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. 






Health Links

I asked for suggestions on a new topic and HealthLinks came up-surprise, surprise. It has been on the radar only since the fall of 2012 and its timing is of interest.  It is the current government driven effort in Ontario to create efficiency and coordination of care including services for high needs individuals and for primary care and ultimately to create more integration of care at many locations and institutions...dare I say it is an effort at creating "the seamless continuum of care". I have not heard a LHIN CEO refer to it as the SCC but perhaps that acronym was taken already. From the illustrations I have seen it seems like HealthLinks is intended to be rather circular which wouldn't be far from the reality of the health care world sucking everything into its vortex.

(Forgive me if I'm not up on my black hole science terminology exactly but I understand that it generally consumes or absorbs most things it encounters-a lot like health care transformation.)

HealthLinks is comprised of Health Links, groups of primary care doctors organizing themselves to coordinate with other necessary institutions and professionals that will exist across the provinces under the control of the regionally based Local Health Integration Networks. They are local. They involve health. They are being integrated. They will create networks. So voila! LHINs now officially have primary care physicians to manage which they did not before, at least not to the same degree. As one of the posters to this blog pointed out, the health IT to accomplish this isn't quite settled yet but it sure is expected to make for excellent coordination of care! We'll see.

The LHIN landscape is littered with acronyms and you can already see that I have not been able to avoid using at least two. When health care types get together they tend to use the acronyms like another language and this may be helpful for abreviating for speedier discussion....mind you, it doesn't seem to matter that we talk and write and report on health care for decades, much about the same things, with little overall improvement in reducing costs or improving care across the big health care board. It's the hurry up and wait approach.

I must admit that I am somewhat suspicious of the timing associated with HealthLinks arriving on the health care scene. I just can't get over the rather sudden emergence of this entity at a time when the Ontario Liberals, who perhaps had previously thought they would be tossed out of power in the fall, found themselves still at the helm with the potential of a spring election and needed to produce something tangible for health care...and quickly.

Out popped HealthLinks and millions of dollars to offer groups of family doctors for the creation of plans to coordinate the care for expensive users of the health care system and to be directly responsible to the LHINs for integration of patient care.

Is this another transformation effort that is politically motivated without any real evidence of improved outcomes for patients or cost-reduction?

If we look to another system-the National Health System in the UK- we can recognize a similar form of transformation that essentially paid patients to stay out of hospital. Health care teams would sit down with  patients using health care resources far beyond the norm and help figure out what would keep these patients using fewer resources. For some it was finding a helper to buy them groceries. For others it was finding a reliable health care contact beyond the ER (or A & E as ERs are called in the UK NHS). Last I checked this program had some success but if one looks at the issues facing the NHS overall, it is clear to see that it is struggling too.

We hear about the horrific reports of elderly patients ignored in UK NHS hospitals and left to die and of the Liverpool Care Pathway, perhaps initially a well-intentioned program to reduce futile care at the end of life, but which resulted in elderly people being denied  care and even water at the end of life. In some instances family members were not  consulted and patients were put on the Liverpool Care Pathway without family consent or even discussion.

To be clear:

I believe efficiency and integration and coordination of care can be helpful.

I believe that there are well-intentioned people who are trying hard to find solutions under the current umbrella of single payer health care.

However, it is quite likely that HealthLinks exists because of political need and not because it will bring down costs or reduce needs in health care.

I believe we need to have a deeper discussion about how to deliver health care in Ontario. While we can embrace efficiency finding, reduction of waste, and improved use of our providers in the public system these still won't be enough to provide the care that is needed in the future-not when so many forces are aligning to challenge the current system.

Unless we confront the serious challenges facing Ontario we will pay more to integrate care and still be unable to meet the needs of the coming decades and on the backs of a population that will not be able to fund the care it needs. Will HealthLinks make a difference? Maybe, maybe not..but it won't be enough-not nearly enough.



If Oprah was in Charge of Canadian Health Care

Oprah came to my city recently. Thousands upon thousands of people (mostly women) paid hundreds of dollars for a ticket to hear her speak--no singing, no dancing, no pyrotechnics --just someone influential speaking.

I'm going to be honest, I'm neutral on the Oprafication of North America. I think Oprah is a fine woman who has an intangible likability, is informed and intelligent and a highly influential speaker......and very wealthy.  I have even used some of her quotes for my own leadership presentations but what would happen to health care if we rely on positive messaging and hope to provide care? What HAS happened to Canadian health care already because of the reliance of politicians on saying what the public wants to hear instead of confronting the facts and real trends staring us in the face?

Now I'm not saying that we don't need hope. We do. It's just that it can't be instead of taking a realistic look at what is happening to Canadian health care now and what will happen to it in the future as changes in demographics, technology, science and economics loom large.

Oprah's inspiring messages give people hope but I am concerned that this kind of evangelical message of hope is also pervasive in health care and amongst communications advisers and PR types involved in health care decision-making and policy. How could they all be wrong?

Over and over again it is said that political messages must give hope but I firmly believe they must also clearly identify the problems that we need to address with  Plan A, a Plan B and even Plans C,D, and E. The public must be given the facts to understand what Canada is up against, especially Ontario and Quebec.

So, as I hear more political handlers and commentators talk about the message of hope that is necessary in communications I am struck by the stark reality that hope just does not deliver health care. It can make us feel better about the short-comings of the current system but it will not provide the changes that we need for the future.

Positive messages are comforting. They make us feel good. When it comes right down to it though, that feeling does not last in the face of shortages of hospital beds, inadequate long term care, patients denied timely care and drug shortages.

The comfort provided by positive messaging about health care is actually diminishing the ability to create necessary change. We need a bit of friction and grit to move forward. The slick and slippery messaging that smears itself over health care challenges by political handlers and advisers is not helping. We need to confront the challenges ahead and the public needs a clear understanding that the system we have created is no longer viable.

Lets embrace the patients, the providers and the people who work in all the various aspects of health care but change the system. We need a hybrid and we need it soon.





Flaherty's Federal Budget 2013

Jobs. Jobs. Jobs.

Better health for Canadians will be created by jobs and employment. This is where the much discussed and trendy "social determinants of health" -also discussed here on this blog-intersect with the economy. Better health for Canadians isn't about asking the Federal government to pour even more tax dollars into provincial health care sieves. It isn't about putting an MRI on every corner or funding health care for denied refugees. It is about making sure that there is an educated and skilled workforce that can participate in infrastructure building and in a developing knowledge-based economy.

When I talk about Canada's debt and deficit as well as Ontario's economic problem to some other physicians they do not seem to see the connection between standard of living and health or the economy and health.That is problematic because representative doctor groups do have a voice but it is sounding increasingly shrill as they miss the point about dealing with serious economic challenges and an aging demographic poised to drive down productivity and GDP.

Flaherty has been a good steward for Canada's economy and we are fortunate as Canadians to be doing relatively well compared to many other developed countries. I expect that this will be Jim Flaherty's last budget. He has done as well as could be hoped for given the fallout from 2008 and I hope the Federal government continues to resist the loud voices for a national pharmacare program and greater transfer payments to the provinces. Neither of these efforts will address the serious issues facing a slumped economy and both are money pits.

For the next generation's sake including my three children, I hope the voices of all the interest groups that perpetuate the monopoly status quo in health care with entrenchment of their own self-interests will be matched with common sense and pragmatism. At least then we might have a chance of moving forward.





Queue Jumping and Outsourcing in Canadian Health Care

When trying to sort out "where do we go from here", it is a helpful exercise to look back on the various trends that government health policy has emphasized as solutions for the challenges that hound Canadian health care. Take a few minutes to review:

Since the mid 90's we've seen MDs blamed as the cost drivers and saw their numbers cut in medical school only to result in continued escalation of overall health care costs and then a rapid influx of Internation Medical Graduates most recently and a doubling of medical students soon to begin practice (maybe not here). With provincial governments squeezed for cash across the country and a federal government equally strapped for cash now and for many years ahead it is not surprising to see new specialist graduates unable to find work. Sad but true despite Canada having less than average number of MDs per capita than most other developed nations.

We've seen the government and many government funded groups promote interdisciplinary care as the way forward to create quality care and as a way to stretch health human resources but I believe it hasn't made much difference and the costs significantly higher than Fee-For-Service. There are still hundreds of thousands of people in Ontario with no family doctor and across Canada the count is in the millions. There are reports of MDs in teams seeing less patients and working fewer hours and I wonder how this strategy of increasing the numbers of providers in health care will play out as the work force shrinks relative to dependents in the next 10-20 years. How do we fund more expensive health care teams with fewer tax payers and sluggish productivity especially when the outcomes aren't any better than what we had for fewer dollars?

There has been the eHealth spending to the tune of billions and billions of dollars in Canada but new reports seem to indicate errors associated with EMR are a reality only different from paper charts. I have no doubt that  developing Health IT provided jobs during a significant recession and I don't begrudge any government for providing them but let's be honest about it: EMRs will not save any tax dollars from the health care vortex. Are they necessary for the complexity in health care that is coming? Yes. Will they save money? No.

We've seen efforts at using a public air ambulance system to generate private dollars but with very questionable oversight from its Board the whole plan crashed and burned--leadership at its worst at many levels and it seems government not willing to be accountable for creating the entity and then letting it run wild.

Managing queues more efficiently and centralizing referral systems was going to reduce wait times and create efficiency. I hazard a guess that with multiple groups doing wait time analysis and studyng how to keep patients from accessing expensive care, the cost is likely in the billions and  we are still treading water with queues for various treatments and procedures.

Ontario comes out better than most provinces in terms of its wait times but the cost has been high and now as a have-not province, Ontario risks having its credit rating driven down so it will cost more to service its debt which means the same service will cost the province even more in the future. It would be ironic if Ontario's good-hearted money dumping to reduce wait times eventually makes them worse because it will cost more to provide the same service.

The ALC problem has nagged Ontario and other provinces for some time. Patients languishing in hospital beds when what they really need is long term care are now seeing action by hospitals and local health integration networks to move them out as quickly as possible. However, the supply of long term care beds and nursing home beds provided through government funding have not kept up. Elderly patients in the community who are frail and who have managed to avoid hospital so far are not a priority and it is only a matter of time before they end up needing acute care too. Despite this, hospital beds are being "closed" and unstaffed as hospitals are desperate to meet accountability agreements required by law. Nurses are laid off. Services are slashed in order to come in on budget and Ontario's Minister of Health Deb Matthews says "it's OK"...we'll move services to the community....only that isn't happening.

The queue jumping inquiry in Alberta serves to show us that despite relatively exhaustive efforts across Canada to reduce waits, it simply isn't working. With colonoscopy wait times measured in years in Alberta, "queue jumping" appears to have become fairly common. No surprises here because if you have a loved one that is suffering or at risk for nasty health problems, wouldn't you do what you could to help them if you knew someone who could help you? It happens all the time and it shouldn't become a witch-hunt to the tune of millions of dollars. Open up the system to those who are willing to pay for the service. Keep the medical specialists in the province to do the work they were trained to do. We all know there is plenty of patients needing care. If there were no queues and if there were reasonable wait times, there would be no substantial queues to jump. Let us be transparent and honest and allow people who can pay to pay.

Last but not least is the newest trend toward moving hospital services to the community. I've heard it all before. I've heard it for over 20 years and it does not happen. If it happens this time, nobody should expect it to be cheaper because all of the smaller facilities will have to have government support OR they will be set up by private groups who will then be paid by the government for public medical services provided. If hospital beds are cut at the same time as services are provided in the community how exactly will savings be achieved? Patients are more complex than in the past with growing ranks of elderly with dementia and chronic disease.  I predict that there will be no savings from moving services from hospitals to the communty.

Where do we go from here?

There must be a way of providing more care in Canada and especially in Ontario.

What would it look like?

How would funding for more care be created?

Should  insurance companies  be allowed to cover medically necessary services?

How would more options for care  be integrated into  our current system?

We need to have an honest and open and reasoned discussion about where we go from here--because queue jumping witch hunts, outsourcing care to the US, EMRs, and teams just aren't going to make health care more efficient or cost less.



More Honesty in Canadian Healthcare

The New Year has begun with a few bumps in Canada:

1. Ontario physicians settled with the Ministry of Health and Long Term Care just in time to have Ontario teachers take to the streets, offended by their treatment at the hands of government. Will this become a shell game for tax payers' dollars? Savings from one area simply redistributed to another?

2. Canada's First Nations groups are armed with drums, signs and anger about many things including living conditions on reserves and resource sharing. Will anybody recognize and acknowledge that the issues surrounding Aboriginal poverty are not as a result of lack of government money but due to lack of accountable self-governance and complex social problems?

3. Ontario's economy is still in a slump mired in deep debt and deficit. Will Premier McGuinty stop insisting that he has done a wonderful job as he walks out the door after proroguing legislature at the tail end of a spending spree legacy?

4. Alberta's economy is shuddering as energy prices hover and do not bring in the anticipated revenue for government to cover rising health care needs. Will this era drag Alberta down too? So much for relying on Alberta to keep Canada's economy on "full tilt ahead".

5. The Canadian trade deficit jumps as weak markets hit exports and the Feds struggle to reduce deficits. Will the vocal groups insisting that the Federal government bail out provinces for spending beyond their means in health care see the reality?

6. Alberta's inquiry into "queue-jumping" points to the reality that even people who can afford to pay for their MRIs or other types of care are forced to be dependent on a lagging public system. Will Abertans see the inquiry for what it is...a waste of time and energy?

7. Quebec stumbles with charges of corruption on building its major health facility while it can't even manage to keep its own paramedic supply sufficient to meet demand. Will the Quebec government open up more private health care options?

8.  Saskatchewan is sitting pretty with oil and potash and a premier that supports entrepreneurial spirit but despite its best efforts hospitals are overcapacity. Will Brad Wall continue his use of private clinics to provide public services and will there be increased use of private options to improve access?

9. Maritime provinces face high unemployment and low levels of skilled labour and an aging population ahead of the rest of Canada. How will it maintain its health human resources and public health care infrastructure as times become more tough? Will oil be enough?

10. BC continues to lean on prevention as a way of reducing health care costs. Will it work? Will the benefits of more hospitable climate of the major cities mean longer lives and more social entitlement costs?

11. Manitoba lays no charges after patient dies in an ER in 2008 with a bladder infection. Does it have to be this hard to get access to care? and what does it say about our universal, accessible health care?

Lots of events point to the fragility of our current state, health care included.

It is important we have leaders at the helm who can see the problems, address them with honesty and avoid decision-making influenced by cheerleaders in their ranks.

Jeffrey Simpson writes in The Globe and Mail on January 11, 2013 about the "Inconvenient truth: We don't have the best health-care system".

He gives credit to Alberta's Fred Horne and Ontario's Deb Matthews for their honesty. He states that  instead of telling the electorate that Canada's health care system is the best, they have  started with "the truth".

Simpson may be right but Canadians still do not have the "whole" truth. Politicians shy away from telling the whole truth in part because it is not politically helpful to them but also because some of them still believe Canada's system is better than it is in reality.

According to Simpson, the Environics Institute has some significant findings on Canadian perspectives about its health care system. Simpson writes:

"What about private payment? The Institute asked whether Canadians should have the right to buy private health care - here comes the condition -"if they do not receive timely access to services in the public system"- and here comes another condition - "even if this might weaken the principle of universal access to health care for all Canadians because some people might have quicker access to services."

55% per cent said YES

43 percent said NO

Even more telling are the comments in response to the article. It seems that Canadians are becoming more aware that an alternative is needed to an overburdened public health care system that is not managing to provide necessary and timely access now let alone in the future.

We need as many solutions to finding increased access as possible. It is no longer feasible for Canadians to deny realities or for interest groups to insist Canadians keep their blinders on.

I hope that in 2013 more honesty about the need for a hybrid health care system can be supported and that more Canadians will understand the benefit of creating options for care beyond the core public health care programs that exist.

Cheers to 2013 and to all of you who have made and continue to make such valuable contributions here! Thank you.


I will post a link to Jeffrey Simpson's article in the comment section.