CARDIAC-SURGERY IN A FIXED-REIMBURSEMENT ENVIRONMENT

Hospital and physician services in Canada are funded by public (govern ment) sources. This article will describe the practice of cardiac surg ery in this setting. Federal legislation has prescribed the principles of accessibility, universality, comprehensiveness, portability, and p ublic administration for essential healthcare services in Canada. Prov incial and territorial governments are responsible for the provision o f services, receiving federal tax and cash transfers that supplement p rovincial/territorial funds for hospital, physician, and community hea lth services. Hospitals negotiate annually for global budgets. Physici ans work as independent contractors in hospitals (and communities) and are usually paid as specified by fee-for-service contracts negotiated at intervals with governments. Cardiac surgical services have been pl anned conjointly with government. Forty-two centers in Canada serve a population of 28 million. All but three of these centers are located i n tertiary teaching hospitals; all but one do more than 200 pumps annu ally. The rate of cardiac operations is 80 per 100,000 population. In Ontario, the Provincial Adult Cardiac Care Network makes recommendatio ns to governments about the distribution of the 7,600 pumps annually ( population, 11 million), rationalizing waiting lists based on an urgen cy rating scale. Patients requiring emergent/urgent operations are wel l served. The average waiting time for an elective cardiac operation i s 10.5 weeks. The waiting list mortality is less than 0.5%. The Provin cial Adult Cardiac Care Network also determines the placement of new p rograms and participates in creating hospital funding formulas develop ed from a combination of resource and acuity intensity weighting. Most surgeons hold full-time academic appointments but are funded largely by practice income. Surgical fees average $2,000 (Canada) per case. Ov erhead, including malpractice insurance, is approximately 45%. All Can adian patients enjoy reasonably timely access to good cardiac surgical care. Further constraints on physician compensation and (academic) ho spital funding will compromise this balance.