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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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Thursday
Sep082016

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

 

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

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

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

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

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

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

There are some important questions that must be fully discussed.

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

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

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

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

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

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

Reader Comments (556)

That's funny Mfo....and since the budget is essentially frozen and the wages and benefits and such expenses of the growing health care bureaucracy are fixed, proportionally the impact will be all the greater on those who have to live off the residue.

The drop in income of those living off the residue with claw backs is going to be magnified even more....one wonders if it will be minus 30% as some anticipate....those with long leases and fixed expenses are going to go bankrupt.
September 28, 2016 | Unregistered CommenterAndris
Not to mention how that drop in physician income reverberates through the economy with a reduction in GDP. Few office staff hired, getting off expensive and bloated EMR service contracts, looking for less expensive accountants, cheaper vehicles, less money to private schools, etc.. If they follow up federally with loss of incorporation the potential drop in GDP and downstream ramifications on the economy will be substantial.

Add in a potential Trump presidency into the mix and we may have the a real financial problem on our hands in Ontario.
September 28, 2016 | Unregistered CommenterCanary in a Coal Mine
Doctors business models may need to change. Those of us who never were able to bill big bucks will actually be hurt less. We have few staff, few contracts and leases to unwind. There never was a business case to justify the model.

The problems will become public problems as service expectations from facility and hospital privileges become losing endeavours. Currently hospitals have large outpatient departments that are dependent on OHIP billings. They be will dropped as hospitals are obliged to shed unprofitable "noncore" services.

It is going to be very lean by 2018 with only obligatory services provided. Long service closures are coming.
September 28, 2016 | Unregistered CommenterEklimek
One forgets under the upcoming rules, you have a regional privilege for the balance of services you are expected to provide in the regional. The contract will specify the services you are obligated to provide to maintain your regional licence.
September 28, 2016 | Unregistered CommenterMovingforwardOntario
The obligation of attending and providing care will become a friction point. Those who have a contract will need to hold the payors responsible for economic decisions. It has been contested, at the CPSO level, that no doctor must provide services tha t are uneconomic. For ecample, referrals that exceed the capcity and resources of the office may be simply declined on that basis. There are other reasons to decline. It will be interesting when a service vanishes but no one notices until a complaint is lodged.
September 28, 2016 | Unregistered CommenterEklimek
Do note central has begun the staffing up for the command and control management entrenched in Bill 210.We are alreday "ahead of the curve".

Regional licenses and contracts for all, within 5 years. Contracts will NOT include benefits for FFS providers.

All contracts will include job description, job obligations (including hours provide each required service type - hospital, clinic, ED,etc, required CME per year,competency training reviewed each year,mandated review of all MOHLTC policy applicable to area, and all actions to be reviewed and signed off by regional supervisor (non MD).

The days of just opening a practice and going at it are over. Officially. You will only be able to provide medical care under MOHLTC specific review criteria, and in the regions the MOHLTC approves.
September 28, 2016 | Unregistered CommenterMovingforwardOntario
The missing lnk is the supply side. To complete the planning it requires both medical school and postgraduate training to be aligned with policy. Judging by the Ontario apprenticeship programs this may be Minister Matthews task.

https://www.ontario.ca/page/september-2016-mandate-letter-advanced-education-and-skills-development?_ga=1.204529808.1801888509.1475101698

https://news.ontario.ca/opo/en/2016/06/premiers-highly-skilled-workforce-expert-panel-releases-final-report.html
September 28, 2016 | Unregistered CommenterEklimek
It seems that there will be two licences...the Ontario licence and a Regional licence which could be pulled by the Regional managers at a moment's notice over a violation.
September 28, 2016 | Unregistered CommenterAndris
Following passing of Bill 210, physicians become widgets, to be moved as central sees the need. That is done through regional contracts controlled by central, and regional licencing.

It will be an interesting transition.
September 29, 2016 | Unregistered CommenterMovingforwardOntario
"Provinces with older-than-average populations are pushing Ottawa to boost health transfers based on demographics as part of a new national health accord."

http://www.theglobeandmail.com/news/politics/provinces-push-for-more-federal-health-spending-as-senior-population-grows/article32116064/
September 29, 2016 | Unregistered CommenterCanary in a Coal Mine
Taxes will need to go up more, as the revenues shortfalls in health are building .One only hope that central can figure this out.
September 30, 2016 | Unregistered CommenterMovingforwardOntario
Dr F, again if I may, direct a message to MovingforwardOntario? Thank you.

Dear MfO,

Thank you for continuing to interpret and (trying to) explain Central's position on all matters "Ministry of Health and Long Term Care" to regular contributors and lurkers alike. Your efforts are truly appreciated and rest assured I believe that almost all of us are able to distinguish between the message and the messenger.

I do have a question about your recent posting suggesting that Central has been staffing up in anticipation of Bill 210. If the statement is correct (and I have no reason to believe that it isn't) why hasn't the government re-introduced the Bill in the past two weeks since prorogation?

Heck, recently presented the private-member sponsored Ticket Speculation Act achieved second reading in a week...further than Bill 210 got in the sitting before prorogation.

I thought there was urgency to this? Or did I get this wrong?

I completely understand why Central wants to move on this with alacrity. But I have a hard time believing that Central is "ahead of the curve". That is not Central's style...which is more suited to the term "fly by the seat of its pants" than anything else.

[No disrespect to you, MfO.]

That Central has already contemplated and actioned drafting of contracts, job descriptions and accountability requirements is hard to believe. It has yet to finalize renewed accountability requirements for hospitals and they have been on the table for at least two (perhaps three) fiscal years.

Too many mixed messages and conflicting hand signals for me here. Can you please provide some input?
September 30, 2016 | Unregistered CommenterExecutive Lead Blogger
This is what makes it so difficult to practice evidence-based medicine


CMPA Sept 2016 vol 8 no 3 page 18

A young man visits a walk-in clinic complaining of a persistent
dry cough that has lasted for more than one month. He has no
other symptoms. He does not have a fever and his chest is clear
on examination.

The family physician (FP) assessing the patient believes he
has a post-viral cough or possibly a reactive airway. The FP
offers the patient a trial of prescription cough syrup or a
bronchodilator puffer, but the patient declines both, insisting on
antibiotics. After unsuccessfully trying to explain the rationale
for his decision, the FP relents and prescribes a 1O-day course
of antibiotics. He documents in the medical record that the
prescription was written on the patient's insistence.

The patient files a medical regulatory authority (College)
complaint alleging that the physician was dismissive of his
concerns and reluctant to prescribe the requested treatment.

The committee is critical of the FP's decision to prescribe the
antibiotic without medical justification.

The College's decision in this case reinforces that physicians
are expected to use their clinical judgment to determine
whether the medication is necessary and whether the potential
benefits outweigh the potential harms. Also, for an encounter to
be successful, physicians should discuss their clinical opinion
with patients, which are not always easy conversations.
September 30, 2016 | Unregistered Commentereklimek
From the Toronto Life article.

"Hoskins is the most hated doctor in Ontario. When he was appointed health minister, a rumour immediately circulated about him in hospital hallways—and persists to this day—that he’s never practised a day of medicine in Ontario. When I asked him about it, he debunked the myth: since the 1990s, Hoskins has practised part-time at a family clinic in Toronto that serves east African refugees and immigrants. (He still does occasional shifts there without charging OHIP, to avoid any conflict of interest.)"


I think the only reason Hoskins continues to work for free one day a year at the Danforth clinic is so he satisfies the College requirement that he has not sat out of practice for longer than 6 months. Again gaming the system to keep his license active. Mr. Hoskins is a politician pure and simple.
September 30, 2016 | Unregistered CommenterCanary in a Coal Mine
Such hogwash. Dr Hoskins should bill OHIP for his services. He is free to bill zero dollars. Without such billing, does he propose to satisfy the CPSO that he remain in "active practice" by audit of the medical charts?

For those unfamiliar with this technicality, it is an obligatory response upon annual reapplication.
September 30, 2016 | Unregistered Commentereklimek
Exactly Eklimek.

And how exactly is he paying the overhead for use of the clinic use? Or does the clinic owner not charge him overhead? In return for what?

That answer, "not billing OHIP", is only a sly attempt to influence public perception, wheras in reality he is gaming the College rules plain and simple.
September 30, 2016 | Unregistered CommenterCanary in a Coal Mine
ELB

Central is well ahead on planning; way off on implementation.
September 30, 2016 | Unregistered CommenterMovingforwardOntario
Interesting using the CPSO doctor search, Google maps, and reverse postal code search it is apparent Hoskins is doing his shifts in a McMaster classmate's office at 2009 Danforth.

Dr. Haregua Getu is a family doctor who owns the clinic and runs her practice out of the 2009 Danforth office. She is one of the founding members and past president of a charity People to People Canada.
http://www.cpso.on.ca/public-register/doctor-details.aspx?view=1&id=%2055371
http://p2pcanada.org/about-us/

Interesting that in 2009/10 the MOH made a donation to the charity according to the AGM mintues available online for that year.
September 30, 2016 | Unregistered CommenterCanary in a Coal Mine
Canary , a conflict of interest on the part of Hoskins even as he games the system?
September 30, 2016 | Unregistered CommenterAndris
Andris at that time Hoskins was not the Minister of Health but he was part of cabinet and was appointed Minister of Citizenship and Immigration in January 2010.

Not saying there is a connection but found it odd to see a funding donation from the MOH. What other charities does the MOH fund? Anyone?
September 30, 2016 | Unregistered CommenterCanary in a Coal Mine
Ontario Trillium funds 1000s of groups a year. If you apply, chances of funding are great. Just another agency for wealth redistribution.
October 1, 2016 | Unregistered CommenterMovingforwardOntario
I am aware that Ontario Trillium funds programs all over the province but there is a donation marked directly from the Ministry of Health.

I looked through several other Ontario charities and while I saw Ontario Trillium I never saw the MOH making direct donations to a charity. For example there is a donation from OT to Alzheimer's Ontario.
October 1, 2016 | Unregistered CommenterCanary in a Coal Mine
In the meantime, in preparation for the 2018 provincial election Wynne is quietly asking the teaching profession to extend their contract...Wynne has also informed her public unions that she will be " loosening the purse strings" ...in the meantime, the noise is tightening around the neck of the medical profession.
October 1, 2016 | Unregistered CommenterAndris
Yes its funny how net zero is no longer a requirement. Makes the Oma look pretty dumb right now.
Clearly there is more money and the docs were correct in turning down the governments offer.
Imagine the resentment towards the OMA and government if we had accepted the offer.
October 1, 2016 | Unregistered CommenterERDOC
Ipaditis with auto corrector...noose turned to noise.

The OMA would have delivered the membership to the government were it not for the Coalition.

Regardless of the loosening of the purse strings for the public servant unions, the medical profession remains as a target to be squeezed.

Teacher and Public servant votes outweigh the votes of the medical profession....so they will have $'s thrown at them whilst the $'s will be extracted from the medical profession.
October 1, 2016 | Unregistered CommenterAndris
Let's hope the Federal Liberals stick to their guns on reducing the amount of money they transfer to the provinces for health care. That should accelerate the changes needed for sustainability.
October 3, 2016 | Unregistered CommenterCanary in a Coal Mine
As it is the Ontario government redirects federal health care $'s from health care to its pet projects ( I gather bonuses for the Pan American games came from the health care pot) ...why give it more $'s to redirect only to have the government point to greedy rich doctors as the cause of the deficiencies of the health care system with medical doctors told to own the rationing.
October 3, 2016 | Unregistered CommenterAndris
Hi everyone

I haven't posted in a while since I am now providing consulting work in hospital.
However, I still follow this blog regularly.

Recently, my small hospital and several other remote small hospitals throughout Ontario have been inspected (no warning, total surprise) by the Ministry of Labour. Their job? To review if the rules and regulations of the Ministry of Labour has been followed. They have been rude, unforgiving, and humiliate staff, especially with small struggling hospitals who have no resources and those resources are to provide patient care, not paper policies.

They have the power to shut down hospitals and send out fines.

I personally do not think these jack boot methods or inspections themselves have been done without the knowledge of the MOHLTC.

Is this a harbinger of what is to come with the Patient First legislation?

Any comments/information welcome
October 3, 2016 | Unregistered CommenterOurPatientPharmD
Is this a harbinger of what is to come with the Patient First legislation?

In one word, yes.

It will all be about flying under the radar of the MOH thugs.
October 3, 2016 | Unregistered CommenterCanary in a Coal Mine
CICM

Unfortunately hospitals cannot fly under the radar.

I believe this was a test run, using MOL as a tool. In my hospital, they were stern but polite. In other hospitals they were truly jackboots. Some staff were distraught.

And the visits all occurred throughout both in Eastern and Northern Ontario in one week. Would that the government was this efficient in other endeavours.

MFO any comments?
October 3, 2016 | Unregistered CommenterOurPatientPharmD
So where are those October 1st unilateral cuts we were promised?
October 3, 2016 | Unregistered CommenterConcerned
As discussed,you will be seeing more overt authoritarian command and control coming. Hopefully it will be polite ,but firm.You will do what we believe is best for you.

As for cuts, no rush.No contract, so retroactive cuts, are not an issue.
October 3, 2016 | Unregistered CommenterMovingforwardOntario
How soon mfo?

You stated at one time that the planners were running ahead of those tasked to actually change the system...perhaps the jackbooted thugs attacking the small and remote hospitals are a sign of the "changers" feeling their oats and honing their combatitive skills.

As for no further cuts....is it possible that the unexpected rise of the Coalition of Ontario doctors is a factor?

The OMA will be increasingly under attack from the disgruntled membership from now on...putting the boot into the profession would simply feed the profession's anger and grow the Coalition while diminishing the stature and influence of the OMA , the government's compliant stooge.
October 3, 2016 | Unregistered CommenterAndris
"But that’s just the start. By the end of 2019, the LHIN aims to have 10,000 patients receiving co-ordinated care through Health Links.

“The level of ambition for scaling up Health Links is quite incredible,” Martell told the LHIN board. “It is by far the most ambitious plan for Health Links in the province.”

Failure is not an option, said the board’s chair, Jean-Pierre Boisclair, who called scaling up and sustaining Health Links “a critical must-succeed strategy.

“Ask me what keeps me awake at night,” Boisclair said. “It’s Health Links, and can we get there. We have to land this thing. There is no Plan B.”"

This smacks of desperation. The pattern of behaviour from the Wynne government appears to be, when in doubt...double down! triple down! quadruple down!

It's unnerving. It doesn't have to be this way.

No Plan B. Please. Is this leadership?
what keeps him up at night...Health Links.
Someone ought to tell Mayor Hector MacMillan.
How foolishly heavy handed--it will backfire:


https://www.theguardian.com/politics/2016/oct/03/jeremy-hunt-promises-to-end-nhs-reliance-on-overseas-doctors-after-brexit
October 4, 2016 | Unregistered CommenterMerrilee Fullerton
R:

Approximately 50% of the budget will be retooled,and focused on 5% of the population,directly under government edit. Services provided will be controlled and rationed by central, through its widgets, to the clients. True authoritarian control.

The plan is good.
October 4, 2016 | Unregistered CommenterMovingforwardOntario
Who will want to go through med school with all of its trials and tribulations, not to mention expense, to become government "widget"?
October 4, 2016 | Unregistered CommenterAndris
Andris

It will take a full generation before the social engineering impacts applications to medical school. And let's not forget that post secondary education is the only available option for many in this economy. Those without marketable skills or family business will always view professional faculties as an option.
October 4, 2016 | Unregistered Commentereklimek
"Growth in medical school enrolment has simply continued because the government continues to fund it."

http://healthydebate.ca/opinions/medical-school-enrolment-is-an-expensive-mystery
October 4, 2016 | Unregistered Commentereklimek
In Quebec the powers that be have decided that there are too many doctors and are planning to slash training positions....they seem to feel that it is much like turning a tap off and on and then off.
October 4, 2016 | Unregistered CommenterAndris
The powers that be will also have to address IMG entry.
October 4, 2016 | Unregistered Commentereklimek
By decreasing medical school enrollment, Quebec will likely make the same mistake Ontario did in the early 1990s and was caught only having to re-establish and expand medical schools later on. Some say we have not yet recovered.

Can we all repeat Barer Stoddart?

Surprised that Quebec does not mention that they should bear a social responsibility to produce French-speaking physicians for the rest of the country and La Francophonie.
October 4, 2016 | Unregistered CommenterExecutive Lead Blogger
Can someone explain why the Minister of Health and Long-Term Care has not yet re-introduced Bill 210?

There are less than 30 sitting days left in the Legislature before it adjourns on December 9, 2016. It does not reconvene again until February 21, 2017.

I have heard that they want the LHIN-CCAC mergers to be done by April 1, 2017.

Meh...take your time. It's not like there is an election coming anytime soon.
October 4, 2016 | Unregistered CommenterExecutive Lead Blogger
Feds are waiting for completion of Day case presentation before they step in to propose a national MD human resource plan for them to run. they coordinate but provinces draw from,thus confusing the blame system. Big lobbying doe NPs and midwives to get full "partnership"in drawing on health resources.
Bill 210 doesn't need presentation ti implement. Order in council can move things forward with less discussion.With the confusion over the OMA issues,why add a second pressure point for the opposition to dwell on in open debate.
The fight with the AG over budget accountability is proving more open and concerning than expected.
October 4, 2016 | Unregistered CommenterMovingforwardOntario
<<Bill 210 doesn't need presentation ti (sic) implement. Order in council can move things forward with less discussion.>> - MfO

Wow. I cannot recall another time in the past 30 years (give or take) where an OIC was used to push a Bill through. Any precedence in that time frame that I am forgetting?

I didn't realize that the current government was considering it a leading option. Remember they do have a majority and the Bill would easily pass a vote in open session.

That going the OIC route is under serious consideration speaks to an overall lack of accountability. Given that there are collateral alterations to 20 other Acts it suggests to the public that there is "something in all that to hide".

In my opinion, bypassing the Legislative process would hand both opposition parties a lot of ammunition for a very long time. I would think that the government may be better off taking the hit as a "one timer" and then - if the transformation is spun as being successful - hold that over the opposition at the next election.
October 4, 2016 | Unregistered CommenterExecutive Lead Blogger
ELB

It is not that OiCs will be used, it is that they may be used. Central's popularity is plummeting,and is dependent on the federal liberals doing something magnificent to prop up the Ontario government. That timing needs to be in about 12 months,so the "magnificent thing" can carry through to the provincial election.

Central has begun to hire into the intent of Bill 210.Numerous provinces have moved to regional boards. Perhaps the"magnificent thing" is a federal health money drop, only to jurisdictions which have in place legislation assuring regional control and local management of the federal money drop, with its attached rules and accountability. Opposition to that might be seen as obstructionist and denying access to needed new money, particularly if LTC and home care for seniors were included. Might swing some voting blocks? Throw into that mix, Pharmacare for those over 65, a lot of votes could be shifted. Remember we now have unlimited capacity to run deficits.

Lots of very intriguing politics going on. Remember this is about maintaining power, not health care.
October 5, 2016 | Unregistered CommenterMovingforwardOntario

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