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. 






Now is Not the Time for National Pharmacare

A recent CMAJ article by UBC's Steve Morgan PhD, and Danielle Martin MD and others entitled "Estimated cost of universal public coverage of prescription drugs in Canada" is making the rounds.

The Toronto Star picked this up and is now spreading the word about how affordable a National Pharmacare program could be stating potential savings of $7.3 Billion. This is misleading to say the least.

The abstract from the CMAJ publication includes as background that,

"With the exception of Canada, all countries with universal health insurance systems provide universal coverage of prescription drugs."

What the authors conveniently leave out is that Canada is the only developed country in the world that has a single payer health care system for medically necessary care. It is no surprise that it does not have universal public drug coverage. It can't even afford to meet demand for what it has already created let alone add other programs. The "game changer" CMAJ study conclusion is flawed on multiple levels.

First, let us acknowledge that despite many tens of billions of additional federal dollars in recent years, timely access to care in Canada is ranked last in comparison to many developed countries. The better performing systems are from countries with Hybrid systems that have universal medical care through a combination of  private and public funding mechanisms and which also have publicly funded pharmacare programs and even dental and eye care. 

Until Canada allows provincial health systems to evolve to hybrid systems using combination funding mechanisms, a National Pharmacare program is unaffordable, not because of the cost of the medication necessarily but because of the burden of single payer health care delivery.

It is not unusual for government programs to exceed their anticipated costs and for any savings promised to be elusive. We can look at the cost of Canada's former Long Gun Registry that was anticipated to cost 2 million and which reached 2 billion. Look at the cost of eHealth in Ontario and Canada to understand how programs that start out with predicted costs begin to balloon and cost many billions more than anticipated without even being completed.

Creating an ongoing National Pharmacare program that creates dependency but that can then have no end is a recipe for creating costs that are not affordable despite what some economists and well meaning physicians say. Once it is created, there can be no going back. Unlike the  Long Gun Registry, closing down a pharmacare program and cutting off medication to patients that have grown to expect it is a very different situation.

Look also to Quebec's experience with its publicly funded pharma program. Despite touting its universal public drug coverage for its citizens, Quebec has robbed its medical system to cover its pharmaceuticals. While the shift is not transparently done, it is at least clear that Quebec has difficulty affording access to quality medical care as its citizens swarm Ontario hospitals and MDs for access to care. There are always trade offs.

Other programs in Quebec were expected to save dollars by creating public coverage but did not. Several years ago a CMAJ article suggested cost savings from a publicly funded In-Vitro Fertilization program and yet cost savings did not materialize. In fact, the popularity of this program soared and costs with it so much so that recently Quebec women were encouraged to go about pregnancy "the natural way" with focus for at least three years!

The accuracy of predictions by the CMAJ and some well-meaning medical doctors is suspect. One Toronto-based MD wrote a few years ago that maintaining Canada's single payer system was no problem, our rising GDP was going to save the day. This is a sober reminder that not all of what we believe is predictable is truly predictable. It is a cautionary example of how a more cautious and thoughtful approach to health care is required so that politicians do not promise what cannot be delivered despite the best of intentions. Creating a dependency on entities that cannot be sustained is irresponsible.

Dr Danielle Martin, one of the authors of the study claims that it is with "certainty" that specific claims of cost savings can be made. I caution Dr Martin that in a world that is increasingly unpredictable, speaking in certainties may sound confident but can also be ultimately misleading.

However, there are many other issues with the report that should be identified.

The authors of this study may defend their report citing that savings can be had in a National Pharmacare program through the following mechanisms:

1. Increased use of Generic medications

2. Lower Generic prices generated through bulk purchasing

3. Lower Brand Name prices through economies of scale in price negotiations.

These premises are flawed.

Consider the drug shortages that have resulted in part from governments favouring generic drugs. The pharmaceutical industry is in upheaval responding to new realities in different ways by altering its assembly lines and looking to rebalance profitability. Only people with little insight into complex systems would believe that prices can be driven down through bulk purchases without some resulting compensatory response.

Look at recent concerns over generic drug manufacturer quality issues to understand where this kind of bulk buying will lead us. A National Pharmacare program that relies on "best prices" has potential to also rely on lower quality products without the choice that patients currently have. It also has the potential to reduce access to brand name medications which in turn creates changes in the pharmaceutical industry that are unpredictable. What effect on production will occur? What shortages will result? It's anybody's guess.

One of the other major flaws with this report is that it uses past information to predict the future. This may seem like a standard approach to health economists or to people who do not study major scientific and medical changes such as Genomics or Epigenetics but anticipating future developments is important to understanding the viability of any potential National Pharmacare program. Although specifics may not be predictable, it is clear to see that on the horizon there are many new life altering and life saving drugs. It is arguable that this is the very reason why a National Pharmacare program is needed but until economic conditions have improved, assuring the viability and sustainability of such a program is dubious at best despite the claims of cost savings in the CMAJ study.

It must be noted that many more expensive medications for rare diseases are in the pharmaceutical pipeline. Expensive immunologics and biologics are being developed and have promise for many people. Adding these to many new and expensive medications for cancer as a chronic disease and medications for age related diseases such as macular degeneration, it will be difficult to avoid the lobbying for coverage of more and more medications.

Once again, we will have created a program that creates dependency on public funding and it will distort access to medication as private options become limited or are passed up by patients. A National Pharmacare program that identifies medications it will include based on cost savings will have repercussions when patients are denied coverage due to cost and who have not purchased private coverage, much the way the public health care system fails patients who were led to depend on it and then who are denied access to the care or procedure based on excessive cost to government.

It is not uncommon for patients who have been denied public coverage of a medication for their cancer to have it funded through their private drug plan. A National Pharmacare program has potential to create an expectation by patients that their pharmaceutical needs will be met. This is as unfair as what has been created in our government funded health care system. Funded care may exist, but it may not exist for you despite the fact that you have paid into the system.

Now is not the time for a National Pharmacare program. The CMAJ study makes assumptions that future pharmaceutical demand can be assessed in a snap shot of today and of previous years. This is simply not the case. The affordability of universal public coverage of prescription drugs is currently not possible despite the best efforts of well-meaning individuals to present it as such. Once there is a Hybrid system for medically necessary care in Canada, this discussion could be revisited.




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?


Putting OMA and the MOHLTC Negotiations in Context

Over the years of blogging and writing about health care I've talked a lot about context. That is because without context we cannot fully understand how decision making happens in health policy or the impact of those decisions.

As a disclaimer before I go on:

I will neither lose or gain from the current negotiations. As a retired MD, or physician in transition as I prefer to call it, I will see no monetary gain or loss from the resulting contract. I have no vested interest in supporting the OMA or Ontario's physicians other than to be a potential receiver of care down the road. I have no interest in supporting the Liberal government either as I have seen them dig Ontario tax payers deep into debt while promising many things they could not afford.

You may not like it but let's confront some realities so we can get on with the solutions.

1. Health care IS political. Government has made it that way. It is not MDs who have done this. In Ontario in 2004, the Commitment to the Future of Medicare Act or "Bill 8" was passed. Then MOHLTC Minister George Smitherman talked about strengthening and restoring confidence in our public health care system.The government made it illegal for physicians to provide necessary medical care outside of the publicly insured program. Hefty fines would result and even jail time was considered.

The good times in Ontario were expected to go on for a long time judging from the stance the Liberals took on health care. Either that or the lack of affordability they had created would become someone else's problem once they vacated office most likely within 12 years of taking power.

The Ontario Liberal government had poured money by the bucketful into health care. It dumped money into eHealth, team care, and new models of primary care such as Family Health Teams and Community Health Centres. When a hospital went overbudget to meet demand, money was thrown at it. When patients were being sent to the US because of lack of capacity in Ontario hospitals, Mr Smitherman threw money at that too and the voices of physicians were quieted.

But the good times didn't last and in 2008 the Great Recession hit. The Liberals were stuck. Debt was mounting and all their promises on health care were becoming unaffordable. Almost a decade of flat out spending doubled the debt and drove Ontario to annual budget deficits that were mounting every year. Credit rating agencies were and are biting at the Liberals' heels.

Despite the unaffordability of what the Liberals have created, they continue to insist that it is perfectly sustainable. If only providers would continue to do more with less. If only physicians would agree to absorb all the costs of the hundreds of thousands  of new patients needing care in the system over the coming years.

Supporters of this approach claim that the system is sustainable. More efficiencies, more team care, more electronic health records, Big Data, wearables, more prevention, better lifestyles will create some kind of health care nirvana. I've got news. They don't. They all cost even more.

The politicians won't tell you that. They will not tell you that the system we have created is unaffordable because it would potentially cost them their jobs and their power. They will not tell you that we need to move to a Hybrid health care system because of the risk to their own power and careers.

2. The Ontario Medical Association will also not tell you that the health care system as we know it is unsustainable. They insist that government provide more dollars for more patient care for a number of reasons including the aging population with more complexity and the growing population both of patients and physicians.

The OMA can't tell you that a Hybrid health care system is needed  because they are joined at the hip with the  Ontario government. The OMA depends on the government for its existence. Legislation exists to require the OMA to be the representative body of Ontario physicians. Ontario physicians must pay annual dues to the OMA.

The government has the power to change this which creates a huge conflict of interest for OMA Board members. If they do not support the government and its agenda, the OMA could cease to exist effectively. It becomes the fiduciary duty of the OMA Board members to support the organization not necessarily the best interests of the public or physicians. The OMA cannot  come out in support of a Hybrid health care system that all other better performing health care systems of other countries have. Instead, it must insist that the government provide more funding to the health system even when it is clear that this is an untenable position.

3. The Public is unaware of the challenges facing a single payer system. The government won't discuss the challenges ahead other than to speak of fiscal responsibility. The public needs to know that our ability to fund more and more health care on the backs of a shrinking tax base is unlikely. The new advances in science and technology such as genomics, epigenetics, organ regeneration, cancer as a chronic disease, stem cell treatments, new expensive medications that will prolong life or save the lives patients with rare diseases are here. They cost huge amounts of dollars. They cannot be funded by holding the line of physician income for the next thirty years or longer.

The challenges ahead in health care in Ontario are too great to ever be carried by physicians. The coming costs of care will not be offset by freezing or cutting physician wages. A Hybrid model of health care is needed. The sooner we can all be honest about this we can get on with finding the way forward. In the meantime, the negotiating game continues to the detriment of us all.

We have until 2020-2025 to create the beginnings of a Hybrid health care system like many other countries with systems that provide better access, more care, and even pharmacare. Let's stop the political posturing, look reality straight in the eye and get on with it.



OMA Rejects Government Offer



Vol. 20, No. 1

January 15, 2015

OMA Board Unanimously Rejects Government Final Offer, Ministry to Impose Further Cuts to Medical Services

Today, the OMA Board of Directors unanimously rejected a final offer from the Ontario government that would cut an additional 4% in medical services, and place an arbitrary ceiling on the physician services budget, which would cap the number of services physicians are able to provide to our patients.

The government’s final offer, submitted late Wednesday evening, included:

· $580 million in cuts over two years, including

- $259 million through 9 specific cuts in physician payments, the majority of which impact family practice;

- $50 million in system savings;

- Increasing the current 0.5% payment discount to 1% on all physician payments;

- Further additional increases to the payment discount by specialty of practice.

· A 1.4% one-time payment in year 3.

The Ministry warned the OMA that if we did not accept this punitive offer, it would pursue unilateral action against physicians immediately. We have received details of this arbitrary action and are assessing its potential impacts.

The OMA and the physicians of Ontario have worked hard to build and maintain a positive relationship with government. We have negotiated in good faith to improve the health care system for our patients. In 2012, Ontario’s doctors did our part and contributed more than $850 million in fee concessions and health system savings. To impose a further $580 million in cuts to medical services and payments is unwarranted and destabilizing.

The government’s position will lock in system underfunding for future years and subject physicians to open-ended liability for growth in the utilization of medical services that is beyond our control. It will limit training opportunities in primary care, mental health, and many other specialties. Also, the government’s pattern of heavy-handedness toward doctors, and unwillingness to negotiate reasonable agreements with the profession, will make Ontario an undesirable place to practice.

The OMA will be active in the media and other venues to ensure that the public and our patients understand the truth and the real impacts of the government’s final offer and its arbitrary measures.

We anticipate the government will claim to have offered the profession a modest raise based on the language in its proposal — this is disingenuous and misleading. In fact, government plans to set an arbitrary baseline for the physician services budget that is more than $80 million below current levels, and fund growth of no more than 1.25% per year, despite the current growth of 2.7%. This difference will be funded through cuts to physician payments. Also, the government intends to claw back from physicians through reconciliation any expenditure that exceeds its arbitrary budget.

While we have rejected the government’s final offer, and it has been withdrawn by the Ministry, the OMA Board considers it vital that we share the government’s proposal with all members. We know that members will have many questions, and we will work to ensure that you get the information and answers that you need in a timely and effective manner.

The OMA will undertake an extensive member education campaign to provide all details of the rejected government offer, as well as the Ministry’s unilateral cuts. We are organizing a series of face-to-face meetings and teleconferences across the province.

OMA Council will meet in the near future to review these developments and plan how we intend to move forward championing our patients and supporting our members in the face of the government’s cutbacks.

The OMA has been negotiating with government for more than a year. These talks have been difficult. Since the outset, the government focused exclusively on cutbacks and balancing its budget. We concluded the first round of negotiations in August and were unable to reach an Agreement. We then moved to facilitation, and subsequently conciliation with former Chief Justice of Ontario Warren Winkler. Here too, we were unable to reach a deal. Justice Winkler submitted his report to the parties on December 11. In his report, he suggested the OMA should reconsider the government’s offer, and we did.

The OMA called a meeting of physician leaders, which was held December 20. More than 150 physicians from across the province attended. The Board outlined the negotiations timeline, the government position, and the results of our facilitation and conciliation process. We detailed the challenges at the negotiations table and the significant gap between both sides. We circulated the offer on the table from government at that time and we shared Justice Winkler’s then-confidential report, which will be available on the OMA website. We set out the positives and negatives of the government position, and reviewed the Winkler recommendations and the critical elements not referenced in the final conciliator’s report. Physician leaders provided valuable perspective to inform the final stage of the negotiations process.

The OMA and Ministry reconvened for a brief final round of negotiating that concluded January 9, with the government tabling its final offer on January 14. Today, the OMA Board met to review that offer. After careful consideration of the potential impacts of the proposal, threatened unilateral action, and the valuable input from more than 150 physician leaders who attended the December 20 meeting, the Board voted unanimously to reject it.

This offer will not improve quality of care, nor will it improve public access to medical services. In fact, we know the opposite will result. In the face of this arbitrary action, the OMA and Ontario’s doctors, on behalf of our patients and our partners in the health care system, intend to candidly and aggressively inform the public and all stakeholders about the truth of the government’s offer and the real implications for health care.

I urge all members to stay focused on our patients and avoid divisive actions or any actions that will compromise patient care. We need to monitor the impacts of the government’s measures on the system and our ability to practice. We need to work together as a profession and with our partners in the system to assess our relationship with government, and establish our collective strategy going forward.

I want to thank all members for your tremendous patience during the past year. The Board recognizes that these developments will be frustrating for physicians and have significant implications for your practice and your patients. We have made every effort to convince government that heavy-handedness is not the solution, however, it is clear the government is entirely focused on fiscal targets and not patient care.

The OMA will be communicating regularly with you in the coming days. Documents will be posted on the OMA website and the site will be updated on a continuing basis (www.oma.org).

Once again, I encourage all members to maintain focus on patient care and professional unity as we assess the current circumstance, and let’s work together to address this challenge collectively on behalf of our patients and our colleagues.

Dr. Ved Tandan

OMA President


Oil, Ageism, and Pharmacare

The complexity of health care never ceases to amaze me. It's like a contrarian puzzle--as more pieces are added, the more complicated it becomes with completion made impossible. To put it concisely, it is a "head banger".

Before I go any further, I'd like to take a moment to show my gratitude for the excellent contributors to this blog. Over the years I am continually appreciative of your insight, dedication to shining the light, and persistence.

More than ever, we need common sense voices to be heard above the din of political posturing and above the vocal groups with union backing.

Thank You!

The posts from the past few days on debt, end of life care, executive salaries, OMA-MOHLTC negotiations, inequality theories,  are all connected. The difficult issues surrounding these areas have developed in significant part from a single payer health care system that has been overcome by harsh realities of an aging population, a sluggish economy likely to go on for decades and attempts at political distraction.

First, Ontario has a debt of approximately 300 Billion and growing even as Premier Kathleen Wynne talks deficit reduction. Her calls for federal collaboration really mean, "give Ontario more money" but her Liberal party has not spent judiciously. You all know the various scandals and overspending from ehealth, to gas plant scandals to smart meters, to failed energy policy. Even the Canadian Medical Association has got into the act calling for a National Seniors Strategy aka more federal funding for health care. In fact, there is more federal money being transferred to Ontario but it can't go on.

The price of Canadian oil has dropped precipitously and while customers at the pump might be rejoicing, there will be an impact on federal coffers. We should be grateful that Canada, at least federally, is in a reasonable situation to withstand another economic shock but for political or health care leaders to think that the answer to medical service delivery issues is to go back to the federal pot is undisciplined and indulgent.

I note that Health Quality Ontario is calling for more palliative care support. I can't deny the need for this. How will it be paid for? As we add more layers of care whether it is patient navigators, preventative measures, more palliative care, caregiver support or more pharmacare, there needs to be an understanding that it all costs more...somewhere the tab gets tallied and somebody has to pay unless, of course, cuts can be made elsewhere.

Lo and behold, I am hearing more and more from people who tell me that their aging family member, friend or acquaintance is being denied care. It is typically a patient into their 80s or 90s whose family is told that the hospital bed or resources are finite and that spending on the dialysis or other life saving procedure would not be best use of the public resources. It is both stunning but predictable.

The patient whose family members are able to advocate for medical services that should be legally available to them survive to fight another day. Those who can't are denied care. I thought Ageism was illegal in Ontario but apparently it is being practiced on an ongoing basis led by physicians who believe they are doing the right thing by sacrificing the patient in the name of the system. Even though the courts have upheld the rights of families to determine when to cease life prolonging medical intervention, MDs are taking it upon themselves and their representative organizations are pushing to create a health care environment where some people's lives are seen as undeserving of resources. It is disconcerting to say the least.

The discrimination is occurring quietly but it speaks volumes of a society that is losing its values. The modern medical profession that was once considered a life saving and life preserving entity is now participating actively in denial of care and is in a serious conflict of interest as it is driven by politicians to control costs. This kind of comanagement is not ultimately helpful. It simply pushes costs further out, where they collect insurmountably.

The calls for poverty reduction, more money for social determinants of health, more palliative care, more, more, more go on and on. Today I read Dr Eric Hoskins, Ontario's current health minister, discussing the need for a National Pharmacare program touting the benefits of being able to negotiate better generic prices. I acknowledge the need for more ways to fund much needed medication but a National Pharmacare program cannot be had until a Hybrid system for medically necessary care is created. Tax payers and fee payers cannot continute to add more and more services that must be funded by a relatively smaller tax base. The reality of demographics stands in its way. A National Pharmacare dialogue is a clever distraction from what ails Ontario's health care system but let's be realistic about how it can be funded. Driving up debt at both provincial and federal levels is not the way to a properous country that can provide opportunity for  the next generation.

Oil, Ageism, Pharmacare...they are connected. In a complex world with our complex health care system, we can begin to take measures to create flexibility for patients and in funding of health care. It will require trade offs and a Hybrid medical system that combines a robust public system with private options. We have until 2025.