Elizabeth Sandomeer needed a new left knee. 

After enduring months of pain, she went to the orthopedic surgeon who had replaced her right knee a year earlier.

“He said, ‘Oh yes, you need to have that one done, too. So when do you want it?'” she told Dr. Brian Goldman, host of CBC’s White Coat, Black Art, at her home in Hamburg, Germany. 

Within two months, the transplanted Canadian saw the surgeon and had the second knee replaced.

The wait time in Germany for a new knee is anywhere from four weeks to a few months — a surgery timeline that’s unheard of for many Canadians. Depending on the province, patients can wait months to years for the surgery, one of the most frequently done operations in Canada. 

Staff shortages, limited operating room time, greater demand from aging boomers and an increase in trauma cases are some of the reasons behind the long waits for hip and knee replacement surgeries for many Canadian patients. 

Germany is one of the top countries for both hip and knee replacement surgeries, outpacing countries like Canada in both the number of surgeries performed and wait times.

“Certainly if you want to compare yourself to Germany, our ability to deliver care to patients is really poor,” said Dr. Pierre Guy, an orthopedic surgeon in Vancouver.

But Guy and other surgeons say there are elements from the German model that Canada could learn from, including incorporating more competition into funding models, increasing the number of orthopedic surgeons and making better use of operating room (OR) time.

Innovation is needed to get more out of the provincial health-care budgets, said Dr. Paul Beaulé, an orthopedic surgeon in Ottawa and second president-elect of the Canadian Orthopaedic Association. 

“We can’t be doing the same thing and expect a different outcome,” he said.

Importance of competition 

Orthopedic surgeons and researchers say Germany’s funding model is a major reason why the country performs more hip and knee replacements.

The German model for hospitals is largely centred around activity-based funding tied to what is known as diagnosis-related groups: the more patients treated, the more money a hospital can earn.

“That’s why every case counts, and we hope to get as many cases throughout the week to get as many patients as possible,” said Dr. Sebastian Braun, an orthopedic surgeon at Charité – Universitätsmedizin Berlin.

He says the funding model largely creates competition among hospitals for patients. Without those dollars, hospitals can and have gone bankrupt.

Orthopedic surgeons hear it, too, if there aren’t enough surgeries being done. 

“There’s a lot of talk of cutting costs, and maybe even employment is a factor. So we have to cut some staff, but usually that doesn’t happen in our place,” Braun said.

When researchers looked at how hip replacements are done in Germany, Canada and five other high-income countries, they found that activity-based funding gets patients to surgery sooner, because volume matters.

“When we look at Germany specifically, I think this really shows us that the way we pay, and changing payment, can influence volume,” said Irene Papanicolas, a professor of health services, policy and practice at Brown University in Providence, R.I.. She was also one of the researchers on this study.

In Canada, provincial or territorial governments largely provide a set amount of dollars to hospitals, often called a global budget. Critics have said this form of funding means that each patient is drawing from the budget. 

“We’re really not competing here; we’re rationing,” said Guy. “A little competition would be good.”

Germany spends more on health per capita than Canada. It also has roughly double the population of Canada. 

Braun, who did a fellowship in London, Ont., says competition for health-care dollars doesn’t exist on the same level in Canada.

“That’s probably the bad thing about the single-payer system in Canada. There’s no incentive to do more surgeries.” 

Maintaining Germany’s level of hospital care is costly, however. Germany is currently revamping its funding model to be a hybrid system that includes both activity-based funding and set amounts for delivering services.

“This is really a moment of reflection that cuts across all OECD countries: How do we want to balance out these different incentives and what is the optimal mixture?” said Ricarda Milstein, a German health policy analyst with the Organisation for Economic Co-operation and Development (OECD), based in Paris.

More surgeons, more OR time

Germany has almost four times the number of orthopedic surgeons per 100,000 compared to Canada, says Guy.

Braun says surgeons also have access to operating rooms for more hours during the day and more beds in the large hospital where he works compared to what he experienced in Canada.

“In this hospital I was at, there were four ORs for orthopedic surgeries and only 30 beds on the ward. Now, here at this place, we do have four to five ORs, but 90 beds.”

The most recent data, from 2023, shows that Canada had 2.5 hospital beds per 1,000 people. That’s lower than the 7.7 beds per 1,000 people found in Germany and lower than the 4.2 beds OECD average.

Guy says in Canada, the answer won’t be to just employ more orthopedic surgeons.

“Certainly having more surgeons is going to be important, but having capacity — either by identifying better ways to fund, or creating more space, more beds — will make it efficient,” he said.

Contact the surgeon directly

In Germany, patients like Elizabeth Sandomeer can make an appointment with an orthopedic surgeon directly and get multiple opinions from surgeons.  

For Canadians in pain, they often need to see a family physician or nurse practitioner for a referral to either an orthopedic surgeon or a central intake clinic. That process can take months to years, depending on the province.

Papanicolas and colleagues noted in their research that Canada was the only country out of the seven reviewed to use a centralized system to access an orthopedic surgeon. 

“I do think that’s the concern — that a strict gatekeeping system … introduces more of a delay to being able to get into the system,” said Papanicolas.

Beaulé at the Canadian Orthopaedic Association says from a patient perspective, Canada’s centralized system can sometimes be a barrier.

“For patients, not being able to access the surgeon directly is a problem. But … that also would open the valve, because then that would put pressure for the surgery to occur,” he said.

Improvements needed

Guy and Beaulé agree that there are short-term fixes and long-term health-care system overhauls needed to get patients to surgery within that six-month benchmark.

Finding better ways to use operating room time — like extending it into evenings or weekends — is a start, says Guy. He points to the work of staff at Sunnybrook Hospital’s Holland Centre in Toronto, which has used ORs on weekends. 

“They still have thousands and thousands of people waiting, but at least mechanisms have been put in place to create capacity,” Guy said.

Beaulé says innovation and a willingness to try new models of care is going to be essential.

“I think right now to have … some freedom to innovate, to think outside the box, is very important.”