Dr. Merrilee Fullerton on Healthcare

Well, I could hardly let this topic go by without commenting so here we go.

Most of you will know that the MOHLTC rolled out its first Independent Nurse-led Clinic not so long ago in Sudbury. There are plans for 24 more and one is in the works in or around the town of Lively.  While I can certainly see the position that the Ministry is in when so many patients in that area are without a family doctor and that it may, quite frankly, feel forced to provide primary care by nurses because of lack of other alternatives,  the reality is there ARE other alternatives.

One alternative is that these nurse practitioners  be integrated into already existing primary care physician teams who are ready and willing to accept them. Local doctors have indicated that this is the case but they have apparently been ignored.

Evidently, the nurses involved want their own show and so much for the sweet talk about team work and all that they can provide in a team setting. Why else would government pour perhaps hundreds of thousands if not millions into refurbishing facilities and providing operational costs to the nurses?

And I suppose they could argue that they are going to work in a team setting with a "collaborating" physician but let's be clear....a "collaborating" physician that is in the office once a week or is functioning at arms length is hardly going to be a "hands on" physician and the availability is questionable.

So really, these nurses will be acting independently without the supervision of a physician...which is exactly what they appear to be after whether patients know what they are getting or not. Will the patients have a  choice of who they see-nurse or physician? Probably not.

Numerous studies show the advantages of nurse practitioners in delivering services for chronic care and even their cost-effectiveness in this area.   Numerous studies show that they can enhance preventative care. But this does not mean they should be providing care independently or that they will be cost-effective providing primary care independently. Primary care is not just prevention or just chronic care.

Looking at the numbers based on  320 days per year and considered very conservatively and I admit without all the details:

A Nurse-practitioner seeing 7-12 patients per day at $85,000 to $110,000 works out to about $22 to $37 dollars per patient. But don't forget that their package typically includes benefits and no  overhead plus recently announced  renovation of office space and operational costs at government expense plus the cost of a collaborating physician which has not been factored in nor has the possibility of increased referrals to specialists been considered.

What happens to the wait times of specialists if more patients are referred?

What happens to  interest in family medicine when primary care appears to be taken over by nurse practitioners?

What happens when government ignores dedicated family physicians in the community who are overlooked as a solution to primary care access?

What happens to availability of nurses in hospital settings, particularly rural hospitals, when nurses are diverted to more primary care?

I don't think the MOHLTC has thought this through very well and in my opinion is pandering to the nursing unions.

The nursing unions may want to be careful what they wish for because as the entire health care system is squeezed for cash they will be squeezed as well. Indeed, if  nurses take over primary care over the next decade as the CNA announced in its vision for 2020, they may see their salaries shrink while they take on more and more responsibility that is beyond just nursing training with a smatter of primary care thrown in.

No disrespect intended but I don' t think they realize what they are getting to.

As for our FHTs, I've commented on them before here under the heading of "Cost-effectiveness of Family Health Teams". I admit that I think the funding for these groups is unnecessarily high with $500,000 for governance programs and such that wouldn't be necessary in other settings but I guess if government is willing to throw money around like that then so be it. But that seems to have stopped now in a setting of deficit financing although the nurse practitioner clinics are rolling out with all of their attached funding.

Seems a bit strange to be flitting from one program to another but it is perhaps because government realizes the bind that it is in with the FHTs...it created an entity ill-suited to pragmatism, touted it as the solution and then was swayed by various experts whispering in its ears.

I doubt that Nurse-practitioner clinics will do any better from a cost point of view. They are likely to be more expensive from a cost perspective even though the obvious expectation is that they will be cheaper.

When government has to step in and provide all the support you just have to know that the costs are going to soar. Family doctors running their own offices had incentive to save costs where they could. Not so if government is footing the bill for the np salary and the facility and everything else that will be said to be needed.

This is quite clear with Community Health Centres. A new report by Dr. William Hogg out of Ottawa showed that compared to FFS, FHNs and HSOs, that CHCs provided superior care but at a higher cost-adjusted for case mix, CHCs are more than twice as expensive as other models of care.

Regardless of the model, there are things that can improve care including having a nurse-practitioner and a small practice, according to Dr. Hogg's study.

So it looks like in an attempt to save costs that government will likely spend even more. How ironic.

As an anecdote, an ex-staff member once again came back to our clinic to report her good fortune of finding a position in a CHC. It appears that they have offered her language training on the government dime so that she can learn French. She already speaks English and Spanish but the administrator thinks it would be helpful if she could speak French as well.

Shades of French language training and all its associated costs (and if you live in Ottawa you know too well that language training in government requires at least three salaries to be paid while one is on training....the person filling in will be paid, the person providing the training will be paid and the person taking the training will be paid). And this is likely the tip of the iceberg as I am told the others are offered training of various kinds as well...paid for by government.

CHCs and Indpendent Nurse-led Clinics don`t sound like solutions on a big scale to me and all the while the government ignores the group most likely to be able to provide efficient and cost-effective care...the family physician.

While the costs of primary care can be expected to soar with government`s new initiatives,  the unintended consequence is likely to be more elderly patients who are going to have to pay more for their long term care for more years.  I can explain if you don`t understand but I hate to make things sound  crass. Think about it.

In just a week from now, on January 15, 2009, American Well Systems will put patients face to face with doctors via web cameras and web interaction. Its first customer is Hawaii Medical Service Association, the state’s Blue Cross-Blue Shield licensee, according to an on line article in the New York Times by  Claire Cain Miller. According to the company as reported by Miller, "it will make the Internet version of the house call available to everyone in the state".

While I've been expecting this sort of innovation for some time, I did expect it to emerge on a much smaller scale and the concept that this insurer would initiate the program now is quite intriguing. The service is for patients who are looking for easier access to physicians, who do not want to spend time driving to a clinic or who don't want to make a traditional appointment.

Where do I sign up!?

Undoubtedly there will be some snags along the way as this kind of program rolls out in Hawaii and likely elsewhere. Most importantly there will be the concern regarding the ability to determine from physical exam if there is significant illness requiring immediate intervention. How does one palpate the liver edge or check for rebound and guarding over the internet? 

My impression is that the web based assessment will have greater application for chronic illness and for follow-up than it will have for assessment of acute injuries or emergency assessment although I expect there will be a role for these as well when the ability to transmit information on vitals and physical exam become more enhanced. This can be achieved either by an assistant at the patient end or through improved blood pressure and cardiac monitoring and even lab analysis via the internet.

I wouldn't want to see the personal interaction between professional and patient go the way of the Do-do bird but I do believe the there is great opportunity in this new approach.

It is not surprising that the initiation of this program is occurring in the US although many remote areas in Canada including some not so remote areas are developing more substantial telemedicine. Recently I had a patient only 30 minutes from a major centre who was evaluated by a specialist through a telemedicine system. He still had to travel to a video access centre but all in all he appreciated saving a drive further to town.

This approach is also a green alternative decreasing unnecessary driving and gas consumption as well as time by patients spent on the road or waiting in doctors' offices thereby increasing their productivity.

Elderly patients may avoid risky road conditions in the winter when they can contact their physician's office to arrange this kind of assessment or review of recent blood work or tests instead.

One pitfall to establishing this sort of scenario in Ontario is the College of Physicians and Surgeons of Ontario and OHIP who are quite likely to see this program as difficult to regulate and we know that command and control is really what they are both about. Whether an arrangement suits a patient's needs and the physician can accommodate them  would be beside the point.

Another area of concern would be patient privacy although Generation Y does not appear to have the same concerns about privacy as previous generations. It is possible that Generation Y will not only embrace this kind of technology as time goes on but they will insist on it. Will they be willing to risk having some of their medical information on a potentially hackable system? My guess is Yes for the most part.

This new program in Hawaii will be important to watch and if successful could revolutionize the way medical care is provided in Canada. Of course, the CPSO and OHIP might have to climb out of their dark caves to see the light but  maybe one day they will recognize that the basis for medical care  is between the patient and the provider and the provider's team.

On this snowy day in Ottawa, I wish you all safe driving.....and I'm off to another dentist appointment with my daughter....we'll leave double the time to get there. No way to get those teeth worked on over the internet...yet.

This tangent is brief but worthy of mention as 2009 begins to look like the Year of the Tooth for my family. I'll get back to posting my next journal entry on web care medicine shortly but I think the private care world of dentistry functions quite well for the most part.

Recently I've had the opportunity to experience emergency dental care for my 16 year old son who managed to get his front teeth knocked out playing soccer (yes, I know mouth guards would have prevented this but how many sixteen year old competitive soccer players do you see wearing mouth guards...not a one...except for my son now that we have spent several thousand dollars repairing his teeth!).

And I've had the chance to experience the whole tooth implant business as my husband undergoes the process for an ill-fated root canal done decades earlier by a dentist who did many questionable root canals on likely healthy teeth then skipped off to South America with this assistant leaving family and other responsibilities behind.

And I've just returned from an orthodontist and periodontist for my teenage daughter who through no fault of her own has managed to grow extra teeth where they shouldn't be requiring all kinds of care after oohs and hmmms and my mys from the specialists trying to sort her out. This is on top of the $6,000 bill that we will cover for her orthodontic work...and strangely enough, her teeth look very good cosmetically it is just the lurking danger of teeth that shouldn't be encroaching upon others damaging roots etc.

And not to mention that my hockey playing middle son will be undergoing braces for the next three years at the cost of $6,000 as well just to sort out less than perfect teeth arrangement but long term effect on bite and jaw alignment so necessary overall.

Fortunately, there will be some help with private insurance to cover some of these costs but not the majority. Strangely, there are many people paying for some of their dental care and some who have private insurance combinations with co-pays. We don't hear people screaming and yelling that this is evil and will be the downfall of our society. In fact, many people like me and my family are grateful for the expertise that we can access in a timely way.

As push comes to move public dental care forward and expand the coverage in general, I think this would be good but know that a cost to taxpayers will be essential. I also worry about what kind of dental care we would have in Ontario if private dental care was prohibited. What kind of public dental care system would afford orthodontics for everyone in need of necessary alignment to prevent later complications such as dental decay, gum disease and jaw pain? How many patients would take it for granted expecting care when they drop in and how many patients would be waiting on a list as government dragged out expenses into the future?

Would there be a shortage of dentists, orthodontists and periodontists if they were only government funded? I'll bet there would....and people would be going to other countries to get their care.

Would people's health suffer because of their lack of access? Sure.

Would people be joining union groups to protest the emergence of private dental care? Sure.

I'm grateful for the care that we have been able to access in a timely way and hope that the dental profession will hold its ground against those who wish to see the socialization of this profession as well. They should be able to learn from our mistakes.

So bring on more publically covered dental care while preserving private dental coverage. It seems to work quite nicely.

I must apologize for my relative absence over the past couple weeks but family needs beckoned and  finding  "work-life" balance is easier said than done. Even though I don't consider this blog "work" but more a labour of urgency, taking a blog vacation is a good thing from time to time and helps me see the bigger picture.

Seeing patients over the holidays has also been an interesting process as more and more patients from many government organized  groups are left looking for care. And its not just the patient access to these  "hyper-funded" groups that causes concern but the fact that even staff who receive double time for working in some of these groups come back and flaunt their good fortune in the faces of those front line workers whose former physician bosses are unable to provide the same kind of compensation.

Don't get me wrong...I don't begrudge anyone doing better financially than they did before even for less work but the issue I see is that this kind of "transformation" isn't going to be less expensive...not even in the long run and those picking up the slack are treated as second class....when they are not.

Recently a former staff member now at a  CHC (community health clinic) returned to us to tell about the double time she was making over the holidays and to rave that she only had to register three (THREE) patients at the CHC that day. Meanwhile, our office saw over 100 patients many of whom had significant medical problems....not 24 hour sniffles, who would otherwise have ended up in the long queue at the ER.

Please don't tell me that the CHC keeps their patients so healthy that they don't need to be seen. The truth is something else.

Rather than spend the rest of this post griping about the inescapable likelihood that health care is going to cost more and that the "experts" don't always have the answers...just look at the global financial system and ask yourselves why didn't the "experts" see this coming when many others did. Why?

Is it perhaps because the "experts" don't want to see or are not in a position to see or are not able to  sound the alarm?

An interesting bit from Charles Lewis in the news the other day: "You're on your own-the ugly truth behind the markets: not even the experts have a clue". And you may say that the markets don't have much to do with health care but they do and consider the following quotes on the economy that can be extrapolated to health care:

Professor Homer-Dixon, who teaches at the University of Waterloo, says that "In so many cases our complex institutions and technologies and arrangements and events within our society exceed human cognitive ability. There are so many unknown connections within the system that are really opaque to us...A lot of people at the centre of the storm, who are supposed leaders and senior decision-makers, did not understand major financial innovations and could not anticipate the connections that developed within the system."

Paul Ritvo, a research scientist at the University Health Network in Toronto, is quoted as saying, "It is wrong to say that no one seems capable of fixing the big problems....It is right, however, to say the solutions needed are bigger than ever before. That is where some leaders fade out and fog out. They get anxious about staking their future on a big idea-not because they think the big idea is wrong-but because they keep worrying that people are not ready for such a big change."

Dr. Ritvo explains that what is disturbing is not that some people feel let down by their leadership but that" when we suspect those in charge are incompetent we react with "passivity". In Canada, the impact on the markets could be worse because "of such unhealthy dependency on others to direct our lives".

"Canadian tolerance mixes with Canadian passivity.....We must sustain the tolerance while shedding passivity", says Ritvo.

And to cap it all off, Homer-Dixon explains that what should be learned from all of this is that "next time we should not trust the experts so much. I think people too readily hand over their fate to others. You have to take some responsibility for your own wellbeing and learn about the world. Take part in the democratic conversation and not just depend on experts. Don't assume other people will take care of you."

My intention is not to imply that health care leadership is incompetent. What I do want to emphasize is the magnitude of health care problems that we are facing and that as these two relatively insightful people point out, breeding dependency and passivity is not in our best interests. And yet this is increasingly the accepted norm and even expected goal in health care by patients and physicians.

How do we overcome such passivity and dependency by both providers and patients when it comes to healthcare? I believe it is through creating an expectation of autonomy and empowerment  which may  be achieved when patients have more freedom to interact directly with their providers beyond the reach of government and all of its bureaucratic paternalism. Wishful thinking? Maybe, but Hope may be our most valuable commodity after all.

I welcome you to list what you believe are the most relevant events from 2008 in health care and what you foresee for 2009.

Remember, the experts and health policy types may not have the answers at all and the solutions may come from elsewhere.

Happy New Year (and I really mean it!)

It`s another snowy day here in Ottawa and we have a transit strike to boot. I`m watching the snow plows blast up and down the roadways and thanking the recent drop in oil prices for making this endeavor less expensive than it would have been just a few weeks ago. Fact is, there are many collective concerns that must be dealt with in a communal way. If I shovelled my section of the road and expected my neighbor to shovel hers....well, it might not get done to anyone`s satisfaction.

But health care is a different matter and much more applicable to the individual. As we learn more about genomics and how this will affect patients in the future, some people including experts will say that we are a long way off from having personalized medicine and the  cost of developing medications based on genetic variation isn`t going to be cost effective. Even though I disagree with this opinion, I`m willing to concede that this may be true. However, it won`t stop the use of genomics from being applied in many other areas and the front-end loading of health care will soon be apparent.

Sure, prevention is very nice for the individual, but it isn`t going to save costs overall to the health care system despite what many people are hoping and it is likely to wind up including more use of private businesses. This isn`t bad....just something that must be understood in order to move forward.

Take a look at the press release ``Bio Trove Announces New OpenArray Platform Applications to Identify Pediatric Respiratory Infectious Disease Agents-Children`s Hospital of Eastern Ontario Collaborates with Bio Trove to Evaluate OpenArray Technology for Infectious Disease Testing.

The announcement Dec. 16, 2008 reflects the changing technology that exists and continues to evolve. Rather than treating diseases at great cost to the health care system, money spent on early detection could be very useful. But you can bet your buttons that this will have a cost associated. Prevention isn`t free.

Early diagnosis of infectious disease agents may help protect young patient lives, and ensure that other children and adults do not become infected. Using Bio Trove`s novel research technology, we intend to design an all inclusive assay to rapidly identify and quantify over thirty infectious respiratory viral and bacterial disease targets, potentially enabling physicians to prescribe the right therapies for their patients almost immediately.

The OpenArray(R) Platform enables genomics researchers to increase the number of samples analyzed while decreasing time and cost required leading to `high throughput genomics``.

And so the technology is available. It is likely to be necessary in the future to have this testing available and I suspect that legal cases where poor patient outcome is involved, that failing to provide this testing will be seen to be less than standard care. This front-end loading of health care costs may save some costs at the other end....but there WILL  be costs and more of them as more technology emerges.

The days of government providing all health care for all patients are over. We need to be asking what patients can do for themselves, including paying for some medical care leaving government resources for those who cannot help themselves.