Dr. Merrilee Fullerton on Healthcare

Since Federal Finance Minister Jim Flaherty announced new funding for the provinces with no strings attached, there has been a brouhaha from the provinces and from the "do-gooder-know-it-all-morally-superior-super-sanctimoneous" types. In today's Globe and Mail, Ms. Gagnon has an excellent piece on Mr. Romanow getting things wrong...and I agree.

I have no doubt that Mr. Romanow is a great guy and that he cares deeply about Canada and Canadians and their well-being particularly when it comes to health care. The reality, however, is that the health care climate is rapidly changing.

I don't have a docudrama of a health care iceberg falling into the ocean to convince people that there is change going on like Al Gore...but I can tell you that the volume of services that is going to be required in the coming decades cannot be provided  in the context of a single payer system, not with a relatively shrinking tax payer base and growing numbers of elderly and scientific advancements. I won't go on because you've heard most of this from me already but it is important to give a different perspective from all the cheer leaders who are feeding at the trough.

It shocks me that "leadership" is so self-interested that it cannot see what is coming.

As for the whining of the provinces when they are handed a "no strings attached, huge sum of federal money" for health care I say: Get over yourselves and get a grip on reality.

I am disgusted with the short term vision and self-interest displayed by the majority of our provincial leaders..Brad Wall aside. For the most part they seem to think that Federal dollars are some sort of magic money pot whose offerings spring eternal.

Feds are in debt. Provinces are in debt. Individuals are in debt. The money all comes from us-the people.

It is going to take a concerted effort for all levels of government and leadership to be more honest about the practical solutons that are needed. I know I am asking for something that won't come easily. The public does not feel the pain yet but it is coming. And where will the Premiers be? Answer: Consulting and leaving the problems they have failed to deal with to another administration. Tsk. Tsk.

I will post the link to Ms Gagnon's article as well as to the article by Adam Radwanski. They are both worth keeping at hand.

Once again, thanks for your support and excellent posts...there is hope.

Some posts ago one of you asked for a blog entry on solutions. By now, many of you know my position on honesty, personal responsibility and coming to terms with new realities, however difficult that may be.

First, let me say that it is not the easy solutions we should be looking for. We've done that for far too long. We've heard that prevention is going to lead to more sustainability and more team work is going to lead to more efficiency and now we are on the "quality" and "value for money" agenda. We've tried the efficiency route for many years as well, about twenty-five, but that seems elusive too.

The difficulty with these solutions is that they are rigid solutions and do not take into consideration the ever changing environment that our health care system survives in. We need a more flexible system. What we are currently creating is a more rigid system with ever increasing bureaucracies for ehealth, for quality, for prevention and chronic disease managment and wait time monitoring. This approach may make us feel like we are doing something substantial but it is  leading us in the wrong direction.

Don't get me wrong..I believe in prevention for individual quality of life. I believe in accountability and quality measures for patient care. Patients deserve the highest quality of care our country can afford.

Key words: "can afford"

Yes, dollars and cents. That's what it comes down to. Compassion helps but it does not pay for health care. Goodwill helps and kindness too...but they don't pay for health care.

Health care expectations are growing. The more tax dollars that are shovelled into health care, the greater the expectation of the public that it can continue this way. I'm here to say that it can't. That's the first step to finding flexible solutions that will allow our health care system to adapt to ongoing changes in science, technology, demographics, pharmaceuticals and ever changing political environments.

Health care is not static. Rather than creating ever increasing bureaucracies to measure, monitor and quantify, we need to be moving to a system that engages patients in their own care and that allows for reasonable expecations of a system based on tax dollars.

We should be allowing the evolution of care and systems that permit patient input--both perpective and monetary. A greater tolerance is needed in health care so that there is less polarization, less politicization and less impersonalization.

Below is my suggestion for a Ten Step List to Health Care Flexibility:

1. Canadian politicians of all stripes must show less posturing and more honesty. "Unlikely", you say? Economic crises have a way of bringing more honesty and more collaborative effort to the foreground. Don't be surprised that as the economic and demographic situation in Canada becomes more difficult, honesty will need to be embraced by politicians. Right now it is more about who can promise the voters the most and then not deliver. Eventually that has a way of catching up to government, and that's us...the taxpayers.

2. "Medically necessary" must be defined. The public health care system should continue to be universal with comprehensive care for medically necessary care. However, private options can also be made available. Take for example the lack of jobs for orthopedic graduates in Ontario and the OR closures to contain hospital budgets while thousands of patients wait on lists.  There is no reason why Ontario should lose the orthopedic surgeons that it trained while ORs are closed for budgetary reasons and patients wait for care. This can be done without destroying the public health care system.

3. Allow private contributions and funding arrangments. Canada already has an element of private coverage for pharmaceuticals but in an era where stereotactic surgery, PET scans, stem cell treatments, organ transplantation, personalized pharmacogenomics and nanotechnology exist, new mechanisms of funding must be found.

4. Politics and health care must be uncoupled. Public payment for medical care has a way of creating a dependency by patients on a system that cannot provide for all the wants and needs of the population yet politicians are reluctant to suggest that the current system cannot achieve universal coverage in a timely way for all of the care promised. In fact, it is the patients at the edges who may be the most vulnerable that politicians ignore in their quest to satisfy the majority. This is wrong.

5. Foster more individual responsibility through the use of mhealth..mobile health using smart phones...rather than building a black hole of ehealth. By creating more patient independence through Self-Care, less dependence on the the public system is possible to achieve.

6. Develop programs that boost Health Literacy. Without Health Literacy it will not be possible to build more Self-Care into the system.

7. Consider how the Dependency Ratio will affect our ability to fund teams and to find the human resources for these teams. Expanding the number of health providers to deliver care at a time when skilled labour shortages are just beginning is not sensible because the tax dollars available to fund multiple layers of providers may not exist in 10 years..and it takes 10 years to make change in health care. Whatever we start to change now, may not be completed for another decade at which point it will be too late to change course.

8. Address the Social Determinants of Health by improving education, providing more affordable housing and more job opportunities. No matter how much health care is delivered, without more thoroughly addressing the SDOHs, the health care system will fail more and more people.

9. Accept that achieving greater efficiencies will NOT offset the growing demand for care or the inability to fund all of the expectations. For every efficiency found, it seems there are two new more expensive developments in care provision. Instead, focus on FLEXIBILITY of the system.

10. Explore opportunities for the corporate world to become more involved in public health care infrastructure whether it is in collaborative efforts in building public hospitals through expanded private/public partnerships or through philanthropy.  As the corporate world moves toward a greater involvement in social responsibility, there is potential for many groups beyond government to be able to foster improved health care opportunities for many citizens.

Overall, many solutions are required. Our universal health care system CAN exist with a greater role from other funding mechanisms. It is time we got our collective heads around this and move forward in finding FLEXIBILITY.

As always, I am grateful for your continued support and I look forward to ongoing and necessary change in health care. Nothing stays the same forever.

Cheers to a Happy Holiday Season and Merry Christmas!

******************************

Added by ELB:

11. Improving end-of-life care including palliative care.

I could not help but notice the stark difference between the TStar article November 11, 2011 by Michael Rachlis and the Ottawa Citizen article from November 17 in which Don Drummond is quoted. Putting the two pieces side by side makes one wonder whom to believe. To say they differ a little would be an understatement. They are staggeringly opposed. Who to trust? Hmmm.

___________________

Rachlis: "Health care costs are not out of control."

Drummond: "..things will only get worse as healthcare eats up every other public service like an insatiable Pac Man."

While Rachlis treats CIHI as some kind of health care god at least Drummond has a bigger picture vision. Rachlis is looking back at data from CIHI that does not reflect what the future is likely to look like.

___________________

Rachlis:  "the CIHI graph of provincial health-care spending over time draws a very different picture from that portrayed in our public debate. Health spending was fairly stable at 33 per cent of program spending during the early and mid-1990s. After 1997, it rose rapidly to 39 per cent of program spending in 2003 before plateauing there until 2008. It has been falling ever since."

Drummond: "There is no way you could ever run a civic society in which 80 per cent of your budget goes to one thing. And people probably want a few police officers and a few parks...Eventually someone would break that growth or pile on the tax increases."

What is shocking about the comment made by Rachlis is that he does not seem to appreciate that the ebb and flow of the health care spending has much to do with policial decisions. Whether spending goes up or down does not mean that the population need has been met. It just means that the economic situation of the time and the politically related decisions allowed for a certain amount of spending. Rachlis's conclusion seems to be that health care spending by governments exactly matches the need of the population. That simply isn't true.

Drummond's comment regarding the "80%" reflects something that is "far-fetched" by his own admission but his concerns about rising health care costs are real...and he is right to be concerned.

_________________________

Rachlis: "we should be spending more public money if it remedies private market failure."

How he comes up with the concept of private market failure in Canadian health care I don't know. It seems to me that most things in the private market are readily available-including the vast majority of pharmaceuticals. Anyone noticed a shortage of complementary/alternative treatments? Nope.

Drummond: "Drummond points to an array of problems in the current system, which, despite being among the most expensive in the world, is also ranked at or near the bottom when compared to those in similar countries around the world."

_________________________

I could go on.

If leadership fails to understand what is coming, fails to envision the bigger picture, then we will be left with no Plan B. Following Rachlis's advice, government would simply keep money dumping in attempt to create "a high-performing, patient-friendly system." 

Although I'm disappointed that Drummond is off the mark in a few areas, overall he is filling a much needed void in the health care discussion. If the media and air waves maintain their tunnel vision then we are headed for a stark reality check and may be hearing the loud sucking sound of an economy being vacuumed up by unrealistic expectation and entitlement.

As always, thanks to all of you for your ongoing support and contributions. There is much to be hopeful about if we could just open our eyes.

Learn from yesterday. Live for today. Hope for tomorrow-Anonymous

When heavily travelled highways merge it makes navigating challenging. It is even worse if the territory is unknown to you and the signage is missing. This is exactly what we face as we enter the next several decades.

A growing elderly demographic like no other known to our society, an expanding maze of health and bio technology, and a younger generation with relatively smaller numbers but raised witnessing entitlements of its parents are about to merge with almost no traffic signs-and many people are standing around suggesting this is not a problem.

We've seen this coming for decades and little  has been done to avert the crash. Why? Politics runs on short cycles without concern for the long term and academia generally does not want to bite the hand that feeds it.

Beyond these two contributing factors is a generation that seeks to blame institutions or systems rather than individuals at the helm. I have my own issues with  bankers but that doesn't mean I'm going to take my iPhone to the local financial district and protest against "profit". It is fairly hypocritical to have purchased a cell phone from the most well-heeled company in the world and then protest against "profit".

However, we do need a better balance. When people have no job and no hope we can expect social unrest which isn't good for anyone.

I wonder if Generation Squeeze understands that despite its protests, it will need to compromise.

What will need to be traded and what values adjusted in order to bring the economy, entitlements and expectations in line?

I leave you with a link to an article from the Globe and Mail today on "Generation Squeeze" as well as a couple links from the National Post on health transfers and the Wall Street protests. They put things in context.

Once again, I would be remiss if I did not thank you for your ongoing contributions. I am not sure there is a blog anywhere with such dedicated contributors. Cheers to you!

At eklimek's gentle request, I am complying with two links to significant documents--one is a letter from the US Congressional Budget Office regarding potential cost of prevention and wellness programs and the other is an article from the New England Journal of Medicine which discusses screening and prevention for various disease entities. Both are worth the read. You may have already read them but worth digging up again.

There is a third article worth reading that is honest and transparent about the value of screening. I originally came across it on KevinMD.

I keep reminding myself that Columbus had a rough time too...going against the standard dogma of the day  and calling the world round didn't make things easy for him nor was the ultimate voyage..but look where it got him!

It is uncomfortable to say that prevention won't save health care dollars when many experts are talking about the savings that we'll be able to generate if we could just have everybody riding bikes and eating sprouts (minus the e. coli) while the provider inputs their most sensitive personal information into their EMR. The public laps it up.

Don't get me wrong--I preach good sleep, eating and exercise habits and advise on healthy behavior, vaccines etc. There is value in preventative medicine for the individual...but it won't save health care dollars.

The way to save health care dollars through prevention is for individuals to take more responsibility for their health and to be respectful of the health of others. That is a tall order and I suppose we must start with expectations. But we do need a plan B I think once ehealth fails to deliver (and actually costs a ton of money) and when prevention doesn't bring down costs. What will it be?

If we want to find solutions, we must first be able to identify the problems.

Please see the comments section for the two links.

Once again, thanks to all of you for your loyal readership and I'm putting in another prod to encourage you to try Twitter!