Healthcare check-up

Canada's healthcare system is undergoing dramatic, and some would say traumatic, changes. Many are questioning where the system is going, and whether it will be there when we need it. The prognosis for the current system is truly a good news/bad news scenario.

First, the good news. We have a payment system that is highly efficient--certainly the envy of our neighbours to the south on a financial, if not ideological, basis. The guarantees of the Canada Health Act--universality, comprehensiveness and public administration as well as accessibility--are still in place, despite the strain.

Despite cries to the contrary, there is enough money in the system today to assure continued high-quality care for all Canadians. (Did you ever notice that the calls for increased funding always seems to come from those who would see the additional dollars end up in their pockets?) The problems in our healthcare system can be fixed without opening the doors to for-profit healthcare firms. Despite waiting lists for some services, which occur in the U.S. as well, people who need care in Canada receive it. If we can carry out the necessary reforms the system will be there when we, and our children, need it.

TROUBLE SPOTS

What ails the system is at the root of many of the problems that have arisen in the past five years. For starters, there are too many hospital beds--yes, too many--and often the wrong people are in them. We also have too few out-patient resources. Excessive and unnecessary use of the emergency room continues to plague many hospitals, driving up costs and denying care to those in real need.

There are also too many doctors in major cities and too many in rural areas, and they do too many things to us--a good number of them unnecessary. Canadians see their doctors too often for minor ailments. We don't use our medical professionals in an effective way. Nurses and pharmacists should be allowed to provide a far greater range of services, most of which are currently restricted to doctors.

Many of us take too many drugs. Some of us take the wrong drugs, and others don't take enough or don't take them properly. We have become part of a phenomenon known as the medicalization of life. We have forgotten how to look after ourselves.

The system has focused on treating disease rather than preventing it. It is largely uncoordinated, unintegrated and unmanaged. Public and private services within each system are not linked. We need to correct all these problems and we have to do it with a bit more wisdom, sophistication and backbone than our politicians have shown to date.

Ottawa slashed billions in healthcare transfer payments to the provinces. The provinces, in turn, slashed millions from the system. This, in turn, led to sharp cuts in the number of hospital beds without first putting the necessary outpatient infrastructure in place. Hospitals faced with bed cuts took the only path open to them--they laid off staff, particularly nurses. Then they tried to hire them back and now we are getting ready to dump them again at a huge cost to the system. At the same time demand has been growing for both necessary and unnecessary services.

Instead of fixing the system, we simply slashed it first and then began looking for ways to rebuild it. I am more than a little concerned that new funding will undermine the reforms that were just beginning to take place.

On top of this, we are getting older and living longer, giving our body more time to break down. The bottom line is, as we age, we will require more medical services. The continued increase in new technologies and drugs make keeping us older coots alive more expensive.

If this were not enough we are being inundated with new diseases and syndromes. Many of these new diseases are really proto-illnesses such as high cholesterol. They do not cause symptoms and produce no direct suffering, but are thought to contribute to other real diseases never the less.

TIME FOR REFORM

There is no doubt the system needs reform. Those of us old enough to remember will recognize our medical program as a 1960s-style Blue Cross or Blue Shield program. It is a physician and hospital acute care system, not a healthcare system. The devil is in the details--the kind of reform that is needed. As I stated in the Mercer Bulletin in March 1988: "Our problem is not lack of knowledge, it is lack of will."

Delivery of services is the key area in need of reform. And the vehicle for reform is the introduction of managed care, Canadian style, using the definition drawn up by the Canadian Council on Integrated Healthcare. The council says that managed care is "a process of quality integrated healthcare based on best evidence which balances quality, access and cost for the purpose of achieving optimum health for the individual."

So where do we start? By addressing the terribly inefficient use of healthcare professionals. Accountability is another problem area. All of the players in the healthcare system must be accountable for their specific role in the delivery or receipt of services. We put our health, and indeed our lives, in the hands of physicians with virtually no knowledge of their capability. Physicians, hospitals and all other providers must be publicly accountable (yes, report cards) for their performance.

This means tracking mortality, morbidity, malpractice suits and their resolution, complaints and their resolution as well as education and certifications. When New York State published this type of data for heart surgery several years ago there was a 52% drop in related deaths. Healthcare is too important to be left to the secret society approach of various self-governing professions.

Practice and prescribing guidelines are increasingly being viewed as another way to encourage clinically sound, cost-effective medicine. Trial and error medicines are unacceptable today. But, how often do we hear the time-worn catchwords of opposition: "Every patient is different," and "as soon as they are developed they are out of date." We must not let those who have closed their eyes to the need for guidelines be charged with improving the overall quality of medicine.

We need a sound system for tracking medical data. The primary reason for recording this information is to provide patients with the best possible treatment and therapies. This requires that all pertinent data related to the specific patient be accessible to any or all physicians, and other medical providers treating that patient.

As well, non-patient specific data must be available for measuring outcomes of the various medical providers including hospitals, and for research purposes, notably to assist in the development of best practices and guidelines on major therapies. Beyond these requirements, individual patient data should be fully protected and confidential.

ROLE OF EMPLOYER

Employers need to be involved in the discussions on the future of our healthcare system. Canada's system gives Canadian employers, in general, a competitive advantage as they do not have to pay for doctors' visits, most in-hospital treatments and surgery or hospitalization. Canadian employers could lose this advantage if they sit on the sidelines.

So far, Canadian employers have been spared serious downloading by the various provincial governments. Many of the services cut when the provincial purse strings were tightened have been of dubious medical value, and their absence has had little cost impact to employers. Drugs under Regie de l'assurance-maladie du Quebec and the continued restrictive formularies of some provinces have resulted in some additional cost to employers.

Having said that, there is talk of more significant downloading. Employers should be concerned about this and be prepared to fight moves by any government that could shift serious cost to them.

The problems with our healthcare system can be fixed without privatization or two-tier medicine. There are those who say we already have two-tier medicine now because of the services not covered by the Canada Health Act, notably those covered by employer plans such as drugs. This is a smoke screen. We all know what is meant by the public system--physicians, surgeons, hospitals and diagnostic testing.

There are those who say since most physicians, hospitals and labs are private we have a partially private system. This is also a smoke screen. There are those who say that because we have groups like Medcan and others providing services such as pharmacy benefits that we already have a two-tier system. This is another smoke screen. There are those who say the public system can't be sustained and private two-tier medicine will help save medicare. This is noble of them. But it, too, is a smoke screen.

We all know that those who advocate two-tier, private medicine want to open the door to allow U.S.-style, for-profit hospitals, clinics and other medical services in Canada so that these services can be delivered and paid for with public funds.

Two-tier privatized healthcare means more expensive, lower quality healthcare. Is this what we want for Canada, higher cost and lower quality? We can do better than this. Healthcare cannot escape being a political issue because ultimately politicians make the decisions on how much money to put into the system. But let's not let ideology dominate the debate.

Jim Norton is the former senior vice-president of health strategies with Aon Consulting Inc. in Toronto.