Dr. Merrilee Fullerton on Healthcare

When we talk about health care, we talk in the billions, and in some cases trillions, of dollars and in time spans of decades and in physicians and nurses per 100,000 population. Numbers are really, really big in health care-- REALLY big.

Planning that utilizes statistics both past and present and then attempts to extrapolate this information to the future is tried, but with significant error, because the world isn't static and neither is science or technology or the economy.

Just a year or two ago, there were suggestions and even insistence that growth in Canada's GDP would be sufficient to offset the rising costs of health care. A great deal has changed since then and no matter how we wish things could be different, we really do need to face reality.

An excellent article recently in the National Post by Terence Corcoran pointed out some significant facts:

* The federal deficit (not debt) for this year, originally estimated at $50 billion is now pegged at $55 billion

* According to Finance Minister Jim Flaherty, by the year 2015, the series of deficits expected over the next few years will run up the national debt (not deficit) by $170 billion

* Ottawa's total net debt will rise to $628 billion meaning about $19,000 per capita which isn't much different from 1997, the peak year for federal debt.

* Provinces and local governments are also running deficit budgets.

*Ontario is heading for a deficit of $18 billion this year with deficit budgets likely for years to come.

* BC, Alberta, Quebec, New Brunswick and Newfoundland....all riding deficits....to the tune of about $31 billion this year alone.

* Canada's provinces are likely to add close to $100 billion in total new debt over the next five years.

* Added to the provinces' net debt of $274 billion as of the end of 2008, this additional $100 billion will bring the provincial net debt to $375 billion by the end of 2015.

* Add $375 billion in provincial net debt to the projected federal net debt of $628 billion by 2015 and you  are looking at $ 1 trillion (TRILLION) in debt...about $30,000 per man, woman and child.

So...the message is likely that to turn this trend around, cuts to government spending will be needed and possibly more taxation. Either one on its own is painful. Together they are even more concerning.

With health care being the biggest portion of all provincial budgets and with federal funding for health care already having been dished out fairly lavishly to the tune of billions and billions only back in 2004 (remember, the "fix for a generation" by Paul Martin) one wonders where anybody gets the idea that   we are going to get the funding to shorten wait times, add a national pharmacare program or adopt new and increasingly expensive diagnostics and treatments let alone contribute to improved education programs and environmental initiatives or to withstand the economic blast of a serious pandemic.

No doubt about it: The public is going to have to be more self-reliant when it comes to their health care whether through monitoring their own chronic illnesses, using social networking sites to connect with others who share the same illness or through funding their own procedures or preventative care.

Once again, I'd like to thank all of you regular contributors that keep this blog going despite my occasional respite. Of all the health care blogs and even non-health care blogs I've visited, this one has the most ongoing contributions. Kudos to all of you for the great input.

The readership continues to grow and I'll be looking at additional ways of bringing more opinion to us. Welcome to Dazzo and a welcome back to Lurker. We all look forward to hearing more from you as well as from our very informed regulars.

Recently I've been struck by the emotional and divided response to President Obama's call for health care refrom in the US. Various individuals and groups on both sides of the discussion have been vilified from time to time and it just doesn't seem like a very tolerant way to go about debating or advancing improvements in health care.

Can't we just get along and allow individuals who want to spend on their own health care to do so whether through health savings accounts, tax free savings accounts, or transgenerational insurance or other?

Can't we just agree to disagree and then let individuals find what works best for them? We've done this in many areas. Why not in health care?

One of the biggest criticisms of Canadian health care recently is that there isn't enough government money spent on prevention and wellness--we are disease oriented in terms of providing health care. That's a fair criticism but look a bit deeper and it may be surprising to find that prevention won't save health care dollars which is why there are discussions about health care reform in the first place. If there were sufficient funds to cover everything for everybody, there would be no debate or even need for reform.

As much as there are many people devoting much time and energy to the promotion of better health and health outcomes, we need to be honest about the cost of such programs. It seems that the underlying premise is that more prevention will save health care dollars. But such may not be the case.

We should first mention that there is a difference between individuals being in charge of their own prevention and taking responsibility for their actions or inactions versus  government funded health prevention programs that take into consideration mass screening, large amounts of pharmaceutical use, and a large scale push toward incentives and pay for performance for providers.

As much as prevention would seem to offer up cost savings, the potential outcome of more government organized screenings and primary care prevention at the provider level (and here  I  make the distinction that the latter should be seen as separate from public health type policies that allow for clean water, improved sanitary conditions and clean air and environmental awareness) to cost more, not less, is quite real.

I will post the link to the Congressional Budget Office and its information on overall cost savings on prevention in health care and also the link to the letter that is mentioned.

Now some of you reading will think that I am a real dope and that I don't believe in prevention. That is not the case. I do believe in prevention. It's just that I don't believe prevention will save the health care system in Canada any money. It will cost MORE. Let me repeat that. Prevention will cost MORE.

On an individual level, better prevention of all kinds will provide improved quality of life. However, costs of health care prevention measures must be weighed against the need for improved education for Canadians as well as the need for more social programs such as adequate housing for dependent individuals amongst other important and urgently needed public health improvements.

The idea that more prevention will keep down health care costs is just wrong. It certainly deserves its place but preventative health care needs to be seen for what it is...an individual decision requiring individual responsibility.

Thanks for reading and for your most enlightening contributions as always. I am most grateful for your support.

I`ve got to say that it seems that the MOHLTC has lost its way when it comes to health care reform and and particularly eHealth. The idea that government funds should be shovelled like manure in attempt to have green shoots pop up for electronic health records and electronic medical records is truly disturbing.

It seems that nobody at the helm has an idea of what is coming...either that or they don`t care. Although developing EHR and EMR systems has a place in transformation, the real key is engaging the population in their own health using mHealth initiatives that don`t have to come from government.

If mHealth is a new term for you, let me explain. mHealth is a technology that uses mobile information using smart phones to allow personal information to reach patients and to allow patients to monitor their own health indices. It will allow individuals to be more educated about their health as  well as more engaged and empowered.

If a leader with a smidgeon of vision and less self-importance could be found, then perhaps a real step forward in reform will be taken. Until our health care leaders can distance themselves and their loyal followers from the great ehealth gravy-train then I`m afraid true transformation will languish only to be lavished with millions if not billions more dollars.

While there is little talk of mhealth here in Canada, it seems that it is picking up steam in the US with the likes of Hello Health and Jay Parkinson (soon to appear on the Oprah Winfrey show this month) and conferences that will enable physicians to provide social networking tools for the improvement of their patients`health.

I`ll post a link to a conference in San Francisco in September on mhealth which I`m considering attending without the help of any government funding. I doubt that the OMA is sending anyone.

I also point you towards an article in the National Post today by Alyse Knorr: Social network imperative, for which I`ve been unable to locate the link in the digital edition. It is however, in today`s print edition.

`Social media will become very accepted and even if you`re an IT person or an accounting person, long term you will need to be able to use social media and be able to communicate on behalf of your company,`.....

Social networking and mHealth are coming to health care--only our leaders haven`t figured that out yet and are still dumping enormous sums of health care dollars into feeding eHealth programs which will ultimately be obsolete in a matter of a few years and which serve to feed large numbers of consultants without any significant patient benefit.

Yes, Caplan should go.

People's eyes glaze over when I begin to mention the "dependency ratio". I'm never quite sure whether they don't know what it is or whether they don't care. Could be both or neither. In any case, when considering solutions to health care supply issues, we would be wise to see the bigger picture.

Too often in health care, the experts become expert in a narrow field such as studying how allele MDNP determines happiness or studying the demographics related to how many health providers it takes to attach a ventilator to a patient ...and all the while taking into consideration "is that with or without the help of the internet?"

Sorry for what may appear to be a poor attempt at humour, but the point is that the experts in their own field often fail to understand the relevance of changes happening outside of their own areas and how the importance of their own studies may be diminished in the face of external realities.

To make it simple: Our internal focus on health care and all of its minutiae makes it difficult to put health care into external context whether it be financial or demographic, including immigration effect.

We've discussed the dependency ratio here before but the newest CD Howe report helps put realities into perspective. I'll post the link in the comments section.

Some key points from the National Post on this report:

-Immigration to Canada would need to more than double from current levels, surpassing 600,000 a year, to offset the drag on living standards from an ageing population--a scenario that is unrealistic

-Government must revisit Canada's productivity growth

-Changing demographics left unchecked will cause growth in the workforce and economic output to slow

-Canada would need "huge" increases in immigration-roughly 2.5 times the current pace--to offset the number of elderly people expected to leave the workforce

-the Old-Age Dependency rate-the ratio of Canadians 65 and over to those of working age-will skyrocket from its current 21% level to over 45% by 2058

In this big picture scenario, where the number of workers and falling productivity is a serious issue, how adding more layers to an already exceedingly expensive government funded health care system is going to help the situation is mysterious.

We need to be moving to the other scenario whereby we minimize the layers of providers and create greater expectation and incentive for patients to behave more responsibly and independently. Granted, this won't be easy...but right now we are moving in the wrong direction, guided by "experts" with blinders on and by groups who see their own agendas and not the big picture.

Please feel free to add your comments  on this issue or on H1N1 or on eHealth or Canada Health Infoway......these topics do seem to resurface.

I hope you had an enjoyable Canada Day and are finding time to reflect on the bigger picture!

Kind regards,

Realist

New provincial health ministers are popping up across the country including in New Brunswick, and Nova Scotia and British Columbia but in Ontario, we're hanging on to David Caplan for a while longer at least.

Why the changing of the guard in other provinces?

Clearly, the provinical health portfolio is a toughy and not for the faint of heart. The complexities of the health care system are vast and attempting to solve one problem undoubtedly ends up with others springing up like bad weeds. There are just so many groups that are accustomed to having their usual share of the pie that creating any kind of unknown such as more options for self-pay just seem to  shake the foundations of their existence. This is unfortunate since we do need to boldly go where others have gone already  but perhaps with a slight Canadian twist.

Looking at the push for the US to spend over a trillion dollars in the next 10 years on developing a more universal system, the billions we spend here in Canada seem relatively less significant. But careful with this thinking because as a much less populated country with a potentially shrinking tax base we are heading for much more difficult times. This is my way of saying "you ain't seen nothin' yet".

This is quite possibly why we will see provincial health ministers changed on the fly....except in Ontario where we apparently like to keep them around for as long as we can. It helps deflect blame from those at the real helm  and changing too quickly could create the appearance of indecision I suppose. But government really has no solutions anyway in my opinion, so maybe it really doesn't matter who gets made the scapegoat in the end as long as somebody takes the fall.

Mary Schryer has taken over from Michael Murphy and she will have her hands full trying to patch up the mess that has been created by the government"s unwillingness to honor its deal with physicians there. The New Brunswick Medical Society has threatened to take the Government to court over its refusal to follow through with the negotiated contract.

Her background is as a financial planner and director on the board for the Atlantic Health Sciences Corporation. Sure will be interesting to see if the docs let the government off the hook or if the new Minister can manage to smooth things over. It will be a dangerous precedent if negotiations in good faith stand for nothing.

In Nova Scotia, Maureen McDonald takes on the Health portfolio....a former social work professor at Dalhousie. Evidently, governments shy away from having physicians as health ministers...better to let every other group have a stab at it. Has a physician ever been a Health Minister in Canada? Don't think so.

And last but not least, BC's Kevin Falcon steps into the fire and hits the ground running even if it is with his foot in his mouth. Comments he made about private care have quickly been "clarified" and he speaks of the need for innovation in health care......I hope this doesn't mean just switching to superboards with multi-million dollar deficits as in Alberta....because I have a secret for you: this isn't a solution.

The more things change the more they stay the same and nobody, well almost nobody, has the guts to tell the public that they must have a greater part in making sure we have a strong public health care system which includes allowing more options for self-pay.