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. 






Private Health Insurance in Sweden, Unemployed Canadian Specialists, and the Rand 

Rigid health care zealots full of intolerance for the needs of people who do not fit their definition of "vulnerable" are damaging the lives of Canadians across the country.

These are the single payer supporters who would have you believe that they are noble supporters of the public, the poor, and the sick. They are not. They perpetuate the status quo that is leaving many people behind including autistic children, elderly dementia patients, and patients waiting years for elective surgery.

The truly vulnerable amongst us who need public health care support are being denied timely and appropriate care while the Unions maintain their self-serving power and workers are forced to join their ranks only to be out of jobs as the economy fails to support ever increasing Union demands.

Despite Paul Martin's Federal Liberal Party's attempt at a "Fix for a Generation" a decade ago and 41 Billion dollars later, patients continue to languish on wait lists.  Despite Premier Wynne professing "fiscal" responsibility, the Ontario Liberal Government has misspent billions of tax payer dollars on eHealth, ORNGE, gas plant cancellations, and failed green energy initiatives. And on and on it goes.

The social responsibility that is so deeply ingrained in Canadian culture is being distorted. We spend more and more on measuring and monitoring in accountability agreements in attempts to respond to government need to demonstrate "efficiency" which remains sufficiently elusive so as not to make a dent in waits or budgets.

Meanwhile, front line care suffers as funds are shunted to providing government optics. Even "value for money" will be an ethereal goal since value very much depends on evidence which is never complete and on the perspective of the evaluator--patient or politician or provider.

Don't misundertand me. I do believe in accountability but only the real kind.

So what does this have to do with Sweden, unemployed Canadian specialists and the Rand?

Canada is the last remaining country in the world to cling to a single payer health care system. It has some of the worst indices in many comparisons with other developed countries. Even socialist Sweden permits is citizens to purchase private insurance. 

From "The Local-Sweden's News in English":

* One in ten Swedes has private health insurance with some giving the reason that this makes more sense than waiting in long public queues for care.

* The insurance plan guarantees that the patient can see a specialist within four working days, and get a time for surgery, if needed, within 15.

In Canada, graduating surgeons including orthopedic surgeons are unable to find OR time to provide much needed service to patients waiting in long queues measured in months and years. Despite having less than the OECD average of physicans per population, Canada is graduating many kinds of specialists who cannot get work in their area of expertise due to lack of public funding and lack of public health care infrastructure.

News of Canadian surgeons travelling to the Turks and Caicos with their patients to access OR time and surgical care requirements has emerged recently from Alberta. Lack of Operating Room time, hospital beds, and nursing and tech support are discussed publicly.

Sixteen percent of graduating Canadian specialist physicians are essentially unemployed in their fields despite growing demand for care due to an aging population with all of its associated health issues and due to a growing population from immigration. Some of this specialist/infrastructure mismatch is due to older physicians staying on longer but the real issue is an infrastructure short fall for ORs and hospital beds and also lack of long term care beds.

Consultants call for more measurement and more coordination/integration within the health care system but the system is already brittle with inherent interdependency that stymies innovation and flexibilty. More coordination is unlikely to work in a complex system such as health care. We need resiliency in a new health care system that can be enabled to adapt quickly to unprecedented change and uncertainty.

There are some simple approaches that can be taken to allow resiliency to develop.

The first is to remove or change legislation that prohibits private provision of medical care such as Bill 8 in Ontario.

The second is to "de-Rand" the Ontario Medical Association. Even though the OMA acts more as the right hand of government nowadays to implement government policy, it does have a role in fee setting which it has less capability to do as funding models become more complex and removed from fees. It is no longer fulfilling its role as negotiating body for all physicians.

Innovation in health care funding that can provide more care to more people in a timely way will only happen when people are given the freedom to change. We have a decade left to move to a Hybrid health care system. We need to start now.

I'd also like to thank all the very supportive contributors here who have kept the discussion going. I am learning first hand about the lack of resources in the community to deal with dementia patients and sometimes my efforts are spent elsewhere.

I'm looking forward to a smoother 2014! Best wishes to All and many thanks!




Health Reports: Bias or No Bias?

There is no shortage of organizations and institutions reporting information on the status of Canada's health care system. Journalists, CIHI, ICES, Statistics Canada, OECD, and The  Commonwealth Fund come to mind but there are many "institutes" and "centres" that gather data on how long patients are waiting, what they are waiting for and how provinces compare.

What's curious is the huge variation in the conclusions. Some say that aging of our population will not pose a problem. The same organizations report that public health care is fully sustainable.  We just need to be smarter about how we use resources. Big Data is going to be the saviour.

Other organizations use data to show that wait times are increasing and that the aging population will cause social entitlements to buckle, including pensions and public health care. Their conclusion is that the public system is unsustainable and that just about every option should be on the table including copayments and private options for medically necessary care. The message I hear from these organizations is that we need to look ahead and prepare for changing times.

Can the public sift through the barrage of information to find the truth?

Is there bias, unconscious or conscious, by journalists and left or right leaning organizations that report on health care?

Answer to the first question is that people judge the health care system by their own anecdotal experience. If things go well for them or their loved ones, they believe the system is just fine. They do not see what is happening to other patients in their own region or elsewhere. The reality is the vast majority of citizens are not waiting in queues. They simply do not know what the reality is for others.

Answer to the second question is that bias is quite likely. It's fairly clear that some groups start out with an end point that they want to prove using data. Unfortunately, the data can be selected and is not complete. I often use the analogy of health care as a balloon. If you squeeze one area, another will bulge-you just may not see it if all changes in the health care system cannot be simultaneously evaluated.

As I've said many times here, the unintended consequences of government health care decisions are not usually apparent at first. They occur over time with the result that the decision that prompted the change elsewhere is difficult to link. Health care is truly a complex system.

The Mowat Centre, a left leaning think tank initially created by Dalton McGuinty with five million dollars in provincial seed money, reports that the "doomsayers" about sustainability are wrong.

The Fraser Institute, a right leaning think tank, raises the issue of unsustainability and makes various recommendations for changes.

What are the risks of siding with one or the other?

If you subscribe to the "just work smarter all will be well" camp, there is a distinct possibility that this prediction will be wrong. It is not possible to know what the changes in a complex system will create. It is also impossible to predict sufficient efficiencies for the future that is unpredictable.

If you subscribe to the "act now to create more ways for patients to get care" camp, there is a  chance that the flexibility created will drive free-minded innovation and that the need for accurately predicting the outcomes of various programs will have less significant impact if the predictions are wrong.

Governments can regulate. They can fund provincial public health care systems, but there is danger in wishful thinking. Let us prepare for the worst case scenario. Let us be prepared.

On another note, I would like to thank you all for your contributions especially in the past few weeks. 

Cheers to you!








Defining the Problem in Health Care....with Vision

A number of current events have prompted this journal entry. We've recently heard from the Health Council of Canada, soon to be moth-balled, where Jack Kitts, chair of the Council's panel was quoted as saying:

"Most Canadians think that they have good health care; yet, the evidence suggests the system is not as good as they think it is."

The newest report from the HCC discusses how the health reforms that governments have taken in Canada have not created the transformation required. So good to hear some honesty about wait times and the failure of billions of tax dollars to make any significant change. Some of you may take this as negative but after so many years of being advised that to lead in health care we must take part in Groupthink it is a relief to see an  evidence based report that confronts reality.

And that made me reaffirm my thinking:

The happy thoughts and attempting to deliver "the right care, to the right people, at the right time, in the right places" might not be working the way the decision-makers intended.

Why is this?

With so many talented, dedicated people trying to innovate in health care, why are the changes not resulting in the improvements that were anticipated and why are there so many unintended consequences?

Quite possibly, it is because we have defined the wrong problem(s) to be solved.

I'm a keen reader of the Harvard Business Review Blog Network and an article by Bart Barthelemy and Candace Dalmagne-Rouge from September 13, 2013 caught my eye. Here are some snippets from "When You're Innovating, Resist Looking for Solutions" :

" soon as you start thinking of a solution, you unconsciously begin shutting off possibilities for getting a deeper understanding of the problem and therefore of finding a truly breakthrough solution....It's better to stay in what we call the "problem space" for as long as possible."

"So go deep. Look for underlying issues. What's the real obstacle you face? Once you've found it, go deeper still. What's the essence of that obstacle?"

"Search for different viewpoints."

"Don't be afraid to bring outsiders into the discussion."

"Staying in the problem space, in particular, can be difficult."

Over the past decade, decision-makers, consultants, politicians, bureaucrats, Ministers of Health and Deputy Ministers as well as organized physician representation have been focussed on efficiencies, doing "more with less", teams, ehealth, coordinating care, improving "value" (however that is defined) and big data. 

But what if the essence of the problem isn't really related to any of these things?

What if the areas mentioned above make the health care situation worse by moving tax dollars for health care to other endeavors that don't improve care or improve access or improve health?

Isn't the problem we are facing in health care really the inability of government to fund all of the medical services  required and demanded by a population that has grown to believe that government can provide for all of its needs?

If we want to find solutions in health care that improve access, maintain or improve quality, and decrease government costs to a sustainable level then we need to redefine the problem with long term vision.

According to a recent report from the Society of Actuaries and Canadian Institute of Actuaries released September 17, 2013, Canada's current health care system is not sustainable over a 25-year horizon. As reported by the Rock Hill Herald, the study predicts that provincial and territorial governments' annual spending on health care will increase by approximately 133% from 2012 to 2037 and the expenditures will be close to 86% of governments' own source revenues.

Key findings:

*Growth rates will make it almost impossible for provincial and territorial governments to service their debts and program other services such as education, social welfare and infrastructure."

*There are two key causes of growth in the proportion of the budget: real growth in health care expenditures largely due to the aging of the population and reduced growth in GDP as the working population grows much slower that in the past."

*The revised Canada Health Transfer formula anticipates the future share of the federal government will drop to 14% by 2037, further reducing the amount available to provincial and territorial governments for other program expenditures."

"This report's findings confirm that funding future health care expenditures will be challenging for provincial and territorial governments even if the CHT remains unchanged."-Gary Walters, member of the report's Project Oversight Group.

Which brings me to the article I first spotted in the Kelowna Daily Courier a few weeks ago regarding the plans of the Westbank First Nations to build a 100 bed private hospital. The first phase would include 10 operating rooms and full lab and diagnostic services. Tentatively called the "Lake Okanagan Wellness Clinic", it would use public funds to treat aboriginal people but would also treat Canadians paying out of pocket including joint replacement surgery and cosmetic surgery.

There are also plans to conduct research into diabetes and heart disease and "treat people long-distance using closed-circuit TV".

The National Post reported on this exciting health care development in the last few days and so far I have not heard any vociferous backlash from DoctorsforMedicare or Friends of Medicare or other loud union-backed groups that prefer to support creating and maintaining dependency on a health care system unable to meet the overall demand for care.

Perhaps by defining the problem in health care as an overwhelming dependency on an overburdened public health care system we can move to truly innovative solutions that create more opportunity for care, strengthen initiative and support truly vulnerable populations.

I am hopeful.

Once again, thank you for your support over the years and for your ongoing participation in this important health care dialogue. I truly value my contributors.

Thank you.


Big Data Consequences

Health Informatics and Data Analytics are burgeoning fields following on the footsteps of ehealth efforts. Big Data is now touted as the solution to solving health care costs by mining for numbers and patterns. Some influential people believe that the "Watsonization" of health care is also at hand whereby computers will diagnose the disease or advise on next steps.

I can't help think of how the car industry has evolved from mechanics to computer identification as to why the dashboard is flashing various lights....problem is that patients aren't cars or widgets with replaceable mother boards. They are a complex combination of emotional, psychological, physiological matter held together with bones and flesh. And our brains...way more than grey and white matter with some synapsing neurons and a few sulci.

As always the devil is in the details and at a time when clear communication and positive relationships are acknowledged as key to patient well being and patient satisfaction, efforts are in full swing to mine for data from health records or any other data that various networks and health systems can get their hands on.

Whether it is analysis of care coordination, readmissions or even medication compliance we should acknowledge upfront that numbers don't tell the whole story. Human behaviour is as complex as our physiology and when we combine the complexity of providers with the complexity of patients and the complexity of our environments we have something that even Big Data  cannot fully elucidate.

For providers it means a system of payment more focused on generating data that can be tied to funding either positive or more likely negative as economies fail to grow.

As provider funding is tied to data and generating patient indices or outcomes deemed "positive", expect a greater attempt by providers to choose more optimum practice locations or select patient populations. The law of unintended consequences will be in full swing.

When governments tie financial incentives to patient selection for various kinds of care including the murky "end of life care", we can expect Liverpool Care Pathway type events to occur.

Providers incented to select patients for end of life pathways and hospitals provided with funding to deny patients care is not a recipe for trust.

Who will the patient trust to give them medical advice on their care when the physician or nurse or other is conflicted in their attempt to preserve the system or limit care?

How do we ration based on evidence or quality or value when there are so many unknowns?

When do we determine that a patient should have an "end of life discussion"?

Why does any decision-maker in health care believe that Big Data can take the place of the relationships that humans seem to need so deeply?

When will the public and patients come to the realization of the risks inherent in the sharing of their personal data for government rationing efforts?

What does Big Data do to caring and compassion?

None of this is to say that evidence isn't important in creating understanding of medical science. Neither is it to say that we don't need statistics and facts.

It's just to say that as we create more complexity and try to comfort ourselves in data, we are mixing a recipe for more costs and not better outcomes either in patient satisfaction or in eventual quality of life.

As always, I'm grateful for your insights!




The Canada Health Transfer-Where Do We Go From Here?

Having observed the mainstream media with interest for the past 10 years or so, I have become aware that it generally has the attention span of a gnat. All a premier or highly seated politician needs to do is mention the word "election" and the media goes into reaction mode, running and twirling about at a frenetic pace trying to get the stories out and align their sources. Almost everything else of significance seems to fall by the wayside as the pursuit of power takes main stage.

Does it matter that the ball gets dropped on so many issues involving health care as the focus switches to power and politics? I think it does.

In Ontario, we have major long term care issues and hospital access being rationed more severely as dementia patients are moved out quickly to home rather than long term care despite the inability to have their needs met even with home care and loving family. We see a rise in interest in "end of life care" and euthanasia which may be timely "compassion" given the demographics but I suspect the interest is driven by an attempt to reduce health care spending rather than anything else.

In Ontario, Premier Wynne is out canvassing Ottawa South neighborhoods with the Provincial Liberal candidate in the next by-election. Meanwhile we have breathtaking news on deaths that could have been prevented had ORNGE not had the problems it had. We have the provincial ombudsman turning away 369 complaints related to systemic and individual problems in hospitals because only in Ontario are hospitals barred from ombudsman scrutiny. Apparently patient advocates are supposed to deal with this but they report to hospital management with no power to investigate or to report publicly.

There are health care and hospital issues that the public should be aware of but reporting them may not be  in the best interests of Ontario politicians.

So what does this have to do with the Canada Health Transfer or the Canada Health Accord? Lots.

In the past two to three decades, the provinces looked to the federal government to solve their health care spending problems. They called on the Feds to pony up more and more cash to solve what what was a provincial denial of the demographic, economic and scientific shift taking place. The health care programs that provincial governments had created while the federal tap was open were no longer sustainable as the federal government grappled with its own financial house in a post 2008 Great Recession era. Even with one eye open, the provinces should have seen the demographic challenges coming but only the short term eye was open...the long term eye was fully closed and the mouth too as provincial political and health leaders only told the public what it wanted to hear.

An aging demographic, growing pharmaceutical use, advances in science and technology and surges of nasty new germs and drug resistant bacteria are upon us.  In some magical thinking the provinces expected the federal government to keep sending more money to the provinces for their needs that should have been identified and dealt with over the past few decades. It's as though the provinces believe the feds have nothing else important to spend tax payers' dollars on. National security? Nah. Combatting terrorism? Nah. Cybersecurity? Nah. Immigration? Nah. Environmental issues? Nah. Economic stability? Nah.

It's not surprising then that the Canada Health Transfer payments will have a new funding formula as of 2014. Payments will be on a strict per capita basis beginning next year and in 2017-18, annual transfer payment increases will be linked to economic growth and not the 6% escalator since Paul Martin's "fix for a generation" in 2004. Paul Martin's fix didn't work including 41 billion tax payer dollars. Try something else.

It's not as though the federal government is discontinuing the transfers. It is continuing them, even increasing the amounts being sent to the provinces but to some critics this isn't enough. I am left to wonder if they want to bankrupt the nation and provinces to provide more and more health care that they are told Canadians "want" which given debt repayments will cost more and more ultimately delivering less and less.

Canadians need to understand this.

Premiers will be gathering for their Council of the Federation meeting in Niagra-on-the-Lake next week. Let's hope that each one of them can open both eyes and their mouths and utter some honesty about what it is going to take to address future health care needs. More provincial whining will not serve Ontarians or Canadians.

What do you suggest?