Dr. Merrilee Fullerton on Healthcare

The School of Public Policy at the University of Calgary has published a new research paper this month, "The Fiscal Sustainability of Alberta's Public Health Care System". Interestingly, its authors are from Ontario: Livio Di Matteo, Department of Economics, Lakehead University in Thunder Bay, and Researcher Rosanna Di Matteo also from Thunder Bay..and may I suggest that they are probably related---just a hunch.

Having lived in Alberta for a number of years, and understanding the independent mindset that generally exists in the Wild West as well as the boom/bust cycles that seem to create a perpetual whirlwind there, it is almost expected that change will come from such a province. The other province offering up change is, of course, Quebec. I don't mean "transformation" because only  Mr. Smitherman knew what was truly meant by that. I mean real change--- maybe even an evolution/revolution toward more patient-driven care. This change can  occur if patients engage in the responsibility of their own care creating a cultural shift supported by new communications technology and a public health care conscience. If only the system would let them.

It can be argued that Alberta doesn't have a provincial sales tax and this could easily be instituted to offset the rising costs . But things are never that simple when it comes to health care as the authors of this report conclude. Several solutions are presented and not one appears to be "just add more cash to the pot" because....to share a little secret....... the health care pot is not bottomless despite what many well-intentioned doctors seem to believe.

The recent downturn in the economy co-incides with increasing expectation and demand for health care along with  pharmaceutical advancement and technological change that the report touches on. Although ageing in itself is not the main problem for sustainability, it is the various new forms of care and treatments  that an ageing population expects that will be the cost driver.

So despite being just another report on the sustainability of health care in Alberta, I think that this time there is more urgency involved. The big health care train rolls very slowly and we need change faster than the bureaucracy can provide. Not only is health care changing, but the pace of change external to health care is happening at an even faster pace. How to keep up?

And I have to ask:

If Alberta, a "have" province, cannot sustain its level of spending on public health care, how is Ontario, a "have-not" province, going to manage? Surely, not just by shuffling  some federal money around and it doesn't look like the manufacturing sector is going to make a come-back in Ontario anytime soon. Will Ontario be relying on other provinces running deficit budgets to bail it out in equalization payments or are we all going to rely on Saskatchewan? The whole situation looks somewhat precarious.

While Mark Carney pumps out more virtual money and interest rates are held to an all time low, some uncertain times are ahead across the country.

Pertinent points from the report:

First the report summary-

"The long-term fiscal sustainability of Canada's publicly funded provincial health care systems is under pressure from an aging population, expensive technological advances, and expanding coverage that is pushing up against constraints on provincial government revenues. Alberta, for example, enjoys the benefit of energy royalties, but the volatility of this bounty has been high-lighted by the recent collapse in energy prices and the loss of upwards of $6 billion in resource royalties. Other provincial governments enjoy more stable sources of revenue but are constrained in their health care choices by heavier tax burdens and larger public debt loads. This paper examines the challenges faced by governments as they attempt to satisfy the needs of the public today, without compromising the needs of future generations."

-projections of real capital spending on public health care in Alberta over the medium term out to 2030: between $5,339 and $14,215, soaking up between 32% and 87% of total government revenues

-growth of spending on non-medicare categories such as drugs, capital and all other health expenditures are growing faster than either revenue base or the economy. Traditional core medicare areas of physician services and hospitals are not.

-options for sustaining provincial government health expenditures include: choosing what other government programs could be allowed to grow more slowly, what tax rates could be increased to cause the revenue base to grow more quickly, and what health programs currently provided by the public sector could be provided privately

-a portfolio of policies that combines these solutions likely would be a pragmatic policy outcome ensuring the fiscal sustainability of Alberta's public health care system can responsibly provide for future welfare of its citizens.

I'll post the link to the report in the comments section as well as a link from the National Post article by David Gratzer from April 22.

Just when Ontario will produce such a report on sustainability is to be seen. In an era of increased accountability and transparency one would think it would be forthcoming...but shhhhhh, maybe we just don't want to know.

Happy Reading!

Much has been said about the benefits of internet technology in health care. It is said that it will decrease adverse reactions and improve efficiency through cost savings that include avoiding duplication of tests and improving the interfacing of various layers of providers. This may be true.

It is also a big, deep money pit into which government may potentially pour billions and billions of dollars without very much at all to show for it. We have already seen how money bled from a variety of organizations that have since been reincarnated. Intentions were good, it's just hard to get going.

Having said this, I am not against IT changes for health care. They must come. I even believe that we will stumble along spending more money than we'd hoped and making costly mistakes along the way. But we must move forward. The world has changed along with patient expectations and we must start somewhere.

The difficulty I have with the IT spending spree is that there seems to be little room for ground up innovation--the kind of innovation that is spawned by physicians having the freedom to innovate on an independent level to provide service that patients need and want. This approach helps eliminate the costly middle infrastructure that not only adds to the cost, but that delays implementation.

We know that it takes about a decade to change very much in health care. As innovative ideas trickle through the various levels of bureaucracy, some meet their demise because they don't mesh with a government driven agenda. Others meet their demise because they can't hope to meet the archaic vision of various provincial  physician regulatory bodies or even because the public insurance computer systems are so antiquated that they can't be made to accommodate modern requirements.

But during all this evolution, we miss the simple communication tools available easily to many of us, both patients and physicians, right now.

At a House of Commons Hearing on Human Health Resources last week, it was clear to me that some MPs are serious about their responsibilities. Others are not. As a witness at the hearings, I was given the opportunity to ask the other witnesses from various groups questions regarding human health resources. To some this might appear quite strange...witnesses being given time to ask witnesses questions. It isn't the usual process that is for sure.

I am left wondering:

Did the MPs want to provide a courtesy to the witnesses like myself?

Did they not know enough about the subject to ask analytical questions?

Had they not followed the presentations well enough to be able to ask questions?

Why this deviation from the usual protocol?

Please do not misconstrue my comments and questions as disrespectful of the MPs and the process. I am merely trying to understand just how BIG the knowledge vacuum is........and I think it is very, very big indeed.

After attending a session at the Rideau Club the week prior at which Keith Martin was also in attendance, I was comforted to read his comment in the National Post Full Comment section April 7 in which he denied our health care system was the "best" in the world. He even admitted that significant change is required. It was a breath of fresh air particularly from the Liberals who seem to be tied to the mast of a sinking health care ship.

Yes, change must come. We need less regulation that stifles innovation. Hang on, please don't trot out the lack of regulation that led to the demise of the US economy. The whole sub-prime mortgage fiasco there was created by  government that encouraged banks to sell products that had no feet to stand on and is not a result of capitalism gone bad.

In health care, we need to find the balance between over-regulation that smothers innovation and patient-driven care vs regulation that could be beneficial and spawn new ways of approaching patient care.

I suspect that as time goes on and the iGeneration begins to need health care in larger amounts, that the system will embrace change. Just look at Jay Parkinson, Hello Health and Myca (Toronto based by the way).

In the meantime, our health care system will shuffle along, not too different from some of  the aging patients we see----unable to adapt quickly and  uncomfortable with  change.

Well, after a hiatus from my blog with just enough time for reflection on what is important and what is not, it strikes me that the media is terribly good at coming up with catchy headlines and phrases on the economic woes without demonstrating much  solution-oriented substance. I suppose it is a sign of the solution vacuum out there, particularly when it comes to health care.

One cutsie headline reads "Ontari-owe", and another conjures up images of the dirty thirties with rusted out tractors in fields of dust, "Big spending, rusty economy".

As one faithful reader pointed out in the last journal entry, Glen Hodgson of the Conference Board of Canada  suggests that "A lot of people would like to return to the Old World" but the Old World is gone. "This is a catalytic moment for the province," he said and "needed tax reductions would not see the light of day until Ontario decides what to do about health-care spending, which is growing at an annual clip of 8% to 10% and is the single biggest expense item in the budget."

It is clear to me that what we have so far in health care transformation is not patient driven. Government sells the changes as patient centred...but let us not delude ourselves. Taking tax dollars, delivering some form of rationed health care while we pretend we have universal, portable, equitable, comprehensive care doesn't make health care patient-driven. Just because it is seen to be "free", doesn't make it patient-driven.

The public is going to have to understand the cold hard facts at some point in the very near future. Right about Now would be a good time.

Tim Hudak, a contender for the provincial PC leadership points out several facts:

*It took from Confederation to 2002 for the Ontario government to take the provincial budget to $68 billion

*This year Dalton McGuinty will oversee spending skyrocket past $100-billion

*Ontario's debt burden is more than $170-billion

*Program spending has increased 50% to $87.4 billion, or 8% per year, since 2003

*the Liberals have installed excess spending that now exceeds $17 billion a year-spending that will now drive the province into serious deficits

*experts like Warren Buffet are warning that a return to high inflation could result from quick-fix solutions ending in skyrocketing borrowing costs and deepening the financial hole

*Public services, especially health care, are only beginning to grapple with the surging demand and increased costs stemming from the retiring baby boom generation

Hudak suggests we need to cut taxes, reduce red tape and make government more productive, responsive and efficient.

I would suggest that all three options above are necessary in health care but instead we have seen more government driven transformation that involves more red tape, more taxation and which has resulted in a complacent physician work force content to believe that they will be taken care of and lulled into their roles as gatekeepers for government.

Doctors for Medicare is a prime example driven by the concept that what is needed for improved health care is more taxation and that the rise in GDP will sufficiently offset the costs of future health care. How wrong they are likely to be.

What is needed is for patients and the public to fully understand what is ahead and to prepare and take responsibility. Now if only somebody would tell them.

Richard Florida, McGuinty's advisor, may well believe that the future of Ontario is in creative endeavors. He may be right but as long as we cling to the old way of doing things and the old structures in health care that stifle creativity and are government driven, we are destined for a downward spiral. Ontari-owe may turn  into Ontari-ouch.

Thanks for reading along and Happy Spring!

The Health Council of Canada has created a web-site "CanadaValuesHealth.ca" to create a dialogue on a number of topics in health care. If you join the dialogue, you will find numerous topics for discussion. Just reading the posts so far gives an indication of the shallow understanding of health care in general. It is a touch unsettling.

The concept behind the new web-site is that the public is given an opportunity to provide their input and their solutions. Didn't we go through this with Romanow's marvelous adventure almost a decade ago? Seems to me we did...but we are back to the drawing board.

The mantra appears to be that patients have the solutions. Well, the Council may be partly right in the sense it is not the system that holds the solutions but patients themselves.

As  we watch the cost of health care rise along with wait times despite billions of dollars in health care "bail-out" packages, I am concerned that there are still individuals within the health care system clinging to the idea that we can afford all health care needs coming our way. Or perhaps they just need their hospitals to live to see another day.

It really looks like a rather slow and uncomfortable death, for patients, for politicians and even for physicians.

If the Health Council of Canada and the government are going to use the web-site as a way of saying to the public "we did ask for your input...there were opportunities for you to contribute your dialogue....but we still don't have the money to pay for everything that is needed" then fine. If they really think they are going to find solutions by looking at the system in the tunnel vision fashion they are using then we are likely to meet with failure again.

When LHINs fail, after the CEO heads fall, we will see how many years the politicians can keep up with the rhetoric. Maybe about the same time that Obama's shine begins to fade. Reality does hurt sometimes.

Sorry for the delay in getting another journal entry up and going. Perhaps you don't care but I do. I am looking forward to having a little more time in the not so distant future to do what I enjoy, including posting here on this blog.

Best wishes and thanks to all for your contributions,

Realist

Four years ago despite the ruling on Quebec's Chaoulli case,  the move towards increased private medical options appeared  to be a marathon and not a sprint.

I expected that in the years following the Supreme Court decision there would be continued stonewalling by politicians to prevent more options for patients despite government's inability to fund all medically necessary care, including expensive life-saving care. At that time the economy had recovered from difficulties in 2002 and things looked positive for Ontario and Canada.

Well, those of us who support private care options are still running and its been tough slogging in Ontario with its entrenched and vocal unions and not-so-brave politicians but  the finish line may be a few years away as legal process applies some force to political posturing.

Remember Forrest Gump's famous line that "life is like a box of chocolates"--- it is quite possible to be pleasantly surprised but also to have some unexpected finds while one picks through the box. Nurse practitioner clinics, pharmacists prescribing and diagnosing dementia based on dosette signals are just some of the unexpected "chocolates" but I am sure there are better options than these.

In an article by Pamela Fayerman from the Vancouver Sun," Private clinics to take government to court", it is reported that Dr. Brian Day is once again stepping up to the plate in an attempt to make significant changes in health care.

"Private surgery centres across B.C. plan to launch a court action against the B.C. government today to challenge provincial laws that block patients from accessing the clinics."

Representative operators include the Cambie Clinic Surgery Centre represented by Dr. Day, the False Creek Surgical Centre and the Canadian Indpendent Medical Clinics Association attended a press conference Jan. 28, 2009.

"The private clinics are expected to argue that citizens should be allowed to buy private health insurance to use in private clinics if their operative care is not delivered in a timely manner in the public system."

While this case appears to involve the rights to operative care, it is likely to have repercussions in other fields as well.

Provincial governments have two choices . They can continue to increase the percentage of their budgets going to health care in the next few years eroding other socially and egalitarian areas including education and social housing  OR   they can ration care with continued queuing, denial of life-saving care for some patients and with the substitution of lesser trained providers with unproven effects on patient safety or cost-efficiency.

Nowhere in the politically charged discussion in private and public care has there been talk about what patients can do for themselves and how they can move from an attitude of entitlement to an attitude of responsibility. It would appear that government is determined to keep patients dependent and beholden  to government  for health care.

Is  the attitude of government dependency a strong foundation for health care or even for Canada as a nation?

I think not.

Someone rather famous with last name OBAMA recently said  that what is needed is  more responsibility for ourselves, for the country and for the world. And at the same time, he suggests a universal style health care system where the vulnerable are protected and supported. These two concepts are not mutually exclusive.

I suggest that in Canada  a gradual cultural shift is required which encourages more responsibility for ourselves including in our own health. Undoubtedly this could take decades but it could start with a little honesty from our politicians that we can't provide everything for everybody all of the time and those of us who are able ought to be given the freedom to find other ways outside of the government funded health care system but inside our own country.

Thanks for reading and kind thoughts to all of you.