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percentage as long as we have a well-functioning universal system and percentage as long as we have a well-functioning universal system and

they'll want to be in the universal system for a chunk of their time we know they'll want to be in the universal system for a chunk of their time we know

surgeons have some extra time we know there are surgeons in canada who can't surgeons have some extra time we know there are surgeons in canada who can't

get operating time because of operating time limitations we know we have get operating time because of operating time limitations we know we have

unemployed orthopedic surgeons in canada graduating out of medical school unemployed orthopedic surgeons in canada graduating out of medical school

finishing their their their practical work they're ready to be surgeons they finishing their their their practical work they're ready to be surgeons they

can't get a placement in a hospital surgical test we have these additional can't get a placement in a hospital surgical test we hav e these additional

resources let's make better use of the resources that are already idle in resources let's make better use of the resources that are already idle in

canada give patients a chance to access those resources in those physicians canada give patients a chance to access those resources in those physicians

additional time that's available and that physicians decide the right blend additional time that's available and that physicians decide the right blend

there are constructs we can put in to limit how much time goes into each there are constructs we can put in to limit how much time goes into each

system certainly a lot of countries have studied that but there's no reason to system certainly a lot of countries have studied that but there's no reason to

say physicians have to be in or out and certainly the international experience say physicians have to be in or out and certainly the international experience

is that if you allow physicians to practice is that if you allow physicians to practice

you'll get some great benefit as a result well i'm trying to think of how you'll get some great benefit as a result well i'm trying to think of how

that would work in practice in canada so what i'm hearing you say is that you'd that would work in practice in canada so what i'm hearing you say is that you'd

have say orthopedic surgeon that's a good example they might have their own have say orthopedic surgeon that's a good example they might have their own

surgical center their own private surgical center and they would do those surgical center their own private surgical center and they would do those

low acuity patients two or three days a week and then they'd have one day a week low acuity patients two or three days a week and then they'd have one day a week

whereas the more complicated patients that they do in the hospital and in both whereas the more complicated patients that they do in the hospital and in both

they'd see publicly funded patients and in both they'd see private insured they'd see publi cly funded patients and in both they'd see private insured

patients and they would just move back and forth seamlessly between the do too patients and they would just move back and forth seamlessly between the do too

but able to do more surgeries in a given week but able to do more surgeries in a given week

absolutely in fact to the canadian experience that surgeon may only have absolutely in fact to the canadian experience that surgeon may only have

one operating day a week in the public hospital so now they can operate every one operating day a week in the public hospital so now they can operate every

thursday maybe thursday friday maybe they have 12 hours what do they do thursday maybe thursday friday maybe they have 12 hours what do they do

outside of all those hours between their consults there may be more outside of all those hours between their consults there may be more

time they can access there's also the labor leisure trade-off the surgeon may time they can access there's also the labor leisure trade-off the surgeon may

be willing to do more surgical time than they currently do if that surgical time be willing to do more surgical time than they currently do if that surgical time

was better funded which might be possible in the private sector was better funded which might be possible in the private sector

none of these are necessarily certain in terms of cost but what we do know is none of these are necessarily certain in terms of cost but what we do know is

that we have medical resources that are idle in canada surgical resources let's that we have medical resources that are idle in canada surgical resources let's

put them to better use let's use the ors for longer hours even if that is put them to better use let's use the ors for longer hours even if that is

privately funded that doesn't change the number of public hours that are privately funded that doesn't change the number of public hours that a re

available but it does change the number of patients that are being treated in available but it does change the number of patients that are being treated in

canada let me ask you the same question asked about sweden was there an aha canada let me ask you the same question asked about sweden was there an aha

moment that we've got to do this thing differently or was there was there um moment that we've got to do this thing differently or was there was there um

just an incremental change that happened over time because that notion of if you just an incremental change that happened over time because that notion of if you

you are high enough income you've got to pay for yourself you are high enough income you've got to pay for yourself

i i've i've advocated that in the past but i i wonder how it gained political i i've i've advocated that in the past but ii wonder how it gained political

currency so that they were able to implement it can you shed some light on currency so that they were able to implement it can you shed some light on

that how do you make a big change like that i think as we look to australia and that how do you make a big change like that i think as we look to australia and

we look around the developed world what we see is is progressive change uh we look around the developed world what we see is is progressive change uh

activity-based funding started to be experiments within the early 1980s we've activity-based funding started to be experiments within the early 1980s we've

now come 30 years forward just about every developed nation has really moved now come 30 years forward just about every developed nation has really moved

into activity-based funding in a meaningful way canada being one of a into activity-based funding in a meaningful way canada being one of a

very small subset of laggards i think what has happened in canada is we've very small subset of laggards i think what has happened in canada is we've

we've really embraced this false dichotomy this false economy has really we've really embrace d this false dichotomy this false economy has really

taken hold of the public and there's a belief that in canada taken hold of the public and there's a belief that in canada

there's the canadian universal way which has its downsides it has its waiting there's the canadian universal way which has its downsides it has its waiting

lists and its people suffering as a result but at least everyone's covered lists and its people suffering as a result but at least everyone's covered

or there's the american non-universal way where apparently and there's not or there's the american non-universal way where apparently and there's not

necessarily any truth to this but apparently people die in hospital necessarily any truth to this but apparently people die in hospital

corridors and you have to swipe your credit card at the door of the ambulance corridors and you have to swipe your credit card at the door of the ambulance

and people low income people die uninsured which is not true it's and people low income people die uninsured which is not true it's

actually not the lowest income it's it's the gap between not quite low enough actually not the lowest income it's it's the gap between not quite low enough

income to be covered by the public system but not quite income to be covered by the public system but not quite

into the private scheme which is where a lot of the work has been done but this into the private scheme which is where a lot of the work has been done but this

misunderstood american system has been used misunderstood american system has been used

to scare canadians to embrace this government-managed system and certainly to scare canadians to embrace this government-managed system and certainly

there there have been political benefits to doing that there are some very there there have been political benefits to doing that there are some very

powerful voting blocks associated with the public system what we find around powerful voting blocks associated with the public system what we find around

the developed world those is countries are moving away from that model even the the developed world those is countries are moving away from that model even the

uk years and years ago started moving away from the system that we embraced in uk years and years ago started moving away from the system that we embraced in

the 1960s they started moving towards activity-based funding to choice for the 1960s they started moving towards activity-based funding to choice for

hospital care they've always had a private parallel healthcare system in hospital care they've always had a private parallel healthcare system in

the united kingdom they just haven't necessarily had some of the other the united kingdom they just haven't necessarily had some of the other

constructs and so it's just a progressive change constructs and so it's just a progressive change

over time as countries look to one another and say well hang on a second over time as countries look to one another and say well hang on a second

that's really working over in sweden they've embraced activity-based funding that's really working over in sweden they've embraced activity-based funding

they're getting eleven percent more care for one percent less money if we look they're getting eleven percent more care for one percent less money if we look

problems to province the differential and cost efficiencies about 13 problems to province the differential and cost efficiencies about 13

between activity-based funding and global budgets maybe this is something between activity-based funding and global budgets maybe this is something

we should do over here whereas in canada we seem to look over there go that's a we should do over here whereas in canada we seem to look over there go that's a

great idea let's do a little study over here but let's not be the american great idea let's do a little study over here but let's not be the american

system let's not change and that has really been to the system let's not change and that has really been to the

detriment of patients and taxpayers there's one last jurisdiction i want you detriment of patients and taxpayers there's one last jurisdiction i want you

to get into and when we were talking about which ones we talked about we said to get into and when we were talking about which ones we talked about we said

switzerland because i i liked the structure of switzerland and you switzerland because ii liked the structure of switzerland and you

described it let's look at switzerland as a stretch goal because they do things described it let's look at switzerland as a stretch goal because they do things

quite a bit differently than we do here but in some ways uh in an optimal way in quite a bit differently than we do here but in some ways uh in an optimal way in

a lot of ways in an optimal way because it operates in my view a little bit more a lot of ways in an optimal way because it operates in my view a little bit more

like the traditional kind of insurances that we're used to for our homes or for like the traditional kind of insurances that we're used to for our homes or for

our cars and i think because it's a traditional insurance is structured that our cars and i think because it's a traditional insurance is structured that

way there must be some good reasons for it we haven't really talked much about way there must be some good reasons for it we haven't really talked much about

co-payments but perhaps we will when we when we understand a little bit more co-payments but perhaps we will when we when we understand a little bit more

about how sweden up our switzerland operates now i i do you've made the case about how sweden up our switzerland operates now ii do you've made the case

very well about activity-based funding being central i think you've made the very well about activity-based funding being central i think you've made the

case very well as well about the need to have a mix of delivery models public case very well as well about the need to have a mix of delivery models public

private non-profit and so we haven't talked as much about this private non-profit and so we haven't talked as much about this

issue of co-payments why is it that putting some of your own skin in the issue of co-payments why is it that putting some of your own skin in the

game some of your own money on the line what what does that prompt in changing game some of your own money on the line what what does that prompt in changing

the way the system operates what happens what's the psychology there i i think it the way the system operates what happens what's the psychology there ii think it

really comes down to how encouraging patients to make a more really comes down to how encouraging patients to make a more

informed decision about when and where it's best to access the healthcare informed decision about when and where it's best to access the healthcare

system as a patient in canada in the canadian province i can go to the system as a patient in canada in the canadian province i can go to the

emergency room i can go to my my general practitioner if i had a referral within emergency room i can go to my my general practitioner if i had a referral within

six months i could get out to my specialist to me as an individual six months i could get out to my specialist to me as an individual

there's no cost difference between the three to the taxpayer there's a there's no cost difference between the three to the taxpayer there's a

meaningful difference between the three i even go to my pharmacist again another meaningful difference between the three i even go to my pharmacist again another

meaningful difference but it doesn't matter where i go i pay meaningful difference but it doesn't matter where i go i pay

the same amount as a canadian i pay nothing the taxpayer covers the entire the same amount as a canadian i pay nothing the taxpayer covers the entire

bill for me when we go to a country like switzerland where we have a deductible bill f or me when we go to a country like switzerland where we have a deductible

and that deductible is entirely funded by the patient up until a certain amount and that deductible is entirely funded by the patient up until a certain amount

is met after that there's a copay to a second amount now as an individual i'm is met after that there's a copay to a second amount now as an individual i'm

acutely aware of how much that emergency room might cost me relative to a general acutely aware of how much that emergency room might cost me relative to a general

practitioner i could go directly to the specialist if i'm absolutely convinced i practitioner i could go directly to the specialist if i'm absolutely convinced i

need to see my heart surgeon and i know he's more expensive than the gp but less need to see my heart surgeon and i know he's more expensive than the gp but less

than the hospital i'm just going to go directly there but i'll be paying for it than the hospital i'm just going to go directly there but i'll be paying for it

so i can make that decision about whether it makes sense for me to go so i can make that decision about whether it makes sense for me to go

direct go to my gp get the referral because it's my money now direct go to my gp get the referral because it's my money now

and i'm spending it as an individual again trading off a dinner out a and i'm spending it as an individual again trading off a dinner out a

starbucks versus healthcare never trading off shelter or food versus starbucks versus healthcare never trading off shelter or food versus

health care that's where the protections have to be in place and when health care that's where the protections have to be in place and when

catastrophic events occur again limiting the amount that is out of pocket because catastrophic events occur again limiting the amount that is out of pocket because

that's where insurance comes into play but it's about encouraging people to that's where insuranc e comes into play but it's about encouraging people to

think about the varying costs of different areas of healthcare nurse think about the varying costs of different areas of healthcare nurse

practitioners pharmacist practitioners who should i be seeing for my particular practitioners pharmacist practitioners who should i be seeing for my particular

healthcare condition switzerland is very interesting in that it actually allows healthcare condition switzerland is very interesting in that it actually allows

people to tailor their co-pay within the universal construct people to tailor their co-pay within the universal construct

if we think from the canadian perspective we are we are locked in this if we think from the canadian perspective we are we are locked in this

old this old and now long left behind healthcare model where government is old this old and now long left behind healthcare model where government is

monopolistic where government provides all the healthcare services we learn monopolistic where government provides all the healthcare services we learn

okay base pretty much everyone in europe is has long ago abandoned or is moving okay base pretty much everyone in europe is has long ago abandoned or is moving

rapidly away from this sweden is maybe the first step we move into some private rapidly away from this sweden is maybe the first step we move into some private

provision of services not a lot we have activity-based funding we have some cost provision of services not a lot we have activity-based funding we have some cost

sharing we have a parallel system australia is the next step we have a sharing we have a parallel system australia is the next step we have a

little more cost sharing we have inducements to go in the private system little more cost sharing we have inducements to go in the private system

switzerland now it's private insurance within the universe so as a swiss switzerland now it's private insurance within th e universe so as a swiss

individual you go out into the marketplace and you purchase your individual you go out into the marketplace and you purchase your

healthcare insurance policy from one of the universal insurers healthcare insurance policy from one of the universal insurers

universal insurers are not allowed to risk rate they can only rate based on universal insurers are not allowed to risk rate they can only rate based on

the area you live in and there are only three premium variations allowed within the area you live in and there are only three premium variations allowed within

an area and they must take all comers there is a standard program which has a an area and they must take all comers there is a standard program which has a

standard deductible and a standard copay after deductible but you can increase standard deductible and a standard copay after deductible but you can increase

that if you want and reduce your insurance premium if you're willing that if you want and reduce your insurance premium if you're willing

individual to take on greater risk you can also go into managed care programs individual to take on greater risk you can also go into managed care programs

which vary the deductible construct and limit your choice provider to bring your which vary the deductible construct and limit your choice provider to bring your

premium down as an insured individual now you have premium down as an insured individual now you have

your private insurance you go to the health care provider either covered by your private insurance you go to the health care provider either covered by

your insurance or provider of your choice depending on your policy you take your insurance or provider of your choice depending on your policy you take

your standard rate card with you the provider gets paid the standard rate your standard rate card with you the provider gets paid the standard rate

card takes the standard amount for deductible and you can choose between card takes the standard amoun t for deductible and you can choose between

the private or the public hospital for profit of the non-profit it's entirely the private or the public hospital for profit of the non-profit it's entirely

up to you as an individual if you're not comfortable with the private for-profit up to you as an individual if you're not comfortable with the private for-profit

hospital not a problem go to the increase in the uncommon government hospital not a problem go to the increase in the uncommon government

hospital but they're out there or go to the private hospital you get to select hospital but they're out there or go to the private hospital you get to select

and everyone in that system is very focused on the patient because the and everyone in that system is very focused on the patient because the

money's always following the patient through the health care system and what money's always following the patient through the health care system and what

happens in a universal construct i'm an individual i can't afford my insurance happens in a universal construct i'm an individual i can't afford my insurance

that's okay the government will provide me a transfer for the cost of my that's okay the government will provide me a transfer for the cost of my

insurance to go and seek it in the marketplace so even the low-income insurance to go and seek it in the marketplace so even the low-income