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. 






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 creating private options for care in Canada and especially in Ontario.

What would it look like?

How would funding for a private hospital be created?

How many insurance companies could be allowed to offer medically necessary services? One? Two?

How would a private hospital or private clinic interface with the public 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, 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.




Kicking the Can Down the Road in Ontario Healthcare

No surprises that the tentative agreement between the OMA and the MOHLTC was accepted by 81% of MDs. All you really had to do was count the numbers of doctors in the Sections that were going to receive significant negative hits compared to the Sections that were going to receive a minimal beating to know there weren't enough of them to squelch the deal.

I suppose you could argue that complacent MDs don't tend to vote (true) and that the more suspicious MDs might have shown up to vote "NO" but the reality is that most physicians don't like uncertainty. They like to be assured that government will keep plowing money out the door in their direction and even if it is less than the year before, MDs see it as a positive. Interesting study of human nature.

With the teachers protesting vociferously, I am wondering if any savings Ontario MDs find for government in health care will be used  to settle the throngs of angry teachers. I wouldn't be surprised at all if that happens. That would be unfortunate since the provincial deficit and debt requires that everybody feel the squeeze together. The teachers' union is a strong one and government will be looking to get this settled by the spring-typically nobody dies if they don't go to work, there are many more teachers in this province than physicians and they have a strong voting lobby.

It will be interesting how the current government, like most other governments before it, will kick the health care can down the road for another government and generation to deal with. It just seems irresponsible to me and we lose precious time to make innovative,  sustainable long term reforms.

In another example, I was astounded to hear from an insider that the Ontario government's Aging at Home strategy is also kicking the can down the road. Apparently, it is well understood that the frail elderly who are hanging on at home with more home care support will eventually need long term care...but government has managed to push this off for some other group to deal with...meaning the next government or the next generation. This also seems irresponsible to me.

While Ontario MDs have taken their lumps and managed to convince themselves that the current deal is one to be grateful for, I don't agree that cuts to fees and services are the way forward-a much bigger and bolder solution is required. I have begun to question whether my profession will recognize what is happening before it is too late to create a hybrid system. I also question why I try to educate the public and fellow physicians when they don't seem to care. I've got some soul searching to do. If they don't care, why should I....but that little voice inside me says: "Keep going. Don't give up".

Cheers to all of you for making the commentary on health care an enlightening one and for providing another perspective. It is much needed!



Tentative Agreement between OMA and MOHLTC

The silence has been deafening. Finally, after many months, Ontario's doctors have a "tentative" agreement.

The agreement is definitely "tentative" in more ways than one. It has yet to be ratified by the majority of Ontario's MDs but it is also tentative in the respect that it is a Wait-and-See deal.

With the uncertainty surrounding Ontario's government, its economy and the ability to fund all the required care that Ontario's population will be demanding for many years, it is tentative indeed.

Whether it is a "fair" deal depends on how far you want to look back. Looking back to the Ministry of Health and Long Term Care's draconian dealings a few months ago, it is definitely an might even call it reasonable, but understanding where we are going with this deal which only lasts until March 31, 2014 is what bothers me.

This is a deal for less than two years. The dust will only be settling and implementation taking shape by the time the big negotiations machine will be gearing up in March 2013. This wastes energy and time and money...on both sides. When we could be spending time creating much needed change, we will be bogged down by a status quo Agreement that does little to advance the necessary structural changes for improved access and sustainability.

I will post some details in the comments section and look forward to your comments. I am taking the liberty of moving several comments from the last post to this one so forgive the formatting issues.

My question to you:

What does this deal mean to you?



Conference Board of Canada's Summit on Sustainability of Health and Health Care

After twenty-five years in medicine watching health policy and implementation shift and flow I have usually returned from conferences, councils and health policy sessions more dubious about the ability for change to occur than before.

This conference was different and I thank the Conference Board of Canada for creating an event that provided balance in the discussion surrounding the sustainability of health care as we know it in Canada.

Typically I hear phrases like "If we all work together with the interests of patients coming first we can create a seamless continuum of care that can be preserved for generations to come."

It's also typical to have MDs from academic centres insisting on the sustainability of the public health care system.... it is just about providing care more efficiently they say.

While there was still some of this, I could sense that there are people from a variety of health and economic backgrounds who recognize the magnitude of the problem we are facing and who are willing to move beyond the jargon and bureaucratese to face serious issues head on.

Several issues crystallized for me:

1. There is considerable entrenchment in health care that will persist no matter how strong the economic case is for change.

2. The bigger economic and demographic picture is not well understood by many who work in the health care field.

3. Clear communication to the public about the challenges ahead for health care is becoming increasingly important.

4. Denial by some groups of the challenges ahead in funding public health care fully is a serious obstacle to reform.

The last point is very concerning.

Susan Eng, Vice President, Advocacy for CARP and  William Reichman, Professor, Psychiatry, University of Toronto and President and CEO Baycrest Health Sciences, were members of a panel for a session on "Population Health: Meeting the Challenges of an Aging Population".

When the question was raised surrounding the Old-Age Dependency Ratio and an aging population's ability to provide the productivity necessary to fully fund the health care system that is being created, the concern was essentially dismissed by Ms Eng and Dr. Reichman.

Ms Eng suggested tha the Old-Age Dependency Ratio was not an issue since the Disability Ratio was really what should be considered instead. However, it is worthwhile noting that a disability does not necessarily cause an individual to be unable to work or cause them to require long term care. Many people with disabilities contribute in a fullsome way to the economy holding full  time jobs and being active in the community.

As Canada's population ages, the fastest growing segment is the "oldest of the old". Many people over the age of 75 that I have met would simply find it impossible to work full time or even part time although I am sure that there may be some who do. At 80 they require considerably more health care resources. By 90 they are often frail and in need of in-home care  or 24 hour supervision.

While Ms Eng dismisses the productivity issues surrounding an aging population and has potential to influence many of her members and the public in general, she does a disservice to those who are trying to move forward understanding the risks that are ahead if we fail as a society to deal with lacklustre productivy and its effect on funding for public health care.

Dr. Reichman was also relatively complacent about the impact of aging on productivity. He suggested that an aging population would purchase many products for daily living and supportive care. What he seems to fail to understand is that there will be relatively fewer workers contributing to the tax base and that there will be more need for more providers but fewer of them...both informal and formal.

The denial on both counts was stunning.

Failure to anticipate the health care and economic challenges related to an aging population will have consequences. Denial is not an option.

I'll post in the comments section an article from CARP. See if you can make any sense out of it.

Enjoy your day. Life goes way too fast.