Dr.
Martin
wrote an insightful book about the Canadian
healthcare system called Better Now: Six Big
Ideas to Improve Healthcare for all Canadians,
Penguin 2017. Dr. Martin became a hit on
You-Tube when testifying to the US Senate about
Canadian Health
Care in March 2014. Her approach is that of both
supporter and critic of the
Canadian Health Care system. Her book follows up
on this US Senate testimony,
telling things about the Canadian system and
developing 6 ideas for making
it better. Each chapter begins with a patient’s
story to illustrate the
chapter’s topic! Here is a very short summary.
The
introductory “The Basics” are a “must read”,
containing basic insights about
our system for Canadians who may well be unaware
of them. The Federal Canada
Health Act 1984, sets up the Canadian scheme
requirements, and unites all
Provincial health care systems and controls them
by passing out federal
dollars. Under the resulting public system,
doctors who are in the provincial
public systems cannot take extra payments, nor
can the hospitals in the system.
Within the system there is one payer, the
government, and one negotiated price
for a procedure. Doctors are either in the
system or not. On the other hand, while
the financing is public, the delivery of the
public health care is almost
totally by private bodies. Doctors are private
corporations in a spectrum that runs
from the single doctor, through various
corporate groupings of doctors to some
large private corporations. Hospitals are mainly
private-not-for-profit
corporations. All these actors are not directly
controlled by a government.
This
public
“basic healthcare” is part of the overall
Canadian system. It provides equal
treatment on the basis of health needs in
hospitals and at doctors’ offices for
all carrying a health card, and it accounts for
70% of healthcare expenses. The
remaining 30% - dental care, prescription drugs,
mental health procedures, glasses,
hearing aids, physiotherapy and the like – is
largely private. The major part
of it is covered by a variety of private
insurance schemes offered by employers
to employees - or it simply comes out of our
pockets. The overhead on the
“public” 70% of healthcare financing is around
2% of the costs. On the 30% private
part, overheads of 18% are embedded in the
charges.
Dr.
Martin
sees three linked objectives: good health
outcomes; good patient experience;
sustainable costs. She dismisses talk about
changing the system to a mixed
system, a European system, improving wait times
by allowing some to pay - and
the like. People proposing mixed systems have a
political agenda or they want to
make money. Equal treatment on the basis of need
for a treatment is what sets
public healthcare apart. Treatment is not
dependent on wealth. Problems within
the system can be addressed. Changing the system
destroys its best feature. For
example, Australia’s experiment to deal with
wait times by having a public-private
mix increased wait times in the public system.
The German mixed system is a
simple choice – be in the public system or stay
totally outside of it. One
cannot choose to be subsidized or insured by the
public system under private
care. Dr. Martin’s contention is that it is
better to talk about fixing what
needs to be fixed – like wait times –than talk
about changing the system. Improvements
were made by Federal-Provincial accords on wait
times for specific procedures
like hip replacements. These
improvements werel enabled by tied federal
dollars to the provinces. But wait
times are not for those with urgent needs. Right
now if a patient really needs any
urgent medical attention he or she will get it.
Dr.
Martin’s
little section on measuring the meaning of
“good” healthcare by “outcomes” is
revealing. How does our public system work in
terms of its likelihood of
success in treating diseases and conditions that
are treatable – that is, by the
outcome? In
fact, our public system is
pretty good compared with other developed
countries. That need not be so in a
private clinic where there is a presumption of
better treatment because one is
paying. A weakness in the Canadian system comes
from the lower
cost-effectiveness of the private insurance
component in the system. If all the
money spent was in the public system, it should
be possible to make the overall
healthcare work well in every way. Dr. Martin
has some particular ideas.
Idea
one, the
first chapter, “The Return to Relationships,”
gives insights into the useful
coordination role that a family physician can
play – improving the patient’s
experience and saving unnecessary trips to
otherwise uncoordinated condition
specialists and emergency ward visits.
Idea
two, “A
Nation with a Drug Problem,” presents an
overwhelming case in favour of a
national pharmacare program that covers
medically necessary drugs under
medicare. Canadians pay far more for drugs than
most developed countries. The
USA, which pays more, is an exception. National
purchasing could dramatically
reduce costs. The cost of other parts of
healthcare are reduced if patients are
getting and taking their medication – and there
are indications that they don’t
do so if they need that prescription money for
the rent etc.
Idea
three, “Don’t
Just Do Something, Stand There,” is really
linked to idea 1. It makes the case
for a more thoughtful nuanced approach to using
the available tests. Any test comes
with a price to the individual as well as to
healthcare. There is a question of
whether a person is a suitable candidate for a
test. One
can test a patient to death. Sometimes a
bit of cautious but careful “let’s wait and see”
is better all round.
Idea
four, “Doing
More with Less,” begins with the case of Susan
who goes to hospital, is treated
by a new team in emergency, but has her heart
medication stopped. Her doctor is
not told. Her doctor sees blood pressure issues
and Susan goes for tests. She
gets congestive heart failure and gets more
treatment, but then gets weaker. So
her family seeks a facility. She must wait for a
facility and she weakens
further. In the facility she weakens
more
and dies. All this is not for lack of dollars
spent. It is caused by lack of
communication and organization within the
system. It is not always the dollars,
but using intelligently what is available. For
example, trying to address wait
times for MRI led only to dollars for more MRI
machines. Yet there are still some
unacceptable wait times. More MRI machines do
not ensure a fair queue, do not coordinate
the various facilities with machines, do not
ensure that those seeking an MRI
are people who have a demonstrable need for an
MRI scan, nor do they ensure
that the wait times are low. Really good
organization around the available
resources is needed to do that.
Idea
five, “Basic
Income for Basic Health,” takes up the notion
that improving measures of health
like life expectancy or infant mortality arises
largely from lack of poverty
rather than from the healthcare system. Beyond
this, Dr. Martin gives examples
of how poverty does cause or maintain sickness.
It goes beyond the issue of not
getting prescriptions to manage a condition and
so ending up in the emergency
ward again, which costs the healthcare system a
lot. She says, "Like
medicare, a basic-income guarantee is a form of
insurance against hard times, a
policy that is both simple and fair…" It is "… a
right of citizenship
rather than an act of charity." She is right,
basic income is elegant and can
come with low administrative cost, as public
healthcare does but unlike the
various welfare schemes.
Idea
six, “The
Anatomy of Change,” gets into systemic issues
that are less accessible to the
layperson. Basically there is a need to get the
good ideas which were tested in
pilot projects out as programs working across
the various Provincial healthcare
systems. And that needs widespread advocacy from
more than groups like doctors,
or nurses or the others with particular
interests who are within the system, or
those with a particular political agenda.