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  Fact

United States  

  Canada

 Introduction and Overview

· Large numbers of diverse racial/ethnic groups (i.e., individuals of Latino, African, and Asian descent, and Native Americans).

· Developed (industrialized) world power

· Strong economy

· In 2006, led the world in health care spending per capita

· Comparatively low life expectancy (ranked 36th worldwide)

· High infant and neonatal mortality (ranked 39th for infant mortality)

· Health care system ranked 37th in the world

·  Largest ethnic groups, British, French and other European groups.

· Largest religious groups, Roman Catholic with strong Anglican and other Christian religions

· Ranked 25th out of 31 countries in the literacy rate.

· High demand for health services

· Long wait time for appointments, especially in Quebec

· “Everything is free but nothing is readily available” (Frogue (2001,¶ 10).

 Historical Perspective

· Physician dominated medical system until late 1980s.

· Physicians decisions regarding diagnostic tests, procedures and referrals, and length of hospital stays unchallenged

· Early 1990s, unsuccessful Clinton health reform proposal

· 2009 Obama Plan (Affordable Health Act) those opposed sought an appeal of the legislation which the Supreme Court

· upheld June, 2012

· In 2009, health care spending escalated to 2.5 trillion dollars

· By 2025 health care spending predicted to rise to 25% of the federal budget unless spending is curtailed.

· The number of uninsured increased from 46.3 million in 2008 to 50.7 million in 2009

·  1867 Canada’s Constitution assigned most of the health care responsibilities to its ten provinces and three sparsely populated northern territories.

· These provinces vary widely by size and fiscal capacity.

· Universal health coverage, a national health insurance program

· Medical Care Insurance Act of 1966.

· The National Medical Care Insurance Act operates on the basis of four principles, It:

· is comprehensive

· provides universal coverage to all legal and illegal residents

· is publicly administrated

· is portable.

· Canada Health Act passed in 1984, established a fifth core principle, accessibility which forbad extra billing and cost sharing.

· Resultant ten percent cut in first year medical school admissions contributed to a drop in physician supply.

 Healthcare Structure

·  Health care since early 1990s have been dominated by insurance companies and business.

· Fragmented and decentralized system

· Hospital and community-based care

· Well educated health providers. Providers licensed and certifications

· Nurses – LPNs, RNs education and background varies, entry to practice levels: BSN (4 years), ADN (two years),

· Diploma (varies).

· The future of nursing includes legislation changing entry level into practice to the BSN

· Hospitals are the largest employers of RNs (62.2 percent)

· During the past fifty years, the US has regularly imported nurses to ease the nursing shortage.

· Advanced practice nurses offset the shortage of physicians

· Nurse experts in informatics, and forensics nursing (ww.nursecredentialing.org).

· A critical need for community-based mental health providers,including nurse practitioners.

· Average annual RN earnings in 2008 were $57,785; The median nurse practitioner’s salary was approximately $87,000.

· Institute of Medicine (IOM) revealed, an enormous number of patients die annually due to preventable medical errors,  standardizing entry level to BSN should correct problem.

· Current physician shortage; predicted shortage of 200,000 physicians by 2027.

· Average net annual income for all physicians, $205,700 (Surgeons earned highest, $274,700; obstetrics/gynecologist earned $227,000; internal medicine physicians earned $196,000; general/family practice physicians earned $144,700 and pediatricians at $137,800 (American Medical Association, 2004-2005.

·  A readily available supply of physicians

· Less availability of nurses.

· Levels of nurses comparable to those in the United States (registered nurses, nurse practitioners, nurse midwives, and LPNs).

· Nurse practitioners and physicians assistants not yet, widely utilized.

· Other health professionals in Canada include dentists, pharmacists, medical and radiology technicians, chiropractors, and physiotherapists.

· Between 1990 and 2005, number of nurses practicing decreased from 11.1 to 10 nurses per 1,000 in the population, with the lowest point occurring in 2003, at 9.6 per 1,000 (OCED Health Data, 2007).

· Increasing numbers of women are entering the medical workforce.

· Twenty-four percent of Canadians live in rural areas yet, only nine percent of the physician workforce practices in rural Canada (OCED, 2008).

· In 2008 approximately 14 percent (5 million) of Canadian adults did not have a family physician.

· Canada regulates physician supply, physician and hospital budgets and technology and coordinates financing, insurance, and payment function.

· Physicians have a great autonomy.

· Medical associations negotiate with provinces for fee schedules.

· The maximum wage ranges between 70,000 Canadian dollars (C$) in Ontario, 51,000 C$ in Quebec, and the minimum ranges from 53,000 in Manitoba and 34,000 in Quebec. However, some nurses in Canada make over 500,000 C$ (OCED, 2008).

 Financing

·  19.3 percent of U.S. budget spent for health care  ($6,714) per capita

· Considerably higher than Canada, France and the  United Kingdom (OECD, 2008).

· Sources of funding health care services includes individual  direct pay, sometimes according to a sliding fee scale

· Charity/welfare which is written off

· Medicare and Medicaid for which the government pays

· Insurance, almost exclusively through Health Maintenance Organizations (HMOs). Patients choose a primary care  physician (PCP) within a network. That physician takes  care of all their medical needs including referrals to specialists. Preferred Provider Organization (PPO) is similar to the HMO but the patient chooses a provider or specialist  from a network, and if they are seen by anyone other than  the PPO, payment for services are typically lower, and can  even be withheld (HMO versus PPO). Managed care, goal is to lower costs

· Modes of payment

· Hospital reimbursements using diagnosis related  groupings (DRGs) or setting fees by grouping similar  health problems

· A negotiated fee-for-service, per diem

· Capitation, a set limit on the amount that providers  are reimbursed for services. Physicians are paid a  standard fee for services. This fee is set by a HMO  and paid directly to the physician.

· Consumers, responsible for a co-payment at time  of provider or specialist visit. The co-payment is  an out-of pocket payment that is a fraction of the  actual cost of care.

·  Medicare for those 65 and older

· Part A covers hospital insurance.

· Part B, known as medical insurance for  retired persons that covers provider services,  durable medical equipment, and some home  preventive services.

· Part C also referred to as Medicare Advantage,  supplemental coverage to pay for gaps in  coverage not paid by Medicare

· Part D covers prescription drugs. Part D is  run by a Medicare approved private insurance  company.

· Medicaid, health coverage for the poor, which is  covered by the Federal Social Security Act, 1966, and  funded through taxes, later amended to fund Social  Security disability, providing health care for persons  with conditions that prevent them from being employed.

· Health care for American Indians, and Alaskan  Natives through the Indian Health Services (IHS)  covered by this Act.

· Comprehensive medical and psychiatric care to  veterans through its federal government operated  Veterans Administration, also covered by this Act.

· TRICARE, the US health care insurance plan  covering active duty and retired military service  workers (covers outpatient visits, hospitalization,  preventive services, maternity care, immunizations, mental/behavioral health for active and retired  service members and their families, and  dental coverage).

· Medigap, funded through Medicare and  coinsurance cover gaps between what  Medicare covers after a person reaches 65 and older, is chronically ill, or is disabled.

·  Health care funded through general taxes and Medicare.

· During the 1970s physicians commonly billed patients for additional costs that were already covered by the government plan.

· In 1984, the Canada Health Act prevented medical providers from billing patients for services if they had also billed the public insurance system.

· “Comprehensive, universal, portable, publically administered, and accessible,” was issued by the Prime Minister in 1999. Portable means coverage continues when patients travel or move between provinces.

· Canada has a single payer system. Single payer is used to primarily describe a system that is government funded and controlled.

· In order to finance Canadian health care, provincial funds gathered from a mix of federal transfers favoring poorer provinces, general provincial revenues, employer payroll taxes and insurance premiums.

· Residents of each province receive insurance cards, which they present when being seen in a hospital or physician office. This card must be produced for care because benefits vary slightly among provinces.

· There is no general dental coverage, but most provinces provide some pediatric dentistry, and all provinces cover in-hospital oral surgery.

· Many provinces provide limited optometric, chiropractic and physical therapy coverage. Financial support for pharmaceutical expenses is included in separate programs, generally for seniors and other categories of the needy.

· Contraception is available to all women in Canada free of charge

· Every provincial plan insures all medically necessary physician and hospital care.

· Private insurance is allowed for what is referred to as non-core services. Private insurance plans are prohibited from billing patients for core services, or any service covered by the standard public insurance plan.

· An estimated 80% of Canada’s population has supplementary coverage for items such as private rooms, dental care, and other non-core services (Irvine, Ferguson and Cackett, ¶ 17).