need to convince the government to let you have your surgery, in private healthcare, you need to show them the money. 

However, the problem of unemployed or underemployed specialists is much easier solved by reducing the number of trainees as opposed to dramatically increasing OR time. The challenge of single payer is that its expensive and its very expensive to give people surgery with short wait times. There are of course ways to reduce costs at little expense to other outcomes, but politically wouldn't look great (i.e. reducing staff pay, reusing equipment etc.) The government is always trying to balance costs with patient outcomes, i.e. the greatest good for the greatest number. In a private system, there likely would be over-treatment because physicians would be incentivized to convince patients they need more treatment in order to make more. 

 

i would disagree with this post.

having been working in the system for a while, a single payor system does not prevent overtreatment or overdiagnosis.

Imagine you own a private endoscopy clinic, cardiology lab, radiology lab where you bill OHIP/MSP etc for services.

You still run a business and the untold truth is that there is a shxt ton of unnecessary tests and procedures being done.

30 yo with chest pain from likely anxiety? Gets an echo, stress test and a holter.

45 yo with simple GERD? Gets an EGD and colonoscopy.

 

Because its a single payor system and the payor is the government, the oversight into overbilling practices is very very poorly run. How would you expect a non-medical government official to argue with a ‘cardiologist’ about ordering holter/stress test/echo on a 25 year old coming with atypical chest pain? 

Frankly speaking, there is no real incentive here either (it’s government workers you’re talking about)

 

Compare that to the private sector with insurance companies. How many times do you hear of people not receiving claims for personal injury. We have a thriving personal injury industry for a reason. There actually is more accountability in private sector because overbilling directly undercuts profit -> upset shareholders. So the incentive is tremendously high to police inappropriate testing/procedures.

 

In addition, in a 2-tier system the private system may actually increase access to health care for the public system. 
One of the limitations of the public single payor system is that the government pays for all hospital capital equipment / resources. 
It’s not uncommon for a fairly large community hospital to not have access to what one might consider to be an important medical equipment for population of that size (eg esp. in the surgical world, but it can be as simple as portable US in ED/ICU)

By incentivizing the hospitals with revenue from the private patients, those expensive capital equipment purchases that you would have had to rely on rich donors to fund now become available.

 

 

 

[Edict]

On 10/25/2023 at 11:03 PM, futureGP said:

i would disagree with this post.

having been working in the system for a while, a single payor system does not prevent overtreatment or overdiagnosis.

Imagine you own a private endoscopy clinic, cardiology lab, radiology lab where you bill OHIP/MSP etc for services.

You still run a business and the untold truth is that there is a shxt ton of unnecessary tests and procedures being done.

30 yo with chest pain from likely anxiety? Gets an echo, stress test and a holter.

45 yo with simple GERD? Gets an EGD and colonoscopy.

 

Because its a single payor system and the payor is the government, the oversight into overbilling practices is very very poorly run. How would you expect a non-medical government official to argue with a ‘cardiologist’ about ordering holter/stress test/echo on a 25 year old coming with atypical chest pain? 

Frankly speaking, there is no real incentive here either (it’s government workers you’re talking about)

 

Compare that to the private sector with insurance companies. How many times do you hear of people not receiving claims for personal injury. We have a thriving personal injury industry for a reason. There actually is more accountability in private sector because overbilling directly undercuts profit -> upset shareholders. So the incentive is tremendously high to police inappropriate testing/procedures.

 

In addition, in a 2-tier system the private system may actually increase access to health care for the public system. 
One of the limitations of the public single payor system is that the government pays for all hospital capital equipment / resources. 
It’s not uncommon for a fairly large community hospital to not have access to what one might consider to be an important medical equipment for population of that size (eg esp. in the surgical world, but it can be as simple as portable US in ED/ICU)

By incentivizing the hospitals with revenue from the private patients, those expensive capital equipment purchases that you would have had to rely on rich donors to fund now become available.

 

 

 

Some great points here, and my opinion on the topic is more nuanced from my experiences in the US. You do make a great point about insurance companies acting as a sort of gatekeep in the US system vs how our government is acting as our gatekeep in the Canadian system. 

The way I see it, the insurance companies have certain advantages as gatekeepers. They tend to be good at stopping expensive unnecessary things, like brand name medications, very expensive tests or procedures etc. However, a few points. One is that doctors and hospitals have their own administrators who try to get around the insurance companies by overselling or overstating the nature of the problem. One example is the "high risk sexual behavior" diagnosis on EMR when trying to get STD testing, which has made its rounds on social media. The other is that when insurance doesn't cover, i.e. when it comes to the deductible, doctors have free reign to overtest. I have seen normal findings reported as abnormal on imaging imo just to justify a more expensive test. 

The government of course has its strengths. They can just make things unavailable through regulation, whereas insurance companies will just offer it at exorbitant price. They can put hard limits on the # of procedures that can be done when it is new and investigational, and they can determine when and where procedures and tests can be performed. However, the government, like you said, has a hard time stopping doctors from overtesting as well, if the doctor wants to order a test, the government won't stop them and there is a lot of waste that goes on. Many tests are ordered twice when a patient switches hospitals, like echos, for example. 

The biggest difference though between insurance vs government, is that the insurance will treat the wealthier person better than the poorer person. If you have money, you get a better plan, get to choose your doctor, shop around, avoid a wait etc. However, if you don't have insurance or are on a bare bones one like Medicaid, you will be limited to doctors who accept Medicaid, safety net hospitals etc. which are less well staffed, offer older and more outdated tests/procedures etc. The government for the most part, treats everyone the same, if you have connections you might skip a line but money can't just buy you a procedure. 

A huge reason the US has such an expensive healthcare system, is because its adversarial system essentially creates jobs to dispute just about everything. Everyone is fighting everyone for a slice of the pie. In Canada, its quite frankly a top down bureaucratic system, its lean but its also slow. It responds to changes like a snail and lets small parties make a killing off of loopholes, but it is also efficient because there is a lot internal fighting over resources. 

The way I see it, theres no simple solution, if we go private in Canada, healthcare costs overall will go up, wait times will go down but they will go down faster for the wealthy than the poor.