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. 





« Private Health Insurance in Sweden, Unemployed Canadian Specialists, and the Rand | Main | Defining the Problem in Health Care....with Vision »

Health Reports: Bias or No Bias?

There is no shortage of organizations and institutions reporting information on the status of Canada's health care system. Journalists, CIHI, ICES, Statistics Canada, OECD, and The  Commonwealth Fund come to mind but there are many "institutes" and "centres" that gather data on how long patients are waiting, what they are waiting for and how provinces compare.

What's curious is the huge variation in the conclusions. Some say that aging of our population will not pose a problem. The same organizations report that public health care is fully sustainable.  We just need to be smarter about how we use resources. Big Data is going to be the saviour.

Other organizations use data to show that wait times are increasing and that the aging population will cause social entitlements to buckle, including pensions and public health care. Their conclusion is that the public system is unsustainable and that just about every option should be on the table including copayments and private options for medically necessary care. The message I hear from these organizations is that we need to look ahead and prepare for changing times.

Can the public sift through the barrage of information to find the truth?

Is there bias, unconscious or conscious, by journalists and left or right leaning organizations that report on health care?

Answer to the first question is that people judge the health care system by their own anecdotal experience. If things go well for them or their loved ones, they believe the system is just fine. They do not see what is happening to other patients in their own region or elsewhere. The reality is the vast majority of citizens are not waiting in queues. They simply do not know what the reality is for others.

Answer to the second question is that bias is quite likely. It's fairly clear that some groups start out with an end point that they want to prove using data. Unfortunately, the data can be selected and is not complete. I often use the analogy of health care as a balloon. If you squeeze one area, another will bulge-you just may not see it if all changes in the health care system cannot be simultaneously evaluated.

As I've said many times here, the unintended consequences of government health care decisions are not usually apparent at first. They occur over time with the result that the decision that prompted the change elsewhere is difficult to link. Health care is truly a complex system.

The Mowat Centre, a left leaning think tank initially created by Dalton McGuinty with five million dollars in provincial seed money, reports that the "doomsayers" about sustainability are wrong.

The Fraser Institute, a right leaning think tank, raises the issue of unsustainability and makes various recommendations for changes.

What are the risks of siding with one or the other?

If you subscribe to the "just work smarter all will be well" camp, there is a distinct possibility that this prediction will be wrong. It is not possible to know what the changes in a complex system will create. It is also impossible to predict sufficient efficiencies for the future that is unpredictable.

If you subscribe to the "act now to create more ways for patients to get care" camp, there is a  chance that the flexibility created will drive free-minded innovation and that the need for accurately predicting the outcomes of various programs will have less significant impact if the predictions are wrong.

Governments can regulate. They can fund provincial public health care systems, but there is danger in wishful thinking. Let us prepare for the worst case scenario. Let us be prepared.

On another note, I would like to thank you all for your contributions especially in the past few weeks. 

Cheers to you!







Reader Comments (586)

Biases and slanted views are the norm, few can rise above seeing what they were trained to see, what their indoctrinated minds were prepared to comprehend....the majority still only see the " official truth" as Orwell described it.

My own bias is towards the more pessimistic view than the rosy view...those who expect the worst are rarely disappointed and when good things happen they are pleasantly surprised...we should plan for the worst and hope for the best.

The government sponsored think tanks are biased towards the rosy " official truth"...whatever comes out of them should be handled with a pinch of salt...it is more likely that the more pessimistic , and to my mind realistic, critics are closer to the actual truth than are those regurgitating the " official truth".
November 14, 2013 | Unregistered CommenterAndris

A good report can trump any data. The wait list times, worse in the OECD can be ignore; the cost per case cared for, amongst the worst in the OECD for nationally funded systems, can be ignored. The mortality on the reserves, amongst the worst in the OECD can be overcome. A good purchased report is worth it's weight in the money paid
November 14, 2013 | Unregistered CommentermovingforwardOntario
' GP decisions will no longer be dictated by generating income' ...Jeremy Hunt, the British Heath Secretary is scrapping the scheme introduced by the Labour Party( and then introduced into Ontario) where FP incomes depended on the meeting of targets and had left them micromanaged to death which did not place persons first..." It is a system that de professionalized general practice....."

The system will be reformed to meet the needs of patients...FPs will have to provide services to 8 PM, provide better care over weekends and a named clinician to be responsible for older patients.

' New GP contract heralds return of proper doctors ' ( Laura Donnelly & James Kirkup) ....under the contract 4,000,000 elderly patients and those with complex conditions WILL BE GIVEN a named GP , to be personally accountable for their care at all times...GPS will be PERSONALLY responsible for the care of all patients aged over 75, AROUND THE CLOCK.

We did this in the bad old days ...the modern generation of FPs who were allowed to drop out of after hours care, won't take kindly to this policy which is bound to be introduced in Ontario...the FHNOTs will likely be the first to have to comply...the older FHNOT FPs will likely retire on the spot....retirement among older FPs will become an epidemic.
November 14, 2013 | Unregistered CommenterAndris
Perspective is important. Low income causes poor health. Poor health causes low income. Cultural values affect both. Humans seem to prefer to concentrate on one relationship at a time while each situation is multifactorial and usually not amenable to a sound bite explanation. Even our colleagues, who must do multifactorial all the time in their clinical practices do not seem to spare the mental energy to pursue this in the economic and political fields.
Andris is right in his prediction and then all the unpredicted consequences will ensue.
November 14, 2013 | Unregistered CommenterJRL
Ah yes... Predictable but why don't others see it or do those in positions of power have more to gain than lose?

I'd be onside with changes that create greater provider responsibility if it would really make a difference to patient outcomes and economically but neither is likely..
As JRL points out, poverty causes poor health and poor health causes poverty.
No manner of care coordination, integration, provider accountability will change that.
The current transformation is misguided, created by misplaced noble notions.
I'm glad I'm at the end of my career and not at the beginning.
If I walk in a patient's shoes, I would also be concerned. All the care coordination is going to be expensive and will create brittleness.
As more GPs of my era and older are prompted to retire to do other things, the gov't will again be left wondering what happened.

And this thinking is not so e kind of pessimism..I would love to be a believer but as Hans Rosling terms it, I'm a realistic possiblist...The decision makers are copying other countries with very different circumstances. Here we go again.

Where are you ELB?

I must say I'm glad to be back. Life got in the way.
If your interested in Hans Rosling you may enjoy this..he has a way of putting things:

Sorry, "you're"...
But we will end poverty by taxing the rich more. Paradise is coming. Get out the maypoles!
November 14, 2013 | Unregistered CommentermovingforwardOntario
The British government intends to tear up its contract with FP's ...elderly patients will be assigned to FP 's who will be held responsible for them even on their days off.

The Health secretary has created a a new ' chief inspector of GP's' who would come down hard on surgeries ( FP offices) that fail to provide good service.

As well as offering patients same day telephone consultations , they will have to coordinate care for elderly patients from ERs and regularly review emergency admissions from care homes to avoid unnecessary call outs in future.

Paramedics, ER doctors and care homes will have a educated telephone line run by the FP practice/ clinic so that they can advise on treatment avoiding the need patients being admitted to hospital.

Similar services will be offered to the rest...children and those with long term conditions.

The BMA delivered the FPs to the government...the OMA will do the same.

The British NHS scheme/ initiative will start in April 2014.

When does our contract come to an end in Ontario? March 2014?

From where do our central planners get their brilliant inspirations ?

Am I'm glad that I'm close to the exit.

When I'm 75 I will be given my own personal doctor with a 24 hour help line....I wonder who that lucky FP will be?
November 14, 2013 | Unregistered CommenterAndris
Damnable iPad auto corrector...dedicated telephone line morphed into an educated telephone line without me noticing it.
November 14, 2013 | Unregistered CommenterAndris

Three points:

Thank goodness for short term crises; they divert from the long-term issues. Mr. Ford's issues have diffused the long-term issues on both the federal and provincial level - a breathe of air to cleanse the pressure on both of those level. This is why all politicians just wait for the next short term crisis; it diverts attention.

As for the NHS - all "high end consumers". will be assigned a nurse navigator, who will assign FDs to each user, including the elderly. We just need more control to gt this fixed. We just need ultimate authority to dictate who must provide care as we see fit. A soon to Ontario product.

As for poverty - when the real figures come out, questions will be asked. Is this model of support working - with more than 50% of the pooled resources going to the "weakest" 10%, are we seeing enough improvement?
November 15, 2013 | Unregistered CommentermovingforwardOntario
As the geezer generation of FP's retire their " high end consumer" patients will be disgorged into the arms of the nurse navigators who will then assign them to the FP's in the FHNOTs now enjoying the solitude of a capitated practice of relatively well patients...the NP clinics will be faced by the horrors of patients on more than two medications...methinks that the nurse navigators will spare them.

As for the retiring geezers, many remain in practice out of guilt, knowing that their complex patients would be left floating in the world of WIC's and ERs if they retired...problem solved...the complex will be handed over to the nurse navigators to be distributed to the unsuspecting FPs...retire in peace!
November 15, 2013 | Unregistered CommenterAndris
Nurse navigators and coordinated care will all cost more just like team care.This is not a solution when we neither have the money or the workforce availability in the future.

Of note, almost every transformation in health care persists in some form long after implemented even though costs keep going up. Reports fall by the way side and the various consultants and politicians just move on to something else.

When will the tipping point come?

As for crisis creating distraction from other crisis, I agree with you mfO. Kathleen Wynne is breathing a sigh of relief I expect. I wonder if she is going to wade into municipal politics to oust RF? That could be a pandora's box.
November 15, 2013 | Unregistered CommenterMerrilee Fullerton (realist)
Seems like a reasonable duty of care, presuming appropriate services are actually available.

"Named accountable GPs will take the lead responsibility for ensuring that all appropriate services required under the contract are delivered to each of their patients aged 75 and older.

Where required (based on their clinical judgement), the named accountable GP will need to work with relevant associated health and social care professionals to deliver a multidisciplinary care package that meets the needs of the patient."
November 15, 2013 | Unregistered Commentereklimek
Well the massive job losses in my old neck of the woods won't help…Essex county survives on the auto industry and a thriving cash crop farming community

Windsor will soon look like its rotting neighbour to the north..and we used to count on Detroit as our safety valve since many US docs took OHIP rates (paid less but was certain money).

NP issues are becoming more serious IMHO. I called the family MD on the management (and diagnosis) of what was obviously a rip roaring otitis media in an adult treated with ear drops…family doc did not change tx despite noting it was otitis media. Patient ended up in ER with ENT. Are family docs too scared to override NP care?
November 15, 2013 | Unregistered CommenterOutpatientPharmD
The NP's ear ache App algorithm likely stated that antibiotics were not required...her gelded FP evidently would not over rule such "medical evidence".

Many an ENT CME advised against treating OM's....although they seem to be changing their tune in recent years.

I recall in the 60's mastoiditis, brain abscesses and meningitis secondary to OM's...rarely seen any more.
November 15, 2013 | Unregistered CommenterAndris
Looking through media accounts of the changes in the GP contract the theme seems to be ..." The buck stops with the GP( FP)".

The powers that be are devising a system where the buck stops with the FP...and no higher...the powers that be design the system, manage the system, the FP's are impotent in designing and managing the system that they work in...yet they will be held responsible for whatever transpires.
November 15, 2013 | Unregistered CommenterAndris
You forget the collaboration of the OMA in co-management of a 1960s system that gov't can't fully fund in 2013 plus.
November 15, 2013 | Unregistered CommenterMerrilee Fullerton (realist)
The placebopaths are at it again but this time they want the ability to diagnose and treat medical disease instead of restricting their practice to wellness care.

"The medical groups question partly the list of drugs naturopaths would be allowed to employ, from epinephrine to lithium and intravenous magnesium sulfate for pregnancy-induced high blood pressure.

“Such treatment in a non-hospital setting is extremely dangerous, as the risk of seizure in the mother and death to both mother and child is very high,” said the College of Physicians and Surgeons in its submission.

The Ontario naturopaths association says full access to laboratory testing is essential to the practitioners’ safely diagnosing and treating patients."

November 15, 2013 | Unregistered CommenterCanary in a Coal Mine
All an effort to get power.

Now in response to political power, what does one get in Ontario. At the municipal level, every effort to maintain power despite management issues, at the provincial level, prorogue as needed to avoid accountability, and at the federal level, the same.

It is broken, but we've all accepted it, as long as we stay away from the margins.
November 16, 2013 | Unregistered CommentermovingforwardOntario
The issue of "governance" is attracting international investment concern. Given Ontario's struggle with jobs on an international basis, do wise global investors put money into situations where:

1. Government contracts are gain or lost based on "pure" politics - eHealth, ORNGE, power plants?


2. Risk investment, when on a "whim" , proroguement or municipal politics can adjust the negotiating power based overnight? These are not goo principles to promote on an international level.

There are consequences to arbitrary actions. Moving to third world governance standards may not be a desirable route.
November 16, 2013 | Unregistered CommentermovingforwardOntario

The premier will not need to step in, in the GTA. It would be similar to appointing a supervisor, meaning all in council would lose power, thus jeopardizing their runs to replace the current mayor. It won't happen. It will just muddle on for a year, diverting attention from provincial issues, and delaying subway action.
November 16, 2013 | Unregistered CommentermovingforwardOntario
<<Moving to third world governance standards may not be a desirable route.>> - mfO

Seriously, mfO?

From where I sit we are already there. In fact, a banana republic would be reasonable option. Except that Ontario doesn't have a proxy for bananas...

And no one want to import our key exportable product: poor governance.
November 16, 2013 | Unregistered CommenterExecutive Lead Blogger
Third world growth in first world illness

(Reuters) - German drugmaker Merck KGaA has invested 80 million euros ($107.67 million) in a manufacturing plant in China, the company said on Friday, underlining the importance of the market for global drug firms.

The Shanghai-based facility will come online in 2017, producing drugs to treat China's fast growing number of diabetics as well as cardiovascular and thyroid disorders, Merck's biopharmaceutical unit said.
November 16, 2013 | Unregistered CommenterEklimek
<<...producing drugs to treat China's fast growing number of diabetics...>>
- Dr. E. Klimek

Excellent point - North America's other export: diabetes!
November 16, 2013 | Unregistered CommenterExecutive Lead Blogger
I expect the anti Pharma types will be conjuring up the image of a conspiracy
contrived by BIG Pharma to propagate diabetes world wide...

Diabetes, Cancer , Dementia are triple threat with many causations. Instead of preparing more ways to get more care for more people, Canadians are fed a continuous stream of solutions that won't work.

Conrad Black does have a way of putting things:

November 16, 2013 | Unregistered CommenterMerrilee Fullerton
As the buck stops at the FD's office.....
I read in the Medical Post that the definition of a "disruptive doctor" has been expanded to one who exhibits passive resistance to the system, who does not "cooperate".
Will re-education camps suffice to make such doctors more compliant and less "disruptive"?
November 16, 2013 | Unregistered CommenterJRL
Overt passive resistance a la Gandhi, Martin Luther King or Rosa Parks doesn't work well in the face of totalitarianism ...a more subtle form of resistance is to "work to rule"....one can completely grind a system to a halt by observing all the rules , regulations and guidelines.
November 16, 2013 | Unregistered CommenterAndris
Totalitarian ideas proliferate. Young Trudeau referred to system of government in terms of utility to achieve, in this case, economic goals quickly. The intrinsic value of personal liberty is thus devalued. among doctors as well personal liberty has a hard time vis a vis economics as they are led into a situation where they risk losing both.
Of course totalitarian ideas are currently presented, not by guys in black hats and with black uniforms, but by charming people wearing white hats. The totalitarian ideas are then not recognized for what they are.
freedom exists for a while. Sic transit Gloria......
November 16, 2013 | Unregistered Commenterjrl
Resistance is futile.

Join the dark side.
November 16, 2013 | Unregistered CommentermovingforwardOntario
Sounding a bit dark.... No need.
The Ontario gov't is shoveling $$ into programs that won't work to improve outcomes, it is 270 Billion in debt with billions in deficit, manufacturing is not coming back and green energy has turned into a dead weight. Feds are not bending to the provincial demand for federal dollars that are believed to be limitless.

Pain will drive change. It's really too bad because it didn't have to be this way.

We are assured by the right medical consultants all is fine, the tide is turning, the health care cost curve is being bent.

All is fine.
November 17, 2013 | Unregistered CommentermovingforwardOntario
Ha! Yes, the sage advice by the "right medical consultants" has done nothing. The only thing that has bent the cost curve is the economic situation that req'd severe rationing of services and less than decent negotiations between the OMA and the Ontario gov't...the old 4x0 approach. OMA should have seen it coming. After the last negotiations in 2008, the OMA team came out gloating. I suggested that would be the last time they get any deal close to what they got and in the next negotiations MDs would be much worse off (I did not use those words exactly).

OMA should have seen it coming. There was no reason for shock. It mistakenly believed that the collaborative relationship with government would pay off for them. The co-management of the system is going to be very painful for MDs. Perhaps it is deserved for the lack of foresight and self-serving nature of the organization that represents them. After all, the OMA Board has a fiduciary duty to support the organization whether or not it means adequately representing all of its members.

The Ontario government may hold the medical profession as a whole by its toes or other body parts but does it hold the individual physician in such a dominating way? I don't think so.
November 17, 2013 | Unregistered CommenterMerrilee Fullerton (realist)
MFO the tongue firmly implanted in the cheek....the health care consultants, clutching their MBA's ( most from the USA, Harvard most likely) have reassured the health care bureacracy that the advice given by the establishment quisling medical consultants, fishing for future government sinecures, that they are on the right track.

One cannot have a parterniship between two unequal parties, one party on whom all agreements are binding with the other quite ready to tear it up at the blink of an eye.

That the weaker " partner" believes that it is on an equal footing with the stronger party reveals the naivety of the weaker party.
November 17, 2013 | Unregistered CommenterAndris
The rise in A&E visits in the UK NHS explained by aging population ??
Coupled with the closure of walk-in clinics, the aging population will only just begin to have an impact this year. The aging will not crest for another decade or two.
How do we get the public to grasp that, as the docs lose the power to choose, so do their patients?
Ultimately this power has to reside in the power to access a parallel private system. In the UK I think the unions grasped this before the professors did. Here the unions are either slow or less motivated to help their members.
November 17, 2013 | Unregistered CommenterJRL
A good model for considering these political-economic changes is chaos theory. The ripples of unintended consequences unfold. Each disturbance creates different ripples. Hopefully enough disturbances will result in the right consequences.
But the predicting part is difficult.
November 17, 2013 | Unregistered CommenterJRL

I have had to reduce my time on here as we have been swamped lately with patients who cannot get into their FHNOT clinics and don't want to wait in the ER for 4 to 8 hours to get seen. Our volumes currently in November are what we normally see in the Xmas holiday period and the odd thing is that I have only seen maybe two cases of influenza to date this year. In other words as the FHNOT clinics sign up more patients but are unable to see them for basic needs such as script refills and sick kids we get swamped. Last Sunday over 70 patients came through the clinic and not one case of influenza was seen. It is very clear that as more and more docs convert from FFS to capitation the rostered system cannot handle the volume of visits so the ER and FFS clinics pick up the slack. It is about time that the rostered docs on capitation were negated dollar for dollar with no group cap if the government really wants to bend that curve instead of paying for the visit twice as they are currently doing.

I wonder if it is considered disruptive behaviour to explain to these patients that their physician gets paid whether they show up or not and that their doc is now more interested in rationing care as an agent of the state?
November 18, 2013 | Unregistered CommenterCanary in a Coal Mine
November 18, 2013 | Unregistered CommenterCanary in a Coal Mine

The system is built on double payment. It is just tax money, it's not as if it's directly out of your pocket.
November 18, 2013 | Unregistered CommentermovingforwardOntario

The system is fine. The bulk of the herd is getting the care it needs. It is just that the margins are increasing a bit. Central knows, but doesn't need to worry as long as no single group gets to large.

The OMA contract will be fine. Most members will be close to stable. Only a few will be impacted badly.

Central will protect the core. The core is fine and well funded.
November 18, 2013 | Unregistered CommentermovingforwardOntario

The system is fine. The bulk of the herd is getting the care it needs. It is just that the margins are increasing a bit. Central knows, but doesn't need to worry as long as no single group gets to large.

The OMA contract will be fine. Most members will be close to stable. Only a few will be impacted badly.

Central will protect the core. The core is fine and well funded.
November 18, 2013 | Unregistered CommentermovingforwardOntario
The core is presumably consists of the FHNOTs, NP clinics, the hospitals, the LHINs and Links...the FFS/ FHGs and WICs are presumably not.

One suspects that the attack on the politically incorrect and unpopular but highly productive, efficient and effective FFS/ FHGs/ WICs will continue...pushed to the edge and then over.

Culling the strong from the herd leads to ?
November 18, 2013 | Unregistered CommenterAndris
It would be very interesting to know what percentage of Ontarians are now rostered to a capitation model or NP clinic?

50% or higher?
November 18, 2013 | Unregistered CommenterCanary in a Coal Mine

About 75% of family physicians are in alternative funding models.
November 18, 2013 | Unregistered CommentermovingforwardOntario
...that includes FHG's...which are not FHNOT's.
November 18, 2013 | Unregistered CommenterAndris

PostPost a New Comment

Enter your information below to add a new comment.
Author Email (optional):
Author URL (optional):
All HTML will be escaped. Hyperlinks will be created for URLs automatically.