Special Article
How Does Canada Do It? — A Comparison of Expenditures for Physicians' Services in the United States and Canada
N Engl J Med 1990; 323:884-890September 27, 1990
- Abstract
- Abstract
As a percentage of the gross national product, expenditures for health care in the United States are considerably larger than in Canada, even though one in seven Americans is uninsured whereas all Canadians have comprehensive health insurance. Among the sectors of health care, the difference in spending is especially large for physicians' services. In 1985, per capita expenditure was $347 in the United States and only $202 (in U.S. dollars) in Canada, a ratio of 1.72. We undertook a quantitative analysis of this ratio.
We found that the higher expenditures per capita in the United States are explained entirely by higher fees; the quantity of physicians' services per capita is actually lower in the United States than in Canada. U.S. fees for procedures are more than three times as high as Canadian fees; the difference in fees for evaluation and management services is about 80 percent. Despite the large difference in fees, physicians' net incomes in the United States are only about one-third higher than in Canada. A parallel analysis of Iowa and Manitoba yielded results similar to those for the United States and Canada, except that physicians' net incomes in Iowa are about 60 percent higher than in Manitoba. Updating the analysis to 1987 on the basis of changes in each country between 1985 and 1987 yielded results similar to those obtained for 1985.
We suggest that increased use of physicians' services in Canada may result from universal insurance coverage and from encouragement of use by the larger number of physicians who are paid lower fees per service. U.S. physicians' net income is not increased as much as the higher U.S. fees would predict, probably because of greater overhead expenses and the lower workloads of America's procedure-oriented physicians. (N Engl J Med 1990; 323: 884–90.)
Media in This Article
Table 1
Selected Background Statistics, 1985.*Table 2
Health Expenditures per Capita, According to Type of Expenditure, 1985.*Article Activity
- Article
AMERICAN interest in the Canadian health care system is growing rapidly for two principal reasons.1 2 3 First, costs have escalated in the United States to such an extent that health care now accounts for approximately 11.5 percent of the gross national product, whereas in Canada the comparable figure is about 9 percent. Second, one in seven Americans has no health insurance, and tens of millions of others have incomplete coverage; in contrast, Canada provides comprehensive, first-dollar health insurance to all its citizens. If U.S. spending could be held to the Canadian percentage, the savings would amount to more than $100 billion a year.
There have been numerous descriptions of the evolution of national health insurance in Canada and of the current federal-provincial system.4 5 6 A detailed statistical analysis of trends in Canada and the United States has identified prospective global budgets for hospitals and negotiated fee schedules for physicians' services as major reasons for lower spending in Canada.7 Other studies have focused on hospital costs,8 , 9 drug prices,10 11 12 the use of surgical services,13 , 14 and administrative costs.15
This study concentrates on per capita expenditures for physicians' services because in this important sector the ratio between U.S. and Canadian spending is particularly large (1.72 in 1985). In other words, after adjustment for population size and the overall purchasing power of the Canadian dollar, Americans spend 72 percent more than Canadians for physicians' services. The comparable ratio for hospital expenditures is 1.34, and for all other health expenditures combined it is 1.30.
How does Canada do it? Do Canadians receive fewer physicians' services? Are the higher U.S. expenditures attributable entirely to higher fees? Do higher fees result from the use of more resources to produce a given quantity of services (more physicians, nurses, equipment, and the like), or do they reflect higher prices for those resources (higher physicians' net incomes, nurses' salaries, and the like)?
Our principal objective was to provide quantitative answers to these questions. Our analysis of the ratio between the United States and Canada was supplemented by a parallel comparison of Iowa and Manitoba. The state and the province have small, relatively homogeneous populations, and we had special access to data for the two regions. Our analysis of the ratio between Iowa and Manitoba in per capita expenditures for physicians' services (1.51) served as a check on the comparison between the United States and Canada and helped to sharpen our understanding of the reasons for the differences between countries in spending, fees, and use. The effect of physicians' services on the health of Americans and Canadians is not addressed in this paper.
Methods
Data on health care expenditures, the number of physicians who care for patients, vital statistics, and socioeconomic variables for the United States, Canada, Iowa, and Manitoba for 1985 were gathered from published sources,16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 and the appropriate ratios were calculated. All data in Canadian dollars were converted to U.S. dollars according to the purchasing-power-parity exchange rate of $1 U.S. equals $1.22 Canadian. This rate, calculated each year by the Organization for Economic Cooperation and Development, is based on the relative prices of the same comprehensive basket of goods and services in the two countries. All dollar amounts mentioned in this paper are in U.S. dollars. Total expenditures for physicians' services were allocated to procedures or to evaluation and management according to a formula based on the distribution of specialists in each country (or region). Details of the allocation are available elsewhere.*
Fees
The necessary data on physicians' fees were not available — except from Manitoba — in published form. We therefore relied on data made available to us on a confidential basis by the Health Insurance Association of America, California Blue Shield, Iowa Blue Cross and Blue Shield, and Health and Welfare Canada. Fees in the United States for surgery (33 procedures) and evaluation and management (22 kinds of visits that we combined in five broad categories to achieve comparability with the Canadian data) are based on billed charges reported to the Health Insurance Association of America by its members. The association did not have data for ancillary services; charges for radiology (eight procedures) and anesthesiology (eight procedures) were therefore obtained from California Blue Cross and adjusted to the levels of the association by comparing surgery fees from both sources. Billed charges for Iowa for the same procedures and visits were provided by Iowa Blue Cross and Blue Shield. A list of the procedures and types of visits according to CPT-4 code (Current Procedural Terminology, fourth revision), as well as the precise methods we used to calculate the fee ratios, is available elsewhere.*
All U.S. and Iowa charges were reduced by 20 percent to measure the fees actually received by American physicians more accurately. There are services that are provided but never paid for; there are differences between what is billed and what insurance companies will allow; preferred-provider and health maintenance organizations extract explicit or implicit discounts from billed charges; physicians who accept Medicare assignment may receive less than their usual fee; and Medicaid is frequently the lowest payer of all. A survey of the Medical Group Management Association for 1985 reported that fee-for-service cash collections were 15 percent less than gross fee-for-service billed charges.35 It is widely believed that the collection ratio for such groups is higher than the ratio for physicians in solo practice or small partnerships. A sample of Medicare-approved charges for 30 major services and procedures showed a median difference from Health Insurance Association of America billed charges of — 23 percent.36 Reducing U.S. billed charges by 20 percent therefore appeared appropriate. No such adjustment was necessary for Canada because bills are paid fully and promptly by the provincial governments according to predetermined, annually negotiated rates.
Fees in Manitoba were taken from the physicians' manual of the Manitoba Health Services Commission and included an adjustment for services provided in rural areas. Because overall Canadian fees were unavailable, Manitoba fees were adjusted to an all-Canada level according to a ratio of benefit rates between Canada and Manitoba that we calculated using provincial data assembled by Health and Welfare Canada. Because there is considerable interest in the United States in reimbursement for procedures as compared with reimbursement for evaluation and management, we calculated separate fee ratios for the two categories of services.
Quantity of Services per Capita
In principle, the quantity of services per capita is the sum of all the visits, tests, operations, and other services provided by physicians. Because comprehensive data to measure these services directly were not available, we estimated the ratios between the United States and Canada and between Iowa and Manitoba by dividingthe ratio of expenditures per capita by the appropriate fee ratio. Because expenditures equal the product of fees and the quantity of services, this method provided an indirect measure of the relative quantity of services provided.
*See NAPS document no. 04801 for 20 pages of supplementary material. Order from NAPS c/o Microfiche Publications, P.O. Box 3513, Grand Central Station, New York, NY 10163–3513. Remit in advance (in U.S. funds only) $7.75 for photocopies or $4 for microfiche. Outside the U.S. and Canada add postage of $4.50 ($1.50 for microfiche postage).
Price of Resources
Physicians' services are produced through the use of resources such as physicians, nurses, equipment, and office supplies. We estimated the ratio of the prices of these resources for the United States and Canada (and for Iowa and Manitoba) from physicians' net incomes, nurses' salaries, and other relevant data. The overall ratio was a weighted average (weighted according to expenditures) of the price ratios for four categories of resources: physicians, other personnel, office, and equipment and supplies. This average was then adjusted to take liability-insurance premiums into account.
Quantity of Resources
Of the four categories of resources listed above, we only had data on quantity for the number of physicians. We therefore estimated the ratio of the quantity of resources per capita for the United States and Canada (and for Iowa and Manitoba) by dividing the ratio of expenditure per capita by the ratio of the price of resources. Because expenditures equal the product of the price of resources and the quantity of resources, this method provided an indirect measure of the quantity of resources.
Results
Table 1Table 1
Selected Background Statistics, 1985.* presents selected background statistics for each country and for Iowa and Manitoba in order to put the data on expenditures in context. Most of the populations of the United States, Canada, and Manitoba are urban, whereas more than half of Iowa's population is rural, which helps to explain the low number of physicians per capita in that state. Despite its huge territory, 90 percent of Canada's population lives in a narrow band of land just north of the border with the United States. Manitoba, like Canada in general, has a large area, most of which is thinly populated. More than half of Manitoba's population and more than three quarters of its physicians live in one city, Winnipeg. The elderly are relatively more numerous in the United States and in Iowa; were all other things equal, this would lead to a slightly higher use of medical services. The higher per capita gross national product in the United States would tend to increase health care expenditures per capita, mostly through higher incomes for physicians, nurses, and other personnel.The differences in the number of physicians per capita, both in the aggregate and according to the type of physician, are worthy of special note. On a per capita basis there are more physicians who care for patients in Canada than in the United States, and many more in Manitoba than in Iowa. The disparity with respect to general practitioners and family physicians is very large. In most specialties and subspecialties, however, the ratio between the United States and Canada is much greater than 1. Rates of hospital admission are similar in the two countries; the average length of stay is considerably longer in Canada, partly because some of Canada's short-term general hospitals include rehabilitation units.
Canada does better than the United States with respect to life expectancy and infant mortality, but Iowa does slightly better than Manitoba. There is no reason to believe that access to or the quality of medical care in Iowa is superior to the U.S. average or that care in Manitoba suffers in comparison with care in the rest of Canada. The reversal in ratios therefore suggests that these differences in gross measures of health are determined largely by nonmedical factors, such as personal behavior, the environment, and genetic endowment.
The data on per capita health expenditures (Table 2Table 2
Health Expenditures per Capita, According to Type of Expenditure, 1985.*) show that the ratios between the United States and Canada and between Iowa and Manitoba are much greater for physicians' services than for hospital services or other expenditures. They also show that within the category of physicians' services, procedures account for nearly all the higher spending in the United States. To understand the difference between the ratios for procedures and for evaluation and management, it is necessary to examine the ratios for fees and for the quantity of services separately.Fees
Physicians' fees for procedures are approximately 234 percent higher in the United States than in Canada (Table 3Table 3
Physicians' Fees, 1985.*); the difference between Iowa and Manitoba is about 199 percent. By U.S. standards, fees for procedures are exceedingly low in Canada. For example, in Manitoba in 1985 total obstetrical care was reimbursed at $245; the fee for a hernia repair was $186 and for a cholecystectomy $311. Canadian surgical fees are much lower across the board than U.S. fees: for the United States and Canada, 27 of the 33 ratios for surgical procedures are between 2.0 and 4.5; and for Iowa and Manitoba, 29 of the 33 ratios are between 1.75 and 4.25.Fees for evaluation and management are also higher in the United States than in Canada, but the ratios are much smaller: 1.82 for the United States and Canada, and 1.72 for Iowa and Manitoba. Canadian fees for hospital visits are particularly low; in Manitoba physicians received only $7.20 for a "moderate" hospital visit in 1985 (a visit limited in scope and duration).
The overall fee ratio was moderately sensitive to our allocation of expenditures between procedures and evaluation and management. For instance, if the true share of procedures were five percentage points larger than our estimate, the overall fee ratio between the United States and Canada would increase from 2.39 to 2.47. If the share were five percentage points smaller, the ratio would be 2.32. The exchange rate also affected the fee ratio. If we had used the market rate ($1.00 U.S. equals $1.36 Canadian), which reflects capital movements and speculation as well as the relative purchasing power of the two currencies, the overall fee ratio would be 2.68. Finally, the relation between the fee ratio and our assumption of a 20 percent discount from billed charges for U.S. fees should be noted. If we had assumed a 25 percent discount, the overall ratio would be 2.24; a 15 percent discount would yield a ratio of 2.54.
Quantity of Services per Capita
Table 4Table 4
Estimation of the Ratios of Quantity of Physicians' Services per Capita, 1985. provides striking refutation of the hypothesis that lower spending in Canada is achieved by providing fewer services. On the contrary, the ratio between the United States and Canada for all services is 0.72, and between Iowa and Manitoba the ratio is 0.69. The disparity in use is much greater for evaluation and management than for procedures. These results are sensitive to possible biases in the fee ratios, but the conclusion that the rate of use is greater in Canada than in the United States appears robust. For instance, if the overall fee ratio between the United States and Canada were 2.0 instead of 2.39, the ratio of the quantity of services per capita would be 0.86, still well under 1.0. These results are not sensitive to assumptions about the exchange rate because using a different rate would change the expenditures and fee ratios in equal proportion; the ratio of the quantity of services per capita would not be affected.Prices of Resources
As a share of total expenditures, the most important resource in both countries is the physician; the physician's net income is 52 percent of gross income in the United States and 66 percent in Canada. In 1985 net income per office-based physician was $112,199 in the United States and $73,607 in Canada.37 , 38 After adjustment for differences in the mix of specialties, U.S. incomes were 35 percent higher than those in Canada, and 61 percent higher in Iowa than in Manitoba (Table 5Table 5
Estimation of the Prices of Resources, 1985.). The price ratio for other personnel was based on the full-time compensation of a registered nurse.16 , 39 40 41 The price of occupying and maintaining an office varies greatly depending on geographic location, and direct estimates were unobtainable. We assumed that the price increases as the relative wealth of an area increases; our calculations were therefore based on regional and state per capita income weighted according to the number of physicians in the area. We assumed that the real prices of equipment and supplies used by physicians are roughly the same in both countries; the ratio was therefore assumed to be 1.0.We calculated the price ratio for all resources as an expenditure-weighted average of the ratios for the four categories, using the average of U.S. and Canadian weights. Liability insurance is an important item of expenditure for U.S. physicians, but their Canadian counterparts do not incur a similar expense; estimates of liability expenses for Canadian physicians are less than 1 percent of gross receipts. We did not consider expenditures on liability insurance to reflect any real resource used in the practice of medicine; thus, liability insurance was treated as a tax on the prices of all resources. The ratios of resource prices were therefore increased by the share of all expenditures attributable to liability-insurance premiums. We concluded that the prices of resources are moderately higher in the United States than in Canada (Table 5), but the ratio is small as compared with the fee ratio of 2.39. Most of the excess of U.S. over Canadian fees must be attributable to the fact that Americans use more resources to produce a given quantity of services.
Ratio of Quantity of Resources to Quantity of Services
The results of our estimation of the ratios of resources to services (Table 6Table 6
Estimation of the Quantity of Resources Relative to the Quantity of Services, 1985.) were extraordinary. It appears that the United States uses 84 percent more real resources than does Canada to produce a given quantity of physicians' services. The difference between Iowa and Manitoba is somewhat smaller, with a ratio of 1.53.Summary and Update
The study's most important results are summarized in Table 7Table 7
Summary and Update of Estimates.. First, higher expenditures on physicians' services per capita in the United States were entirely explained by higher fees; in fact, the quantity of services per capita is actually lower in the United States than in Canada. Second, the higher fees were attributable primarily to the fact that Americans use more resources to produce a given quantity of services. Third, a small portion of the higher U.S. fees was reflected in higher prices of resources, especially physicians' net incomes. Fourth, the results of the comparison between Iowa and Manitoba were similar to those of the comparison between the United States and Canada, except that a larger proportion of the higher fees in Iowa reflected higher physicians' net incomes. Finally, updating the analysis to 1987 with data on changes in each country from 1985 to 1987 yielded results similar to those obtained for the 1985 comparisons between countries.Discussion
Two striking conclusions emerged from our statistical analysis of the difference between the United States and Canada in spending for physicians' services. First, the data firmly reject the view that Canadians save money by delivering fewer services. On the contrary, the quantity of services per capita is much higher in Canada than in the United States. Second, as compared with Canada, the United States uses appreciably more real resources to produce a given quantity of services. We will discuss eight possible explanations for these findings: the effects of insurance on demand, the effects of physicians on demand, billing costs, amenities, other administrative costs, overhead accounting, the workloads of procedure-oriented physicians, and the quality or intensity of care.
Effects of Insurance on Demand
Canadians have universal coverage and face no out-of-pocket expenses, whereas U.S. patients pay coinsurance rates ranging from 0 (full insurance) to 100 percent (for the uninsured). Thus, lower rates of use in the United States must reflect in part the price sensitivity of the demand for physicians' services. If, on average, Americans face the equivalent of 25 percent coinsurance, the results of the Rand Health Insurance Experiment predict that there will be 27 percent fewer visits and 33 percent less outpatient expenditure per capita than if they had full coverage.42 We found that the use of evaluation and management services in the United States was 36 percent less than in Canada, and the difference between Iowa and Manitoba was 40 percent. Another source has estimated per capita contacts with a physician at 7.1 in Canada in 1985 and at 5.4 in the United States in 1986.43
Effects of Physicians on Demand
To the extent that higher rates of use in Canada are not fully explained by more complete insurance coverage, they may be explained by demand induced by Canadian physicians.44 The number of general practitioners and family physicians is very high in Canada, and their fee per visit is low. They may thus be more inclined to recommend additional evaluation and management services.
Billing Costs
In each Canadian province there is only one source of payment for physicians' services. Physicians typically submit one bill, and payment is usually punctual and complete. In contrast, American physicians must bill a myriad of private and public third-party payers, and often must also bill patients directly. Numerous complex forms must be filled out, there are frequently delays in payment as well as disagreements concerning the amount to be paid, and collection efforts impose additional costs. The differences in billing undoubtedly account for some of the additional resources reflected in the U.S. data, but we do not know exactly how much. The order of magnitude can be inferred from the fact that approximately 16 percent of the gross receipts of physicians are devoted to personnel who are not medical doctors. If one fourth of those personnel are needed for billing tasks that are not required in the Canadian system, then 4 percent of U.S. expenditures can be explained by this factor. There are also additional billing costs for physicians' time, computers, stationery, and postage.
Amenities
Fragmentary data from one Canadian province and the American Medical Association suggest that U.S. physicians spend considerably more than their Canadian counterparts for rent and related office expenses, possibly twice as much. It is unlikely that this large difference is primarily the result of higher prices for identical offices. Some portion, probably a considerable portion, reflects a higher level of amenities in the average U.S. office. This may take the form of a more desirable location, more space per patient, newer furnishings, or more elaborate decor. Why would this occur? One reason is that real per capita income in the United States is 10 to 15 percent higher than in Canada; Americans are therefore accustomed to a somewhat higher level of amenities in most aspects of life. But the income difference would probably explain only about a 10 to 15 percent difference in amenities. More important may be the fact that competition for well-insured patients is more intense in the United States, especially among procedure-oriented physicians, many of whom have lower workloads than they desire. Physicians usually do not compete for insured patients by lowering fees, but they can try to attract such patients by offering a higher level of amenities.
Other Administrative Costs
There are numerous other costs incurred by many U.S. physicians that are lower or nonexistent for their Canadian counterparts. For instance, concern over possible malpractice suits (much rarer in Canada) may cause U.S. physicians to keep additional notes and records, or to undertake other activities that require their time and other resources but that are not reflected in the measures of quantity of services. (If concern over possible malpractice suits leads U.S. physicians to order additional visits and tests, the ratio between resources and services is not affected, because both the additional services and resources required to produce them are accounted for.) Other administrative costs that are more likely to be incurred by American than Canadian physicians involve maintaining contractual relations with preferred-provider organizations, dealing with third-party use reviews, and marketing.
Overhead Accounting
Overhead makes up 48 percent of expenditures in the United States, but only 34 percent in Canada.37 , 38 Some of this difference undoubtedly reflects the greater use of resources in the United States, as discussed above. Some, however, may reflect more stringent scrutiny of overhead accounting by the Canadian government, because the overhead percentage is part of the background for negotiations between the provincial governments and physicians' organizations over fees. This constraint is not present in the United States. If identical accounting practices were applied in both countries, the overhead percentages might be slightly closer to each other and the difference in net income might be slightly larger. Such an adjustment would increase the ratio of the price of resources in the two countries by a few percentage points and decrease the ratio of resources to services by an equivalent amount.
Workloads of Procedure-Oriented Physicians
There can be little doubt that the average Canadian physician who specializes in procedures does more of them during a year than his or her counterpart in the United States. We estimated that there are about 40 percent more procedure-oriented physicians in the United States than in Canada (relative to the population), but the number of procedures performed appears to be about 20 percent higher in Canada. For some specialties the difference in workloads may be of the order of magnitude of two to one. This explanation is not as relevant for the comparison between Iowa and Manitoba, because the per capita supply of procedure-oriented physicians is about the same in both places. The difference in the supply of physicians may help explain why the ratio of resources to services is much higher between the United States and Canada than between Iowa and Manitoba.
Quality or Intensity of Care
The most uncertain and potentially controversial explanation concerns possible differences in quality or intensity of care. This question required that evaluation and management and procedures be considered separately. We estimated that approximately two thirds of the evaluation and management services in Canada are delivered by general practitioners and family physicians, and one third is delivered by internists, pediatricians, psychiatrists, and other specialists. In the United States the proportions are reversed. Should this be interpreted as a difference in quality of care? Some would argue that care provided by physicians with specialty training should be considered as "more" care. But there are others who believe that in most cases the quality of care provided by general practitioners or family physicians is as high, and may even be superior because of their greater familiarity with the patient and his or her circumstances. The question of intensity of care arises because of the possibility that some of the additional evaluation and management services provided in Canada are for patients with minor problems such as colds or upset stomachs. Some visits of this type may be deterred in the United States because insurance coverage is not as complete and because patients have been urged by employers and insurance companies not to visit physicians for minor problems. If the category of moderate office visits included fewer patients with minor problems in the United States, an adjustment for intensity would result in a slight increase in the ratio of the quantity of services per capita and a slight decrease in the ratio of resources to services.
With respect to procedures, the question of possible differences in the quality of care arises for other reasons. The technical competence of the specialists performing the procedures in the two countries is probably not an issue. A comparison of surgical mortality in Manitoba and New England concluded that the differences were small.45 Timeliness and convenience, however, may differ. Because on a per capita basis there are so many more procedure-oriented specialists in the United States than in Canada, it is likely that Americans with insurance find it easier to have procedures performed when and where they want. From the patient's perspective, this may offer an additional source of satisfaction with the service provided. Whether such differences exist, how large they are, and how they are valued by patients are subjects for further research. These issues are much more muted in the comparison between Iowa and Manitoba than in that between the United States and Canada, because there are so few physicians per capita in Iowa as compared with Manitoba.
This discussion points up the need for additional studies to determine the magnitude of the many factors affecting fees, use of services, and use of resources to produce those services. Further refinements in the ratios of physicians' fees and the prices of resources would be particularly valuable, given the central role of these ratios in the statistical analysis. Such studies and refinements, however, are not likely to alter the principal lesson of this paper: U.S. fees are more than double those of Canada, but physicians' net incomes are only about a third higher. The disparity is explained in part by much greater overhead expenses in the United States and in part by the lower workloads of American procedure-oriented physicians as compared with their Canadian counterparts.
Supported by grants from the Pew Charitable Trusts to the National Bureau of Economic Research and from the John M. Olin Foundation to Mr. Hahn.
We are indebted to Evelyn Shapiro for valuable advice on all aspects of health care in Canada; to Allan Detsky, M.D., Ph.D., Joseph Newhouse, Ph.D., Douglas Owens, M.D., David Redelmeier, M.D., and Noralou Roos, Ph.D., for helpful comments on specific points; and to the Health Insurance Association of America, Iowa Blue Cross and Blue Shield, Blue Shield of California, and several people in Canada for making data available to us on a confidential basis.
Source Information
From the Departments of Economics and Health Research and Policy, Stanford University; and the National Bureau of Economic Research, 204 Junipero Serra Blvd., Stanford, CA 94305, where reprint requests should be addressed to Dr. Fuchs.
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