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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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Sunday
Nov262006

Open and Honest Discussion

As a physician working in  Ontario's healthcare system for close to  twenty years, I have witnessed many changes. An aging population, an aging provider workforce and ever advancing technologies and pharmaceuticals are contributing to create a healthcare environment in which public expectations  may very well not be attainable.

At some point, we need to discuss what our publically funded healthcare system can provide and what it can't and find other means to provide the rest. We need the input from patients, from the providers and from the public in general. This should not be left to politicians whose careers are mostly much shorter than the time required to find viable solutions. This discussion is too important to leave to politicians.

 Please join me in this discussion and post your comments. Please remember that although there is much passion associated with healthcare opinions, respect for differing perspectives must always be maintained.

I hope you find my future posts enlightening and thought provoking. 

 

 

Reader Comments (21)

Merrilee,

Best of luck with your new blog.
November 26, 2006 | Unregistered CommenterExecutive Lead Blogger
Guest Column published Thursday March 23, 2006 St. Catharines Standard

In his book 1984, George Orwell suggested Big Brother knew everything. In 2006 the Ontario Ministry of Health and Long term Care has the absolute right to review physician records to ascertain if billings to OHIP are justified. This serves to monitor and control public spending and detect instances of misbilling.

Now Opposition Leader John Tory suggests sending monthly account statements, like Visa, to let you know how much health care costs.

"Visa seems to keep track every month of everything we buy," he says.

This chestnut comes around every decade or so. Visa sends statements out because it's their business to do so. Visa doesn't take out your appendix or deliver your baby; that's not their business.

There is an iceberg of problems in this proposal. First, it exposes your record of attendance to any one who reads your mail.

Second, it distracts you, the taxpayer, into thinking the problem is doctor fees. The fact is, there is never enough money at the federal level for pharmacare or provincial levels for hospital care. No government can endure the true costs of all public services, be they road building or health care, without a tax base.

Third, people do not always need the best health care or the services that only doctors can provide. Most people need minimal care until later in life when costs soar and benefits may be limited but vital. Government's priority is to satisfy the majority of health care needs with equally effective but less costly providers, not physicians.

The province is working to establish family health teams that use nurses and other health-care practitioners to help take the medical load off doctors.

In part, this is because medical practice in Ontario is now so unattractive and hostile that doctors have simply left traditional medical care. Those remaining seek delisted services or business to supplement their income and reduce bureaucratic drag.

We are left with the paradox of paying for hospital recruiters to offer local inducements but seem unwilling to publicly advocate fundamental change at the ministry level to correct the problem. Public hospitals are now in the business of paying for doctors and must provide stipends for physician services. Why?

Newly graduated physicians practicing in Ontario take a pay cut compared to British Columbia or Alberta. Ontario infrastructure shortcomings compound the disincentive.

In Niagara in 1991 there was a neurosurgical service, family doctors were not in short supply and three hospitals served St. Catharines alone.

Those living here recognize a change. We have since been re-engineered, downsized, and restructured. The Health Services Restructuring Commission amalgamated most of the region into the Niagara Health System.

In 2006 there is no neurosurgery, few family doctors and one acute care hospital in St. Catharines.

Is it surprising there is no political will to make decisions that will displease the electorate? The administrative problem for government is budget predictability. The political problem is an electorate unwilling to foot the bill.

Perhaps, if the government is considering sending out invoices, they would start by telling me what the Ontario health care premium is spent on?

For the McGuinty government this results in a problem for which they found the answer in the last election. It is always expedient, easier and cheaper to sell the public another ruse and then renege as necessary, instead of making tough choices. Resourceful leadership and a trusting public always find a new scapegoat, a new administrative direction or a new paradigm promising better things just around the corner. The continued spotlight on controlling and reducing costs, eliminating waste and reducing expectations encourages the electorate to vote for the political leader promising better without additional cost and neglecting lessons learned.

The patients of Ontario are not restless to have more people engaged in conversation and decisions about their healthcare delivery or mail out invoices for services. They have asked for hospital beds, medical care and needed tests. How exactly will the government provide them?

E. Klimek MD FRCPC
145 Queenston Street, Suite 301
St. Catharines, Ontario, Canada L2R 2Z9
Telephone (905) 688-2066
Fax 688-9335
November 27, 2006 | Unregistered Commentereklimek
Congratulations Realist---I hope that ELB will maintain his moniker and contribute to this new blog---hopefully those within "the system" will keep us informed as to the developments in their areas---2008 seems to me to be the crucial year when the powers that be might make such a screw up, such a hash of things, as they try to apply/impose their various schemes, that it would cause the health care system , as we know it, to keel over once and for all.
November 27, 2006 | Unregistered CommenterAndris.
Thank you for the initiative and wherewithall to continue the discussion Dr. M.

I look forward to fulsome discussions.
December 1, 2006 | Unregistered CommenterNew Peon
Dear Realist: This was our parting message to ELB. We hope the views we express in here are not incompatible with the intention of your web site. We believe that diversity of view can be valuable. We look forward to the future of this blog. The Hayseed Docs




We,the Hayseed Docs,are moving over to the Realist's blog site. But, before we do, we would like to make a couple of parting observations.

This blog has seemed to us a worthwhile venture. And, yes, there has been galvanization, qvetching (did I spell that right?), sarcasm, cyincism, etc. But there has also been a valuable sharing of information and views from an amazing wariety of sources. It would be a pity were this not to continue.

It is easy to put our institutions, agencies, and governing bodies between the cross-hairs and take aim. We have done our own share of that. But it cannot be the sole purpose of what we share on this site or the new one. One of the greatest things of value that each different sector or profession that participates brings is its unique perspective on a huge mass of very difficult issues.

We look forward to penetrating and cogent observation on the Realist's site. We look forward to good information, and a sounding board for issues we all face where solutions can be hammered out that help us and our patients.

So we really hope that The Advocate, Dr. Leilmanis, Dr. Klimet, Tragically OHIPster (we can guess where you live!), Fat Cat, Fidel, NOT an EA, FURSTR8TD, re-tired, Semi-Rural Doc, and other will all meet us there.

We also encourage you, dear ELB, to put in your two cents worth as a participant. We also encourage the professional governing bodies to "put their ears on" and contribute.

We fully intend to bring the "grassroots" perspective from some points of view, but we also want hard discussion on policy issues relating to such things as patient utilzation, IT, system integration, and physician manpower. We look forward to hard discussion on operational issues facing the provider in the field.

And last, we look forward to being able to share our inevitable frustrations with difficult days ahead.

So, full steam ahead and damn the torpedos! Is anyone game for this?

The Hayseed Docs


December 1, 2006 | The Hayseed Docs
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December 1, 2006 | Unregistered CommenterHayseed Docs
Well posted, Hayseed.

My particular interests are Primary Care, provider compensation and IT, so I'll be sure to offer my two cents (or whatever it's worth) during discussion of these items.

And to all the grassroots out there, my sympathies, but also my best wishes for a brighter future.

December 1, 2006 | Unregistered CommenterTragically an OHIPster
Hello Tragically! Glad to hear from you. We also have interest in precisely the things you specify. We may come from different perspectives from time to time, but here we have an opportunity to share and maybe create????

And the grassroots are not so bad. And we believe in the future! That's why we began Primary Care Reform. That's why we'er out here. And, may we say, we have actually found folks, perhaps like you, at OHIP who are helpful. All is not lost. Just very inefficient and more complicated than any of us finds comfortable! But, what is life without challenge!

We hope that ELB and the rest come back to us. We have a sense that the original blog was a place they could vent to each other with a modicum of anonymity and honesty that ministerial and hospital corpoare life sometimes make hard. They should not be made to feel that all they are going to find here is hostility and the wages of chasm.

Now, I suppose that to be polite, we should pay some attention to Dr. L's piece--which says a great deal--and frame some response. And, in between this kind of thing, we can find a moment to share views about physician compensation and IT, two of the big things on our plate.

We think our Administrator might be interested in joining the blog. She's a hard case; she's worked in every conceivable service delivery venue, HSO's, CHC's FFS,APP's,PCN's, and she's hospital administrator by trade. She knows most of the IT packages out there, and is a whiz with an ACCESS database which is basically how we survive. She may have something to offer that is of a non-medical perspective.

But that is for another day.

Hayseed Docs.

December 1, 2006 | Unregistered CommenterHayseed Docs
Greeting:

News from central for the troops:

1. http://www.health.gov.on.ca/english/providers/project/hosp_plan/pdf/nl_2.pdf

Pay attention to the Hospital Accountabilty Agreements and their changing into Service Accountability Agreements in 2008-09.

The HAAs currently are the mandated budgets submitted to the MOHLTC to fix the budgetary process. They are now to be transferred to the LHINS for fiscal 2007-08 for their approval, and then in 2008-09 will become part of the LHIN regional SAA to fix the budget for the region. Thus by 2008 lobbying will be occuring to start moving beds/programs/services to fewer sites in order to improve efficiency. All resource allocation isues will be run through the LHINs - at arms length from the Minister - expect to see more letters like - "we at the Ministry received you letter of concern over resource allocation, and stress the importance that you bring your concern to your local LHIN which will address it"

2.http://www.health.gov.on.ca/english/providers/program/pubhealth/manprog/mhpsg_mn.html

Although mandatory programs are used, at this time, primarily by public health, the change in language is important.

"Move from guidelines to program standards that are linked with specific performance measures for increased accountability."

Guidelines will become "standards" - more leadership from central to assure that services will be delivered in accordance with the MOHLTCs policies and not those of the professional colleges.

Interesting how much Ontario just lifts straight out of the UK NHS - that model of truly effective single payer care (oops sorry I forgot they allow "private" money as a pressure release).

The plan is good - long live the plan.

December 2, 2006 | Unregistered CommentermovingForwardOntario
Good for Dr Fullerton to keep the discussion alive in the new blog.

If anyone is interested in my perspective, it comes from 23 years in primary care with a time in most of the models. Through practice audits, I’ve seen the spectrum of practice styles and philosophies. I've seen the practical application of many of the current CMS that are on offer by OntarioMD. I also bring a perspective from many cases CMPA has asked me to look at to come to the aid of accused colleagues.

My dream is to see the rekindling of passion in primary care. I hope to see my friends and colleagues, confident in their contribution to their communities, and proud how they make a real difference to real people.

I hope this blog is a part of this process.
December 2, 2006 | Unregistered CommenterOtherGS
I'm in
December 2, 2006 | Unregistered CommenterThe Advocate
Grand River needs leadership
KW Record Editorial(Dec 2, 2006)

excerpt

"What can be said is that Egan's position will not have been helped by Smitherman's comments. To have a health minister express disappointment in a hospital's leadership is not a career-enhancing comment for anyone in a leadership position at that hospital.

It is interesting to note that Smitherman himself acknowledged a certain level of frustration with the health system. He recently told the Ontario Nurses' Association that the province's hospitals "squirm off the hook" by blaming the province for not giving them enough money.

Significantly, Grand River has a deficit of about $8 million. No doubt the hospital would like more assistance from the province in reducing that deficit.

To be fair, nothing in the health field is easy, but the health minister has to get beyond expressing frustration. Regardless of whether he likes the situation he is in, Smitherman is personally accountable for the health of Ontario's hospitals. He and his ministry are responsible for either providing the additional resources the hospitals need or advising them how they should operate more efficiently.

Grand River's recent history is disturbing and unsettling. Public confidence has been shaken. One point may be made with certainty: The residents of Waterloo Region expect the emergency wards at all regional hospitals to remain open and fully staffed 24 hours a day, seven days a week. They also expect the health minister to ensure that this happens."

December 4, 2006 | Unregistered Commentereklimek
Busy week-end and many responses to make. Some interesting stuff and newcomers with interesting back grounds. We look forward to this.

DR. KLIMET has posted two articles with serious issues.

In relation to the first one, we don't suppose many remember when Peter Ellis, then CEO at Sunnybrook got his picture in The Toronto Daily Star handing a patient a statement of the cost of her hospital visit including procedures. CMG's were the big thing then, and Hildo Boley was busy working onthe IT costing piece. John Tory appears to want to reinvent the awareness wheel in this connection. The issues are too many to address, but we would like to agree that the political will to police ourselves and our utilization of the system as patients is in some other galaxy; farther out still is our political leaders' will to call our cards on it in direct fashion and risk a disaster at the polls.

It is in fact easier to take aim at medical fees and physicians. The pressures from the payer and insurers to limit aid to that which is only medically necessary is enormous. On the other side is that percentage of patients who sincerely believe that the healthcare system should be available to them in unlimited supply, especially those who "run with scissors". Medical necessity doesn't come into their frame of reference. And who is the ham in this particular sandwich, we ask you?

As to Mr. Smitherman's remarks about hospital leadership, it beats us why anyone in their right minds would want to be a hospital CEO these days, it's such an ugly scene out there. Gone are the days when, if something wasn't working out, one could just walk over to the Minister's office and talk about it. One remembers a CEO doing this when, one day when there were upwards of 20 gurneys lined up the back hall of the ER, and bed occupancy in Medicine was at 115%, he said "enough is enough". He put his coat on. When asked where he was going -- "Over to see Eleanor," he said. There seemed to be leadership in both ministerial and hospital sector that cooperated in some fashion then. Not any more.

Thanks to MOVING FORWARD ONTARIO for the "heads up". You clearly believe the plan is good and are sleeping well. Those of us who are less well informed, (although we have tried every means to become informed, but keep running into political responses) and who are not sleeping so well,would be pleased if you were to share with us some of your sleeping potion in the form of what you believe the best features of "the plan" to be. We want to know.

And, given the (according to The Economist) miserable time the UK system is having, why, pray tell, are we excerpting so much from it? (We agree with your view.)

ADVOCATE: What are your particular interests?

OtherGS: Glad to hear from you. Yes, we are most interested in your perspective. You bring a good variety of experience. You dream of rekindling passion for primary care? Many are indeed mourning what is perceived to be its imminent demise. But, who knows? From the ashes may arise a phoenix! Alas, the days of Ian McWhinney's Principles of Family Medicine with its holistic perspective, and value of the ongoing therapeutic relationship with the patient are perhaps gone as we knew them. So, we will try to build anew. And we look forward to sharing views. The reductionist approach reigns, even among our younger patiens who appear only to be looking for the appication of technical skills, invasive procedures, and the sprinkling of the chemicals...just wait until they're our age and need someone who knows their patient history to get the decisions for that individual decision right...one size does not fit all inspite of what the algorithm in the handheld says...

Bye for now.


The Hayseed Docs


December 4, 2006 | Unregistered CommenterHayseed Docs
Dear Hayseeds:

Sleep, as we all know, is highly dependant on "happiness". Thus, if one can "believe" the plan is good, sleep arrives.

Ontario's issues,however, are serious. Not necessarily better or worse than many (we are well off economically,overall).

Our problems do however relate, a lot to trust. We know that many of our "leaders" (note many of our leaders are appointed, not elected) do lie. It is particularly worrisome that some of our hospital and CCAC CEOs are dishonest. That portends badly for the future.

It will be a tough next 3 to 5 years. I'm not optimistic (I note that in the last week, 2 of the systems best CEOs of hospitals have departed - what a loss!! - but politics must rule). I'm hoping that we can "move forward", but the signs are scary that it is becoming purely a political system based only on who's ass you're willing to kiss to get your money.

There remains encouragement from places like the outside Kingston area, where reports trickle in that people can care. Keep up the good messages.
December 4, 2006 | Unregistered CommentermovingForwardOntario
Dear MovingForwardOntario (MFO henceforth).

Darn! We were looking for insight! We here out in the sticks tend to be gullible and to believe everything central command tells us. So we thought "the plan" was good and we were dumb for not seeing this!

Dishonesty and politics, you say! Why do you think we are out here? We have personally known some of the types whereof you speak over our many years.

Of course, the system is purely politically based. That's because it's easy as an approach. And we are very particular about the asses we choose to kiss...which may also go a long way to explaining why we are out here.

Trust is everything. And that is another reason we are out here. We work with colleagues we know and trust, and have developed a nice little network within "the system" whom we know and trust. That is how we survive the maelstrom around us.

But trust can often lead to workable plans which actually require resources to implement, resources not otherwise necessarily consumed if the system is at a standstill and nothing is actually happening. Does that mean that trust is the enemy of the bottom right-hand corner?

Hayseed Docs
December 4, 2006 | Unregistered CommenterHayseed Docs
Hayseeds:

Glad that you've found a trusting system. You can build on that.

As for resources, action from Central will be frozen for at least 2 years, so don't expect much (some may come but it is dicey).

Hate to use the evil "private" money idea, but at least that comes without the strings attached from the MOHLTC. Might offer some room to change without "review" by central.
December 5, 2006 | Unregistered CommentermovingForwardOntario
The Hayseeds have found an trusty, home made, ark in which they try to brave the health care maelstroms created by the central planners---not all of us are so fortunate---mine resembles more of a Kon Tiki type raft---we are all wary of that MOHLTC power boat that seems to be driving about quite recklessly and seemingly haphazardly, the wash from which could easily swamp us.

A politician is a person who pushes a non swimmer off the dock into the waters of a turbulent lake, thrashing ones' arms in distress, he throws out a life saving ring, built to government specifications and thus constructed out of concrete, that grazes ones' head and promptly sinks; one struggles to reach the edge of the dock, whereupon the politician walks over, stands on ones finger tips, bends over and asks as to whether he/she could be of any assistance, one screams at them to go away to which the politician responds with complete disbelief since he/she considers him/herself as being indispensable, eventually one manages to wrench ones bloodied and nailess fingers free leaving bits of one's own tissues on the dock's edge; one struggles in the waves eventually, with tremendous effort, reaching the shore on which one lies in pure exhaustion, only to find the politician rushing up to one expecting eternal gratitude.
December 5, 2006 | Unregistered CommenterAndris.
Good morning, Andris. Lest you think we live in an idyllic world of trust, we don't. We just have lucked on a place where, relatively speaking, life is workable. And we all like each other which helps.

We still feel the pull of the powerboat. We often wonder if anyone at all, or how many would-be captains, is driving. We have reasonable connections at the sub-levels, but, as Not an EA observed, you never know who is actually occupying a particular chair at any one time. So you learn to become quite self-reliant on dealing with your contract, various MOH guidelines or fiats, or whatever. But, we also have some sympathy for those ever-rotating individuals who find themselves in a chair without the base knowledge to handle what comes at them. Most organizations, not just the Ministry, seem to eat their young in this way these days. Pity.


The type of polician you describe is really a character type. That type would be the same no matter what walk of life he/she chose. They do tend to gravitate to the top of any given food chain nowadays, though, don't they?

We have our black days. Paper in particular makes us cranky.

Hayseeds
December 6, 2006 | Unregistered CommenterHayseed Docs
Methinks a new posting is needed as it is 7 days since the last response.

My suggestions for topics that might get some action:
1. latest information and rumours an the CCAC restructuring
2. make one (realistic) New Year's wish for improving helath care in Ontario - and why it would
3. what, exactly, do the 6000 plus souls at MOHLTC contribute, given that few if any provide hands-on care (I know some work for an insurance company)
4. are the stated "big 5" results true/accurate/what are they really?

Have a good one

December 13, 2006 | Unregistered CommenterTrebor
Hello, Trebor. All the action for the last few days has been on the opinion piece as you have probably discovered.

Of interest would be some good information on the CCAC restructuring. Got any?

I would have to think about the New Year's wish, but, I agree that to start with something actually realistic, and, better yet, DOABLE, would be good.

I think your poke at the MOHLTC is somewhat gratuitous. The folks we deal with (those who are left) actually do try to be helpful. The collective in its juggernaut mode is less attractive, however...but then, so is our own from time to time...

As for the "big 5", I would be interested on someone else's take on the degree of "spin" that went into the presentation of the results. Optics is everything. So how would we know the good information in there?


Cheers!
December 13, 2006 | Unregistered Commentersybil
Welcome aboard Trebor and thanks for your contribution.

Sybil is right. "Doable" is important. But there are many things from the past that were not thought to be doable. It took the right thinking and some determination or desperation to make it happen.

I think honest communication is important and clearly the spinning on the big five shows some desperation.

I don't think the Big Five was a mistake...but what it does is create an oozing bandage over a festering boil.....eventually the patient gets sicker and needs even more extensive care. And so it is with healthcare in Canada.

The lack of overall improvement in the "system" was predictable when the big five were trotted out.

If there are finite funds in the system, the pressure will be felt somewhere else if human resources and OR time is spent on only a few areas.

The idea that wait times would include both inpatients and outpatients' wait could be argued as being fair since it gives an overall picture. Of course, our universal healthcare looks to provide for the majority and taking an average isn't all that bad....unless you are one of the people waiting for cancer treatment, being denied cancer treatment, waiting for pain relief (some pain clinics have had patients on their waiting lists for three years!), waiting for surgery to make you life liveable again etc. etc.

But isn't our universal healthcare system designed to make people wait? Yes, so how long is OK....that is what the benchmarks are for....but even if you can reach the decided upon benchmarks for some procedures what happens to the other patients in the areas not being measured? Don't they count? Apparently not.

Absurd.

December 14, 2006 | Unregistered Commenterrealist

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