The standard of Canadian healthcare is high, but too many services are provided in high-cost hospitals, says Jeffrey Simpson in Chronic Condition. Can Canada de-hospitalize into other institutions?
The Romanow commission a decade ago naively argued that heaps of new money would “buy change.” Instead, the money bought time, but little change. Wait times in five designated areas – cataract surgery, joint replacements and the like – did come down somewhat, but at a cost much too high to justify the results. More change actually occurred when funding was restricted in the mid-1990s.
Three objectives now beckon: to enhance quality, improve timeliness of care, and tilt down the cost increases. Achieving them will require changes to many aspects of the system, starting with de-emphasizing hospital care, wherever possible. A bed in a hospital, or a patient treated in emergency, costs more than care provided in clinics, nursing homes or even at home. Our system, originally built around hospitals, has to be “de-hospitalized” so that hospitals can do what they are best equipped to do: provide acute care.
As well, under the current system, hospitals struggle to handle as many patients as their budget allows. Instead, they should be rewarded for how many patients they see, and the outcomes that result.
The Canada Health Act, contrary to popular view, does not prohibit private delivery of health-care services. The act says only that health care has to be administered publicly; it is silent on how services are delivered.
Moreover, the civil servants who drafted the fact later wrote an interpretive manual (published for the first time in my book, Chronic Condition) explaining what each clause meant.
They wrote: “The Act cannot be interpreted to mean that services cannot be provided on a for-profit basis. It simply means that the organization, commission or agency that administers the provincial plan cannot record a profit on its operation.”
As part of de-hospitalization, private clinics for repetitive surgeries and testing should be encouraged, just as private providers of long-term care, in-home care and nursing homes should be welcomed, provided that they are regulated and monitored by the state and can provide lower costs. The state should be agnostic about who provides service, as long as the state pays.
Observers of health care have championed for years the need for more nursing and long-term-care facilities. If we wait for cash-strapped governments to build them, we will be waiting too long, and far too many hospital beds will be occupied by the frail elderly, at great cost. Private-public partnerships should start immediately getting on with the job.
And if hospitals have unused capacity in operating rooms, as many do, they should be able to charge patients to have surgeries done more quickly in rooms that would otherwise sit idle – with the money earned put into the hospitals’ budgets – and to bring patients from abroad to earn money.
Before any of these, and many other changes, can be considered, Canadians need to think about medicare as a program, not an icon. We need to understand its costs and what those costs are doing to other programs. As our population ages, we should begin to think about intergenerational equity, not just horizontal fairness.
Our system has undoubted assets and solid underlying values, but it is not meeting the value-for-money test. So we need to shuck off ideology and fear and open our minds to the changes that will make health care better.
An urgent prescription for medicare (in Canada) | Jeffrey Simpson | September 29, 2012 | The Globe and Mail at http://www.theglobeandmail.com/commentary/heres-my-prescription-for-reviving-medicare/article4576368/?page=all.
The newspaper article reproduced a 2010 comparison of seven countries, from the Commonwealth Fund, that ranks Canada next to the bottom in overall health system performance.
See “U.S. Ranks Last Among Seven Countries on Health System Performance Based on Measures of Quality, Efficiency, Access, Equity, and Healthy Lives” | June 23, 2010 | The Commonwealth Fund at http://www.commonwealthfund.org/News/News-Releases/2010/Jun/US-Ranks-Last-Among-Seven-Countries.aspx .
In another interview, Simpson makes it clear that privitization of health care in Canada isn’t the best path forward, but instead de-hospitalization.
… Chronic Condition … is Simpson’s take on the Canadian health-care system. He is not complimentary. On the back page of the uncorrected proofs of the book is a bold-type assertion: “Canadians need to have an ‘adult conversation’ about the unsustainability of our health care system.” It goes on to say, “Jeffrey Simpson meets health care head on and explores the only four options we have to end this growing crisis: cuts in spending, tax increases, privatization and reaping savings through increased efficiency.”
In the book, in summary fashion, Simpson dismisses tax increases as a non-starter. He spends slightly more time — although not much — dismissing cuts in government spending so that more money can be diverted to the steadily ballooning health-care budget. Which leaves priva-tization and increased efficiency.
… Simpson makes it clear that he doesn’t think much of the last option. “I do not believe the problem can be solved by the god of efficiency,” he says. “There is no bottom-line imperative in our health-care system, no incentive to do things differently.” Which leaves privatization, the “dirty word” in Canadian health care. Much of Chronic Condition is an attempt by Simpson to make the private delivery of publicly paid for healthcare palatable to the reader — or at least something less than a capital crime. He often succeeds.
There is no disputing the success the United Kingdom has had since opening its doors to limited privatization, which goes back to the early 1980s, or the stats that show Canada is near the top of the heap on money spent on a public health-care system but closer to the bottom when you examine value for money. “We are absolutely hung up on the word private,” he says. “But unless we get the private sector involved, unless we establish some private-public partnerships in health care, we will always be playing catch-up.”
“The Globe & Mail’s Jeffrey Simpson releases Chronic Condition, a not-so-complimentary take on the Canadian health-care system” | Ron Cobbett | September 20, 2012 at http://www.ottawamagazine.com/profiles/2012/09/20/jeffrey-simpson-a-healthy-debate/