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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Private Health Insurance in Sweden, Unemployed Canadian Specialists, and the Rand 

Rigid health care zealots full of intolerance for the needs of people who do not fit their definition of "vulnerable" are damaging the lives of Canadians across the country.

These are the single payer supporters who would have you believe that they are noble supporters of the public, the poor, and the sick. They are not. They perpetuate the status quo that is leaving many people behind including autistic children, elderly dementia patients, and patients waiting years for elective surgery.

The truly vulnerable amongst us who need public health care support are being denied timely and appropriate care while the Unions maintain their self-serving power and workers are forced to join their ranks only to be out of jobs as the economy fails to support ever increasing Union demands.

Despite Paul Martin's Federal Liberal Party's attempt at a "Fix for a Generation" a decade ago and 41 Billion dollars later, patients continue to languish on wait lists.  Despite Premier Wynne professing "fiscal" responsibility, the Ontario Liberal Government has misspent billions of tax payer dollars on eHealth, ORNGE, gas plant cancellations, and failed green energy initiatives. And on and on it goes.

The social responsibility that is so deeply ingrained in Canadian culture is being distorted. We spend more and more on measuring and monitoring in accountability agreements in attempts to respond to government need to demonstrate "efficiency" which remains sufficiently elusive so as not to make a dent in waits or budgets.

Meanwhile, front line care suffers as funds are shunted to providing government optics. Even "value for money" will be an ethereal goal since value very much depends on evidence which is never complete and on the perspective of the evaluator--patient or politician or provider.

Don't misundertand me. I do believe in accountability but only the real kind.

So what does this have to do with Sweden, unemployed Canadian specialists and the Rand?

Canada is the last remaining country in the world to cling to a single payer health care system. It has some of the worst indices in many comparisons with other developed countries. Even socialist Sweden permits is citizens to purchase private insurance. 

From "The Local-Sweden's News in English":

* One in ten Swedes has private health insurance with some giving the reason that this makes more sense than waiting in long public queues for care.

* The insurance plan guarantees that the patient can see a specialist within four working days, and get a time for surgery, if needed, within 15.

In Canada, graduating surgeons including orthopedic surgeons are unable to find OR time to provide much needed service to patients waiting in long queues measured in months and years. Despite having less than the OECD average of physicans per population, Canada is graduating many kinds of specialists who cannot get work in their area of expertise due to lack of public funding and lack of public health care infrastructure.

News of Canadian surgeons travelling to the Turks and Caicos with their patients to access OR time and surgical care requirements has emerged recently from Alberta. Lack of Operating Room time, hospital beds, and nursing and tech support are discussed publicly.

Sixteen percent of graduating Canadian specialist physicians are essentially unemployed in their fields despite growing demand for care due to an aging population with all of its associated health issues and due to a growing population from immigration. Some of this specialist/infrastructure mismatch is due to older physicians staying on longer but the real issue is an infrastructure short fall for ORs and hospital beds and also lack of long term care beds.

Consultants call for more measurement and more coordination/integration within the health care system but the system is already brittle with inherent interdependency that stymies innovation and flexibilty. More coordination is unlikely to work in a complex system such as health care. We need resiliency in a new health care system that can be enabled to adapt quickly to unprecedented change and uncertainty.

There are some simple approaches that can be taken to allow resiliency to develop.

The first is to remove or change legislation that prohibits private provision of medical care such as Bill 8 in Ontario.

The second is to "de-Rand" the Ontario Medical Association. Even though the OMA acts more as the right hand of government nowadays to implement government policy, it does have a role in fee setting which it has less capability to do as funding models become more complex and removed from fees. It is no longer fulfilling its role as negotiating body for all physicians.

Innovation in health care funding that can provide more care to more people in a timely way will only happen when people are given the freedom to change. We have a decade left to move to a Hybrid health care system. We need to start now.

I'd also like to thank all the very supportive contributors here who have kept the discussion going. I am learning first hand about the lack of resources in the community to deal with dementia patients and sometimes my efforts are spent elsewhere.

I'm looking forward to a smoother 2014! Best wishes to All and many thanks!



Reader Comments (476)

from Alberta:
From Twitter:
Canada is worse off than Sweden

Waiting >4m for surgery Can 25%, Swe 22%
Acute beds/1000 Can 1.7, Swe 2.0
MDs/1000 Can 2.4, Swe 3.9
A few decades ago the cry was that Canada should follow the example of Sweden....I didn't agree with them then,but now do...odd that did agitate for Canada to follow the Swedish example have become silent.

Those few who do point to Sweden as an example are pointing to the Sweden of yesteryear and have no idea of the fact that the Swedish health care system had run into trouble and had changed course.
January 23, 2014 | Unregistered CommenterAndris
Sweden seems to have a "compassionate pragmatism" as it evolves its health care and social supports.

Sweden began years ago developing a private hospital. I'm not sure whether it started as private services publicly funded but the private provision of health care including specialty care seems to be evolving to a full Hybrid.

Canadians are being fooled into believing the single payer system can be sustained through efficiency and prevention. That's not realistic.
It looks like the UK NHS is doing some interesting things with wait time stats...

We're not going to change. Far to much entrenchment by those control the system.
January 23, 2014 | Unregistered CommentermovingforwardOntario
"Those that control the system".

The fear of those in control is NOT that allowing private insurance into the system will leave those not able to purchase it behind,

but rather the fear is the loss of control and their insecurity that they will be found out to be incompetent once some private enterprise enters the equation.
January 23, 2014 | Unregistered CommenterConnie LHINgus
One issue is much of what has been designed was based on theories of how health care works designed by economists who had little understanding of health. They create nice theories and the bureaucrats picked up the theories, driven by the right consultants, who drove the briefing books to the politicians, who believed thebriefing books. The theories now are being found not to work, because ththat's what happens to theories. The Grossman theory was one. It has huge flaws but it has influenced the system.

So the underlying theories and principles which built up the system are failing, but your career is based on those theories. You hang on for dear life to the power you've got and you can retire out because you haven't been trained on the new theories.
January 23, 2014 | Unregistered CommentermovingforwardOntario
mfO and Connie...I believe your observations are accurate.

Grossman theory?
Maybe doing some work with the Conference Board of Canada has helped Mr Picard's thinking on health care:
You make a number of solid points here, Merrilee.

Everyone agrees we need change. None of the major stakeholders seems to have the stamina to risk the political capital of entering into a serious conversation about substantive change.

Or, we are all just resigned to the status quo.

We must re-focus on patients: access, quality, choice. We less regulation to let professional providers come up with innovative ways to meet patient needs at the local level.

Thanks again for writing! Your new site looks fantastic!


January 23, 2014 | Unregistered CommenterShawn Whatley
Thanks for the comment Shawn. I agree.
Drop in any time!

I encourage fellow contributors to visit Dr Whatley's site at the link above-always a worthwhile read.

It's impossible to change. It will either keep running, or collapse. The issue of control and power drives the entrenchment, but the demands for entitlements is rising. The push for the expanded pension will have mandated contributions from all.
January 24, 2014 | Unregistered CommentermovingforwardOntario
I see that Saskatchewan is going to miss its wait times targets. Apparently, there was an unanticipated surge in demand. Imagine! A surge in demand...with an aging population... and obese Boomers.

Imagine that....a surge in demand...well, I never!
Collapse will be disguised as End of Life Care policy...?
So what's happening? Seems like everyone knows there is a problem. But who wants change?

Health Minister Deb Matthews says she is troubled by the many letters she gets from Ontarians complaining about bad experiences in hospitals and other parts of the health system and wants to do something to improve “the patient experience.”

"When the Premier appointed me Health Minister, he told me that my job was to forge ahead with the government’s two biggest health care priorities:
•reducing wait times, particularly in our emergency rooms
•and increasing access to family health care.
And he also asked me to do two other things.
The first: get eHealth back on track. It’s simply too important to let up on.
The second: restore Ontarians’ trust …show them that we’re building a health care system for the future and that we’re spending their tax dollars wisely."

Remarks By The Honourable Deb Matthews Minister of Health and Long-Term Care November 18, 2009

National Post January 30, 2012
" ... Ms. Matthews suggested that the province would only pay for those services that are shown to provide a real benefit.

“If there is not evidence to support a procedure or a test, we don’t want to pay for it,” Ms. Matthews told reporters.

"Matthews likes to boast about her action plan’s “progress” over the past year. But failing to address health care’s dirty little secret is surely nothing to brag about."
January 24, 2014 | Unregistered Commentereklimek
A moving post about a hospital pharmacist who went overseas to get his hip replaced (it's password protected so I have excerpted a large amount...)

First, a brief history. My hereditary hemochromatosis may be the reason for premature loss of cartilage from my hip joints. I have had hip pain for over 15 years. As with most joint degeneration, the pain and disability got worse over time, but the last few years have been the worst.

When a principle causes patients to continue to suffer, that’s unfair
The pain and fatigue advanced last fall to the point where it forced me to cut back to part time work, because I was falling asleep talking to patients and dozing off while trying to do pharmaceutical care assessments. Every night, the pain would wake me up dozens of times.

Quality of life is a crucial factor
Despite the recommendation for surgery, my referral to a surgeon was delayed, because the two surgeons in Ottawa I was referred to (no one in Sudbury does resurfacing, a procedure with better outcomes for more active, younger patients) were not accepting referrals due to the lengthy wait list for surgery. I can’t blame the surgeons for not wanting to disappoint still another patient with the bad news of another year or two of suffering.

This is when I began investigating other options, and the only ones I found were outside of the country. Even after the process in Turks and Caicos had begun, I got booked to see a surgeon in Ottawa, so I hoped there might still be a solution. However, the near three-month wait just to see the Ottawa surgeon meant I either had to forfeit my impending and confirmed surgery appointment on the island, or put down a deposit of half the amount of the procedure.

I paid the deposit, but still hopeful, met the Ottawa surgeon. He agreed I would benefit from hip resurfacing, but told me the wait would be over a year, not because he was not available, but because of a lack of beds to put me into in the hospital. I asked him if the facts of my quality of life and inability to do my job would impact the wait time and he had nothing else to offer me.

To me, it is clear that my health system failed me. It will have lots of excuses and misdirection about waiting lists and resources, but the fact remains that I am not the only person affected.

The rationing of health care means that paying for death avoidance comes before reducing suffering; usually with a delay, and all too often with the exclusion of care for the latter. Governments in Canada are clearly afraid to address this issue because the baby boomers need lots of hips and knees and shoulders fixed.

The principle of our universal health care, taken from Health Canada’s website, described as “universal coverage for medically necessary health care services provided on the basis of need, rather than the ability to pay” perhaps defines necessary as life-saving, but not as life-improving, or restoring one’s ability to make a living.

This is evidenced by the apparent inability of government to invest in those types of care, so we may need to rethink who can, or should, pay. When a principle causes patients to continue to suffer, that’s unfair. Let’s quit lying to those people that this part of the system works.

It’s not the patient’s fault
I used to believe that people slipping through the cracks was accidental, and those who did not get the care they needed when it was needed was because they didn’t go to the right place, or because the patient somehow failed to coordinate what they needed to do.

What I have learned from my experience is that a patient can be as educated as possible (I was actually told by a surgeon that I was too educated), and motivated and connected enough to investigate all options (I work in a hospital, and checked with many clinicians, managers, administrators, and programs), and still not get the service they need. I was assured that patients with urgent need do not need to wait for a year.

The public needs to think about whether increased taxes, or a mixed public/private model system, or some other solution, should be engaged to fill in the obvious gaps for suffering, not just in orthopedics, but across the whole spectrum of chronic pain (which the system does a pretty inadequate job of treating) as well as mental health—two notable areas among others that affect quality of life for millions of Canadians and their families (to say nothing of the workplace, productivity, and other increased costs in care caused by inadequate management of these conditions).

What can pharmacists do to help?
The other implication is what pharmacists can offer to help in these problems; and should we wait for a public payer to come along, or begin to provide the service for those willing to pay. The work I do for a limited number of qualified patients could help many others.

I know from personal experience that some health care is worth paying for, and although the challenge remains to convince some of our patients that some services are worth paying for, approaching them may be easier and more productive than trying to convince the public payer. In fact, making inroads in the private health care sector may be the best way to get the public payer’s attention.

Ultimately, there are no medals for suffering more than necessary. Being aware of and sensitive to that fact when taking the opportunity to help our patients as much as possible means understanding all we can do to help. All of what we do has a value and cost to it, and our patients may be required to pay for some of it. That does not mean it is not worth having—in fact, that which you pay for may be the best used and appreciated. A cultural shift for sure, but without it, people are suffering for no good reason.

If we do not learn from our experiences, we are doomed to repeat them.
January 24, 2014 | Unregistered CommenterOutpatient PharmD
Thanks for that OpPD. Once again, a patient speaks out. The reporters and media and politicians would like to think that this kind of issue is simply an "accident" or very rare. It happens all the time.

If this is a paid subscription, I do not want to infringe on copyright, OpPD.
Even if it is gated, it might be better to post the link if you can and I will remove the full text.

If it is intended for distribution then fine. I just want to be careful that we don't overstep.

Dr F

It is not a paid subscriptions but here is the link

Of note, this is a hospital pharmacist and arguably they have some of the best access... Ask me how I know.
January 24, 2014 | Unregistered CommenterOutpatient PharmD
Thanks OpPD!
also of interest:

Who owns your personal health data?
Should it be sold?
Should you give permission?
To whom?
This is a particular drum that I've been beating...privacy has gone out of the window with EMR....those who want privacy will have to find paper based doctors with encrypted penmanship as mine own...they will tend to be the older geezer doctors...the younger generation are completely in love with high tech EMR's , iPads, iPhones and other electronic toys....completely obedient to protocols, algorithms and guidelines ...those who feed the programs will be able to lead them by the nose.
January 24, 2014 | Unregistered CommenterAndris
The system which is being constructed is population health dominates over individual health. ontario is perfecting that system so that, central will try to do it all, but in the end overt rationing will occur for the "common good". Your health is controlled by the state. For those who prosper both fiscally and with good health, it is good; for those whose health fail to meet central "levels", it becomes health care "terrorism", forced to endure morbidity or mortality by others actions of mandated rationing.
January 24, 2014 | Unregistered CommentermovingforwardOntario
As for data collected in Ontario, once in the system is belongs to central, and is being mined and linked by central, to improve the population's health. Central is data mining to separate those in good haelth and thus low consumer of resources, and those in poor health and thus big users. Those in good health will be taxed to the tolerated level to aid those in bad health. Once that tolerated level is reached, if all the bad health can be treated, the guidelines for acceleration of early death will be instituted by those in good health, for the good of the population.

This will not end well, but we do know the end point of the model.
January 24, 2014 | Unregistered CommentermovingforwardOntario
There are plenty of reasons why health care is getting more and more expensive which have nothing to do with cost of providers:
Another reason why we need a Hybrid system:

Dementia care and associated health care costs are going to rise. Politicians should not be denying this long term reality while focusing on Aging at Home strategies that will fail in the future.
What's being built requires some suffering now, so that in generations in the future things "coudl" be better.

The plan is good.

"It will take several generations to realize the full benefit of investments in disease prevention. In the short run, these investments may draw resources away from tests and treatment for some sick people. In the long run, disease prevention and better low-cost technology could reduce the outlay for treatment."
January 25, 2014 | Unregistered CommentermovingforwardOntario
"In the long run, disease prevention and better low-cost technology could reduce the outlay for treatment."

but it will likely lead to increased government costs and individual costs as longevity requires more and more dollars in pensions, in housing, in care providers..
Andris regarding privacy I had a new request this week which I had not seen before but signifies a worrisome trend in the workplace.

My patient had 12 sick days over the last year due to viral gastros and flus and some due to personal issues. He works for a large financial institution downtown. Due to his self-acknowledged excessive sick days this year the institution has contracted another large insurance company (likely with a tower nearby) to provide him with a case manager from the "Absence Management Solution" department. So he has been red flagged to justify the above average absences,....fair enough.

What has raised my eyebrow and I've never seen this before is the employee is asked to consent to giving the third party absence manager his entire health care record for four months prior to the 12 months under question. In other words an contracted 3rd party working for the employer will receive all health information not only about the absences under review, but also for example and not pertaining to this case specifically any health information regarding STDs, marital problems, addictions, and possible expressed concerns regarding the work environment, medications, etc.

The employee is not happy about divulging this material but the alternative is he will lose his job. So the employer is essentially gaining access to one's private health care record through a back door route. On the consent form one gives the 3rd party permission to share all information with the employer.

Anyone else seen this before and is it even legal?

There is a very extensive four page document I must fill out regarding each identified absence and the fee for completing this form will be covered by the insurance company not the employee.
January 25, 2014 | Unregistered CommenterCanary in a Coal Mine
"the employer is essentially gaining access to one's private health care record through a back door route."-CICM

Big Data at its most worrisome...
and no, I have not seen this before..
Health prevention is not equivalent to replacing incandescnt bulbs with LEDs. The up front costs don't necssarily pay off. At best the upfront costs kick acute care costs down the road to a future illness. The cheapest health care is always no care.

In a known risk such as BRCA1 or 2 risk of cancer is reduced with preventive removal of "at risk" tissue. Will that person benefit. Yes that risk is reduced. Will the lifetime use of health care be reduced?
January 25, 2014 | Unregistered Commentereklimek
The upfront cost works to keep you well, however when you become unwell we must limited you unwell costs by capping them. It's coming.
January 25, 2014 | Unregistered CommentermovingforwardOntario
mfO, I suggest that the more we fret over ways to keep us well, the less well we will be. We hit "reasonable" some time ago...Not that there isn't room for improvement, it's just that adding more layers of complexity won't necessarily provide additional "value" to anyone except to the purveyors of new gadgets and gizmos. "Value" in health care is such a cloudy term.

You're correct which is why this will not end well. We are building a social system based on the ideology that we all can live well and be happy, that there is no reason for disease but bad planning. Disease is biology which means they are true causes to disease, including some we will never be able to fix. Until the authoritarian social system occurs, we got a problem. To date we have try to make people who don't want good health to pay for their flaws to cover the expense that costs us all. Tobacco and taxes being the best example.

With a single payer rigid system, those who behave well and achieve good health and then die quickly, lose but support those who behave badly,or have the issues because of bad biology. The issue is those who have minority even major disease which compromise their lives are being left behind because they could have betterlives because they have resources to help, but are denied the "right" to access more resources because that is not fair.

Life's not fair.
January 25, 2014 | Unregistered CommentermovingforwardOntario
We are entering a nightmare...the dream of a liberal medical utopia free of disease and pestilence...the voting public bought the dream, so sacrificing their liberties in exchange for the false promise of a perfect health care system run by a giant reality the Wizards of Oz McWynnie and Matthews ( the female of wizard could be witch...the Witches of Oz?) , hiding behind giant curtains, sitting on stools with their feet too short to touch the ground, pressing buttons and pulling levers, maneuvering mirrors and creating smoke in an attempt to impress the populace and to convince them to vote them back into power.
January 26, 2014 | Unregistered CommenterAndris

We are entering interesting times. Unfortunately, neither of the three parties have roadmaps through it. All three parties will need to raise taxes.
January 26, 2014 | Unregistered CommentermovingforwardOntario
<<neither of the three parties have roadmaps through it>> -mfO

Then is it time for a new party?
January 26, 2014 | Unregistered CommenterExecutive Lead Blogger

It may be time to question whether the democratic system will permit the organizational changes that appear to be needed, to occur. Should we restructure how we, as a collective, want to function? What we currently have, may be failing us. In Ontario, the bureaucracy is not trusted, and does not function well. The political layer is now there to do "good", not govern, and the "elites" and "takers" argue, while those in the middle are seeing their ability to "succeed" diminish.

Innovation is occurring and will occur, but there is concern that innovation in Ontario is on the decline. Not a god position to be in , as the world globalizes.
January 26, 2014 | Unregistered CommentermovingforwardOntario
In the interim, we sit, stuck, until the budget comes down. Then, if rejected, 3 months of delay, and the real possibility of yet again, a minority government.
January 27, 2014 | Unregistered CommentermovingforwardOntario
Any party that calls a spade a spade, that punctures the various collective delusions, will not get elected in the present political climate.

As long as a party can organize hatreds, pandering to the collective delusions, so that it can gain a majority vote , the avoidance of dealing with reality will be evaded.

It is only when a brick wall of reality is hit that the electorate sobers up...but even then, only temporarily.
January 27, 2014 | Unregistered CommenterAndris
I believe the opposite is happening. The general population has become so disenchanted with the political process of lies, denial, and optics when the real problems are festering that it craves honesty.

"Any party that calls a spade a spade, that punctures the various collective delusions, will not get elected in the present political climate."

The question I have is "Are they ready for the full honesty load?"

I'm not sure the public is ready, just yet.
They are still in the "believer" mode.

But it will come. Time has a way of creating change.

Any party that calls a spade a spade, that punctures the various collective delusions, will not get elected in the present political climate.

It's the loud union backed groups like "Working Families" that are of concern.
The public needs to have an equal foil.

You have far to much faith. The general public loves free health care. They will not abandon the free health care system. It can work as well as the free education system. The "free" systems can work. They just need proper funding. Raise the taxes.

Now one must just ignore that fact, that new businesses in New York state, now pay no corporate taxes, and thus on a business point of view, would need to decide Ontario is better because we are trying to be "good", and thus as good corporate citizens being"good" is better that proving revenue to your shareholders.
One must also now remember, the US now has universal health care as of Jan 1, 2014. A huge economic edge Ontario had, has disappeared.

2014 in Ontario will be an interesting transition.
January 27, 2014 | Unregistered CommentermovingforwardOntario

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