COST-EFFECTIVE PROVISION OF CARDIAC SERVICES IN A FIXED-DOLLAR ENVIRONMENT

In the Canadian single-payer system, all hospital payments, including payments for cardiac operations, are negotiated with the government an nually. Each hospital is required to remain within 50 cases of its neg otiated surgical target. Physicians are paid on a capitated basis and are subject to penalties if negotiated targets are exceeded. There is a computerized waiting list for cardiac operation, with patients class ified by an urgency rating scale and objectives set for the maximum pe riod for any given urgency category. Experience has shown that many pa tients are delayed in the queue, waiting longer than expected for surg ical procedures. Waiting times are not influenced by age, sex, or reop erative status, but are influenced by factors such as the presence of multiple risk factors, the number of diseased vessels, stability or un stability of angina, left main coronary artery disease, and recent ang ioplasty. Waiting time has not been shown to affect operative mortalit y, the incidence of postoperative low-output syndrome, or length of ho spital stay. Canada's 30-year experience with the provision of cardiac services under managed care may provide useful information to hospita ls and physicians in the United States currently confronting capitatio n. The following overview focuses on two critical issues: negotiation of costs and management of patient waiting lists.