Physicians in the U.S. are held more accountable for their results than their counterparts in Canada and Great Britain, as the health systems of the three countries have responded differently to pressures of cost, access and quality, says Carolyn Touhy, a political scientist at the University of Toronto.
Touhy wrote about the roots and effects of health system changes in the three countries in Accidental Logics: the Dynamics of Change in the Healthcare Arena in the United States, Britain and Canada (Oxford University Press). She will give an ACHE presentation called "Driving Forces in Healthcare: Comparing the United States, Great Britain and Canada" at 2: 25 p.m. Wednesday, March 29.
The experiences of health system reform in the three countries during the past decade are markedly different, she says.
While President Clinton's comprehensive healthcare reform effort was rejected by Congress, health delivery and finance have changed more profoundly in the U.S. than in any other Western country, she says.
In Britain, the Conservative governments of prime ministers Margaret Thatcher and John Major attempted to change the hierarchical National Health Service and divide it into purchasers and providers. Regional authorities were created to purchase medical and hospital services from local trusts on the basis of their capitated populations. The idea was to introduce contracting relationships into the system and thus more flexibility and choice.
"It was supposed to mimic a market within a publicly financed system," Touhy says. "In fact, as it played out, there was limited competition among providers for purchaser contracts."
Writing contracts is an information-intensive exercise. But Britain doesn't have the information on costs and expenses that U.S. providers have, Touhy says. In a system with fixed budgets, "it was natural for them to fall back on their established relationships because information was not available."
If the British reforms occurred as intended, transaction costs would have soared. To avoid those new costs, people returned to what and who they knew. The reforms, Touhy says, "made the bargaining more explicit but didn't really create an internal market."
Canada, which has a different national health system, trimmed national expenditures on healthcare without changing structural relationships among hospitals, doctors and bureaucrats, which caused strife, she says.
Provincial governments bear 70% of the country's healthcare costs. They pay for doctor's visits and hospitalization but not for ancillary services such as home care, pharmaceuticals, dentistry or eye care.
"That has meant hospitals and physicians have been bound into an accommodation with governments," she says. "Physicians have traded off entrepreneurial discretion over price but have maintained their clinical autonomy within their practices."
In the 1990s, however, the provinces balked at continued budget increases. "Real per capita spending declined in Canada," she says. "This was a huge shock to the system and to the accommodation between the profession and the state." It's an open question now whether a parallel private system of care will develop, she says.
What these three national systems have in common, she says, is a reduction in the autonomy of physicians and patients as new intermediaries have arisen. In Britain it's the NHS purchasing authorities, while in the U.S. it's private managed-care companies, on orders from employers.
"The collectivization of finance, whether public or private insurance, has given those financiers access to databases that can countervail the traditional informational advantage of (physicians)," Touhy argues. This new information allows purchasers to analyze patterns of care and demand value for money from providers.
Ironically, it's the private, employer-driven system in the U.S., which once made physicians rich, that has now placed them at the greatest relative disadvantage in this power equation, she says.