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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Bending the Cost Curve Can Be Deceptive

This journal entry was prompted by a discussion on the cost savings efforts being put forth for end of life care. There has been concern voiced by various groups about futile care and how valuable health care resources are used in our dying days. Bending the cost curve at the end of life is seen as a way of improving use of health care dollars and quite a lot of effort has been put into pushing an agenda of "advanced care planning".

I am certainly supportive of palliative care efforts and supporting patients and their families in the process of dying. However, it has crossed my mind that these discussions were not had before now to any significant degree. While there has been the occasional Supreme Court case every twenty years or so regarding physician assisted suicide, there has never, to my knowledge, been so many efforts to advance end of life planning.

Rising costs to the health care system of government funded services near the end of life are one reason for the new found angst over "bending the cost curve" but is it true that encouraging limiting interventions and treatments in final years of life will save our single payer system from it's own success?

I don't think it will.

The reality is that dying is quite inexpensive....people have been doing it for a very long time at zero dollars.

Here's why all the fuss over costs at the end of life will make little difference to the sustainability of single payer care:

Longevity is increasing at approximately 3 months per year. As we get better at prevention, people live longer lives.

If you don't die from dysentery, diarrhea, pneumonia or child hood diseases, you grow up.

If you grow up and don't die from infectious diseases or war or trauma, you live to older age.

If you live to older age, the likelihood of having heart disease and cancer rises.

If you survive your cancer, diabetes, heart valve problem or quadruple bypass you then go on to have a 1 in 2 chance of dementia for which nobody has any good treatment right now and likely won't for a very long time. It turns out that our brains are complicated.

So all the efforts we provide in terms of prevention, or being "proactive" as Dr Hoskins likes to say, end up pushing up longevity. All the diseases we manage to stave off are replaced by others.

And I'm not trying to be negative about this. I'm simply pointing out the reality that the better we get at providing all the prevention and quality care, the longer we live and the more things there are to provide and screen for.

There will be no true bending of the cost curve other than by distorting it over a much longer timeframe or by rationing using indices created by government. If you fall outside the standard line that gov't draws, you are out of luck. In the current health care arrangement of "single payer only medical care", you have no options should your needs not fit the standard or vote-determined priorities.

We've said all this before but it is worth repeating because bending the cost curve isn't going to happen in any significant way. We might appear to be reducing costs at the end of life but that won't make up for all the screening and interventions that will need to occur in the last DECADES of life due to advances in genomic understanding and epigenetics as well as other technological advances.

The only way out is a Hybrid system. The "prevention" and "proactive" stuff isn't going to save single payer.

Now, let's get on with forging the way forward with a Hybrid system.

What legislation needs to be eliminated, changed first?

How should the innovation beyond gov't single payer be supported?

Who should support it?

When should it be started ?

What do you think? What are your suggestions?

Reader Comments (435)

Dying Canadian veteran stuck with $61Gs medical bill 47


Dying Canadian veteran stuck with $61Gs medical bill
Jim Holt, a former Canadian fighter pilot, is stuck with the burden of a $61,000 bill from OHIP. His family plans to fight the province before a committee in the next 30 days. (Dani-elle Dube/QMI Agency)

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OTTAWA - Veteran Jim Holt has stage 4 cancer, two months to live -- and a $61,000 medical bill.

The 79-year-old former Canadian fighter pilot had been living with his wife in Italy and Argentina for the past 12 years.

But when a fractured vertebra brought Holt back home, doctors at the Ottawa Hospital found that the cause of the fracture was in fact cancer.

Even though Holt had remained a Canadian citizen and continued to pay a quarter of his pension income to Canadian taxes, OHIP slapped him with the hefty bill.

"After you've paid your income taxes all your life you feel kind of like the country has some sort of obligation towards you," Holt said. "But it turns out that OHIP doesn't quite believe that."

Doctors at the Ottawa Hospital and the Elisabeth Bruyere Hospital, where Holt is now, were nice enough to waive their service fees. The cost of the tests and the hospital boarding in the three-month probationary period with OHIP that racked up the bill.

So when Holt turned to his private insurance for coverage, they told him he didn't qualify because he had returned to his home country.

Holt first saw doctors in Argentina in November after suffering back pain. They told him it was a fractured vertebra.

At the time, Holt and his wife were already making plans to return to Ottawa to live closer to Holt's kids.

The day after Holt stepped off the plane, he applied for OHIP. He also wanted to follow up with Ottawa doctors for his pain and that's when they found the cancer. After a blast of radiation treatment, Holt lost the use of his legs.

He now lays in his bed on the hospital's palliative care floor, his last days with his family overshadowed by his fight with OHIP.

"It's very frustrating and it's taken away a lot of time we should have had together," said Caroline, Holt's daughter. "We shouldn't have to spend our last moments together worrying about this."

Holt finally received his OHIP card Thursday, but for him it's $61,000 too late.

Holt and his Toronto lawyer, Perry Brodkin, have taken their case to the OHIP Eligibility Review Committee.

But it's a long shot. According to Brodkin, all 200-plus appeals that have been presented to the committee have been denied.

"We're faced with unfairness and injustice," Brodkin said. "And when I go before the board I'm going to argue one legal issue after another. It's going to be all law before the board."
February 5, 2015 | Unregistered CommenterStephen Skyvington
He should have entered Canada as a refugee from Argentina....
February 5, 2015 | Unregistered CommenterAndris
It's an interesting point. There are people who have paid taxes all their lives into the Ontario hc system but then can't get the coverage for the care they need.

Where are the MDs from Doctors for Medicare on this one? Nowhere to be seen or heard. Their interests aren't really about patients.

It is not about patients. It is about control of what patients get to do.
February 6, 2015 | Unregistered CommentermovingforwardOntario
Should learn today whether the campaign to add euthanasia to the list of "active therapies" physicians must deliver, becomes available. Remember, "conscientious objection" will cease to exist, shortly. Mandated servitude with no conscientious objection" not possible.
February 6, 2015 | Unregistered CommentermovingforwardOntario

The end of health care as we know it
Liberal contract imposed on doctors features $580M in spending cuts
Stephen Skyvington
Hamilton Spectator
By Stephen Skyvington

"There can be no justification for doctors turning away patients or rationing care. We don't believe Ontario's doctors would let that happen."

— Dr. Eric Hoskins, Ontario's Minister of Health and Long-Term Care

So this is where it begins. The end of Ontario's health-care system as we know it. Going out, not with a bang, but a whimper.

For those who've been out of the country, or just plain hibernating, Kathleen Wynne's Liberal government — for the first time ever — imposed a contract on the doctors of Ontario, instead of having negotiated one with the Ontario Medical Association, on the first of February.

The new deal — I hesitate to call it a "deal" because the doctors haven't agreed to any of this — will feature $580 million in cuts to health-care spending, including a 2.65 per cent reduction in payments to doctors. Funds previously earmarked for weekend coverage will also be chopped, as will funding for continuing education programs for doctors. There will also be a 1.70 per cent reduction in the fees paid to doctors working in walk-in clinics.

As mentioned, all of this was scheduled to come into effect on February 1, assuming ministry lawyers were able to finish dotting i's and crossing t's in time.

Rookie Health Minister Eric Hoskins — himself a doctor — has been particularly busy since talks broke down on January 15, visiting various media outlets in order to explain how he had no choice but to impose these cuts in order to counter the 61 per cent raise in salary doctors have received over the past decade.

Doctors, of course, have received no such raise. But if there's one thing the Wynne Liberals have shown a propensity for, it's perpetrating the Big Lie. Which, in this case, is a doozy.

While it's true that the Liberal government has dramatically increased the amount of money they've invested in the physician services budget since 2003, when they formed the government — going from approximately $7 billion in 2004 to $13 billion in 2014 — it should be pointed out that the province of Ontario has 4,000 more doctors and 1.4 million more patients today than it did when the Liberals took over.

But that's only half the story.

The OHIP schedule of benefits, which is what all provincial governments here in Ontario use to determine what doctors are paid, and which is based upon the OMA's original schedule of fees, dating back to 1922, only covers 47 per cent of the actual recommended fees.

You heard me right — 47 per cent. This means the government of Ontario is paying doctors less than half of what the fee schedule says it should be paying. Forty years ago, that number was 90 per cent. Quite a difference, wouldn't you agree?

But what's most galling for Ontario's 28,000 doctors is that the Wynne Liberals have chosen to punish them this time around, even after they helped the Liberals, if not exactly "fix" our health-care system, then at least get it off life support. Thanks to the hard work and many sacrifices made by the province's physicians, one million fewer people are today without a doctor than in 2003.

And those waiting lists for hip replacements and cataract surgeries? Pretty much under control. Again, thanks to the investments made by the Liberals and the heroic efforts of our doctors.

But that was then, and this is now.

Thanks in no small part to boondoggles and scandals such as eHealth, the Ornge air ambulance fiasco, and the cancellation of the gas plants, the Wynne Liberals are about to go over a fiscal cliff unless they do something dramatic.

So they decided to impose a new contract — not just on doctors, mind you, but on all of us. For the reality is, by making all these cuts unilaterally, the Ontario government is about to do something no other government has ever dared do in quite such a dramatic way — namely, ration health care.

Don't believe me? Here are just a few of the consequences we can expect, as a result of the Wynne Liberals risky and irresponsible move:

• Every March 1, starting in 2016, doctors will be closing their practices until the first of April — when the new fiscal year begins — in order to avoid the inevitable clawbacks that government will impose for exceeding their health-care allotment.

• Surgeries will be cancelled or delayed, tests will not be run, and appointments with both family doctors and specialists will be harder to get in a timely fashion.

• Even worse, can the day be far off when those over a certain age — say 70 or 75 — are denied expensive medical care, and/or other interventions and investigations, simply because there isn't enough money to go around?

Sadly, this is what the future will, in all probability, look like. Thanks to the Wynne Liberals, who now own our health-care system here in Ontario for the next three years, as a result of the contract they are imposing on our doctors, who thankfully had the good sense not to participate in this ridiculous charade.

My advice to everyone? Don't get sick. At least, not in Ontario.

Stephen Skyvington is the director of the Meighen Institute’s Centre for Healthcare Reform and Innovation, and former manager of government relations for the Ontario Medical Association. Follow him on Twitter @SSkyvington.
February 6, 2015 | Unregistered CommenterStephen Skyvington
So, by end of day likely:

1. Euthanasia is acceptable.
2. All regulated HCP members of team care will be obligated to discuss both beginning of life options (abortion), and end of life options (euthanasia), as approved "active therapies.
3. No conscientious objection permitted.
4. MDs in Ontario will do this, with a 4% decrease in price.

The world may be shifting.
February 6, 2015 | Unregistered CommentermovingforwardOntario
That's a dark list mfO.
The pendulum must swing back sometime.
So the Supreme Court rules that the ban on physician assisted suicide infringes on Section 7 of the Charter of Rights and Freedoms....shouldn't it follow that prohibition of payment for medically necessary care is also an infringement?
From the Star no less.

"There must be something rotten deep in the bowels of the Ontario Ministry of Health.

But how else can you explain a bureaucracy that touts home and community care as one of the key elements of our cash-strapped health system, then either silently encourages or turns a blind eye as local agencies slash vital services for thousands of sick and elderly patients?

How else can you explain a bureaucracy that lets senior executives at provincial health agencies get huge pay raises of up to 50 per cent, or $90,000, over three years?"
February 6, 2015 | Unregistered CommenterCanary in a Coal Mine
Here is a link for your enjoyment. I'm surprised we didn't write that here already!
From the link:

"How else can you explain a bureaucracy that lets its new boss, Health Minister Eric Hoskins, deliver a major speech earlier this week about a new “action plan” that was filled with public relations buzzwords about “transparency” and “transformation,” but lacked real details and, at its worst, was a rehash of an “action plan” issued in 2012 by his predecessor Deb Matthews?"

Good find CICM! Thanks!
My wife says she doesn't need a doctor to perform the deed.

When it's time, she'll just step on my air hose herself.

Very independent, that one.
February 6, 2015 | Unregistered CommenterStephen Skyvington

Just an update on the new standards for MD in Ontario as we move ahead:

1. Euthanasia is acceptable.
2. All regulated HCP members of team care will be obligated to discuss both beginning of life options (abortion), and end of life options (euthanasia), as approved "active therapies.
3. No conscientious objection permitted.
4. MDs in Ontario will do this, with further decrease in price.

Those with strong religious beliefs are in a very difficult position.

Physicians no longer as agent of life; they are agents of the state regarding socially valued members whose life has value to society.
February 6, 2015 | Unregistered CommentermovingforwardOntario
The ministry will have to place a coin under the tongues of those selected of transportation over the river Styx in order to pay Charon and the rest of the team before approaching Cerebrus.

No problem for me however, the Valkyries will sweep down and transport me to Valhalla….one huge party for eternity….that is, until we face that final battle against the Frost Giants.
February 6, 2015 | Unregistered CommenterAndris
Interesting times.

So the system will develop criteria for "active therapy" to be provide by physicians where, issues of "life" departure MUST be discussed, for "equitable" care. Perhaps, an active list of the "bad" issues, perhaps, first, a prompt that must be initiated by the client. Regardless, "death services" formally enter the list of mandated services, to be discussed by the public servants. What "code" will be entered into the EMR so that we can confirm each person has had their "life quality consultation"? Is it an annual service, or a service triggered by age? Or it is triggered by one's chronic disease status?

Couple that with the developing discussions about the need for "mandatory" vaccinations, with no opt out, for the good of us all.

Most interestingly, this is evolving in a culture where we know that political level uses eveyr tool it can to manipulate to maintain power. It is the infrastructure we need to work on, as, in the end, if we don't fix it, these very complicated issues, will be misused for political reasons.
February 7, 2015 | Unregistered CommentermovingforwardOntario
In the UK FPs are supposed to identify which 1: 100 is the most likely to die in the next 12 months....and identified as such on their EMR....imagine their care in the health care system when the ticked off box appears on the screen.

Also, don't forget the Liverpool end of life protocol where both the doctor and hospital earn a bonus if the identify a patient likely to die in the next 48 hours....all treatment and support is stopped saving money for the British National Health system.

Canada has mimicked the British NHS and Ontario's version will soon be wonder the powers that be want to eliminate the few surviving paper practices such as mine which provide privacy and safety to patients.
February 7, 2015 | Unregistered CommenterAndris
It will all be fine, with the EMRs, and behind the scene registries, and the decision" that quality of life", exceeds life, the cost curve can be bent.

The plan is good.
February 7, 2015 | Unregistered CommentermovingforwardOntario
EMR & Bending the curve....they are related.
February 7, 2015 | Unregistered CommenterAndris

Assessment of impairment and disability, the underpinning of QALY, will be a friction point. Proceed down this road with care. Anyone involved should have more than legislative authority to proceed. Close scrutiny of every step along the way will occur.

The study and implementation of this social policy will require familiarity and expertise in biopsychosocial evaluation. For this purpose simply generalizing existing scales will be inadequate.
February 7, 2015 | Unregistered CommenterEklimek

We are all in agreement, but we are going down this road, and , with "bending the curve", we are speeding up as the path slopes downward. The overt rationing by the publicly employed , controlled physicians, is accelerating.
February 7, 2015 | Unregistered CommentermovingforwardOntario
It should be apparent cost savings will be limited unless the process can save more than the last few days holding vigil waiting on palliative care. If the driver is cost , then this must be driven much earlier. I am not an economist and will leave that to those knowledgeable.

However, given the finality of the proposal to "accelerate" the end of life, the apparent conflict of interest of an agent of the state/insurer would require a third party well versed in the matter. Dependent upon the definition of a CNS disorder they may comprise 1.4% of all deaths but account for 28% of all years of life lived with a disability.

From a chapter draft - the topic was disability, but you see where I am going with it. ...

"This should result in a growing need for a thorough evaluation by individuals schooled in neurologic disease and well versed in impairment and disability issues. It can not be stressed too much or too often that an evaluation should carefully avoid simultaneous attending care duties. This may compromise both the patient care relationship and cast doubt upon the advocacy role of the doctor.

A patient-physician relationship may be established if treatment and diagnosis is undertaken. This permits allegations of medical negligence, professional misconduct and conspiring with the third party requesting the evaluation to arise in the setting of a disability evaluation."
February 7, 2015 | Unregistered Commentereklimek
Pity the poor new graduate, with strong religious beliefs, coming out into July, into Ontario's new reality.
February 7, 2015 | Unregistered CommentermovingforwardOntario
"A patient-physician relationship may be established if treatment and diagnosis is undertaken."

Under such a premise, what is the "diagnosis", when the treatment is "euthanasia? Unworthy life?
February 7, 2015 | Unregistered CommentermovingforwardOntario
I'm hearing from medical graduates from the past few years who believe that they are obligated to refer for assisted suicide just as they are for abortion or birth control bills.

These are not in the same realm.
Times change. Will this need reevaluation?

"With regard to healing the sick, I will devise and order for them the best diet, according to my judgment and means; and I will take care that they suffer no hurt or damage.

Nor shall any man's entreaty prevail upon me to administer poison to anyone; neither will I counsel any man to do so. Moreover, I will get no sort of medicine to any pregnant woman, with a view to destroy the child."
February 7, 2015 | Unregistered CommenterEklimek

They are the same. Quality of life is now the standard; not life at any cost.

The list will grow, as the curve gets bent.
February 7, 2015 | Unregistered CommentermovingforwardOntario
Perhaps, the resolution of the "quality of life issue", is to make it a responsibility to inquire, not a responsibility to offer. That is, all citizens have a responsibility to assess the duties a citizen bears by having children, or in consuming extraordinary health care resources. As that assessment occurs, where assistance is needed to assess those issues, the CPSO has a list of providers trained to assist, and can make referrals to assist.
February 8, 2015 | Unregistered CommentermovingforwardOntario
You may be close.
I anticipate that MDs will not be climbing over each other to offer Death.

Perhaps the fee will be high....but that could create a conflict of interest. Should it be "pro bono"?!
We have our Shipmans....prize box tickers who believe themselves to be gods.
February 8, 2015 | Unregistered CommenterAndris
Has Kavorkian's time come in Canada thanks to the Supremes?

At the very least, let me buy medically necessary care should I deem that more appealing than Death.
February 8, 2015 | Unregistered Commenterrealist2
The NYTimes has an interesting article on what happens when an universal health care system collapses as in Greece.

Nurses are expensive and hospitals can't afford them, so Greece has seen the rise of non qualified nurses....there are 18,000 unqualified alternate nurse providers ( mostly non Greek) in Greece, working in the black market, doing mostly the night shifts....there is a great demand by patients for cheap inexpensive nursing both in and outside of hospitals as in home care....real nurses are having trouble getting work....retiring nurses are not replaced by qualified nurses
February 8, 2015 | Unregistered CommenterAndris
How hard would it be to verify these nurses credentials rather this is just a symptom of the overall Greek 'problem'. The corruption and fraud probably just doesn't touch nursing care but likely one can find illegal teachers, doctors, lawyers, and yes pilots.

I'm sure if a Greek airline is having financial problems a pilot without sufficient EU regulated hours on a particular model of plane or a non-Greek pilot looking for additional hours in return for lower pay would be hired in order to keep the business afloat.

Tourist beware.
February 8, 2015 | Unregistered CommenterCanary in a Coal Mine
Kavorkian is synonymous for 'end of life pathway'.

Jim Smith was an 85yo who entered hospital with a pneumonia and got Kavorkianed.
February 8, 2015 | Unregistered Commentergot2Bkidding
Just stay away from hospitals, and their need to kavorkianize the major cost centres.
February 8, 2015 | Unregistered CommentermovingforwardOntario
I may be completely off base here, but the Liverpool Care Pathway was initially introduced to serve a specific purpose: to improve communication and standardize end of life care. Period. At the beginning it was never linked to any ''pay-for-performance" scheme.

It became successful and end-of-life care improved at the Royal Liverpool University Hospital and the Marie Curie Hospice (also in Liverpool).

It is in the spread beyond Liverpool where things began to fall apart. Incomplete, misdirected training and introduction of financial incentives to promote adoption bastardized the LCP. The good initial work is now tarnished.

It is an important lesson that has not really been properly learned.

Damn shame.
February 8, 2015 | Unregistered CommenterExecutive Lead Blogger

Good to hear from you!

Yes, I believe that is an accurate description of what happened with the Liverpool Care Pathway. It started with good intention but the slope became slippery the farther it was removed from the originators...which is not too different from what happens quite often with these types of efforts.

People don't like to believe there is a "slippery slope". There is indeed and it comes in many, many forms. Sometimes steep, sometimes insidious.

Wait times in ER used to be considered excessive when they were 90 they are measured in days and for patients requiring admission they wait may be measured in days.

Can you boil a frog on a slippery slope?
I think the most important part of any initiative when it comes to patients is the character of the provider.

Character of the provider vs Pressures of the state

An interesting battle.
" Nearly all men can stand adversity, but if you want to test a man's charracter, give him power".
(Abe Lincoln)
February 8, 2015 | Unregistered CommenterAndris
Back to bending the curve: Daily Mail has an interesting article on British Councils' handling of the elderly... ' Old people auctioned off to care homes on the Internet ....', long term care homes bid on the elderly after knowing their details, the least expensive bid wins....neither the client nor the family may have seen the home prior to the transfer.
February 8, 2015 | Unregistered CommenterAndris
All will be fine. A federal liberal win, money dumps through increase debt on the federal level. Power maintained. The populace remains with free care.
February 9, 2015 | Unregistered CommentermovingforwardOntario
All will be fine

"According to IMF figures, the gross debt-to-GDP ratio in Ontario is more realistically around 95%.

If the average Ontario family were run like the Wynne government, a family of four with a household income of $80,000 would owe $76,000 on their credit cards.

When reality is that terrifying, it’s no wonder our politicians prefer not to tell us the truth."
February 9, 2015 | Unregistered CommenterEklimek
All will be find. Quantitative easing will succeed, once the federal liberals step in and drive it.
February 9, 2015 | Unregistered CommentermovingforwardOntario
heh heh mfO
Here you go Andris:

"One critic likened the system to “auctioning your granny” and said it was like a “cattle market”. Others complained computers only interested in costs should not be making sensitive decisions about an elderly resident’s final years.

However, the system does save money. One city council said it had reduced spend by almost a fifth."


MFO: Trudeau's ability to understand human nature is as bad as Harper's. These parasites are our elected officials. God help us.

PS: how did Wynee do with the OPP in regards to electoral bribery
February 9, 2015 | Unregistered Commentergot2Bkidding
Feb 9,2015

Revenue reduction - done.
Conscientious objection - on its way out within the year
Euthanasia offer by MDs - within 1 year.
Unrestricted abortion offer to be made by MDs - done.
Further physician controlled rationing - in place

The plan is good.

Further revenue reductions - guaranteed

New graduates had better carefully make their choices.
February 9, 2015 | Unregistered CommentermovingforwardOntario
Perhaps we should produce "Survivor Health Care Ontario" starring folks my age who are about to retire and who are not about to play by the rules?
February 9, 2015 | Unregistered CommenterSybil
A book revealing methodology for the elderly as to how to avoid the negative impacts of government health care policies, on how to look after their interests and the interests of their loved ones, in the face of the schemes of the pointy headed central planners.

'Surviving Ontario Government social hygiene policies for dummies'
February 9, 2015 | Unregistered CommenterAndris

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