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ОглавлениеChapter 1
Medicare
Dragging medicare into the twenty-first century
Nothing matters more, individually or collectively, than our health. Regardless of political allegiance, Canadians are nearly unanimous that a universal health system is a good thing—for reasons of economics and social justice. That’s why every Western country save one has a universal system. When it comes to health care, only the United States is morally bankrupt and economically inept.
Canadians take pride in besting the United States on the health front, but it is a hollow victory. In reality, every other developed country has universal health care that is better, fairer and cheaper than ours. We are big on grand pronouncements such as, “Medicare is what defines us as Canadians.” But we are laggards on the practical side.
Canadians want care that is appropriate, timely, accessible, safe and affordable, from birth until death. Yet our system is failing on virtually all those measures. Why? For starters, we lack vision and goals. Canadian health care is a $228-billion-a-year enterprise with no clear goals and a dearth of leadership. We talk endlessly about the sustainability of medicare but have no idea what we want to sustain. Our medicare model is a relic, frozen in time. Tommy Douglas’s role in shaping publicly funded health insurance for hospital and physician care is celebrated, mythologized even. But we conveniently ignore that medicare was designed to meet the needs of 1950s Canada.
In 1957—when the program became nominally national—the average age of Canadians was twenty-seven. Health care consisted of acute, episodic care: going to the doctor for treatment of an infectious disease, or to the hospital to give birth, have surgery or die. Today, the average age of Canadians is forty-seven. The technological advances of the past half century have been dizzying. The great majority of our care needs are now for treatment of chronic illnesses. Yet neither the model for delivering care nor the insurance payment model has adapted to the new reality. You can’t deliver modern health care with a 1950s model.
So how do we drag medicare, kicking and screaming, into the twenty-first century? Our favoured response has been to throw more bodies and more money at problems. But the solutions need to be more fundamental and come on two levels: funding and delivery.
Let’s start with delivery. Action is required in five broad areas:
Primary care. Essentially, we need to take our hospital-based care system and turn it on its head to make community-based primary care the focus. We need to move away from an acute, episodic-care model to a chronic-care model. Every Canadian needs a medical home, a central co-ordination point for their care—preventive, acute and chronic—and an electronic medical record. And care should be delivered by teams, not individual practitioners, due to the complexity.
Drugs. We need to extend universal health coverage to prescription drugs. Currently, through a patchwork of public and private schemes, about thirty-five million Canadians have drug insurance (twenty-four million are covered by private plans and eleven million by public plans, but hundreds of thousands have no drug coverage). A public plan need not pay for everything from Aspirin to Zyprexa, just the essentials. Nor does it have to be a centralized bureaucracy. Quebec has demonstrated that a universal prescription drug program—a mix of public and private insurance—is feasible and affordable.
Home care. We need to treat people where they live, in the community, not in expensive, soulless, germ-ridden institutions. Too expensive? Not if it’s an alternative to hospital and nursing-home care. For example, seventy-five hundred Canadians currently live in hospitals—meaning they have been discharged but have nowhere to go—and that’s the tip of the iceberg.
Social determinants. We need to invest in prevention efforts, particularly for socially disadvantaged and marginalized groups such as indigenous people. Let’s stop pretending that health is merely a medical issue, and spending as though it were. Good education, housing, income and the environment are essential to good health. A whole-of-government approach is required.
Quality. Safe, prompt and effective must be the guiding principles for care delivery. For the most part, these are engineering and administrative issues, not medical ones. Care is rationed in every country. You can ration by creating financial barriers, as they do in the United States, or you can ration based on results—which ensures everyone gets basic, effective care. Quality care is cheaper in the long run.
Reforming the delivery of care is the easy part. In Canada, funding is unquestionably the Gordian knot.
Spreading risk—and health costs—across the entire population, as we do with medicare, is a good model. But an essential element is missing that undermines medicare: a failure to define clearly what is covered by public insurance and what is not. Canadians have to accept that public-health insurance covers only the basics. At the same time, those who oversee the system have to recognize that physician and hospital care is not enough in the twenty-first century. We need to expand the areas medicare covers—into drugs, home care, long-term care—while at the same time limiting coverage across the board to the essentials.
Universal coverage is not a synonym for unlimited, open-ended coverage. There are choices to be made. They include:
As stated already, defining clearly what is covered by medicare and what is not.
Paying only for what works. Many interventions are of dubious value or are not cost-effective. They shouldn’t be covered by public insurance.
Paying a lot more attention to patients with complex needs because they drive costs. One percent of patients account for 25 percent of costs, and 5 percent account for half of all spending.
Instituting a means test. An equitable system does not mean providing equal services to all at equal cost; user fees and co-payments are not necessarily unfair, but these approaches have to be used smartly.
Regulating rather than outlawing private insurance and care. One of the most important lessons we should take from Europeans is that we need a combination of a well-regulated private system and a well-managed public system.
The so-called public–private debate is the third rail of Canadian health politics. But it’s a false dichotomy. Every health system worth its salt has a mix of private and public delivery and payment. In every country, including this one, most delivery is done by private providers. (That includes not-for-profits, for-profit businesses and independent contractors such as doctors.) On the funding side, the split is usually in the 70:30 to 80:20 range, public–private. The only unique feature of Canadian medicare is the bifurcated payment system. Hospitals and doctors are 100 percent publicly funded. Other services—drugs, home care, long-term care and dental—get between zero and 50 percent public funding.
The question is not whether or not we have private and public care. It’s getting the mix right. Private enterprise does certain things well, and public and non-profit enterprises do certain things well. Let’s be pragmatic and benefit from both, as most European countries do. We need to pay much more attention to equity—making sure everyone is cared for—and less to who is delivering the services.
Implementing these changes will, of course, require leadership. But nothing is radically new in these proposals. The real challenge in Canadian health care is implementing what we already know is needed. Everyone has a role to play: Ottawa, the provinces and territories, health professionals, allied workers, labour, business, consumer groups, patients and citizens. But they all have to put a little water in their wine—and whine a little less. Reform is going to happen only if the political environment changes, if we stop shouting down every proposal for change because it threatens vested interests. It’s time for the interests of patients—and society more broadly—to rule. We don’t need a values debate. We don’t need more tiresome private–public rhetoric. We don’t need Chicken Little screaming that medicare is unsustainable. We need a debate about structure and funding and priorities.
Let’s be frank. For many years, we have failed to live up to our responsibilities. We have been lazy and we have been profligate in our spending. But there is reason for optimism. The public isn’t just ready for change—the public is demanding it. It’s time to stop talking and start acting.
Stop moaning about medicare
In April of 2005, the Los Angeles Times ran a fascinating story about a growing underclass of Americans who have been dubbed the “insured poor.” The story is still relevant today. Reporter Daniel Costello told some chilling tales about working stiffs struggling mightily to pay their monthly health-insurance premiums. It was noteworthy that the people profiled—the working poor, middle-class white-collar and blue-collar workers, small business owners—all had stable, long-term employment, yet they were all on the precipice of joining the forty-five million Americans without any health coverage.
There was Terri Matthews, a teacher’s aide, who spent US$613 a month for her family’s health insurance, one-quarter of her take-home pay. Rather than go without coverage, she skimped on other basics. Matthews stopped heating her home and dropped her car insurance. Ron Dybas owned a lumber company for seventeen years, but he shut it down to take a job with a business that had health benefits because he could no longer afford to pay one-third of his income, US$729 a month, to insure his family. “Such sacrifices for health insurance are far from rare,” Costello wrote. “As employees continue to absorb more of their health-care costs, an increasing number of people—even healthy ones—are drastically altering their lives simply to hold on to their insurance. They are delaying home ownership, putting off saving for their children’s education, or otherwise sacrificing their financial security to guard against a catastrophic medical bill.”
In Canada, we like to moan and groan about our medicare system. The care is never fast enough or good enough. We have too much rationing and not enough choice. The solution that is invariably held out is privatization. Private care, we are told, has no waiting lists and no shortage of physicians, and patients have access to the latest and greatest drugs and technologies. And indeed, that may well be true—for a tiny, well-to-do minority. But for all the problems we have in delivering health care in Canada, embracing a profit-driven health system as the United States has done is not the solution because it does not serve consumers well. For a growing number of Americans, health care—any health care—is increasingly inaccessible and unaffordable. In 2015, the average annual premium for a single person was $6,251, and for a family of four the premium was $17,545. Moreover, insurance rates are soaring and coverage is shrinking. Employers are capping what they spend on health, meaning employees have to absorb all premium increases. Insurers are also tightening the services they will pay for and capping payouts so people with chronic illnesses simply run out of coverage. Since 2005, US health premiums have increased more than 25 percent, and deductibles have soared by 67 percent.
Compare that with Canada, where we take health insurance for granted, to the point where we have developed a deeply rooted sense of entitlement: everybody is entitled to be treated now, or sooner. Everyone is entitled to the most recent, most expensive drug, even if the drug is of dubious or marginal benefit. Everyone is entitled to state-of-the-art techniques and equipment, regardless of cost. If we don’t get it, we’re going to sue. It has reached the point where politicians and policy-makers dare not say no, lest they be publicly eviscerated. And, oh yes, we think our taxes—taxes that pay for the medicare system—are too high.
Canada’s medicare system is not perfect. Far from it. But health-care services in Canada are excellent. The system is cost-efficient—at least compared with the United States. Americans spent just over US$10,000 per capita on health care in 2016, compared with Canadians, who spent C$6,299. Put another way, if we spent at the same rate as Americans, our annual health tab would exceed $340 billion, up from the current $228 billion. Canada’s medicare system is also largely accessible and equitable. The care is there when you need it—with very few exceptions—regardless of where you work, where you live, the colour of your skin, and your income. We should be proud that our medicare system makes care affordable to all, but we should not use that as an excuse for its flaws, such as unbearably long wait times.
The predicament of the American “working poor” provides some important perspective. For Canadians, it is unimaginable to spend 25 percent or more of our income on health care. But with the costs of private care and out-of-pocket expenses creeping up, especially for prescription drugs, we can’t be too self-righteous. Like the house-rich, cash-poor who stretch their finances to pay for housing, the “insured poor” are barely hanging on to their coverage. “Eventually, many probably will lose the battle, joining the forty-five million Americans without medical coverage,” Costello wrote. (That figure is now at twenty-nine million, but will likely jump again if President Donald Trump follows through on his promise to dismantle Obamacare.)
In the United States, routine health matters—the birth of a baby, heart disease, depression, arthritis—can have catastrophic consequences. Medical bills are the primary cause of personal bankruptcy, affecting more than two million families a year. Notably, all those affected began with private health insurance but soon exhausted it. Illness can also result in job loss, and along with it health insurance just when it is needed most.
Dr. David Himmelstein, an associate professor of medicine at Harvard University and the study’s lead author, put it this way: “Unless you’re Bill Gates, you’re just one serious illness away from bankruptcy.”
Funding overhaul is needed to cure our ailing hospital system
Hospitals are the cornerstone of our health system. We rush to hospital in emergencies; we go there for life-saving surgery and for treatment of serious illness; and, increasingly, chronic illnesses are managed through hospital-based clinics. Hospitals are also powerful symbols. Most Canadians are born in hospitals, and most still die there. A community without a hospital is viewed as a place without a heart or a soul.
Hospitals are the single biggest expense in our health system. Of the $228 billion Canadians spent on health care in 2016, $66 billion went to hospitals, compared with $36.5 billion for drugs and $34.9 billion for physician services. Yet the public knows surprisingly little about how the nine hundred or so hospitals in this country are administered or funded.
Dr. Brian Day, past president of the Canadian Medical Association, said in 2007 that one of his priorities was to change how hospitals were funded. He decried block funding, the transfer of set budgetary amounts from provincial coffers to individual hospitals. What he wanted to see instead was “patient-focused funding,” where the money follows the patients and hospitals are allocated money based on the number of patients treated, the procedures performed and the timeliness of care. While discussing the pros and cons of such an approach can be useful, it’s also important to examine the issue of block funding and place it in some context. (Day’s vision never did come to pass, but a number of jurisdictions have experimented with variations on patient-focused funding.)
Medicare, a state-administered health insurance program, began because people could not afford hospital care. A heart attack, traumatic injury or complicated childbirth could instantly impoverish a family. When governments began to offer “free” hospital care—beginning with Saskatchewan in 1947, fifteen years before physician services were also covered and medicare was born—hospital budgets were reviewed line by line by provincial health officials. By the late 1960s, this process had become onerous, so hospitals were allocated global budgets. The starting point was the previous year’s budget, adjusted for inflation and growth—but almost always with a cap. New programs were funded separately for a few years, then rolled into the global budget. From a government point of view, block funding was very successful because it was an effective way to contain costs. For the past forty years, hospitals’ share of spending as a percentage of total health expenditures has fallen steadily.
But the shortcomings of block funding are many. Stated bluntly, hospitals on fixed budgets have a perverse incentive to do less to keep costs down. That’s why we have surgical floors shutting down during the holidays despite wait-lists. And block funding is, more often than not, inequitable. It is not responsive to increases in the volume of care; nor does it take into account the characteristics of the patient population. Further, block funding doesn’t create incentives for cost-effective care. The result is a constant game of catch-up and hospitals with chronic deficits.
But the rigid, bureaucratic block funding of yore no longer exists. Governments have introduced all manner of programs to supplement core budgets. Increasingly, we are seeing regionalization, which allows more sensible funding of programs regardless of where they are delivered (be it hospitals, long-term care facilities, clinics or the community). Governments are also moving to multi-year budgets for hospitals and adopting incentive programs to reward efficiency and quality care. The goal, ultimately, is to ensure that hospitals that provide comparable services receive comparable funds. Budgets also need to take into account the characteristics of the patient population—meaning that hospitals in low-income areas need more money than those in high-income areas. One of the biggest challenges is having budgets and facilities that keep pace in hospitals in communities with explosive growth, like those in parts of Alberta and Southern Ontario. There is also the thorny issue of what to do with hospitals that underperform; few politicians dare shut down a hospital.
In a health system like Canada’s, where 90 percent of funding comes from state coffers, overall budget control must remain with the state. We can probably all agree that, in the twenty-first century, block funding is not the way to do it properly. But we must be careful not to trade one set of problems for another. Performance-based funding, while it would introduce the so-called discipline of the marketplace by having hospitals compete with each other for patients, would also cause widespread carnage. Programs, and even entire hospitals, could shut down. Care could be fragmented. Administrative costs would likely increase and so too would overall costs. And while patients might have more choice, would it be meaningful choice?
Regardless, we should be having the discussion, vigorously and publicly. Hospitals are just too important and too expensive to simply accept the status quo and not strive to do better.
Canada’s two-tiered health system: The rural–urban split
Running a health system in a country as vast and sparsely populated as Canada poses many challenges, big and small. But some of those seemingly small challenges have vast implications. Take the case of Flower’s Cove, Newfoundland. Located near the tip of the Great Northern Peninsula, the coastal community has a population of about three hundred—and maybe double that number if you include the surrounding areas. Flower’s Cove is home to the Strait of Belle Isle Health Centre, which operates twenty-four hours a day, seven days a week. It offers basic emergency services, everyday family medicine (provided largely by nurse practitioners), an ambulance service (principally for transport to larger health-care facilities), home-care nurses, dental care and medical diagnostic services, including some laboratory testing and X-rays.
On August 31, 2009, the provincial government decided to cut back the operating time of the clinic to twelve hours a day and shut down the lab. A great hue and cry followed, with protests in the streets. The health minister, Paul Oram, reversed the decision on the clinic hours so emergency services would again be available around the clock. Then he resigned, saying the non-stop pressure and scrutiny of even the most mundane decisions was taking a toll on his personal health. “There’s no end to the stress and strain,” Oram said in his words of farewell.
Flower’s Cove is, in many ways, representative of the major challenge in our medicare system: Where do we draw the lines? And who draws them? Canadians have developed an incredible sense of medicare entitlement: we want all care for all people, instantly and free of charge—after all, we pay high taxes! While this may be possible—at least theoretically—in densely populated, infrastructure-rich urban centres, distance poses a major challenge in health-care delivery in huge swaths of the country. Canada’s land mass is about 95 percent rural/remote, but less than 30 percent of its population lives in rural/remote areas.
In reality, we have a two-tiered health system, but it’s not a private–public split, it’s an urban–rural split. The health outcomes of those who live in remote settings are poor compared with urban and suburban dwellers: life expectancy is lower, child mortality is higher, injury rates are astronomical and there is far more obesity and chronic illness such as heart disease. Much of this can be explained by the fact that residents of rural communities are poorer and older (with the exception of indigenous communities, which have their own particular health challenges).
The reality, too, is these challenges predate the creation of medicare half a century ago, when the folkloric country doctor trudged miles on foot in a snowstorm to save a patient’s life. If anything, the factors that impede the availability of, and access to, good-quality care for rural residents have been exacerbated by technological advances and social change.
The question is, how do you improve the situation? Do you build a twenty-four-hour-a-day health clinic in every community, even those with a few hundred residents? A hospital in slightly larger centres? If so, how do you staff them? Modern medicine is heavily dependent on diagnostic testing. Do you build a lab in every outport? If so, how do you ensure quality and cost-efficiency? What about surgery? Should that be done in small hospitals or only in larger institutions? After all, we know that outcomes are far better in high-volume centres.
We have this jingoistic love for hospitals and health clinics—communities that don’t have one or two feel inadequate and neglected. But are patients not better served by having high-quality diagnostic tests done at a central lab and getting the results by e-mail or FedEx than being dependent on a rinky-dink facility? Should scarce health-care dollars not be invested wisely in improving transportation and family support so patients can be treated in well-equipped regional centres with a minimum of disruption instead of dotting the landscape with clinics that overreach their abilities? More important still, can we not have these discussions without their being subsumed by political rhetoric? Can we not make rational, good-for-the-system decisions without them being substituted by politically expedient ones?
The tragedy of Flower’s Cove is not whether the clinic lost a lab or some operating hours. In the grand scheme of things that doesn’t really matter. What matters is that ten thousand Flower’s Coves exist across Canada. Tough decisions need to be made—and a balance found. But decision-makers can seemingly no longer make decisions. Politicians like Paul Oram have become punching bags for those with vested interests. Health administrators and government bureaucrats whose role should be to ensure the delivery of quality care in a cost-effective manner have been emasculated. Anytime their policies make ripples, they get trashed. (And the media do a lot of aiding and abetting.) Is that any way to run a health system?
Here’s a radical health-care idea: Put the patient first
“Our current health system has been designed around the people who deliver the care. It is time to realign the values of the health system so that the patient is again made the centre of attention.” That is just one of the refreshingly frank comments found in For Patients’ Sake, a report out of Saskatchewan, one that should be mandatory reading for every politician, health administrator and health professional.
Patient-centred care and family-centred care are the buzz terms du jour. But there is a lot more talk than innovative action. Offering up convenient, timely care, making it easy to navigate the system, actually communicating with patients and treating them with respect do not seem like radical ideas, but sadly, they are far from the norm. There are too many self-interested lobby groups and too many silos, and there is always too little time to listen. Health professionals want to deliver high-quality, compassionate care (and despite the barriers, often do). But they are too beholden to systems and constrained by traditional ways of doing things to put patients and their families first.
Saskatchewan, to its credit, decided to move beyond the rhetoric. In November 2008, health minister Don McMorris announced the Patient First Review, under the leadership of long-time health administrator Tony Dagnone. The health system has had many federal and provincial reviews over the years, so the move was greeted with a lot of eye-rolling and yawns. But the strength of the Patient First Review was that it focused on two key questions:
Is the health system putting the patient first?
Is the health system achieving good value in care delivery and system administration?
The other strength was Dagnone himself, a man with a Tommy Douglas–like passion for medicare, coupled with an insider’s knowledge of the system’s strengths and weaknesses. In the half century since the foundations of medicare were forged out of Prairie populism and the pursuit of social justice, Canada has built an excellent universal, state-funded insurance program. (Or, more precisely, fifteen vaguely interlocking programs, but that is a discussion for another time.) But the underlying theme of Dagnone’s report was that, along the way, we lost sight of the people the system was designed to serve: the patients and, by extension, their family members.
What was needed to repair this fundamental flaw, he said, was not more rejigging of bureaucratic structures but a change of culture and a rethinking of priorities. “Patients ask that health-care workers and their respective leadership see beyond their declared interests so that the interest of patients takes precedence at every care interaction, every future contract negotiation and every policy debate,” Dagnone wrote. “Only in this way will we achieve a patient- and family-centred health system for Saskatchewan citizens. Similarly, government leaders and policy-makers must keep the patient front and centre when policies, programs and new models of care are designed and implemented.”
The formulation of that statement is noteworthy. “Patients ask” is used because the commissioner did extensive consultations with patients and families. Dagnone did what is so rarely done in the day-to-day operations of the health system: he asked patients what they wanted and then he actually listened to them. A vast reservoir of untapped patient knowledge exists that we need to explore to improve medicare. What the commissioner heard is that the system performs relatively well. The care is good, but not good enough.
So where does medicare fall down on the job? In a few areas:
Convenience and timeliness. There is too much waiting, and it’s not easy to get in the right door for care, so people end up in emergency rooms by default.
Lack of co-ordination. Patients do not move seamlessly through the system; there are often big cracks to fall through at transfer points.
Lack of equitable care. Patients want reasonable access to care but feel they are discriminated against based on where they live, their age, their ethnicity and other factors.
Lack of communication and information. When someone is sick or injured, they are frightened. They crave basic information, but everyone is too busy.
Lack of electronic health records. Patients hate repeating their medical histories over and over, and tests are oft-repeated because of lack of modern records.
Lack of respect. All too often, patients feel they are treated as a bother to health professionals. Patients are not cost centres, they are the raison d’être of the system.
Dagnone does not use the term, but reading his report one is left with the sense that the primary frustration with medicare is the total lack of customer service. That does not seem like an insurmountable barrier. In fact, Dagnone concludes that there is no need to dismantle and reinvent the health system but rather the need for a collective will and vision to implement fixes and change the culture of caring. “‘Patient First’ must become more than a mantra. For the sake of patients it must become a movement that is embraced by all who have a stake in creating healthier communities.”
Montreal’s super-hospital saga was a historic farce
It took twenty-two years in the early seventeenth century to build the Taj Mahal, the awe-inspiring white marble mausoleum in Agra, India. It took longer than that for Quebec to build a utilitarian hospital in Montreal in the twenty-first century.
The Taj Mahal is a glowing symbol of eternal love. The “Taj Hôpital” is a shameful symbol of political dithering. In a December 2010 instalment of the absurdist tale, then-Quebec Treasury Board president Michelle Courchesne announced that construction of the Centre hospitalier de l’Université de Montréal (CHUM) would begin the following spring and be completed by 2019. The tentative price: $2.1 billion. Well, she actually announced that there would eventually be another announcement because bids had yet to be tendered. Not to mention there were no final blueprints. And so it went.
The idea of building a Montreal “super-hospital”—merging archaic institutions scattered around the city into one state-of-the-art facility—was first floated in 1991. It was an eminently wise plan, particularly in a city where most health-care facilities were built decades and in some cases centuries ago. But in the health field there is no idea, however sensible, that cannot be bogged down by bureaucracy and perverted by politics. The Quebec super-hospital saga is a case in point. (In the interest of brevity, let’s leave out names and political affiliations: suffice it to say that six premiers and ten ministers of health have been involved in the file to date, and the Liberals and Péquistes have handled it in equally bumbling style.)
In 1995, Quebec’s health minister announced a merger of the three “French” hospitals—Hôtel-Dieu, Notre-Dame and Saint-Luc—to create CHUM. A similar process happened with the “English” hospitals—Montreal General, Royal Victoria, Montreal Chest Institute, Montreal Neurological Hospital and Lachine Hospital—and that was called the McGill University Health Centre (MUHC). In 1999, it was finally decided that CHUM and MUHC should be more than virtual institutions. They would become bricks-and-mortar “super-hospitals.”
Then the real jockeying began. Where would the facilities be built? What would happen with the existing hospital properties? How many beds would each super-hospital have? And so on. Forests were felled and tens of millions of dollars spent to produce studies, including a 2003 commission of inquiry headed by former prime minister Brian Mulroney and former Quebec premier Daniel Johnson.
Back then, CHUM was going to cost $860 million, and the super-hospitals were going to be built and operating by 2007. But a shovel in the ground by this date would prove to be a pipe dream. One of the most politically vicious battles was about the future site of CHUM. It came down to 1000 St-Denis St. (in the heart of downtown) or 6000 St-Denis St. (in tony Outremont). There is enough intrigue in those choices to fill a book—and, in fact, a book has been written. The travails of MUHC, by contrast, were minor. All they had to deal with was contaminated land and angry neighbours near the planned construction site in Notre-Dame-de-Grâce. And, oh yes, the costly foot-dragging of indecisive political leaders and a kickback scandal.
Plans to have the new facilities built as private–public partnerships (PPPs)—an approach in which private enterprise would build the hospitals, then lease them back to government over a thirty-year period—added to the controversy and cost and, in the end, private enterprise would play a token financing role so the government could save face. By 2016, the 772-bed CHUM’s projected total cost was $2.1 billion, along with a $470 million CHUM research centre. Not to mention the $500 million upgrade of Sainte-Justine, the “French” pediatric hospital. MUHC cost about $2.4 billion, including a new five-hundred-bed facility, a new Montreal Children’s Hospital and extensive renovations to the 332-bed Montreal General Hospital. That’s $5.5 billion and counting—though one economist calculated that when the final tally is in, the total will reach $8.6 billion.
That sort of profligate spending is difficult to justify, but the fact remains that all the facilities were needed and overdue. Quebec’s flagship hospitals were crumbling, inefficient and increasingly unsafe. (It’s no coincidence that Quebec had an inordinate number of hospital-acquired infections such as C. difficile.) Quebec’s political leaders should have received credit for their bold investments in health care. Instead, they received derision because they took too long to do the right thing. They lost sight of who really matters: the public. An endless list of excuses was trotted out each time a minister made a new announcement and revised the timeline for construction. But the bottom line is that these hospitals should have been up and running at the turn of the new millennium. The delays served the interests of property developers, construction companies, donors to political parties and various interest groups within the health system, not the sick and injured who needed hospital care.
Almost two and a half decades after planning began, the MUHC finally opened in April of 2015, while the CHUM is slated to open sometime in 2017. That no premier or health minister ever demanded that the shuffling of paper end and the roar of construction equipment begin is a disgrace, plain and simple. In Canada, we talk a good game about patient-centred care. But it will never be a reality unless it becomes a priority and a guiding principle from the upper echelons of power on down.
When even Dr. Optimism is losing faith in medicare, it’s time to fix it
“We have seen a slow and steady decline in what we would all now agree is a deeply troubled health-care system. To be clear, this pillar of Canadian society is eroding … We are losing something of great value. It’s slipping away slowly, incrementally.”
This kind of rhetoric is so commonplace that we have become largely inured to it. At first blush, it’s another medicare-is-doomed pronouncement much as we’ve heard seemingly every day for the past half century or so. But pay attention this time—those mournful words were spoken by Dr. Jeffrey Turnbull, past president of the Canadian Medical Association, in his valedictory address of August 2011.
Turnbull is one of the most unwaveringly hopeful and positive people in medicine. He knows the Canadian health system inside out, and from the bottom up. He cheerfully treats poor, homeless addicts as part of Ottawa’s Inner City Health project. He is equally upbeat as chief of staff at the Ottawa Hospital, a thankless position. He affably headed the CMA, which speaks and lobbies on behalf of the single most powerful and prickly group in the health system, physicians.
If Turnbull is losing faith in medicare, we need to prick up our ears—and roll up our sleeves and fix it. When he expresses his frustration, it is not rhetoric. He backs his feelings with cold, hard facts and incisive anecdotes. “I’ve always been immensely proud of our health-care system—one that was once considered to be one of the best in the world,” he told CMA delegates. “But times have changed and Canada now ranks below Slovenia in terms of effectiveness and last or second last in terms of value for money.” Ouch. Equally scathing is his summary of the frustrations he has heard expressed by patients in his travels coast to coast. “They’ve told us they’re suffering because of a lack of access to timely, effective care, confused by a system that is limited in the services it provides, that is cumbersome and almost too complex to navigate, and angered by a system that fails to put their needs first or even engage them about their health issues.”
That takes care of the international comparisons and shortcomings in care delivery. What about administration of the $228-billion-a-year health system? “I’ve been struck by the lack of leadership, co-ordinated management, accountability, and responsibility—and, yes, needless waste,” Turnbull said. “Worse, we allow staggering inefficiency, ineffective management processes, incoherent decision-making and practice variations that undermine quality and safety.” Despite it all, he remains optimistic. “I do believe this can be changed ... that we can create a better health-care system in the future.”
Turnbull has a diagnosis and a prescription. It begins with getting back to basics. Medicare—and other social programs—were created to address social inequities, to make good health achievable and affordable for all. Yet today in Canada there is “devastating and epidemic health inequity”—and it has become a major driver of health costs. One way to address inequality in health-care delivery is to ensure all Canadians have access to a basic level of prescription-drug coverage, a “glaring failure” of medicare, Turnbull said. Similarly, there needs to be a massive shift in approach (and resources), from the 1950s-style illness-care system we have now to a twenty-first-century health system that emphasizes chronic care and prevention.
In his time as CMA president, Turnbull championed this transformation. He created a blueprint, a document titled Health Care Transformation in Canada: Change That Works, Care That Lasts. It’s by no means perfect, but it’s a start. It does not merely advocate shoring up the system that is eroding but rebuilding it from the ground up—all the while keeping the foundation, the public insurance model. As Turnbull told his CMA colleagues, “Leadership demands vision to see the path before us, the courage to take it and the strength to follow it.” Not just hope, not just words, but purposeful actions.
Is Canada’s public health-care system financially unsustainable?
It is often stated that Canada’s health system is unsustainable—a vague, undefined term that is used as a synonym for unaffordable. The problem is the unsustainability argument is based on a few dubious assumptions:
that annual spending will continue to grow at the same rate as in the past, if not faster;
that the aging of the population will actually accelerate the spending increases; and
that nothing can be done to reduce spending. This, in turn, assumes that nothing can be done to change the way we deliver health care or to keep people healthier longer.
In short, it is a pretty cynical world view. And, more importantly, concrete solutions are rarely proposed to alleviate the problem, other than to privatize more health services. Philosophical arguments aside, doing so does not reduce overall costs but merely shifts them from the collectivity to individuals, from public insurance plans to private ones or, worse yet, to out-of-pocket costs. What this dreary set of assumptions does do, however, is remind us of one of the major failings of Canada’s publicly funded health system: we do very little planning and analysis, especially of a financial nature. That’s why a 2013 report from the Canadian Institute of Actuaries was a welcome contribution, albeit a modest one.
The CIA (the actuaries, not the US spy agency) undertook a straightforward task: to create a model for projecting future health-care costs. They chose the province of New Brunswick as an example of how that model could be used. The limitation was that the modelling exercise examined only steady-state health-care costs—meaning costs based on the assumption that there would be no changes to health-care coverage or financing, and no major changes in the economic environment. But this was nonetheless useful because it provided some concrete data about what health spending would look like if all things remained the same. In this analysis, health costs were predicted to rise 4.43 percent annually until 2020, just as they had done in the previous decade. Practically, that meant the provincial health budget would increase to $4.6 billion in 2020 from $2.8 billion in 2009. Per-capita costs would rise to $5,976 from $3,711 in that same period. Put another way, at the time of the study it cost about $75 a week to provide health care to each of the 750,000 residents of New Brunswick. By 2020, it will cost $115 a week. (That is slightly above the Canadian average.)
Is that unreasonable? Unsustainable? The actuaries’ report didn’t answer those questions. It just crunched the numbers. But data make for a much more concrete discussion than rhetoric.
One of the more interesting sets of numbers was a breakdown of the 4.43 percent annual increase. Based on data from the Canadian Institute for Health Information, the actuaries said the rise in health costs had three main elements:
Health-care inflation accounted for 1.99 percent of the increase, money that goes mostly to wage increases. In fact, about two-thirds of all health spending is for labour.
Aging, which is often cited—wrongly—as the principal reason health costs are becoming unsustainable, accounted for 1.27 percent of the annual rise in costs. This is because per-capita costs increase as people age.
Increased utilization made up the rest of the cost escalation, at 1.10 percent. This is a reminder that people of all ages are using more services, not just seniors.
The report also estimated projected annual increases in major categories, including hospitals, physician services, drugs and other institutions (like nursing homes). Overall, the numbers are sobering. Without changes in how we deliver health care, per-capita costs will have tripled from 2000 to 2020: to $3,599 from $1,219 for hospitals; $1,105 from $354 for physicians; and $452 from $104 for drugs.
These data give some ammunition to those who argue that the system is unsustainable, at least superficially. But what they should really do is provide impetus for reform. Canadians don’t need a discussion of how to rein in costs, because that usually results in little more than trimming around the edges. What we need to discuss is delivering care differently, including actuarial modelling of new approaches.
A public insurance plan should, like a private plan, ensure that it has enough money to provide insured services. But the first crucial step is determining what those insured services are. Those are political and societal choices. The accounting exercise comes later.
Medicare needs a culture change
“Canada is a country of perpetual pilot projects,” Monique Bégin famously wrote in the Canadian Medical Association Journal. The former minister of health and welfare pithily described a long-standing, frustrating problem in our medicare system: we have solved every single problem in our health-care system ten times over, but we seem incapable of scaling up the solutions.
This inability to learn, to share and embrace innovation across jurisdictions, is explored thoughtfully in the 2015 report of the Advisory Panel on Healthcare Innovation. The panel, led by David Naylor, a physician and former president of the University of Toronto, emphasized that “Canada has no shortage of innovative health-care thinkers, world-class health researchers, capable executives, or dynamic entrepreneurs who see opportunity in the health sphere.” But innovation is stifled by the structure and administration of the health system, and by a dearth of leadership. Medicare—the name we give our publicly funded health-insurance scheme—is, in fact, not a system at all; it’s a collection of fourteen federal, provincial and territorial programs (plus Workers’ Compensation, which is private) that are neither integrated nor co-ordinated. Worse yet, within those programs, there is a near total absence of vision and goals.
The role of our health bureaucrats is to hold the line on spending as best they can and, above all, ensure that the names of their political masters don’t appear in damaging headlines. Improving patient care is rarely the number-one priority. The way our system is funded—predominantly with block transfers to hospitals and fee-for-service payments to physicians—encourages volume of procedures and the status quo. It does not reward quality of care or responsible stewardship. In fact, when an individual or a program goes out on a limb and makes changes to improve efficiency or cost-effectiveness, the benefits often accrue to others; perverse disincentives are commonplace and counterproductive.
These problems and frustrations are not new. The Naylor report cites an example from 1974, when Canadian researchers published a landmark paper showing that nurse practitioners could do 70 percent of doctors’ work with no difference in outcomes or patient satisfaction. Using nurse practitioners also saved money, but hiring more of them was hampered by the fact that, generally speaking, doctors are paid on a fee-for-service basis and nurses are salaried. Over four decades later, that same bureaucratic hurdle remains. Most other Western countries acted on the research: nurse practitioners are an integral part of health-care delivery and most physicians are salaried. But in Canada, nurse practitioners are still grossly underused—except in pilot projects, of course. We still negotiate physician and nurse contracts separately, and our management of health-care human resources is a mess. Until you get workers with the right skills in the right place at the right time, you will never deliver seamless, patient-centred care and you will never control costs, because labour accounts for two-thirds of all spending. As the nurse practitioner story and countless not-acted-upon research findings have since illustrated, innovation is hampered by policy gridlock. The managers of the system are largely powerless and beholden to the whims of politicians; moreover, with few exceptions, they are profoundly mistrusting of entrepreneurship and pathologically risk-averse.
For decades, we have produced reports about the need to transform health-care delivery and funding while simultaneously clinging to the same old way of doing things. It’s a fundamental disconnect between evidence and action. If you don’t take risks, you will never innovate. So how do we break the log-jam? According to the Naylor report, it has to begin with leadership, and it should come from Ottawa.
One of the panel’s central recommendations is the creation of an independent health innovation agency to not just fund pilot projects but to promote scaling up, to use searchable repositories of successful programs, to offer financial incentives and to encourage regulatory change—all with the aim of spurring innovation. More resources alone will not ensure the scaling up of good ideas. There needs to be partnership, commitment and monitoring to ensure implementation. In short, it’s not more money the system needs, it’s culture change—a shift from perpetual pilot projects to embracing innovation and best practices.
Canada needs a “coalition of the willing” to fix health care
Which country has the world’s best health system? That is one of those unanswerable questions that health-policy geeks like to ponder and debate, and serious attempts have been made at measuring and ranking. In 2000, the World Health Organization (in)famously produced a report that concluded that France had the world’s best health system, followed by those of Italy, San Marino, Andorra and Malta. The business publication Bloomberg produces an annual ranking that emphasizes value for money from health spending; the 2015 ranking placed Singapore on top, followed by Hong Kong, Spain, South Korea, Japan and Italy. The Economist Intelligence Unit compares 166 countries and ranks Japan as number one, followed by Singapore, Switzerland, Iceland and Australia. The Commonwealth Fund ranks health care in eleven Western countries and gives the nod to the United Kingdom, followed by Switzerland, Sweden, Australia and Germany.
The problem with these exercises is that no one can really agree on what should be measured and, even when they do settle on measures, data are not always reliable and comparable. “Of course, there is no such thing as a perfect health system and it certainly doesn’t reside in any one country,” Mark Britnell, global chairman for health at the consulting giant KPMG, writes in his book, In Search of the Perfect Health System (Palgrave Macmillan, 2015). “But there are fantastic examples of great health and health care from around the world which can offer inspiration.”
As a consultant who has worked in sixty countries—and who receives in-depth briefings on the health systems of each before meeting clients—Britnell has a unique perspective and, in his book, offers up a subjective and insightful list of the traits that are important to creating good health systems. If the world had a perfect health system, he writes, it would have the following qualities: the values and universal access of the United Kingdom; the primary care of Israel; the community services of Brazil; the mental-health system of Australia; the health promotion philosophy of the Nordic countries; the patient and community empowerment in parts of Africa; the research and development infrastructure of the United States; the innovation, flair and speed of India; the information, communications and technology of Singapore; the choice offered to patients in France; the funding model of Switzerland; and the care for the aged of Japan.
In his book, Britnell elaborates on each of these examples of excellence; in addition, he provides a great précis of the strengths and weaknesses of health systems in twenty-five countries. The chapter on Canada is appropriately damning, noting that this country’s outmoded health system has long been ripe for revolution, but the “revolution has not happened.” Why? Because this country has a penchant for doing high-level, in-depth reviews of the health system’s problems, but puts all its effort into producing recommendations and none into implementing them. “Canada stands at a crossroads,” Britnell writes, “and needs to find the political will and managerial and clinical skills to establish a progressive coalition of the willing.”
The book’s strength is that it does not offer up simplistic solutions. Rather, it stresses that there is no single best approach because all health systems are the products of their societies, norms and cultures. One of the best parts of the book—and quite relevant to Canada—is the analysis of funding models. “The debate about universal health care is frequently confused with the ability to pay,” Britnell writes. He notes that the high co-payments in the highly praised health systems of Asia would simply not be tolerated in the West.
But ultimately, what matters is finding not a perfect approach but one that works: “This is the fundamental point. There is no such thing as free health care; it is only a matter of who pays for it. Politics is the imperfect art of deciding ‘who gets what, how and when.’” The book stresses that the challenges are the same everywhere: providing high-quality care to all at an affordable price, finding the workforce to deliver that care, and empowering patients. To do so effectively, we need vision and we need systems. Above all, we need the political will to learn from others and put in place a system that works.
Taking patient-centred care from rhetoric to reality
Patient-centred care is a term that gets bandied about a lot these days. But what does it really mean? How does our health system need to change to make it truly patient-centred? What reforms and innovations are required on a systems level? How do front-line care providers need to change to make care truly patient-centred? And how do patients need to behave differently? These are all questions that need to be answered if we’re going to move from feel-good rhetoric to doing-some-good reality.
The US Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine defines patient-centred care as “care that is respectful and responsive to individual patient preferences, needs and values.” That’s nice and inspiring and all-encompassing. It means everything and nothing. There’s a well-worn expression: “I don’t know anything about art, but I know what I like.” Patient-centred care is a bit like that; you know when you experience it—and especially when you don’t—but you can’t necessarily articulate the characteristics.
In many ways, the concept is more easily expressed in aphorisms than with a formal definition. “The needs of the patient come first” is the tagline of the Mayo Clinic; “Every patient is the only patient” was carved above the front entrance of the Harvard Community Health Plan Hospital. “Nothing about me without me” is the rallying cry of many patient activists. Another description of patient-centred care is a more esoteric one: “Giving a patient a better day.” When all is said and done, that’s what health care is all about: making patients feel a bit better. But like many aspirational goals in health care, these things tend to be a lot easier to say than to do, a lot easier to promise than to deliver. Maybe a better way to understand what patient-centred care means is to articulate what it is and isn’t.
So what do patients dislike about being in the health system—aside from being sick, of course? A number of things: the helplessness, the feeling of anonymity, the discontinuity of care, the rote and repetition, being talked about and talked to rather than talked with, the waiting, and the loneliness. Judith John, a long-time health-care executive who was diagnosed with an inoperable brain tumour sixteen years ago, has, along the way, become an eloquent and inspiring patient advocate. She says that in a system that has become obsessed with data, with measuring and metrics, we often lose sight of the importance of relationships, conversation and, ultimately, the person. “When you’re a patient, there’s only one metric that matters,” she says. “Treat me like a person. Not a chart, not a number, but a person.”
The failure to do so, which generates so much angst and fear, stems from a fragmented system and from poor communication. We have a sprawling, elaborate, expensive health system with buildings and equipment and all manner of health professionals, but we haven’t quite figured out where the patient fits in. There is a broad range of views on this—a spectrum that ranges from radical consumerism, a belief that the patient is God (or, if you prefer, the customer is always right), through to classic professionalism (or, more accurately, paternalism), which holds that medical professionals have to use their knowledge to give patients what is best for them and, in many cases, to protect them from themselves.
Let’s not forget the etymology of the word patient. It means “to suffer,” or more precisely, to be silent in your suffering. Perhaps we need a new word. At the very least, we could use a new definition. Patient-centredness has come to mean “empowerment.” But it does not—or should not—mean giving patients everything they want, when they want it. Health care is not an all-you-can-eat Chinese buffet. But it’s not a military exercise either, where patients must unquestioningly follow orders. In between those two extremes is the sweet spot: partnership, sharing of information, exchange of opinions, mutual respect. These are all the characteristics you want to see in a patient–provider relationship—and in the system–patient relationship, for that matter.
While these ideals sound great on paper, they are not easy to achieve, especially in the high-octane daily grind that is modern medicine. A whole academic literature exists on shared decision-making and its complexity. Health-care providers need to act in the best interests of patients. But patients often have a view of what is best for them that differs radically from the guidelines and medical teachings. Shared decision-making is about more than agreeing to disagree: it’s a lot dirtier and messier than that. It’s about finding a compromise that respects medical responsibility and patient autonomy. It’s a delicate dance that we’re going to have to master if we truly want quality, patient-centred, appropriate care.
Lack of dental-care insurance is a gaping hole in medicare
Canada’s medicare system has many quirks, but one of the more glaring anomalies is that the mouth does not seem to be considered a part of the body. In our predominantly publicly funded and publicly delivered health system, almost all dental care is funded privately, through employer-based insurance or out-of-pocket. The result is that many Canadians—about one in four—are unable to access dental care. The most vulnerable are the hardest hit. “The system is really not working, and it’s only going to get worse unless we act,” said Dr. Paul Allison, dean of the faculty of dentistry at McGill University in Montreal.
Annual spending on dental care in Canada tops $13 billion, but only about $800 million of that total is publicly funded. First Nations and Inuit have state-funded dental insurance, at least in theory, but they often have trouble accessing care because they live in remote communities and dentists visit infrequently. Dental care is free for children under ten in Quebec and for those under fourteen in Nova Scotia. All provinces and territories also pay for in-hospital dental surgery—which usually becomes necessary when oral-health problems are neglected for long periods. And a number of ad hoc and charitable programs provide dental care to the poor, many of them run out of Canada’s ten schools of dentistry. “But these programs are a drop in the bucket compared to what’s needed,” Allison said.
Providing “free” dental care to all Canadians under the umbrella of medicare—sometimes referred to as “denticare”—is probably unrealistic in the current economic and political environment. But Allison said there is no question that publicly funded dental-care programs need to be broader and more coherent. They need to provide essential oral care to those most in need, including children in low-income families, seniors living in institutional care, people with disabilities, the homeless, refugees and immigrants, indigenous peoples and those on social assistance.
Why does that matter? Oral diseases, including cavities (which are caused by bacterial infection, not sugar), gingivitis and mouth and tongue cancers, can have a significant impact on daily functioning and quality of life. Dental problems are not merely a nuisance. Evidence is mounting that poor oral health is a bellwether for the rest of the body.
Gum diseases like gingivitis are low-grade infections that cause swelling and bleeding of the gums. The same kind of immune response is triggered as when the immune system fights off bacteria and viruses elsewhere in the body, and this inflammation, particularly in places like the arteries, can have serious consequences, such as exacerbating the symptoms of heart disease or diabetes. Numerous epidemiological studies, including a long-term study of US veterans, show that people with gum disease are far more likely to have heart attacks and strokes. Pregnant women with gum disease are far more likely to have premature and low-birth-weight babies. Diabetics with poor oral health have more symptoms. And some scientists think rotten teeth may even be a factor in cancers; after all, the bacterium H. pylori, which causes ulcers, is a key factor in stomach cancer.
Good oral health is clearly not strictly an issue of vanity. Potentially important public-health implications could be derived from better dental care. Healthy habits could ultimately prove to be cheap and effective prevention measures for a host of serious chronic diseases. Yet Canada has one of the lowest rates of publicly funded dental care in the world—only 6 percent of total spending. Even the United States has a higher public share, at 7.9 percent. Many European countries include dental care in their universal health programs. In Finland, for example, 79 percent of dental care is publicly funded.
Dr. Stephen Hwang, a research scientist at the Centre for Research on Inner City Health and a physician at St. Michael’s Hospital in Toronto, said lack of dental care is a “gaping hole” in Canadian medicare and causes significant health problems for many of his patients. “Their teeth are atrocious,” he said, and the result is that they live in pain, and it affects their nutrition, mental health and cardiovascular health. “These patients have abscesses in their mouths that, if they were in any other part of the body, we would treat,” and that’s illogical and a false economy because it exacerbates other conditions. “I’m not talking about cosmetics but necessary medical care,” Hwang said. “A lot of people aren’t getting that necessary care because they can’t afford it.”
If we want a healthier population—and a more equitable medicare system—we have to put some of our money where our mouths are.
