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Better - Six Bold Ideas about Healthcare
                        April 2017


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A family doctor at Toronto’s Women’s’ College Hospital, Danielle Martin, became famous for her spirited testimony before a US Senate Committee that was seeking information on foreign health care. Her book, Better Now: Six Big Ideas to Improve Health Care for All Canadians, Allen Lane, 2017, is a bit more pedestrian.

 

A firm believer in the Canadian public health care, she is not reticent in calling for cures that would make it work much better. So, sandwiched between an introduction and a conclusion, come chapters on each of her six big ideas for improvement. The book comes in a Canadian bedside delivery manner style with the mandatory human interest story per chapter. Her grandparents arrived as refugees and were ruined financially by illness before the era of healthcare. There are illustrative tales from several patients. Despite a sense of ho-hum-ness, I found myself getting insights into health care and being persuaded by some clear arguments for change. It ended up being a useful informative read.

 

In her opening chapter she says the aim of healthcare is: “To deliver accessible high quality services in an equitable way. And to give us something to be proud of.”

 

By way of background, she says most provinces have a single payer scheme – the government pays. At the same time most of the health care delivery is some form of private delivery. Doctors are self-employed with a single payer for their service bills. Hospitals, although acutely aware of government expectations, are not government- owned. They are forms of private not-for-profit corporations. Some areas, including dental care, drugs, and physiotherapy, are deemed additions and are privately financed. Employee benefit programs mainly pay these bills, and they account for 30% of total health spending.

 

Using a single payer for health care has two big pluses. The care is equitable - given on the basis of need rather than wealth. It is administratively much cheaper. The lower administrative cost comes from much foreign experience. The administrative costs for the Canadian private schemes for drugs are a lot higher. Although healthcare is basically a provincial jurisdiction, a federal role comes from the 1984 Canada Health Act. Canadian doctors have a lot of autonomy in the provincial healthcare schemes. Yet they cannot extra bill or have a second practice. OECD data indicate they are among the best paid in the world. So there hasn’t been a problem of “brain drain” to the south.

 

Martin says there is a triple aim: improve the health of the population; improve the patient experience; and hold costs sustainable. The performance statistics are not all bad. Canadian life expectancy is good. So are responses to urgent needs. But experiences of wait times for less urgent things are not so good. Although total health expenditures are near the top for OECD countries, the public expenditures component is near the bottom for OECD. Things like prescription drugs are private. (As a senior in Ontario I can add that the government pays for most prescription drugs for seniors after an annual $100 total payment by the senior. But, as for everyone, some prescriptions are just not covered.)

 

Value for money is a question - and often a public issue. Yet suppositions of burgeoning costs tend to be wrong or exaggerated and need a closer look. For example there is no huge wave of aged population, rather a current 1% per year growth. And quick intuitive fixes to presumptive cost problems can be unhelpful on examination. User fees are suggested. Yet they make patients think twice before seeking help, deter necessary as well as unnecessary care, and don’t save any significant money because the administrative costs are always large. Offering parallel private care is touted to remove delays. It certainly removes equity; and such schemes are found to undermine the public system further. Studies show that a private-pay care scheme increases wait times in the parallel public system and indeed provides an incentive for longer public wait times. Why not try the European mix of public and private say some people. A closer look at European mixed public/ private schemes reveal they are not simple. In Germany one has to be entirely out of the public system if one wants private care. In France, private is something closer to the Canadian private add-ons discussed above. Martín argues it’s better to deal with the problems in the Canadian model that has the big plus of being equitable. She moves on to the chapters about the six ideas.

 

The first idea pushes the role of family doctor as a primary trust relationship to oversee the health of a person, accessible and able to be aware of and to support and stabilize any other interventions such as a hospital emergency visit. Access and trust are key issues. The need here is to make sure the family doctor is told by the hospital about a hospital emergency visit and the interventions taken so that the family doctor can work with the patient on long term overall care.

 

The second idea concerns prescription drugs that are outside the system once one leaves a hospital. The cost of drugs is high in Canada. A public plan would have leverage to reduce costs. The private plans are administratively costly; and to get drug benefits, a private employee benefit package is needed and not everyone has one. Some people do without critical drugs - often adding to healthcare costs elsewhere in the overall system. And some key drugs are just prohibitive in cost anyway – witness MS drugs. There needs to be care in prescribing too. There tends to be over prescription of drugs. A public plan would cut drug costs and program-delivery costs. It would require more public funds. (And I think private plans would no doubt resist – they would loose their cash cow sinecure incomes. Somehow we manage to believe that paying out of our pay for higher administrative costs to private health plans who then pay drug companies higher costs is somehow better than paying less by tax and public funds. But I digress …)

 

The third idea is learning when not to do something. Doctors are set up psychologically to cure. Patients like to feel that something has been done. There is a tendency to order a battery of tests, and patients may want the most elaborate machines. Yet tests and drugs and machines carry risks and can harm. The doctor’s holding one’s nerve with a “wait and see” may make diagnosis clearer, save the patient inconvenience and the system some money. The trick is to get it right, and that requires trust and cooperation. The chapter notes that doctors and nurses in palliative care are often presumed to do nothing, but in fact they do a lot – it’s different caring. When it is time for palliative care, everyone benefits from facing this option rather than resisting it.

 

Idea four is to do more with less by organizing what we already have more efficiently. Having people with chronic conditions repeatedly going through emergency wards is very unpleasant for patients, as well as inefficient. Complex chronic conditions are best overseen by the family doctor - or her support team. Several family doctor units are developing ways of bypassing the emergency experience with timely alternatives and a lot of communication between the different actors. Throwing money at a problem isn’t always an answer. Money to speed up access to some long–wait procedures like hip replacements did help. However, getting a sound objective basis for some tests and procedures would help. The differences in approach and statistics on procedures across Canada are enormous. Efforts to better coordinate things helped improved wait times. Interestingly, in some areas, like MRI scans, where more machines were purchased, there was an increase in the number of scans, but not a big decrease in wait times and the results left questions about whether all scans were really based on evidence of need and extent of benefit.

 

For the big issue of elective surgery, a common equitable queue (or line up) could help, rather than the present system of trying for the surgeon I or my doctor knows. There are  other things: A willingness to accept the care from others in the system like nurse practitioners where this is as good or better would help. Avoiding hospital use as mentioned above helps the system and the patient. Using technologies to assist with selected needs in remote areas instead of flying people to urban centres. Using palliative care approaches earlier for terminal illness, not to deny treatment, but to facilitate patients controlling their realistic options for best spending their time left.

 

Chapter 5, idea five, Basic Income for Basic Health, brings a dramatic new thought. Poverty has the biggest impact on health of any determinant. Health is income related. So introduce a basic income and give equity in health a chance.

 

The chapter tells the story of someone with asthma who had to stay for two years in a social housing unit that had developed mould after a flood. Trapped in the housing, with lung puffers, then mental health issues, then relationships ending, there were repeated hospital and doctor visits. The solution is to end the poverty and its highly controlling systems. The chapter gives evidence that equity improves health and social problems. Martin also notes the dehumanizing process of welfare in Ontario. A Basic Income Guarantee is a well-developed idea. Income below a certain level gets topped up. Poverty could be virtually eliminated efficiently because the level is set to remove poverty and the administration is through the existing tax system. There are models already with implementation by cash or negative income tax. A pilot in 1970s Manitoba was not completed on account of a change of government and a time of high inflation and unemployment. However, the data collected show that, as in US pilot projects, there was little reduction in work as a result - there was some extension of the then meager maternity leave, and some younger people who reduced their work effort stayed in school instead. Interestingly, there was a sizeable reduction of health care use across the entire community! Canada already has forms of Basic Income Guarantee – the Old Age Security and the linked Guaranteed Income Supplement, and the Canadian Child Care Benefit. The evidence is that this kind of program encourages work and it cuts tobacco and alcohol use, with their attendant costs to the health care system – hinting that these may be tied to financial hardship.

 

Big idea six is about System Solutions. I found this harder for general public consumption. It basically runs over areas where the health care system itself might evolve to be more efficient by better integrating the components of provinces, private doctors, private hospitals and payers with common data on a patient and on performance and the usefulness of pilot projects - and the like.

 

So all in all, this is a useful book raising big political challenges in its two really big payoff ideas – a national drug program and Basic Income Guarantee. Still, there can be useful improvements made by follow-through on work in progress set out within the other ideas.

 

Perhaps a seventh idea would be to find ways – beyond a book like this – to make those of us who are patients better aware of what is being tried to improve our healthcare so that we understand what our doctors are trying to do - and education and public reminders to us of the good case for a national healthcare system with equity.

 



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