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Looking for Solutions in Health Care for 2006 and Beyond

Our health care system needs to change to accommodate new demographics, new technologies and new pharmacologic advancement.

The roots of compassion and caring in health care should not change however, and it is with this in mind that the dialogue of change should be had surrounding health care.

How can we adapt to different needs that emerge as our population ages?

How can we  find sustainability in the midst of so many new advancements?

How can individuals become more empowered in serving their own health care needs?

What role does the individual have in enabling the  health care of others  beyond paying taxes?

Many questions like these need to be answered and if we are willing to look with open minds at the problems within our health care system, and beyond political posturing, then we can find new  solutions to take us further into this century. 

 

 

 

 

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Tuesday
Feb072017

Resignation of the OMA Executive-What Now?

So, the Executive of the Ontario Medical Association has resigned...sort of. The Executive is resigning to sit on the Board of Directors and then will go through an electoral process. At least that is what we are told currently.

This follows after a 55% non-confidence vote in the OMA Executive at a special meeting of the OMA Council but at which other motions failed to win the required two thirds majority to pass. These other motions if they had been successful would have led to the resignations at the individual executive level.

In the face of the quasi-win by the groups challenging the OMA's representative performance, there had been murmurings of requiring the OMA to hold another General Meeting of Council to address the non-confidence vote which had initially been arrogantly passed off by the OMA as a demonstration of support. Another General Meeting of Council would have been disastrous for the OMA. It managed to avoid that through this resignation process.

However, the OMA should know that this result was not the end of this non-confidence wrangling. It is just the beginning.

The Ontario Liberal government should also understand that the advocacy efforts of front-line physicians are not going away. These physicians are not dissidents as they have been labelled by some reporters. They are simply aware that the Liberal government's cuts to front line health care and patient care in Ontario will cause more and more hardship for patients as time goes on. It's not the 1990s anymore.

Fact is that we are up against the demographic wall made even more challenging due to a sluggish economy affected by the shift in aging--a double whammy. Instead of cuts to care, government ought to be planning how to allow more care for more people. Cuts do the exact opposite of what is needed. Even if the deficit is eliminated for 2018, growing health care need will not be eliminated. The pent-up demand for care will be even greater after 2018 due to the current Liberal cuts.

Physicians are becoming more vocal. Despite government-created positions for paid "Physician Leaders" to push through the government's self-serving and short-sighted version of transformation, many physicians see the negative impact of government's efforts to balance its budget on the backs of patient services.

Physicians I know and have known care deeply about their patients. They see that health care access is becoming more and more difficult. They want to continue to provide much needed services but they may differ on how those services can best be provided. We should be able to differ on the "How" and value different perspectives and approaches and still be united in providing quality patient care.

We must ask the "What if" questions.

What if the government is not forthcoming with more and more funding for care to adequately serve citizens who are dependent on it?

What if government providing  more funding leads to higher debt and greater interest payments resulting ultimately in fewer services?

Billions of dollars going to interest payments every month are one reason why Canada has fewer physicians and hospital beds per population than most developed countries and which results in lack of timely care, delayed diagnoses, and patient hardship--even death.

A couple years ago a fellow physician told me not to worry--all that was needed was a Liberal federal government and the money would flow. They were surprised to discover that the Trudeau Liberals are no health care saviours.

So what now?

I have no doubt that some of the former OMA Executive members will be re-elected to a new Executive. That will change nothing. Some new MDs may find themselves elected and in a position to create change from within the OMA but it is external factors beyond the OMA that have brought us to this point of upheaval. It is only by addressing external  structural health care system issues BEYOND the OMA that substantive, sustainable change can occur.

I'm hoping that a new OMA Executive will understand that their most important role is not to align with the government transformation flavour of the day. Instead, it is to give critical input on how more care for more patients can be realistically achieved while supporting our human providers who deliver that very necessary care.

We need to be asking the hard questions.

As always, thank you for your continued insights and thoughtful comments.

 

Tuesday
Nov152016

Ontarians Should Be Very Wary of Bill 41- "The Patients First Act"

If ever there was a piece of legislation inappropriately named, it is Ontario Bill 41. If the Ontario Liberal government had more accurately named its legislation, “The Grow Bureaucracy and Invade Patient Privacy Act”, it would have garnered a lot more public and media attention. Even the Ontario Medical Association might have been forced to deal with it earlier instead of waiting until the legislation was under fire from front-line physicians.

Bill 41, cloaked in the reassuring sounding title of “The Patients First Act”, has passed second reading and is before a legislative committee. Premier Kathleen Wynne and Health Minister Eric Hoskins want to see it passed in the next four weeks.

Three things you should know about Bill 41:

1. Bill 41 gives the right to government to access your private medical records. The privacy of an individual’s medical record has traditionally been a source of reassurance and trust for patients during the medical process. For government to give itself the power to invade your privacy is as an affront to an individual’s right to have a confidential relationship with their doctor. Today, providers work in teams and more people do have access to a patient’s record now than ever before. But for government to insert itself between providers and patients has potential for negative consequences including further rationing of care and denial of government funded care-which is undoubtedly the rationale for this invasion of privacy.

2. Bill 41 will grow the bureaucracy adding more layers to the fourteen Local Health Integration Networks creating an additional eighty sub-LHINs to be filled with various personnel. Piling on more bureaucracy to the already inefficient LHINs is not the way to stretch our tax dollars to deliver more needed care. Since 2004, the growth in bureaucracy under the Ontario Liberal regime is staggering.  We have seen many layers of managers created to measure quality and wait times, while front line funding is being cut to offset the Ontario Liberals’ waste and mismanagement elsewhere.  The efficiency of the bureaucracy is not even measured. Ontarians will be paying for more managers, not more care.

3. Bill 41 empowers the Ontario Minister of Health with extraordinary levels of autonomy. This dictatorial positioning is of serious concern and raises many red flags. The legislation gives the government more power over patients and providers and it gives one individual, the Minister of Health, the power to do whatever is considered “in the public interest”. This is extraordinary power. Without ever consulting the public about its “interests”, doctors’ offices may be closed, providers may be limited in their ability to work based on geography, and various groups that exist to deliver care will cease to have a voice. Doctors and health care providers will be forced to comply with government decisions and those decisions will not require engaging the public or the medical profession in the process.

Make no mistake. The Ontario Liberals’ Bill 41, "The Patients First Act", is not about putting patients first. It is about the invasion of patient privacy, injecting the government into health care at every turn with a bulging middle management bureaucracy, and expanding the power of the Minister of Health to limit access to care and to treatments.

The public should be very wary of Bill 41. The rights and power seized with this legislation should remain with the people and not be snatched by a government to grow its bureaucracy while rationing our care. Bill 41 entrenches a heavy-handed, top down health system that no longer guarantees the trust and privacy of the doctor-patient relationship. It is truly unconscionable--even for this Wynne Government and Health Minister Hoskins. 

Thursday
Sep082016

B.C. Courts will bring into Focus the Hard Questions about Canada’s Health Care System

 

Canada’s health care system has been called many things including a “jewel” and “the very essence of what Canada is all about”. It has also been called “sclerotic”, “archaic” and for politicians it has become “a sacred cow”. For many Canadians, our health care system has become a mirage. Aside from the illusory notion that our health care is “free”, many cannot explain how it works and how it is financially sustained. Many cannot access the care they need.

However, this mirage is going to be drawn into clear focus in the weeks and months ahead as the B.C. Court is hearing a case put forward by surgeons and patients that accuse the B.C. government of denying them their rights to timely medical care.

Perhaps the B.C. case will allow Canadians to begin the necessary discussions about how our health care must change to address the serious systemic shortfalls within it. We have a strained health care system due to an increasingly aging population, more pharmaceutical options, more medical technology with associated potential interventions, and emerging science that requires more medical research and money.   

For people waiting for care, or denied care, or whose disease is treatable elsewhere but not here, the limitations of our current system have become numbingly clear.  We should walk a mile in patients’ shoes to understand the importance of the B.C. Charter Challenge for those who have been denied timely care. While the outcome of the case is important at an individual level, it will also resonate at a societal level – throughout our country.

Some people choose to frame the case as a “private vs public” health care battle and foresee the destruction of Medicare if B.C.’s provincial health care service loses the case. However, at a foundational level, the case is a challenge about the rights of Canadian patients in a system that denies timely care.  What rights does a patient have? What recourse should a patient have? What suffering can the government health insurance plan fairly impose on an individual patient, if any?  (In a country that has recently witnessed the Supreme Court of Canada rule in favour of an individual’s right to die, one might expect that it would also rule in favour of an individual’s right to live.)

Now is the time to ask the difficult questions about what we want from our health care system that was designed for another era and which, despite transformation, is a laggard in the developed world. Many of us who have been part of the on-going debate about patients’ rights and the short-comings of the system recognize that we can and must preserve what is fair and equitable about Canada’s health care system and move forward to improve what is not.  

There are some important questions that must be fully discussed.

Must we pit patient against the system? What is more important, the patient or the system? Can we not all agree the system must exist for patients? So, the question then becomes “How to provide more care to more patients?” In that context, how is it ethical to preserve a system that cannot meet patient demand despite almost fifty years of trying?

How comprehensive a system can we afford? Do Canadians want modern health care that keeps up with change, or do they want an archaic system designed for fifty years ago? As pharmaceuticals become more and more prominent in treatment options, many Canadians want to include pharmacare in our country. However, the cost of Canada’s government funded system makes it difficult to move forward in publicly funding other areas of care such as eye care, dental care, and newer pharmaceuticals for cancer and other previously untreatable diseases.  How can a better balance of services be achieved that will meet our expectations for an advanced health care system?

There’s the important issue of “Universality”. Do Canadians want universal health care coverage in theory or in reality? The term “universal” does not mean “government funded”. It simply means coverage for everyone. There are many ways to provide coverage for everyone in a truly universal system that creates access instead of imposed rationing. Many other countries have hybrid systems for medically necessary care and manage to achieve universality at lower cost and with better outcomes. Why aren’t we looking at and learning from other better performing systems? And, what of portability of care in Canada? Do Canadians want a system that provides similar services across the country, or do they want the system to be determined simply by the degree of rationing required in each province?

What is to be done about the under-utilized infrastructure and medical workforce? What do Canadians want, more government rationing of care or more ways for more patients to access care? Canada has less than the average number of physicians per capita compared to many developed countries yet we cannot fully employ our medical workforce due to costs associated with utilization of government funded services. Operating rooms and surgeons sit idle, hospital beds may exist but are “unfunded”. Hybrid systems of other developed countries have more providers, more hospital beds, and better access to medically necessary care at lower cost than Canada’s health care system.

Canadians must have this honest and difficult discussion about our health care system if we are to create a truly universal system with quality health care that addresses patient need. I believe the B.C. Charter Challenge will help in this dialogue. Contrary to rhetoric about the case being an attack on Medicare, it is not. Given the history of our country, Medicare will continue, but we must acknowledge its faults. A more robust health care system is needed, one that is truly universal, comprehensive, and accessible and not so negatively impacted by government short comings both in funding and in vision.

The B.C. case will bring our health care system into much clearer focus. It will drill to the core of the debate. If we are to give patients the dignity and respect they deserve, then we must acknowledge that they are part of the solution and give them the necessary freedoms that are currently lacking.

Sunday
Aug142016

Wynne's Dysfunctional Approach to Solving Ontario's Healthcare Challenges

**Please note that the original journal entry from August 14 has been modified to reflect the vote result from  August 15.

 

 “Abdication, Distraction, and Deflection.”

 Ontario’s doctors voted NO to the tentative Physician Services Agreement between the Ontario Medical Association and the Wynne government that would have doctors co-manage the Province’s ailing health care system. The results of the vote from August 14 were shared the following day. Of voting OMA members, 63.1% voted Against the Agreement, 36.9% voting For the Agreement. The rejection is indicative of the negative view of Wynne’s overall approach to healthcare in the Province – one of abdication and deflection.

Given that Ontario is at a pivot point in health care that will affect patients, physicians, and the province for many years to come, the vote result will be important.  Simply stated: it is a bad deal, indicative of Wynne’s overall

 Abdication

The Wynne government has demonstrated its abdication of responsibility to patients by limiting the physician services budget for patient care below what can conceivably meet patient demand.  Instead of dealing honestly with the surge in health care need due to our growing population, new advances in science and technology, and an aging population with all of its associated requirements the Ontario Liberals are using health care to balance their budget. They have used rationing of patient care to offset the burgeoning debt that they have created through mismanagement and wasteful spending.

The centrepiece of the Liberal government-OMA deal was Wynne’s design to use  Ontario’s doctors as its collaborative rationing tool through co-management of the Physician Services Budget. This would have bureaucrats and doctors, together, deciding on the healthcare cuts to meet the government’s scheduled budget targets. Obviously, neither the OMA nor the Liberal government appear to have the interests of patients at heart. If they did, they would not be resorting to rationing under the guise of “co-management” and “collaboration”.

 Distraction

The Liberal government-OMA deal included components to address Relativity (the relative difference in the OHIP fee codes of some MD specialities compared to lower fee codes of other specialities). Although some physicians believed this was a positive attribute, it will require Ontario’s physicians to be internally focussed on slicing and dicing their profession – rather than spending time and resources on providing input into major structural issues that afflict health care delivery.

While the OMA is distracted with Relativity, the Wynne government master plan is to bring in more bureaucratic management in the form of Bill 210, The Patients First Act. Doctors kept busy with co-managing the rationing of care allows the government to move forward with minimal resistance to its major expansion of powers that allow it to unilaterally impose accountability agreements. Individual freedom for both patients and providers is at risk with this legislation.

 Deflection

The Ontario Liberals are intent on deflecting blame for costs of their own debt and waste onto the Province’s health care system and its providers. It is harder and harder to provide publicly funded patient services when the government is spending approximately one billion dollars a month on servicing the massive debt it created over the past decade through waste and mismanagement. Consider what can be paid for with a billion dollars per month: the medical staff, operations and procedures, the equipment. With the deal and physicians given a co-management role, the Wynne government has found a deceptive way to deflect public criticism from government decision-making.  

 As a disturbing aside, thousands of physicians who oppose the government’s current rationing plan are not “dissidents” as some government spokespersons and media have referred to them. By branding physicians who perceive solutions differently from the government as non-collaborative the government is attempting to quiet dissenting voices and deflect attention from its own failed policies. It’s a ruse. Differing perspectives could be used to create a more respectful and compassionate plan for health care transformation. It is often at the interface of opposing views that the best solutions will be found. It would be wise for our political and association leaders to do more listening and less deflecting.

The Liberal government’s approach has created a dysfunctional healthcare system

The Wynne Liberal government’s deal with the OMA suggests this government is clueless on how to proceed with its healthcare challenges. Constraining the freedom of physicians in a command and control system where they cannot meet patient demand and then labelling this as being in the “public interest” is disingenuous at best.

This is not the way to create a leaner and more efficient health care system or a way to meet the growing demand for patient care. Instead of squeezing the breath out of our public health care system, as our population grows and ages Kathleen Wynne should be answering the question “How can we provide more care to more people?” If we want innovation and “modernization” of care, it will not be found in rationing or managing wait lists. More management and more bureaucracy are not what we need.

As this deal so clearly illustrated, Wynne’s healthcare legacy is an abdication of duty, deflection of responsibility and distraction from her government’s wasteful ways. Hardly inspiring. Hardly a vision. Ontario can do better – it must do better.  The vision of health care in the future cannot be about rationing care, denying care, and limiting the freedoms of providers and patients.  It must be about empowering patients and empowering providers including Ontario’s physicians in providing more services and more care, not less.

The rejection of the deal was the ethical and appropriate response to a poorly considered health care rationing master plan pushed by the Wynne Liberals. Ontario doctors have spoken with resounding support for patients. However, any celebration of the rejection of this deal should be dampened by the reality that there is much work ahead to be done to shore up Ontario’s hobbling healthcare system. Let’s start with the resignation of Dr. Eric Hoskins.

 

 

 

Wednesday
Jul132016

The Tentative Ontario Doctors' Deal-What it means to you

Whether you are an MD, a patient, or an Ontario resident, you should know what the tentative deal between the Ontario Medical Association and the Ministry of Health means to you. In essence, this deal will not provide greater access to care, nor will it meet the growing demand for care. With the proposed co-management arrangement, the Wynne Liberals will be dictating doctors’ services to an even greater extent, making it harder for many patients to get the care they need and harder for physicians to provide it.

It is clear something had to happen as Ontario MDs have been without a contract since 2014. Of the contract details, two proposed aspects are being heralded as breakthroughs: the 2.5% “increase” for doctors and the “co-management” of the system by physicians and Ministry of Health officials.

The sudden news of a 2.5% “increase” annually for four years arriving on the coat tails of the hard-nosed negotiations by the Ministry seems too good to be true. Understanding the details is critical to understanding what this contract really provides.

The 2.5% “increase” is for total services to be provided by physicians via the “Physician Services Budget” or PBS. Just as the name implies, this is a pool of money that government provides for physician services. It does not mean that your local physician will receive a 2.5% pay increase. This does not signal that s/he will now be paid more and able to provide more patient services or that patients will have improved access.

So, what does it mean then?

The 2.5% “increase” is simply an expansion of the funding pool to be spread across more people and more services as our population ages and expands over the duration of the four-year contract. However, this falls short of the demand for physician care. It is estimated that the need for physician services rises on average by 3.1% per year. That 2.5% “increase” per year is simply a continuation of the underfunding of the health care system by the Wynne Government.

Once again, hidden behind the headlines we see that political optics drive the self-serving Liberal agenda. This deal is not about access for patients or empowering front-line providers to meet the demand for care. If it was, it would have taken a very different form. Instead, the tentative agreement is all about self-preservation, by both the Ontario Medical Association and the Ontario Liberal government. It’s about how best to sell the public (and the physicians) on the merits of a possible contract that will continue to underfund health care.

The harsh reality across Ontario has many medical clinics struggling to stay viable and hospitals being forced to cut front line workers in order to meet their budget obligations required by law.  Meeting the growing need for patient care is being made harder and harder under the Ontario Liberal government. As costs of overhead continue to rise due to flawed provincial energy policies (and now we all must brace ourselves for the introduction of the provincial carbon tax), costs of operating medical facilities will grow—whether they are hospitals or community clinics. Under the Wynne Liberals, it is harder and harder to provide medical care to a larger and aging population.

It is an understatement to state the Ontario Liberals have been undisciplined in their management of tax-payer dollars. The waste, spending scandals, and mismanagement are well-reported over many years. Ontarians have a billion dollars a month siphoned off to pay interest on the Wynne Government’s debt instead of addressing patient need and funding for patient services. Now, under this tentative contract, physicians will be co-opted into “co-managing” the health care system hand in hand with this reckless government. Is this something to be celebrated as the headlines suggest? Where is the independent physician organization that can stand up to government’s self-serving political agenda?

Co-management of Ontario’s health system is a slight of hand given the government’s ability to pay for the services Ontarians require is diminished with every monthly billion dollar interest payment. As is the Liberal tradition of naming their legislation, the new deal is being sold to physicians and to patients as “The Best Deal Ever for Everyone.” But it isn’t—far from it.

Physicians, patients, and the public in general should understand that the tentative agreement as it currently exists will not provide more access to care or meet the growing demand for care. What it will create is further rationing of care required contractually to be done by physicians. And, unfortunately, Ontario’s physicians, through their provincial association and the new “co-management” arrangement, will be co-managing our health system’s retractions.  

Ontarians and the province’s medical community are to learn more about the details of this Ministry of Health-OMA agreement in the weeks ahead. One can only hope that there is a more serious review of both the inadequate funding and proposed "co-management” arrangement. Our doctors deserve better; Ontarians deserve better.