Saturday, August 18, 2007

The Odds? 13 Million-to-1, but Somewhat Higher in Canada

The quadruplet sisters, Autumn, Brooke, Calissa and Dahlia, born to Mr. and Mrs. J. P. Jepp began life with the odds stacked heavily against them. First, successful delivery of naturally conceived identical quadruplets occurs only once every 13 million births. According to Dr. Jamie Grifo of the NYU Fertility Center in New York, there are only 50 living sets of such twins in the entire world.

More daunting, the Jepps are Canadians.

That Karen and J. P. Jepp lived with their 2 year old
son Simon in Calgary, Alberta presented a potentially life-threatening challenge Friday night when Mrs. Jepp began labor. For months, the couple had planned their high-risk delivery—all multiple births are by definition high risk—with the medical team at Calgary's Foothills Hospital. Unfortunately, when the time for delivery arrived, dictated by intrauterine stress affecting one of the babies in the 31st week of pregnancy, there was no room at the hospital for the Jepp family.

Foothills Medical Centre is one of 12 hospitals run by Calgary Health Region, the Canadian governmental agency responsible for medical care to the 1.2 million residents of southern Alberta, including Canada's third largest city. It employs a staff of 23,000 with an annual budget of more than $2.3 billion and in an average year delivers 15,000 babies.

But like all such agencies in Canada, Foothills Medical Centre manages health care costs by managing health care access and on that Friday night in August, there was to be no room for Mrs. Jepp and her soon-to-be four daughters. Foothills' Neonatal Intensive Care Unit was full up.

Not to worry. Under the Canadian system of managed care, described by several American politicians as the very finest such system in the world, such things happen frequently enough that there are protocols for emergencies like this. The medical team at Foothills reached out to the other hospitals with NICUs spread out across Canada, only to find that "no other Canadian NICU had space for the Jepp's four babies. There wasn't space anywhere in Canada," population 32 million, "so we had to turn to our friends in Montana," according to Lynda Phelan of Calgary Health Region.

Specifically, Great Falls, Montana, with a population a hair over 56, 000 and home to Benefis HealthCare Center, a relatively small religiously-oriented community hospital, a hospital either (able) or (forced) to compete for consumers' health care dollars within the American system.

Calgary Health Regional chartered the medevac flight from Calgary, Canada's third largest city, to Great Falls, the 356th largest in the U. S., a 40 minute trip. Calgary Health will pay the Jepp's hospital and doctors' bills during their stay in Great Falls. It also paid for the two charter flights back home when the babies could travel and after the Calgary hospital created room for them. The three flights alone will run about $45,000.

According to Toronto's The Globe and Mail

Ms. Jepp's case highlights the increasing tendency for Canadian women with high-risk pregnancies to be sent to the United States to give birth, a development some attribute to an increase in the number of premature births, a nursing shortage and a stretched health-care system.

With no beds available in their home province or nearby, expectant mothers going into labour before 32 weeks gestation (when babies need the highest level of neonatal intensive care) are often sent by air ambulance to hospitals in Washington, Montana, Michigan and New York.
So far this year, Calgary has evacuated five delivering mothers to Great Falls, a city one-twentieth its size.

Canadians today say what many only thought privately in earlier years: The Canadian single-payer medical system is terrific as long as one is in a position to use the emergency backup system, if necessary.

Where will Americans turn for backup when our system becomes Canadian?

RELATED LINK: Mr. Jepp is an analytic sort who estimates the family will need 14,600 diapers the first year. For more on the Jepps, go to The Jepp Family.

You might also appreciate Don Surber's pointed analysis at No Room at the Inn, where he observes "After all, they didn’t fly Mrs. Jepp to Cuba, did they?"


S said...

It looks like we have a illegal immigration problem here as well. These kids that are born to Canadian mothers who come to the US because of inadequate hospital facilities in Canada automatically become US citizens. These become "anchor babies." I don't think this is right. Just because we try to help people out, they should not thereby automatically acquire US citizenship. Something is wrong here.

Bob Leibowitz said...

Not to fear. Being Canadians, they'll only come down for winter vacations and medical care.

Seriously, the Canadians truly are our closest allies, in more ways than one. Having a few of them hanging around would not impose a strain.

I do wonder if Benefis charged Calgary Health full retail for the backup services?

Darren said...

1. Calgary is not Canada's third largest city. (Vancouver is much larger, as are Toronto/Montreal). It might be fourth.

2. I'm not sure why you portray Canada's system as a cheap, cost-cutting system. Calgary Health Authority paid retail price, in full, for the stay in Montana... with flights the full bill came to about $190k US according to CBC.

3. Yeah, we use you for backup... so what? The US has one-third greater per capita GDP than Canada IIRC, and spends TWICE per capita on health care as Canada does (adding public and private expenditure together). If you want to insure every citizen as we do AND keep four empty neo natal care beds free at all times in every one-horse town in the lower 48, I'm sure you can manage it.

(btw, beware selection bias... obviously Great Falls had four free beds because that's where they were sent... is it *routine* for such a small town anywhere in the US to have that many beds free? I bet it ain't.)

Bob Leibowitz said...

Darren -- Thanks for the comments. My replies:

1. According to the 2006 census posted by Statistics Canada, Toronto has 2,503,281, Montreal has 1,620,693 and Calgary has 988,193. Vancouver ranks 8th at 578,041.

2. Canada's system is "a cheap, cost-cutting system." Those are it's positive points. It's certainly not its sophisticated technology, innovative treatments or miraculous drugs that makes the Canadian system newsworthy.

Canada controls costs by rationing access. The U. S. controls access by rationing costs. In one system, you wait, in the other, you pay. Fair enough.

The bigger problem with the Canadian system is that it under-invests in medical care resources, shortchanging the future, because it has the U. S. system to fall back upon, and then brags about its greater financial prowess. No magic to it. That's called "a free ride."

On the economics, the Jepp deal was fair all the way around: The U. S. had excess capacity, as it generally does, and the Canadian system paid, hopefully retail. Again, fair enough.

3. My exact point. Canada does use the U. S. for backup. If the U. S. were to adopt the Canadian system (Hillarycare, as it is known down here), where would Canadians go for backup? How does Cuba appeal?

Actually, yes, many "one-horse" towns in the U. S. would and did have 4 NICU beds available that night. The Jepps and their doctors had a number of choices available to them in the U.S.

The U. S. system has extra capacity baked into it, whether it's hospital beds, prescription drugs, MRIs or other sophisticated technologies, or doctors. That's what we—and you!—get for our money that pays the investment tab.

Finally, interestingly enough, nearly all of the critical press on the Jepp's case was Canadian. None of the U. S. press made any critical comments. Zero-tier health care is an absolutely chilling article, written by a Canadian, that I didn't link to in the post, but should have. You might consider it.

We're delighted to be of service, just please don't try to make the comparison of the two systems anything other than what it is.

Darren said...

Bob, your error re: the relative sizes of Calgary/Vancouver is understandable... obviously Calgary and Vancouver are using a differernt criteria for definition of their metropolitan areas. I'm FROM Vancouver and I've lived in Calgary, the population of the GVRD (City plus burbs.. which are quite compact as there it is surrounded by mtns with no room for sprawl) is around 2m. The 988k figure for Calgary is for the whole thing (there are no 'burbs', it's all City of Calgary). Vancouver is a much larger city than Calgary. No matter, it's not an important point.

You are assuming that
1. If the United States adopted elements of a Canadian style system, its spare capacity would disappear. Why assume this? The US spends 2x per capita what Canada does. Simply spend that 2x under a socialized medicine umbrella, fire all your hospital lawyers and insurance adjusters, and have the same spare capacity that you have now (plus no uninsured people).
2. If the United States did not have any spare capacity, Canada would be incapable of building any of its own. I think you are greatly overstating the net benefit that the Canadian medical system derives from being next to the US. Yes, you have extra capacity, but the private tier of health care in the US poaches enough doctors and nurses from Canada to make staffing an ongoing problem.
3. You say that I should not make the comparison of the two systems anything other than what it is. Oh really? What is it? Because according to this report,

neonatal outcomes (ie infant mortality) are WORSE in the US than Canada. Yes, worse! Highly profitable intensive care is well-provisioned, but the basics of prenatal care, less so.

I think there are elements of the Canadian system that could be improved (we're unique in not permitting private provision of services which is dumb), but to suggest that it is undesirable to fix the American system is completely laughable.

Bob Leibowitz said...

Darren -- Thank you for your comments.

Statistics Canada, which is the federal agency tasked with such things, did the population ranking. You can find it here:

1. Every single system or subsystem than has ever adopted socialism directed by politicians has ended up more concerned by costs than outputs. Every single such medical care system existent today controls its costs by rationing its availability. There are no exceptions. To assume that the U. S. would eat of the same fruit with a different outcome requires faith appropriate for churches not politics. Even those politicians who have embraced the Canadian system for adoption in the U. S., every single one of them, has done so with a goal of "controlling costs." I'm a big believer in taking the attorneys out, and taking the bureaucracies out of medical care, but to adopt the Canadian system inserts both more deeply, just not as apparently. (Who else to write the manuals and make the decisions that control the costs?)

2. Canada is completely capable of building anything it can imagine and is willing to work for.

Canada enjoys a tremendous health benefit by being a good friend and good neighbor, just compare the list of the last five fantastic drugs developed in each country and available to each country. I find neither fault nor problem with that, Americans enjoy reciprocal benefits in other fields from our friendship.

Differences in infant mortality rates between the countries is a function of race, not economics. When you normalize the races (almost any which way you want) American mortality at all levels compares favorably. That issue, however is better left for another day.

Look, there's really nothing wrong with being proud of a "cheap, cost-cutting system." Nowhere in my article do I disparage Canadian doctors, nurse, ambulance drivers, surgeons or others in comparison to the American team. They're good.

My over-arching point is that the U. S. system provides an availability for the Jepps and similarly situated folks that the Canadian doesn't.

Anonymous said...

To be both a speaker of words and a doer of deeds.

The Australian National University

Anonymous said...

It's great to be great , but it's greater to be human.