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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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