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. 






Maintaining the Pace and Hitting the Wall

I recognize the need to give hope and maintain optimism but I also believe in looking ahead. The ability to anticipate is important when it comes to health care but often we are left analyzing data.

One of the knocks against the way SARS was handled in Toronto was aimed at the delay that resulted from a prolonged debate about key issues such as the need for, and effectiveness of, the N95 respirator mask which was supposed to protect health care workers.  Time was spent discussing what size of droplet would be the most infectious instead of arranging for the most protective masks and equipment for front line pandemic fighters in case things got ugly. Labour boards will now be involved early in any kind of process like SARS to protect workers and hence the public.

Lesson learned: If something seems dangerous, it probably is and action is required.

So it is with interest that I see CIHIs report from January 10, 2007: Trends in Acute Inpatient Hospitalization and Day Surgery Visits in Canada, 1995-1996 to 2005-2006.

Highlights in summary:

-Canadian acute care hospitals handled 13.4% fewer hospitalizations in 2005-2006 since 1995-1996. (Of note however, is that the downward trend began to reverse in 2003-2004 with a modest annual increase of 0.6%,0.4%,0.2% over the last three years. Ontario has shown an increase in the number of hospitalizations since 2002-2003.)

-Day surgeries were up 30.6%.

-The absolute number of hospitalizations has started to rise in the last three years but the age-standardized hospitalization rate continued to decrease over the 10 years.

-The number of days spent in acute care hospitals also decreased by 13.1%.

-Increasingly surgeries are being performed in a day surgery setting ( increase of 30.6%) compared to inpatient hospital setting (down by 16.5%) .

-Total number of surgical events has increased by 17.3%.

This information may look good on the surface but it raises several concerns:

If hospitalizations are decreasing in general, one would expect that this would impact healthcare in a positive way. But health care costs are still rising across Canada including in Ontario.

Efficiency is apparent in the ability of hospitals to provide 17.3% more surgeries and to provide 30.6% more day surgeries. All well but we need to ask if this pace of efficiency can be maintained. The fact that hospitalizations have started to increase modestly over the past three years is a sign that it can't, especially when we face continued aging of the population.

The age- standardized hospitalization rate is declining but is this a fair way to consider the status of the system? Age-standardized rates are adjusted for population aging and account for population growth (via rate calculations). Fact is, our population IS aging and growing so adjusting to take into consideration the age and growth of population could give false optimism. The actual numbers of surgeries performed and hospitalizations are what will generate costs to the system whether they are age adjusted or not.

With the growing number of day surgeries and the growing number of aged citizens, one can wonder where these patients are recuperating and what the rate of complications is. Accordingto Caroline Heick, CIHIs director of health services information, patients are being cared for in other settings such as the community, home care or long term care facilities. Many of these costs are hidden and outcomes unreported.

So just like the auditor general in Ontario has suggested wait time reports need to be taken with a grain of salt, we need to understand what the decreases in hospitalization rate and increases in day surgery rates mean. At some point, the decrease in hospitalizations and decrease in length of stay will negatively impact patients and outcomes just as early discharges did for mothers and babies when they were discharged too quickly from maternity wards in the not so distant past. At what point will this happen? Who is measuring the outcomes? Who is measuring the costs being borne outside the hospitals?

The SARS lesson should have taught us to value the ability to anticipate even though analyses are helpful and make decisions more comfortable. We cannot always act based on fact, sometimes we need to act using common sense.

This CIHI report gives statistics that could give a false sense regarding health care delivery. They do not tell the whole story. Our monopoly system may hit the wall , but I am still hoping for vision and foresight. Is that too much to ask?


What's It Going to Take?

Working over the holidays it became clear to me that patients will have to get much more vocal about their lack of access to medical care before things will improve.

I watched the line-up stretch out the door and down the hallway at 9am yesterday when I arrived for my shift at an urgent care medical clinic.

Patients knew to come early and the line wasn't much better by the time I left at  3pm, with no lunch, no breaks and insufficient staff. But it is the best we can do considering physicians are hard to come by.

 Needless to say, I saw many patients who can't find a family physician and the Family Health Teams in the area  supposedly taking new patients with their new nurse practitioners don't seem to be, or more simply:   they aren't making a dent in the gradual demise of the family physicians in the area.

The brouhaha over the emergence of nurse practitioners seems to be mute and neither positive or negative. They just don't seem to be making a difference.

 Nor do all the new facilities we have here in Ottawa.  $800 million of facility expansion is supposed to be good for our area but tell that to the patients who were wearily sitting around the foyer and waiting room of the office building I worked in yesterday. It sure didn't seem to be helping them much.

But the media is starting to get it and an editorial in the Ottawa Citizen questioned the benefit of the large infusion of money into the infrastructure without the manpower to actually service the patients. It is a kind of "build it and they will come" mentality. However, this concept doesn't work well if gov't is rationing services at the provider supply end of things.

I suppose there are individuals who like to leave themselves legacies, a building perhaps, a cardiac institution, a palliative care facility etc. and this is all well. But leaving a legacy by providing more manpower is tough because it is a committment that goes beyond just building the facility. If one trains more physicians in a monopoly system, only the gov't can pay for their services. So there is impetus to control provider numbers. 

The Ottawa Citizen editorial goes on to say: "Politicians like new labs and hospital wings--ministers and MPPs get to clip ribbons at grand openings while people applaud. Nobody cuts a ribbon when CHEO hires a nurse or a general practitioner opens a family practice in Barrhaven.

As always, the underlying problem is that the government rations care--the health ministry, not Ontario's sick and injured, decides when the care is good enough."

 Until we have more honest editorials  like this and until we can get both our political and medical leaders to stop the  "positive" spinning, we won't get any closer to long term solutions.

What's it going to take?







Different Strokes for Different Folks

 Two areas of the country are experimenting with new approaches to healthcare. Quebec and BC are leading with vision and whether their vision is good or bad depends on who you talk to.  But they are allowing evolution to occur within healthcare. One cannot say the same for Ontario, where the status quo is retained at the population's peril where there is an attitude of "short term safety, for long term pain".

Quebec has always been a little heavy handed with its medical practitioners. Probably because it understands many will stay because of language and cultural issues but this is changing. So it is not surprising to see that Queb ec tried to cap specialists wages at about 60% of what their colleagues earn in the rest of the country. "The Special Bill", Bill 27 inspired Quebec specialists to respond and they did, suing the government and encouraging its members to effectively work to rule until the government came back to the table.  Time will tell whether Quebec physicians regard their cultural identity as more important than their ability to earn a living on par with other provinces as talks resume.

Quebec is also attempting to respond to growing medical need of its population by opening  the doors for more private experimentation which seems to be quietly accepted by much of the population. Even Paul Martin used Montreal-based Medisys, an executive wellness centre, whose CEO is Dr. Sheldon Elman, the former PMs personal physician.

Quebec's Bill 33 was slated to pass this fall.  The Bill establishes a role for private healthcare delivery in the public system. It gives doctors permission to run publicly funded, privately owned, for profit medical centres. It will create a wait list management system in public hospitals to determine when overflow patients must be sent to private clinics. It ends the absolute ban on private medical insurance which will allow hip, knee, and cataract procedures. Non-hospital surgical centres (affiliated medical centres) may be allowed to expand into other areas acting as "safety valves". These changes are in direct response to the Chaoulli decision's requirement to improve accessibility to public healthcare.

 As always not all doctors (or patients) agree, but something has to be tried and it is possible that by bringing these centres on in a controlled way  the fear mongering may be assuaged regarding the "private care boogeyman".

In Victoria BC, a new private health clinic has sprouted up called "Options Health Systems". It opened in November and has been criticized for collecting an annual fee for a range of "executive" style health services. It claims to be the first clinic in Canada to bring affordable "executive" care to average Canadians with a fee-based mix of GP services with complementary medicine and alternative medicine. Service fees are $300 a month for year one then $200 a month each subsequent year. Patients get a minimum half-hour visit with guaranteed same day appointments.

As mentioned previously on this blog, boutique practices are springing up quietly but executive care has been around for years. Why should the elite executive have access to more care than the average senior? Why should a person who chooses not to spend their retirement income on a car, be refused the liberty of spending their money on an annual fee to provide themselves with more time with their physician and more medical attention?

Interesting that Don Copeman, founder of the Copeman Clinic in Vancouver, tried to establish similar clinics in Ontario but was held off by the MOHLTC.

 In some parts of the country, patients are allowed to spend their money on healthcare, while in other jurisdictions the same clinic is banned.  So much for consistency across Canada.

 Quebec and BC may differ in their approaches, but at least they are willing to try new approaches on a small scale and see where it leads. Ontario seems to want to keep plodding, afraid of it's public shadow.

Not a bad plan to evolve and respond to the changing medical climate; just remember what happened to the dinosaurs and how more agile and adaptable organisms managed to survive.

Let's hope Ontario figures it out before its too late. 








The Attitude of Gratitude vs. Entitled to Entitlement

Premier Dalton McGuinty has admitted that three years after promising to reduce wait times, cancer surgery wait times have gone up.

A quote from the Ottawa Citizen: “It is absolutely true that we have some real challenges with respect to our cancer procedure wait times….The fact of the matter is cancer surgery wait times are up overall by 6.2 percent,” he told the legislature.

Now, to be fair, the Liberals did set up reporting of wait time data so that we can actually measure what is happening in a few areas but it is my understanding that this was tied to receiving more federal funding and part of what the 2004 federal money was earmarked for. One could say that the province felt some pressure to come up with the wait time reporting.

But in any case, what happens now?

In general, you don’t hear people congratulating the Premier for his most excellent “measuring”. People should be able to see positive results with all those billions of dollars pouring into healthcare.

Are they grateful? Well, it depends on who they are. If they are in the group that needed access improved for angiography or angioplasty then they are grateful. If they are the individuals waiting for cancer care access then they are probably somewhat worried and hopeful but grateful might be a bit of a stretch.

We will see more silos popping up on the healthcare horizon as various groups battle for funding not only from gov’t coffers but from donations. Cancer groups are competing with general hospital groups, pediatric hospitals, and cardiac institutions. We see hospital lotteries in direct competition with each other not only within the same city but from other cities as well. The fundraising turf is getting crowded.

People give out of gratitude and they need to have more access to donating mechanisms. Currently, patients cannot be approached during their hospital stay for donations when they and their families would be most grateful. Is it wrong to give money to show one’s gratitude? Is it wrong to ask? Are the patients so entitled to their care that providing an opportunity for patients or they families to make a donation is unethical?

As a society, Canadians seem to have a great deal of difficulty equating money with healthcare. People can manage to avoid donations to healthcare with the excuse that they “already pay lots of taxes for healthcare” and “if I need serious healthcare, I’ll just go to the States.”

More and more, healthcare institutions will be relying on donations. How can we make it easier for grateful patients to give. Or are they entitled to their entitlement?

My suggestions:

1.) Provide patients with websites and internet accessible donating sites.

2.) Create an environment in healthcare which includes an understanding of costs and money involved.

3.) Educate the public regarding the need for acute care and urgent care required in their own cities and the dangers of “outsourcing” lifesaving care.

4.) Educate healthcare providers that the care they provide costs money and government will not always be able to provide all that patients require.

Merry Christmas and Happy Holidays.


The Big Picture and Why I Can't Go Along Willingly

Where is the current agenda of healthcare change headed you ask?

Let us stand back and look at the big picture rather than our little kingdoms and let us look without blinders on and without cheerleading and posturing from politicians.

The Conference Board of Canada , an Ottawa-based, non-partisan think tank whose mission is to bring business people and policy makers together, has spent three years assessing where Canada is headed which will influence the sustainability of our universal healthcare.

In January 2007, the Conference Board’s Canada Project will release its report “Mission Possible: Sustainable Prosperity for Canada”. This research program has taken the rose-coloured glasses off and hopes to provide an honest assessment of Canada’s future.

Sure, Ottawa keeps racking up budget surpluses and our currency is strong but we are slipping in global rankings compared to other G8 countries.

“No one has been talking about our economy being adrift, but it’s an absolute fact,” says chief economist Glen Hodgson of the Conference Board. “The things Canadians cherish-our standard of living, our natural environment, our health care and public education systems-will become unsustainable if we don’t act now.”

“Mission Possible” set out five key areas for improvement and one includes addressing our aging labour force, which of course in my opinion, should include physicians. We need more seniors at work and we should be doing everything possible to keep our highly skilled and highly trained physicians working with as much support and incentive as possible.

I do say this without bias. I say this as a daughter of aging parents, as an aging individual myself, and as a mother to my children. As much as I appreciate what other healthcare providers offer, or even what complementary health care can offer, they do not offer the skill or expertise of a physician.

The first wave of baby boomers is about to turn 61, an average age for retirement for Canadians. Next year, 2007, will be a big retirement year where boomers are likely to be retiring in droves, physicians included. (Perhaps by coincidence, my eighty year old father’s physician is retiring in January with no one to replace him, not even me, as it is unprofessional to treat one’s own family and one risks the reprimand of physicians’ regulatory bodies.)

According to Hodgson, we have only about 10 years before the wave starts to undermine our economic performance and social well-being.

“Mission Possible” points out that immigration alone cannot come close to making up for the impending shortfall.

We will undoubtedly see that the numbers of IMGs being recruited from other countries will not make up for the physician shortfall in Canada. Also of interest, is the net migration of physicians to other provinces, mostly Alberta and BC, leaving Ontario with a net loss of physicians in 2005 as shown by CIHI.

Other countries are now doing more to enable older workers to extend their careers, including financial incentives, training programs, placement services, phased retirement programs and pension reforms. “Mission Possible” says Canada should do the same.

So why are physicians, particularly in Ontario and Quebec, seemingly under attack by government and its “transformation agenda” when our aging physician workforce should be supported and enabled?

Is it because other groups have managed to position themselves in the political arena and physicians have been too busy caring for the sick while others have found the most advantageous political seats? We have put veterinarians in charge of closure of hospitals, few physicians sit on LHIN boards in Ontario (except in rare instances in which I will not elaborate in this public forum) and we see more nurses taking on more prominent positions within the transformation hierarchy while physicians seem to be shunned.

How is this a balanced approach to finding solutions to provider shortages in healthcare, access shortages, and funding issues?

Instead of blaming medical workers for healthcare expenses, or creating more groups to scrutinize and regulate, we should be talking about how patients can contribute; how we can empower our providers to keep working; how we can allow market forces to help dictate numbers of physicians and other providers; how we can find other acceptable ways for Canadians to purchase healthcare, electronic medical records or other items that would contribute to more efficient healthcare.

Some say that physicians should just lump it and accept the transformation as it is unfolding; that it is a done deal.

I say that accepting this transformation is a big mistake and that more compromise is needed, more realism is needed and more understanding that sharing the facts with the Canadian people is necessary.

I guess time will tell, time we may not have.

As always, I am interested in the perspectives out there, particularly regarding non-physicians who might have something to say regarding contributing individually to EMR’s, to contributing to co-operatives, to how they might support their medical manpower.

Because ultimately, you don’t know what you’ve got ‘til it’s gone.