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Bad medicine
02-03-2002
Moderated
by Kevin Press
This year's annual roundtable tackles Canada's evolving
healthcare system and the role of employers. Consultants and plan sponsors
discuss the future of healthcare in Canada. Is Canada's healthcare system
broken?
Marilyn Reddick: There's a huge crack
in it perhaps, but it's not broken. It is meeting the primary needs of
consumers. The problem is that consumers' expectations have changed a great deal
over the last five to 10 years. There's an expectation of longer life; there's a
greater expectation of the quality of life. I just don't think the system is
prepared to deal with those expectations. I also don't think that the system has
evolved as quickly as it should to meet the needs of the growing population.
Paul McLenachan: The system is
sustainable, but certain changes have to happen. I don't think we have finished
looking for efficiencies.
Chris Bonnett: We're perhaps unduly
focused on cost at this point. We don't really have a good grip on how the
system performs. Right now the voices are just so fragmented and the
accountability is so weak that I think there's nothing else to focus on besides
cost.
Dr. Arif Bhimji: If you were on one
side of the Liberty Bell, you would see a crack. If you were standing on the
other side, you wouldn't. For a patient who is seriously ill, the system works
fine. For a patient who is only unwell, the system breaks down. The key issue is
access to care. If I don't have access to timely care when I need it, then the
system is broken. The same thing applies to employers who are footing the bill
for income replacement. If the system is not accessible to their employees, then
it's failing them.
McLenachan: Benefits professionals
are probably the only folks unhappy about the big medical breakthroughs.
Benefits plans bring people back to work. These things lead to happier
people--families are better, employees are happier. But there's a fear when we
hear about things such as the genome project. We're going to have to make some
really serious financial decisions down the way. It is going to put us in the
position of having to pick and choose, and we don't feel equipped.
Dr. Bhimji: I was working on the
Comprehensive Health Reorganization Project. I remember sitting across from the
assistant deputy minister at that time. We had a discussion about employers'
role in healthcare. The statement that was made to me was, "Employers don't have
a role in healthcare. We carry the whole shop." I had to remind the gentleman
that there was an employer health tax, and that various corporate taxes go into
general funding. We had quite a vigorous debate. Part of the problem is that
employers are downstream from the main healthcare delivery system. I think that
governments now recognize that employers fund healthcare in various forms. But
it is downstream funding. It is mostly funding what the government doesn't
cover, and therefore employers are not in on the debate. It is a
David-and-Goliath story. Unfortunately, I don't think David is going to win this
one. We may be able to have some discussion, as minority players, but we will be
given the respect and [opportunity for] input that a minority player gets.
Hetty Ngo: Employers could have a
bigger voice in this debate. A lot of major employers in Canada provide health
coverage. It's a direct hit on their bottom line. Pretty soon governments will
start hearing that. They can't just ignore employers.
McLenachan: It was interesting that
Roy Romanow seemed to at least acknowledge that a good health system makes for
healthier people and healthier workers and Canada's competitiveness [in his
interim report Shape the Future of Health Care]. But I don't think we have a
good voice in terms of influencing change.
Dr. Bhimji: As employers we should be
involved in a broader discussion. My sense is that talking to the government has
not been fruitful because the government is not willing to listen to any of its
providers. It's not willing to listen to provider groups in general. I have not
seen an opening for the better part of 10 years on the part of any ministry.
Bonnett: I think they're listening,
but they've got everybody talking to them. You have all of these separate voices
trying to organize this. Plus you have the media dominating the policy agenda.
Headlines scream about emergency department crowding. So what do they do? They
put money in emergency. Government is reactive. They'll fight the immediate
crisis.
Reddick: Look at the difficulty in
recruiting that we have within the healthcare system. We have a shortage of
nurses. We have a shortage of anaesthesiologists and pathologists. Healthcare
has not been the employer of choice. We all saw the shortage of nurses coming,
and yet the government was behind the times in trying to help us. They were not
proactive at all.
What does that mean to employers?
Sandra Pellegrini: In terms
of return-to-work, we're talking about waiting lists. We tend to see a lot of
private clinic use. A lot of dollars are going outside the public system. It's
more cost-effective to do that, and get the employee back to work, rather than
to wait six, eight or nine months for the public system.
Reddick: One of the good examples of that is
outpatient physiotherapy. Hospitals can't afford to provide that service any
more. Now employees have to wait, or somebody has to top it off and pay for a
private clinic.
Bonnett: We're
talking about human resources (HR) management fundamentally--creating a more
interventionist and leadership-oriented model. It would be great if HR would
have the mandate to organize external resources, like using pharmacists more
effectively, establishing some sort of communication with local area physicians,
getting a sense of what creates or denies health for employees and then getting
in front of those root causes.
Dr.
Bhimji: I'm going to put a little different perspective on
this. I am encouraging employers to have a greater sense of entitlement when it
comes to the healthcare system. I think that as taxpayers, as parties who are
impacted by the actions of governments in general and the healthcare system,
they should have greater expectations from those individuals within the
healthcare delivery system and within the healthcare funding system, primarily
on the public side. I see no reason why we should have employers tolerate the
waiting lists they are subject to. Employers should have a greater voice. I
would encourage employers to be more demanding and have greater expectations
from those who are running the majority of the healthcare system because I think
we need to keep them accountable.
Ngo: People are sent to the U.S. to avoid
waiting lists in the health system. If we don't address this now, it will become
a bigger and bigger issue down the road. It is inevitable that somebody else
will address the need.
Pellegrini: I have clients who will send their
employees to Detroit or wherever for an MRI or a CT scan.
Dr. Bhimji: Why should they have to leave the
country to get care? As a Canadian citizen, why do I have to leave the country
to get my suffering resolved?
Bonnett: But there's so much of this we don't
know. The danger is that we say, "We're unhappy with the current system. It's
not responsive to our needs. We can't seem to influence it. We don't have a
voice as the employer community. Let's try something else." The problem is that
we keep jumping into these crisis responses without backing up and asking why
this is happening, and what is it that we can do to manage the entire system.
Dr. Bhimji: I'm not taking issue
with measurement and making sure that you get the proper outcomes. But we need
more capacity. If we don't maintain access, if we don't have that capacity,
human nature will demand that capacity be created elsewhere.
Bonnett: Is it a capacity issue? I'm playing
devil's advocate here. We've had lots of people--lots of physicians, lots of
systems managers--say that 30%, 40%, 50% of the services that are delivered from
this healthcare system are unnecessary. Now if that's true, is it a capacity
problem or is it how we are managing the system?
Pellegrini: Or designing it. Why is it, when
the doctor's office closes at five o'clock, that your only option is emergency?
Dr. Bhimji: Because the
incentives are not aligned for physicians. Bonnett: That's a management issue, not a
capacity issue.
McLenachan: We
have a good, solid public education system. You can send your child to a private
school, and that's OK. The key is establishing a good basic level of
expectations. The Canada Health Act and its mandate of providing a basic level
of service is a good thing.
Dr.
Bhimji: One of the key issues is there's not enough funding for
the type of healthcare that we expect. I'm not convinced we should lower our
expectations because with new technology we should expect a better lifestyle and
general health. What can we do to bring more funding in? Government should
establish a base level of funding that should be linked to the cost of living.
The public system should continue to increase that on a reasonable basis--say 1%
over inflation. Then we should permit individuals who find value in other types
of services or more services to alleviate their suffering. It's unjust, it's not
the Canadian way, to tell people, "We want you to continue to suffer and we're
not going to allow you a mechanism to relieve your suffering." In the broader
context it's unfair that we don't allow employers access to improved capacity.
What will employee benefits plans look like in 10 years?
Marilyn Reddick: I would like to
see benefits plans turning more and more to the flex model. I would like to give
our employees the choice of what suits their lifestyle. I would like to have
more choice within the benefits plan, and hopefully be able to spend our
benefits dollars better.
Paul
McLenachan: There may be more choice. We'll need an underlying
catastrophic protection. But as younger workers come in, they want more choice.
I see that evolving over time.
Dr. Arif
Bhimji: The benefits plan 10 years from now is likely to have
more flexibility. It may also have a medical savings account component. The plan
will be more expensive too.
Sandra
Pellegrini: We expect benefits plans to be more closely aligned
to a business-model--one that ties corporate objectives and employee health and
productivity to bottom-line results. To some extent today, we see employers
using benefits plans more strategically, but, not often enough. In future, the
norm will be to directly link benefits plan strategies to population health
outcomes and their effect on corporate profitability.
Chris Bonnett: Those plans are going to have
to be much more closely linked to the community. So the employer is going to be
better linked to the local area in terms of health-related services. Plans are
also going to require professionals to manage those benefits in the context of
the business strategy.
Hetty
Ngo: I see benefits plans not in isolation, but more and more
they're going to become part of total rewards. So younger people who just want
catastrophic coverage can say, "Well, I'll take everything else and cash it in a
medical savings account, or whatever, and I'll opt for the least coverage
because I don't really need it right now."
Ottawaspeak
Does Roy Romanow care about the challenges facing health benefits
plan sponsors? Kathryn Dorrell, BENEFITS CANADA's managing editor asked him.
Employers are picking up healthcare expenses as the
provinces make cuts. What is your response to this concern?
There is a need for stable and predictable funding in the Canadian
healthcare system. The provinces are under tremendous financial pressures, not
just from healthcare. There is also a strong and compelling argument that there
is enough money in the system [but efficient use of resources is a problem.]
Money, alone, is not the solution to the problems facing the healthcare system.
How does one measure sustainability in terms of health outcomes? In 29 measures
of health outcome used by developed nations, the U.S. is dead last, failing in
27 of the 29 categories. Yet it has some of the best medicine in the world if
you have access to it and can afford it. It also spends 14% of its [gross
domestic product] on healthcare compared to Canada's 9.4%. We spent 10% in 1993.
Sweden spends less than Canada today but it has user fees.
Will
there be a greater role for other healthcare providers such as pharmacists in
the future?
Pharmacists are the ones who are trained in drug
interaction and have the greatest knowledge of drugs. I think they should play a
greater role. In Sweden, nearly all pre-natal care is done by midwives. We have
a good relationship with the Canadian Medical Association and there is a greater
willingness [on their part than ever before] to [discuss the roles] of
healthcare providers.
Employers shoulder most of the burden of
drug costs. Is a national pharmacare program still on the table?
There is no doubt that drug costs will continue to rise. A national
drug formulary is long overdue. There is rheumatoid arthritis medication
available on two provincial formularies and nowhere else. It should not work
that way. We can keep prices under control better at a national level--this is
what the provinces have agreed to do.
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