Physician heal thy system

My column this morning is on health care.   I don’t pretend to be an expert in health care economics but I have studied the data in fair detail and was involved in the preparation of two health care regional strategic plans.

My premise is that doctors and health care practitioners need to lead the effort towards economic sustainability in the health care sector.   

We have over 11,000 more workers in health care today in New Brunswick compared to 1999 with no real evidence of better outcomes.  We are spending $1.2 billion more this year than in 1999 on health care.

I recently read Dr. Furlong’s book – Medicare Myths – and I think this is a great first step to change the conversation.  He argues that over-utilization is the number one problem with the system.

The data backs him up.  We have massively enlarged the size of the health care sector in New Brunswick in the past 15 years on a population base that has not increased.  Therefore, there must be either a) far more interventions per capita than before or b) significantly less interventions per health care practitioner.   My limited research into this says it is the former.

I was involved with the tele-care initiative way back in the mid 1990s which was meant to stem the tide of visits to emergency rooms across the province.  While I don’t have much data on this, it would seem that it hasn’t.

So the system reverts to ‘time’ as a substitute for money as the only way to limit use.   Hospitals could easily staff up emergency rooms but they use waiting (time) to try and discourage usage.   There is ample data on wait times that shows the shorter they are, the more usage there is.   

Dr. Furlong wants people to start paying directly for a portion of health care – through the taxation system.  He doesn’t get into too much detail in the book but goes to great lengths to say it is no user fees and not a parallel system.  In his view, this is the only way to get people to understand the cost implications of their health care decisions and – on the supply side – to get health care practitioners to understand the cost implications of their health care decisions.

Nobody likes talking about ‘cost’ and ‘health care’ in the same sentence.  This is Canada after all but it is basic human nature to equate things that are ‘free’ with ‘cheap’.  Health care is not cheap – it is rapidly becoming the second largest cost behind housing for the average household – if you were to apportion the public cost and add in employer cost and direct cost.

The best time to have this conversation is now – when we have a fiscal crisis.  It was easy for politicians to pour virtually all new money into health care when they could – now they can’t so let’s talk.

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8 Responses to Physician heal thy system

  1. You write, “We have over 11,000 more workers in health care today in New Brunswick compared to 1999 with no real evidence of better outcomes. We are spending $1.2 billion more this year than in 1999 on health care.” Implicit in this argument is the supposition that the level of health care in 1999 in NB was adequate. It was not.

    I moved here in 2001 and it took me years to find a family doctor. We simply could not obtain prescriptions for things like asthma medication. It still takes far too long to obtain service on some kinds of treatments.

    I don’t know what the evidence is (or isn’t) that there is “no real evidence of better outcomes” but I’m quite sure I’d like to see it presented. In my own household, the level of health is much better today than even five years ago. I can document it pretty easily. But I am not sure how this would translate into evidence of outcomes.

    Yes, I use health services more now than in the past. That is because, in the past, I was not able to access health services at all. There were no clinics, there was no way to see a physician, the only point of access was through the emergency room.

    I would want to see more evidence that ‘greater awareness of the costs’ would impact usage of the health care system. When you’re sick, you’re sick. People would love to be less sick, but it doesn’t work that way.

    I’m sure there are ways to reduce health care costs and to improve outcomes, but they are a far cry from the sort of solutions the privatization set proposes.

    – address income inequity. The gap between richest and poorest in NB is among the widest in Canada. There’s plenty of research showing health care costs are reduced with income gaps are lowered. The Globe and Mail published more evidence of that today. http://www.theglobeandmail.com/news/opinions/opinion/to-manage-health-costs-invest-in-social-well-being/article1828960/

    – improve points of access. The biggest shock for me on moving here from Alberta was not the hospitals (though, honestly, NB hospitals were 20 years behind Alberta’s). It was the complete absence of drop-in clinics. Now we have more clinics, but they are not well-advertised and you still have to book an appointment.

    – manage bookings and appointments with computers. Make (and keep) appointments. I mean, seriously now. The NB system has yet to enter the computer age. Here’s how bookings work now: your doctor will send a referral (by paper) to the specialist, and then some time in the future, the specialist will phone you. Appointments? Scheduling system? Not in NB. Those of us who are newcomers are quite certain that locals are called first, with the rest of us getting the leavings.

    – invest in education. When you launch services like tele-health, advertise it (I learned about it originally only when my doctor told me). Use the media to describe the system to people, the different ways to access it, and the appropriate ways to do so. Also, media about general health, health issues, and similar campaigns is essential.

    – stop threatening people with privatization. Big business would love to own the hospitals and insurance system. We get that. But it doesn’t help anyone to have them constantly lobbying for reductions in services, reductions in expenditures, methods for tracking fees, etc. Make it clear that the hospitals are a public service, for the good of NB, and will not be privatized.

    Remember, investments in health care are net gains for the province, not line-item expenses. Health care is absolutely essential in order to attract and retain population and industry. We should be using our health care as a selling point, not trying to explain away the expenses as mismanagement and abuse. Health care can form the basis for an economy – a big part of the resurgence in Moncton over the last decade is the provision of health care services around the hospitals – everything from clinics to pharmacies.

  2. richard says:

    ” He doesn’t get into too much detail in the book but goes to great lengths to say it is no user fees and not a parallel system.”

    From what I have heard him say since publication, it sounds like some sort of medical savings account – where the health care budget allocates everyone a certain amount of funds. Not sure how well that could be administered nor how people with chronic medical conditions would be dealt with, but could be looked at.

    Fee for service is another thing that might be contributing to over-utilization.

    Perhaps putting cost information on health care might encourage more attempts at ‘wellness’, i.e. less ATVing or snowmobiling and more XC skiing.

    I can’t see the current govt going very far in these directions. They will just cap spending somehow and let the pressure-cooker effect lead us into some sort right-of-the-spectrum ‘solutions’.

  3. Derrick says:

    NB Power:
    – one billion dollar error at Coleson Cove,
    – one billion dollar error at Lepreau and counting.

    Does anybody really thing that Health Care is better managed ?
    Is more money the solution ? In Canada Health Care public or private
    should be fee for service, not block funded.

  4. Scott says:

    Excellent post, David. Maybe you can do a review on Dr. Furlong’s book and submit it to one of the policy outlets? Anyway, on health care. As I see it, there are still some advantages to keeping the private option out of the equation. Number one, it’s still a competitive advantage that we have over our neighbours to the south, even with their recent reforms under Obama. Why? Because it is a known fact that our health care system has long been a selling point for industry in that it is (and has been) a key factor in their decision to locate and invest in Canada. Thus creating many good jobs along the way. No, most of those jobs in the automobile sector did not directly impact us as much as the southern horse shoe, however, because they powered one of our national economic engines, Ontario, it allowed other provinces to have services and perks until own source revenue became a better reality right here. Which is why, even in a recession, that I believe it would be wrong to fritter away that huge advantage simply because we face a few challenges within the system.

    So if we do decide to have “that” conversation, we should start by remembering that Canadians want good health coverage, one that is reasonably assessible, and most of all, timely. But first and foremost, Canadians want to enjoy good health so that it is not a factor when it comes time to enjoy the things that bring joy to their life, like family, children’s activities, travel and leisure.

    That said, there are challenges, but not the type of challenges that require a complete overhaul or dismantling of the system. A few things that stand out for me personally are: 1.) Quality of health care. Are we getting the best coverage within the universal system? And does this system attract the best professionals to our region? Recently, i’ve witnessed three family friends die of complications during (or caused by) procedured and wondered would this have happened if the procedure was paid for and administered by a world class physician. I’ve become a little sceptical after seeing what went on with the Newfoundland Premier, and his recent heart troubles. My concerns stem from the fact that maybe the system “here” is failing us and that it could be the result of thousands receiving lower quality, which in turn, could lead to further problems, and in the case of those family friends I spoke about, death. Too many doctors are inundated with patients so the challenges are vast. However, when you see people being turned away because they can’t access a physician or a specialist, then there must be something done, and quickly. 2.) Which brings me to my second challenge, wait-times. Even with this being a plank on the well discussed list of 5 priorities of the feds, and one they claim to have addressed, it still seems to be a problem. Just recently the Ontarion government release a policy report which made claim to patients waiting an average of 10 hours for emergency services and 8 hours for non-emergency services. This is too long. Solution? A wait-times strategy where more of the latest technologies are applied to improving the management of care (i.e. “e-health”). 3.) We must look at ways to better cover the cost of catastrophic drugs for all Canadians. It has come down to economics and those that don’t have a job plan or money, don’t get access to the drugs needed. This has to change. 4.) Employ a wellness plan that best addresses child obesity. No, it does not come in the form of forced menus in public schools, but it does need to be addressed. Economist have clearly said that wellness plans pay for themselves as it gets more people healthy and out of the system. 5.) And last, but not least, we need to embed performance reporting into the Canada Health Act so that indicators and common benchmarks can allow governments to better report information to the general public. The end result will allow government’s themselves to be more accountable and transparent in they way they spend public funds and the performance they achieve overall.

  5. I am a full supporter of public health care and I am skeptical based on the US, Australian and other models that a two-tiered system (beyond what we already have) is the best way to manage the cost of the system.

    As for wait times, I continue to believe the ‘system’ uses this as the only real mechanism it has to control over-utilization.

  6. mikel says:

    First, the criticism-‘over utilization’ is another way of saying “we don’t want you to seek health care”. That may or may not be legitimate, but seeing as how taxpayers foot the bill, I think its disingenuous to say “stay home and suck it up”.

    Thats the problem with non-experts, everybody has an opinion, but nothing to do with it. On Ontario Today yesterday they actually talked to ER heads in two hospitals, and they pointed out that the BIGGEST problem in hospitals is the lack of COMMUNITY care. In other words, mentally ill, senior, and other individuals who SHOULD be managed out of the hospital, simply had nowhere to go. I doubt NB is that much different.

    As for paying for it, once again you have to try selling higher taxes. Here in ontario they introduced a ‘health premium’ which was a progressive income tax based on your salary. The wealthier pay more, and since you can’t even get the richest millionaires to talk about giving up their Graham tax cuts of three years ago, I suspect that the idea of a health premium won’t go far.

    Over utilization is also a problem for society. There was a short lived idea here a couple of years ago for a ‘fat tax’, which would be on fast food, but that would be extremely hard to implement. Yet I seem to recall that NB schools were using McDonalds franchises in their cafeteria’s-we really haven’t seen much on proposals to actually get people healthier. It’s always a shock for me to walk through town and see just how FAT maritimers are-sorry to say, but in a university town thats a very unusual sight.

    Getting people healthier though also means looking at industry, and say, protecting ground water from contamination by industry. There is also a large population on welfare as a result of work injuries-thats a by product of a largely ‘body based’ workforce.

    I’d suggest that the problem IS ‘getting fewer people to the hospital’, but the way to do that is a healthier society with more access to alternatives other than hospitals. It’s bad enough now, but can you imagine how bad it would be if all those ‘alternative medicines’ that are so popular were included?

  7. I guess we have different definitions of ‘non-expert’. For me a non-expert is someone ranting about how NB Power is worth $42 billion. Dr. Furlong is a former Minister of Health and a 30 year family physician. You may not agree with him, but if he is a non-expert I wonder who is an expert?

    As for the utilization argument you (Mikel) make it sound like the choice is between staying at home and dying or using the system willy nilly. Those aren’t the choices.

    From Furlong’s book:

    “Patients try to build a case for CPP, a ‘case’ for workers compensation, a ‘case’ because of an inattentive spouse. Patients visit the doctor for letters for school absence, letters for work absence, and of course the ‘biggie’ prescription refills on a monthly, bi-monthly or tri-monthly basis These are only a few of the many useless, ulterior and non-illness related reasons that patients visit their doctors.”

    He also talks about the soft-tissue neck pain after auto accidents which gets miraculously better after the settlement with the insurance industry (I think this must have been written before the soft tissue cap?).

  8. Scott says:

    “Patients visit the doctor for letters for school absence, letters for work absence, and of course the ‘biggie’ prescription refills on a monthly, bi-monthly or tri-monthly basis These are only a few of the many useless, ulterior and non-illness related reasons that patients visit their doctors.”

    His point brings back memories of the Elgin Street doctor who was notorious for signing sick notes and handing out boxes of painkillers like they were going out of style. During flu season it was like a Tim Hortons drive thru with everybody looking for the same useless thing. What a waste.

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