Failing The Sustainability Test

I really don’t think there is a provincial government that has been in power over the past fifteen years that thinks our Medicare system in Canada is sustainable in its present form. Further, I don’t believe there has been a federal political party during this time that believes provinces can continue to comply with the Canada Health Act. This, to my mind, is clearly evidenced by the fact that the federal government stopped designating transfer payments to the provinces specifically as health, education, or social assistance, years ago. Instead transfer payments are made without specific designation, thus putting the dilemma of uncontrollable health care costs and the competing interests of education and social services in the hands of provincial governments.
All provincial governments over the past many years have experienced a greater proportion of their disposable income going to health care. This in spite of the fact that waiting lists (risk lists) are getting longer and most provinces in Canada over the past few years are experiencing good economic times. Innovations to date have been disappointing and for the most part have been mimicking Walmart or re-inventing community clinics at twice the cost; e.g. the 8th and 8th clinic in Calgary. Not only is the cost of medical care within the Medicare system increasing faster than inflation and population growth, but the cost to Canadians of health care outside the system is out-pacing inflation. The Jan17/06 edition Medical Post shows that Albertans lead the way with out of pocket costs of $2,150.oo per person for deemed health care costs not covered by the government insurance program in the 2004 calendar year. The average per Canadian was $1,690.oo, a 6% increase of 2004 over2003.
This clearly indicates the cost for health care in Canada is outpacing inflation for governments and outpacing inflation for the average Canadian. Some people will claim that much of the money spent by people and governments on “health care” pertain to “wants” and not “needs”. I certainly support that position. It would appear that Albertans and the Alberta Government have more disposable income per capita and spend more money per capita than other Canadians and provinces so there seems to be a situation where: a) if you have more money you spend more money, and, b) some variance between provinces and the people of provinces as to what comprises a need for health care spending, exists. The logical conclusion to me is that if the government wishes to control its portion of health spending several thing will need to be done: 1) they must define and update from time to time, exactly what it is they will cover in the government program, and, 2) they must tie this in to some relevant way to the amount of money available e.g. a percentage of GDP. If they do this it would seem apparent to me that the cost to each individual Canadian out of pocket expense will increase. The problem then becomes one of; how do we open the door to those people who can insure and personally pay for this added expense and still protect those that cannot?
I think that it is safe to assume that costs in health care will continue to outpace inflation for the following reasons:
1) The first wave of baby boomers are within ten years of retirement and Canada has the largest ratio of baby boomers to the rest of the population of all countries. Not only does this mean greater health care costs as they age (you are 40 times more likely to be hospitalized at age 80 than age 40) but the tax base to support health care will be severely eroded.
2) Pharmaceuticals have taken over as the second largest consumer of health care dollars (first place is hospital care) and are rising quite independent to inflation. New medications to treat and sustain the life of the chronically ill prolongs the period of treatment and cost. Shortening patent times will only drive up the price of new drugs on the market since research companies will have a shorter time to recapture cost and profit.
3) New technologies are expensive but lend themselves to both discovering and treating disease. Treating disease is not synonymous with curing disease. Therefore, in spite of the cost of new technologies, the overall impact is probably not going to be cost effective.
4) The human condition is that we will always seek and move to comfort. Where is the dividing line between suffering (should be treated) and comfort (unobtainable and unsustainable)?
5) There are no market forces within our system to curtail consumption and reward being a thrifty consumer. Both the Ford motor Co. and General Motors are faced with bankruptcy or competing to become more environmentally friendly at a lower cost. This is occurring because of market forces and competition. This does not exist in our present health care monopoly.
6) Physicians and other health care providers, by the nature of the work they do (help provide longer and better quality of life) may be at odds with cost containment.
7) Preventative “solutions” have not been well studied from a cost perspective. Although they are always put forward as a solution, there are studies, for example, that suggest smokers contribute millions of dollars to our Canadian Health Care System rather than cost the system money.
Now that we have elucidated the problems pertaining to sustainability, we will try to think “outside of the box” tomorrow for possible solutions!

More on Assisted Suicide

Why is it that we humans always want to “put the cart before the horse”? In today’s Calgary Herald there is a front page story about Dr. Jose Pereira leaving Calgary and taking a position at the University Hospital in Lausanne, Switzerland. Apparently, assisted suicide and euthanasia have been approved at this University since Jan.1st of this year and they are bringing in Dr. Pereira as a counterbalance to their euthanasia policy. Dr. Pereira has stated: “you can’t engage in physician assisted suicide until you’ve provided good and adequate palliative care. In most cases, when the patient receives palliative care, they rescind the request for euthanasia”. However it would seem that, in fact, the University Hospital in Lausanne, Switzerland, has in fact “engaged”!
It should be stated that palliative care does not simply refer to end stage cancer care but to any and potentially all disease conditions that can be terminal. Thus it has the potential to be an enormous part of any health care system. But why didn’t the Swiss bring in Dr. Pereira FIRST, then, after implementing an aggressive palliative care program, look at the need for euthanasia and assisted suicide. Would not the criteria and laws pertaining to these activities be more specific and appropriate? Previously I spoke of Calgary’s palliative care program starting with an acknowledged need in the community by the people and the caregivers. It then grew into a very treatment effective and cost effective program capped finally 4 to 5 years ago with the recruiting of Dr. Pereira at the University level. Its success was a needs driven, not cost driven initiative and now other countries are looking at it as a model. Yesterday, I talked about the case of Mrs. Houle who assisted her son in committing suicide. What a travesty, but what a flagrant example of a community health need that was not addressed in a timely or appropriate manner.
Dr. Hamilton Hall, the Back Doctor, once told me that he did not give pain pills to his back patients on their first visit to him. Instead he prescribed a battery of exercises and activities to relieve the pain and would see the patient in 24 to 48 hours. At the second visit the patient would have experienced some relief and would be a believer in the exercise program and carried on with it. If he would have given pain pills on the first visit, the patient would have been a believer in the pain pills and compliance with the exercise program would have been poor. The conclusion is: the best program is not always the easiest or the quickest and conversely, if the easiest and quickest is experienced first we may never implement the best. Personally, I believe that if we as a society can afford a trial that involves a twelve member jury, lawyers, judges, and millions of dollars of expense to decide the loss of a person’s freedom for two or three years, we should be able to afford a pretty complex “decision making” system before someone’s life is taken from them, albeit with their consent. Is it my paranoia or do we rush into the quick, easy, and cost effective solutions in our thirst to preserve Canada’s Medicare system in its present state? Are there possible alternatives that are difficult, compassionate, slower, and possibly even more cost effective? This directly relates to our discussions tomorrow on sustainability of a Universal Health Care System.

More on Assisted Suicide

Why is it that we humans always want to “put the cart before the horse”? In today’s Calgary Herald there is a front page story about Dr. Jose Pereira leaving Calgary and taking a position at the University Hospital in Lausanne, Switzerland. Apparently, assisted suicide and euthanasia have been approved at this University since Jan.1st of this year and they are bringing in Dr. Pereira as a counterbalance to their euthanasia policy. Dr. Pereira has stated: “you can’t engage in physician assisted suicide until you’ve provided good and adequate palliative care. In most cases, when the patient receives palliative care, they rescind the request for euthanasia”. However it would seem that, in fact, the University Hospital in Lausanne, Switzerland, has in fact “engaged”!
It should be stated that palliative care does not simply refer to end stage cancer care but to any and potentially all disease conditions that can be terminal. Thus it has the potential to be an enormous part of any health care system. But why didn’t the Swiss bring in Dr. Pereira FIRST, then, after implementing an aggressive palliative care program, look at the need for euthanasia and assisted suicide. Would not the criteria and laws pertaining to these activities be more specific and appropriate? Previously I spoke of Calgary’s palliative care program starting with an acknowledged need in the community by the people and the caregivers. It then grew into a very treatment effective and cost effective program capped finally 4 to 5 years ago with the recruiting of Dr. Pereira at the University level. Its success was a needs driven, not cost driven initiative and now other countries are looking at it as a model. Yesterday, I talked about the case of Mrs. Houle who assisted her son in committing suicide. What a travesty, but what a flagrant example of a community health need that was not addressed in a timely or appropriate manner.
Dr. Hamilton Hall, the Back Doctor, once told me that he did not give pain pills to his back patients on their first visit to him. Instead he prescribed a battery of exercises and activities to relieve the pain and would see the patient in 24 to 48 hours. At the second visit the patient would have experienced some pain relief and would be a believer in the exercise program and carried on with it. If Dr. Hall had given pain pills on the first visit, the patient would have been a believer in the pain pills and compliance with the exercise program would have been poor. The conclusion is: the best program is not always the easiest or the quickest and conversely, if the easiest and quickest is experienced first we may never implement the best. Personally, I believe that if we as a society can afford a trial that involves a twelve member jury, lawyers, judges, and millions of dollars of expense to decide the loss of a person’s freedom for two or three years, we should be able to afford a pretty complex “decision making” system before someone’s life is taken from them, albeit with their consent. Is it my paranoia or do we rush into the quick, easy, and cost effective solutions in our thirst to preserve Canada’s Medicare system in its present state? Are there possible alternatives that are difficult, compassionate, slower, and possibly even more cost effective? This directly relates to our discussions tomorrow on sustainability of a Universal Health Care System.

Be Careful What You Wish For

Well, that certainly was an experience! Over the week-end my wife and I traveled to Edmonton where we were joined by our daughter. We thought it may be interesting to attend a function at the city library called the “Philosopher’s Café”. Since the topic to be discussed was “assisted suicide” I thought it would be interesting to get lay input on this since I have been blogging on cost effectiveness in our health care system and since the next item I was to address was “sustainability”. About 70 people were in attendance and the “moderator’ was a professor of philosophy from the University of Alberta. In no time at all it became apparent as to which way things would go.
He spoke of the need for compassion. Since many severely ill people were incapable of ending their lives they required an “assistant”. Further, since suicide and attempted suicide were not a crime, why should assisting suicide be a crime? He stated that he had no fear of the “slippery slope” phenomenon because legislators simply had to draw a line. Belgium and the Netherlands were mentioned, and when I pointed out that recent reviews showed that in 50% of cases the “rigid lines drawn” were not adhered to, I was not asked for my opinion again over the next 90 minutes in spite of my obviously invisible hand being up several times. Participants speaking on the pro side of the assisted suicide question were often asked for further input.
The next position the “moderator” posed to the audience was “If there was a right to life, should there not be a right to death?” This was not specifically addressed and was left out there as a given. Perhaps this moderator has not seen many creatures, let alone people, die, but a can assure you that I have. There seems to be an incredibly strong drive in us to struggle to continue our lives under all circumstances. As long as we are even slightly conscious we will use our last bit of energy to draw our last breath. Perhaps compassionate societies in the past, having witnessed these Herculean efforts to sustain life, thought that a just society should proclaim that free people within that society should have the “right” to live. But what observations over the years would lead us to believe that we struggle daily to die and therefore the right to die should be enshrined in law?
As one might expect, the Marlene Houle case came up. As you may recall, her son, who suffered from multiple sclerosis, committed suicide with his mother’s (Marielle Houle) very active help and participation. The group and the moderator seemed to conclude that the mother was the best judge as to whether her son was rational in his decision---certainly more able to judge his state of mind than a physician or a psychiatrist. At the conclusion of the 90 minutes of “philosophical discussion”, 95% of the attendants felt assisted suicide should be legal. The prevailing sentiment was “I want what I want, when I want it.It is my right! I am entitled! My thought was: “be careful what you wish for lest your wish be granted”. What happened with the idea that we, as a compassionate society, must protect the weakest among us? (If you haven’t yet, read my “Euthanasia is Cost Effective”).
I believe the above case is a good example how the chronically ill may not get the support they need in our system. Every medical student is taught: “If you see a depressed child, look for a depressed parent”. Apparently Mrs.Houle had suffered from depression in the past and the newspapers report that since her son’s death she had become a recluse, seldom venturing out of her assisted living domicile. We and everyone at the philosopher’s café assumed that the son (Charles Fariala) no longer wished to live because of his multiple sclerosis. WHAT IF, as a caring son, watching his mother suffer, and feeling he was the cause, he chose to end his life. The pathology and failure was in a system that did not intervene adequately in a very dangerous situation. The system was not there for the mother, who with her depression could not cope with her son’s deteriorating condition, let alone support him psychologically. The system also failed to protect the son from feeling responsible for his mother’s depression. It is no secret that mental health in Canada is seriously under funded. As long as we want to do everything for everybody, those that really need our help, the frail elderly, the chronically ill, and the poor will be under funded. The last things we need are laws that lubricate the slippery slope of rapid death for those in our society that are most vulnerable.
But a reporter at Saturday’s Philosopher’s Café may report that 95% of those at attendance favor assisted suicide. There will be no mention that the “moderator” was less than impartial in leading the discussion. And our legislators will see an opportunity for more cost effectiveness in our health care system. Again: “Be careful what you wish for, lest your wish be granted.

"First, Do No Harm" or "Forgive Them For They Know Not What They Do"

One of the over-ruling axioms in the medical profession over the years has been: “First, do no harm”. I wonder if the movers and shakers of health care reform, innovation, and all those other wonderful initiatives over the last 15 years or so considered “first, do no harm”. The elimination of some 1500 hospital beds when the population of Calgary was exploding doesn’t speak well for the planners. (using the term loosely). The driving force was to cut costs with little or no thought of the consequences for the sick in our society. If there was a plan, it was simply to confiscate the bedrooms of the community and conscript the loved ones as care givers. Doctors were left out of this planning process since they were labeled as being a “special interest group”. In the last five years doctors are being invited to come back to the planning table. Unfortunately, it reminds me of what someone once told me many years ago: “An expert is someone we call to share the blame”.
A system that is patient centered needs to start with an assessment of patient needs at all levels, starting with the community. Palliative care in Calgary is a good example of a successful program. It started by looking at patient needs and then found that the solutions were positive for patients, AND were cost effective. Resources were put in place in the community along with funding provisions, and slowly the program has assisted palliative patients to be downloaded from the Acute Care Hospitals to the community.
A similar process did not exist for other ill patients.
Ten to fifteen years ago I was instrumental in starting a transitional care unit at the Rockyview Hospital. This basically put patients who were waiting for more appropriate accommodation on one unit. Savings could be had by downgrading the acuity of nursing care but more importantly the specific needs of this group could be addressed i.e physiotherapy, rehabilitation, ambulation, etc. Meanwhile there had been a moratorium on the building of long term care beds (nursing home beds) in the community. When the region realized transitional care beds could free up acute care beds, a process of down-loading patients that still needed institutional care (not ready to go home yet) began, and continues to this very day. The idea certainly has merit, but the point is these transitional patients now take up beds that had been designated as long term beds. The personnel (doctors, nurses, etc) and the tools (laboratory, x-ray, oximmetry) was not in place and stress increased dramatically for patients and caregivers. The unavailability of nursing home beds caused a back-up of patients into the community and home care and community doctors needed to assume responsibility for them. Home care was chronically short of resources, and stress leave among home care nurses became common place.
All of the above was and is, predictable. Ten years ago I recommended that an annual assessment should be done of the impact changes in our system was having on the people at the community level. There are good “tools” that can be used for doing this. A minor attempt is being done at present but the baseline should have been established at least ten years ago. Perhaps there was a need not to know! With few exceptions, the changes that we have seen in Canada over the last fifteen years have been cost driven. In a just and compassionate society the agenda must be “patient needs” driven! The medical community has, for years, excused governments on the basis that they didn’t know any better. The scary thing to me is I think they know exactly what they are doing and don’t really care. Can intelligent people really be that stupid?

A Basic Health Care Package.

I think the Oregon Project must have shut down any incentive to come up with a basic health care safety net. The project of course gets its name from an attempt to arrive at a basic package the government would cover. As I recall there was so much infighting by self interest and special interest groups that the top 100 priorities could not be established. In Canada I think the process could be simplified and would work. A federal body would look at what is at present covered by the various provinces, and put together a basic package that is a composite of the various plans. This package would be covered by all provincial governments and recognized by the federal government. These procedures would be considered “medically necessary” and meet the stipulation of the Canada Health Act. It would also be reviewed by an expert body on a regular basis for inclusions and deletions.
I believe that another category would be needed----a grey area. These procedures would be comprised of medical treatments and procedures that had not yet been shown to be warranted and old procedures that may be falling into disrepute, but the public may still wish them. It may also included procedures that the designated federal body did not deem to be “medically necessary” according to the terms of the Canada Health Act. It may include chiropractic, naturopathic, and other treatments, and would be optional. If patients wished some or all of these optional treatments, they could be covered through various packages paid for by premiums. This could be government covered and/or insurance company covered. The important thing is that each one of us would have a menu of coverage to choose from above the basic plan. An empiric exemption could be made for people below a certain income i.e. they would be given $150.oo a month credit (as a premium) to choose their specific needs. This would not be unlike packages offered by some companies in which one can pick certain perks up to a set value.
There would need to be a federal body similar to Canada Food and Drug that reviews the basic package every two to three years to ensure that it meets the criteria of the Canada health Act. Treatments would move into the premium side and out of the premium side from year to year or on some other timely basis and people would review their coverage accordingly.
Probably, there should be exempted groups of people. We already have dozens of people within our society who require physicians statements to advocate on their behalf for special consideration e.g. workman’s compensation, palliative care pharmacy program, notes for school athletic programs, sick notes, handicapped parking---- the list goes on and on. Why not have physician-designated authorizations for premium coverage for our chronically ill and frail elderly?
I’m not saying the above scenario is the only scenario, but it does involve participation on the part of patients to some degree (cost and choice), and it deals with the issue of what should be covered in a taxpayer funded universal health care system. To my mind there must be involvement of the people most impacted by any government program. The federal government long gun registry ---billions, and still dysfunctional, the cattleman’s cow registry------1% of the gun registry cost, and it is working smoothly.
Before I leave today I must take note of the comments of Mr. Jack Davis, our Calgary Health Region C.E.O. While commenting in today’s herald on bed shortages, he stated something to the effect that the Holy Cross and General Hospitals were costly to maintain and therefore needed to be replaced with new hospitals. But how many of us blow up the home we are living in today without having arranged, in advance, someplace for us to live tomorrow? This leads into the next point for discussion, “when considering cost effectiveness, look at the impact of the change on our most vulnerable before enacting the change”.

If We Build It They Will Come

Let us at least allow ourselves the possibility that private systems and a Universal Government system could co-exist. All too often we hear from the idealists and those who paint in black and white. In Canada, the “Friends of Medicare” claim that physicians and nurses will leave the government system and go to the private system if a private parallel system were to exist. Are these health care providers being treated so badly in the public system that they would vacate it in significant numbers? If this is so, perhaps we need to address the problems in the public system that would cause this.
My own experience is that most Canadian Doctors at this time are quite satisfied with the system but not with the difficulty in addressing their patient’s needs. If adequate resources were present I doubt that there would be many desertions. There would seem to be within our public system an ever increasing array of options for physicians. A parallel private system would simply provide more options. The physicians that felt strongly about control of their freedoms in medical practice left Canada over the last number of years, mostly for the U.S. They, at present, are getting progressively fed up with the HMOs in the U.S. and 2004 was the first year in many years that more physicians returned to Canada from the U.S. than left for the U.S. If we had a parallel private system Canada could experience a huge influx of Canadian doctors and nurses.
In fact, the private system would be actively recruiting them.
If we are reading the mainstream news media, we must ask ourselves if our governments actually want more doctors and nurses in Canada. Are they still practicing cost containment with long waiting lists? Recently, it has been reported that hundreds of residency spaces each year, are taken up by foreign medical students. We are told that no qualified Canadian medical student is turned down, but this unfortunately is true only if you selectively use the term “qualified”. There certainly are medical students in Canada that pass their exams and must go internationally to obtain residencies in their chosen fields. At times, after completing their residencies abroad and wishing to return to Canada, they are denied licensure. We moan about foreign physicians not being given practicing privileges in Canada, but how many young Canadian physicians are hitting bureaucratic road blocks to training and practicing in Canada? The fact is a foreign medical student has to pay large sums of money to do a residency in Canada. A Canadian medical school graduate has to be paid during their resident training. To sum up: our residency program in Canada is making money by selling these spots to foreign medical students (who most often will not practice in Canada upon completion of their residency program) at the expense of Canadian students and the people of Canada they would serve upon completion.(a residency program can be from 2 to 5 years, depending on the specialty, after medical school graduation, and is requires to practice medicine in Canada in your chosen field).
The cost of shortening waiting lists would be tremendous. Not only would government have to keep up with existing demand but would have to pay for “the catch up”. Decanting this off to a private system at a discounted cost could act as an incentive. What if the government paid half the cost and the patient picked up the rest. Yes, some patients would be jumping the queue, but what if this was available only after being on a list for three months? Waiting lists for everything would shorten. Right now there is no incentive other than public pressure to shorten waiting lists.
Jack Layton’s position of outlawing private facilities and not allowing doctors to work in both private and public facilities is politics at its worst. Right now all abortions and cataracts in the Calgary region are done in private facilities. Would that mean that these procedures would be done in hospitals? We don’t have the capacity to do our joint replacements in hospitals at present. Allowing doctors to work in both the public and private facilities makes better use of our physicians (at least they are working). At present most surgeons are severely rationed as to time in our public system. Mr. Layton’s “solutions” would certainly mean longer waiting lists. It is time our political leaders took part in honest dialog and quit using the chronically ill and poor to garner votes.
I think Canada has to open its doors to many options for work opportunities for health care providers including a parallel private health care system. If we build it, they will come! Many Canadians need a “hand up”, we don’t all need a “hand out”.

Designing a Healthcare System

The idea of coming up with a health care system that works for Canadians is no small task. I’m hoping as I struggle along there will be suggestions, questions and criticisms. Although it is something that I have thought about for years I have no clear easy answer. In my experience, the more choices people have the happier they are and the “one size fits all” is an idea that simply cannot be applied to humans as many socialist countries have found out. We often use the term “rights” to justify social programs, but I believe at the root of every democratic society must be the right to be “different”. So I will start with my first premise: 1) A workable health-care system in a free democratic society must have many options for its citizens.
My second premise is that:
2) There must be a basic safety net of coverage that can be applied to all citizens (with specific attention to the most vulnerable) and the coverage must be clearly defined. It is not good enough to use terms such as “medically necessary” when that term has not been defined and there is no federally designated body that is recognized to define the term in keeping with the Canada Health Act. Can you imagine any other insuring body that would allow an open policy that did not spell-out your coverage?
Thirdly:
3) The system must be patient centered, not cost driven. In the event of any funding change or system change the question must always be asked “how will this affect the most vulnerable in our society” and provision made to deal with the consequence in an acceptable manner PRIOR to the action occurring.
The economic vitality of a country and competing priorities will determine to a large degree what is spent on healthcare funding. Therefore:
4) One of the most important criteria for a universal health care system is that it must have “sustainability. For this to happen, along with criterion (2), a body or system needs to be devised to look at, on a regular basis, the appropriation of money in an environment of competing interests and fluctuations in government’s capabilities. Another option would be to have an agreed proportion of the total budget that should go to health care and then the system devised would adjust the items covered as to capabilities.
5) If the federal government is involved, which I feel is desirable, the responsibilities and jurisdictions of each government must be clearly spelled out as well as its financial obligations (e.g. a federal drug plan).
I put these initial items out and invite input and criticism. To my mind, the major problem with the present system is its monopolistic nature and inability to be sustainable and therefore instead of being patient driven it is cost driven. Large companies are criticized for being driven by the bottom line but governments are equally pressed to control and justify expenditures by the competing priorities of education, social services, infrastructure, etc.

Election Day

Today is Election Day---thank heavens (Am I allowed to say “heavens” in Canada today?). Since I started this blog I have pointed out where I felt things went wrong in the past and are going wrong today. In the next few weeks I will be talking more on a positive note as to where we need to go in Canada to provide a good basic health care plan for all Canadians and still provide options for people and care givers. I did not wish to bring out some of these more positive ideas pre-election since I had concerns that Paul Martin would jump on them in the midst of the debates and use them as part of his platform (only partly joking).
As you may have surmised by now I have grave concerns that the preventative medicine “fences instead of hospitals” mantra in the hands of government bent on cost control will eventually be a “corral” and personal freedoms will be jeopardized. Perhaps there can be middle ground that will satisfy most Canadians. Perhaps it is possible for socialistic programs and private enterprise to work side by side to serve the medical needs of Canadians. To start thinking “out of the box” we have to at least look at that possibility.

Survival Of The Fittest

Wow, the headline for the Jan.22/06 edition of the Calgary Herald reads: “Coed Hospital Rooms Come to Calgary”. Two other articles in the same edition speak of personnel and bed shortages. All this the day before a federal election. It seems as the Titanic is sinking, someone is finally noticing!
The headline article admits that bringing in coed beds will not increase bed utilization (unless the plan is to put two people in one bed!), but merely save some nursing time required to shift patients around in the existing beds. Who would have thought that saving a small amount of staff time would make headline news? Or is it the fact that people’s dignity and privacy in our health care system is no longer recognized as important?
The editorial in this same edition recognizes that medical manpower (is there such a word as “personpower?”) is the prevailing issue in the future. Unfortunately they suggest methodologies for Crisis management as solutions for long term medical personnel shortages. They rightly state: “It’s a proven fact that when faced with crisis, people and organizations are able to accomplish feats never imagined in their day to day work lives”. But what happens when a crisis scenario IS their day to day work life? By this I do not mean the fact that we are dealing with sick people and occasionally have to make life and death decisions. This is difficult but we are trained in these areas. The crisis is: knowing what NEEDS to be done and not having the tools, capacity, or capability to deal with it! On a daily basis Emergency physicians send people home they would rather admit to hospital, specialists keep people in regular beds that they would feel more comfortable treating in Intensive Care beds, and your family doctor would rather get your C.T. scan next week instead of next month to rule out cancer and other pathologies.
These kinds of abnormal stressors in the workplace will have several effects. Health care providers may simply quit, some will eventually become physically or mentally ill, and some may simply become emotionally detached to survive. Enrollment in medical related vocations and professions will decrease. My understanding is that nursing schools in the U.S. have had trouble in the past few years filling their training spaces.
The article goes on to talk about active recruiting of volunteers and retired health care workers (in the case of physicians it is more of a conscription program) as a solution for the periodic “blips” in demand that occur. Twelve such “blips” supposedly occurred during the first three weeks of Jan/06 in Calgary---at least half of the time. These were only the times recognized by the hospital system to be “crisis” times. The truth is that the system is in sub-acute crises the majority of the time. The question we must ask is why the system is in almost continual “survival mode”? Why can’t we do planning to take our health care system out of the Intensive Care Unit? And is it really a just society that drags retired physicians and nurses back into the work place?
The third article was by Don Braid and the headline was: “Rockyview ER Jammed with the Wrong Patients”. Nothing could be farther from the truth. Calgary hospitals track their emergency department visits and categorize them from 1 to 4 with “1” being patients that need life saving intervention and “4” being people that could have waited and seen a community physician or did not need to see a physician. The number of category “4” patients attending our emergency departments has been continually falling over the past ten years and now likely represents less than ten percent of patients. After all, who would wait for hours if they were not genuinely worried or need care? Besides, I thought the original premise of our Universal Health Care System was that people concerned about health matters did not have to make the difficult choice of “should I get help or not”. No matter how we educate our patients should they be expected to make the differential diagnosis between “flu” and “pneumonia” and not get a medical opinion when in doubt? This dilemma was to be remedied by the Canada Health Act.
Have no doubts, our emergency departments are filled and stacked up with very ill people. Often, our EMS people and vehicles are stacked up with no place to unload their patients. The problem is in lack of resources to deal with sick people at all levels. Community physicians send patients to the emergency departments because they do not have the resources to deal with them in the community and emergency departments overflow because emergency physicians don’t have beds and personnel to take on the care of patients that need admission. It is totally wrong to blame our sick people for the present overcrowding in the emergency departments. Canadians need to look back at the very popular T.V. series “MASH”. This was a medical unit dealing with casualties in a war zone. We seem to be moving progressively in the direction of a MASH unit----if it’s a life and death situation we’ll do what we can, but to a large extent, luck, and survival of the fittest will be the primary determinants. Luck if you get into the system or program in time, good survival genetics and good self preservation capabilities if you don’t.

The Slippery Slope

Some fifteen or so years ago Cancer Clinics in Canada did not prescribe Tamoxifen to patients who were found to have stage one breast cancer. As a family doctor I would receive a copy of a letter that had been sent to the patient from the Cancer Clinic. In short it would say something to the effect that the patient was lucky to have the earliest stage of breast cancer and no other treatment was required. I had read research that indicated Tamoxifen significantly lowered the recurrence rate of stage one breast cancer so I made an appointment with one of the head oncologists at the Calgary Cancer Clinic. To my surprise I was told that this information had been known for eight years but there was not yet evidence that it lowered the DEATH rate. After some discussion and subsequent phone calls to other clinics across Canada I found out that the problem was a budgetary one, and until real survival rate improvements could be shown, the drug would not be covered. However, shortly after significant national publicity, Tamoxifen was prescribed for most women with stage one breast cancer.
The issue though is the accuracy of the information given to the patient and the family physician at the time. Should the letter not have stated that Tamoxifen lowered the recurrence rate? To most patients, recurrence of cancer is equated with eventually dying of the cancer. Should not the patient have had the option of paying for the drug themselves? The confidential answer I got was that politically this would be unwise since it would seem the system was being negligent in providing necessary care.(accurate!).
The experience with Tamoxifen must raise questions about access to drugs and treatments in today’s cost effective orientated system. How many drugs and treatments (not just for cancer) are being withheld because of cost or haven’t been proved to save lives,( but have been proven to prolong life or improve the quality of life)? When discussing treatments with patients are physicians presenting only that information to the patient that is cost effective?
Recently, I obtained information about a treatment program for treating cancerous liver tumors. The control group’s life expectancy was seven months, the treated groups life expectancy ranged from 24 to 48 months. Is this program available in Canada, or will it ever be available since all patients in the study eventually died? (Keep in mind we all eventually die). The side effects of the treatment program were described as mild and the quality of life described as good in the extended months. Will patients who qualify for this treatment be told of its existence since it would be costly and out of country? We say that a patient should have full disclosure of treatment options but the question is: “Have the approved treatment options been predetermined by a mentality of cost effectiveness?” Have we learned nothing from the hepatitis C disaster? When physicians become business men who do we turn to for medical advice?
In the Calgary region when a patient enters a long term care facility a CODE status is established with the patient and his/her family. This basically is a determination of the degree of medical intervention the elder wishes should negative medical events occur: e.g. heart attack, heart stoppage, pneumonia,---- and what action the elder wishes the nursing home to take e.g. resuscitate, transfer to hospital, treat on site, etc.
To make a reasonable decision full disclosure of potential benefit and potential harm should take place. If the information given is pro intervention, medical treatments may ensue that the patient may not wish, but, if the information has a “cost effective” priority, the patient may not receive treatments that could be beneficial. This could be a life or death decision!
I have been assured many times by leaders in “cost effective medicine” that a price is not put on a human life, but the research will actually quote how many people need to be treated to prevent one death. Why is a treatment not offered when it will extend life but not necessarily save life? Is there no deemed value to an additional six months of life? By the very nature of our monopolistic universal (one size fits all) system the care providers will present information that will shape the decisions made. In a system that is “cost effective” the decisions on the part of the patient (unknowingly) will tend to be cost effective. Dying quickly is cost effective unless there is still much taxation potential. Prolonging life in the terminally ill and the frail elderly likely has little taxation benefit.
Shouldn’t we all be just a little bit more paranoid about our Universal (one size fits all) monopolistic health care system? In ancient times sacrifices were made to the gods. What sacrifices are we making to the Canadian Medicare god?

Euthanasia Is Cost Effective

This blog site is titled “what’s wrong with our health care system”. Many of my previous blogs talked about how medical care in Canada got to its present state and my perception of the dynamics of that process. There also have been discussions as to some of the deeper complexities of health care and the roles played by various groups. On the surface what is wrong is clearly evident: long waiting lists for all levels of care, severe shortages of health care providers and technicians, rising costs, and ever increasing inability on our governments to meet their obligations for funding in a society with competitive demands on our tax dollars.
Initially, Medicare was sold on the premise that no Canadian would be refused essential health care for financial reasons. The targeted population was the poor, the chronically ill, and the frail elderly. Compassionate Canadians totally bought into the program as we might expect. Governments saw the opportunity to grab votes for decades, medical groups at the time warned that it would become too expensive, and political activist groups saw it as an opportunity to underscore their philosophy that everyone be equal. This amounted to sabotaging the original intent of the program.
Think about it: when services are rationed who will suffer most?---- the chronically ill and the frail elderly because they need those services more often. When services are rationed, how does that affect the poor? We know that poverty is one of the determinants of health: more chronic disease, more hospitalization and a shorter life expectancy. Again they need the services more often and will be impacted more frequently. So who is really being impacted most by cost containment and cost effectiveness?--- the healthy people in our society or those people that the Canada Health Act was meant to protect? We have to ask ourselves the important question: Who’s to bless and who’s to blame?
Much has been said about which politician and what political party is most “scary”. If we understand that one of the top priorities in our health care system is to contain cost and the above mentioned groups are the greatest cost generators, shouldn’t we expect that group to be most impacted by cost containment. If we understand that a person in Canada consumes at least 60% of their life time cost to health care in the last two years of their life, should we not fear that the financial powers will see that reducing the last two years of life to one year of life could be the most cost effective approach to the problem. Is there a conflict of interest having the same system determine the services provided, who they will be provided to and when they will be provided, and containing cost in a society of competing values. As an aging senior, I find the entire scenario and any person or political party that supports the ongoing “Medicare” monopoly, extremely scary!

Education versus Motivation

Preventative medicine and holistic medicine certainly are nothing new for traditional family doctors. Every clinical medical course I took between 1958 and 1962 emphasized that disease and illness must always be looked at within the context of the whole person and the individual patient. On graduating in 1962 I was a firm believer in promoting healthy life styles. We told patients not to smoke, that alcohol could cause cirrhosis, and obesity and lack of exercise could lead to heart disease. By the early 1970’s we were aware of good cholesterol, bad cholesterol and its relationship to heart disease.
In the last ten years of my practice my patients would have scored 100% on a questionnaire regarding healthy life styles. Unfortunately, they would have scored 20% to 30% in terms of compliance pertaining to healthy life styles. So what makes us think that public health education will save our public health care system? And is the issue really lack of education or lack of motivation?
At least 25 years ago, studies with alcoholism showed that the initial investment in providing education was extremely cost effective. Ten percent would change their drinking habits. Unfortunately, more investment in educating the remaining 90% was not cost effective because there was a lack of readiness on the part of the patient. In fact, as practitioners, we failed miserably at treating alcoholism, and a peer group called Alcoholics Anonymous seemed to have more success and more cost effectiveness. Education was involved but more importantly, there was incentive and support and it was community based. Look at the tremendous number of weight control groups that have been in existence for the last thirty years. Most of them have an education component, an incentive component, and a support component. Still, obesity continues to be on the rise and as a consequence, type II diabetes. So how will educating the public re “healthy life styles” save our health care system? How do we motivate people to change?
About ten years ago an asthma treatment program was shown to have considerable success. The community was quite remote and the program consisted of a variety of health care professionals that registered all the asthmatics of all age groups in the area. They were involved in intensive education, regular visits, reinforcement of goals, reminders of appointments, and regular reporting protocols.. In other words, a type of ongoing parenting program was in place. Hospital emergency department visits and admissions definitely decreased. Caregivers had intensive control over the patients; almost like a hospital without walls. Caregivers were motivated, but were the patients?
I believe it was Dr. Rachlis who coined that wonderful saying: “It is better to build a fence at the edge of a cliff than a hospital at the bottom of it”. From a “disease prevention perspective”, this certainly is true in the case of the asthma program mentioned, but do we want, from a freedom perspective, government or any-other designated group having that much control of our lives? When will that “fence at the edge of the cliff” become a “corral” that completely surrounds us? In a “one payer system we should remind ourselves of the old saying: “He who pays the piper, calls the tune”. In Canada, people who have liver failure from alcohol intake, may be rejected in our transplant program but accepted in private clinics in the U.S.
It should be noted that there has been some success with smoking cessation in Canada. I saw the first good move in that direction with the dramatic increase in the cost of cigarettes 10 to 15 years ago. Along with this there was the trend to label smoking “uncool,” and now to where it is thought to be disgusting. More societal regulation has caused the smoker to be uncomfortable both physically and mentally while smoking and we know most creatures move to comfort and away from discomfort. Education, in my view, only played a small roll in the decrease. Labeling of cigarette packages seemed to have little impact. In fact, teen age females still seem to be a prevalent smoking group. The panacea of prevention in my view will not save our “Universal” healthcare system and the “We will look after you no matter what” attitude is both counterproductive and demeaning. Positive and negative incentives must be and will be necessary to motivate and change people’s high risk life-style behaviors. The issue is our choice as to who imposes the incentives, and what they will be. In a “one payer taxation supported provider system” it will be the government and may be unilateral. In a multi/provider/payer system it will be between you and your provider/insurer system. You choose: Government control and dependence---- or self determination for those that can, and a hand UP for those that can’t.

Are Friends of "Medicare" Friends of Canadians?

Ethicists have stated that in family medicine, we have an ethical obligation to assist families to grow in their ability to make choices and take responsibility for those choices with regards to their health. If this is true, is it not also true that our medical leaders and government leaders should work together to help Canadians make good choices regarding our health care system? Ethical transplant surgeons have difficult choices to make with respect to the patient that would benefit most from an organ transplant when there are a limited number of organs available. This would be called an absolute lack of a resource. But what if the restrictions to transplantation were budgetary? What if the transplantation program was only allotted so much funding and “cost” determined how many surgeries could be performed. What if the number of Intensive Care Beds in the Calgary Region was determined by competitive medical funding interests within the region and the “upstream driver” of that---competitive funding interests of the provincial government---- and the upstream of that, competitive interests of the federal government and society as a whole? Should the medical profession, from an ethical perspective, become embroiled in a “relative” resource allocation system? Some physicians obviously felt we had an obligation to society as a whole, and that, to them, meant working with a cost driven system to best use the resources allocated to health care. I say our obligation to society is best served by remaining the patient’s advocate, and, working within that society to help patients and families to grow in their abilities to make choices and take responsibilities for their choices! This would entail at the provincial and federal level, advocating for resources but also advocating for alternate provider systems. The profession has failed miserably in this regard!
Before ‘Universal Medicare” in Canada, doctors determined that surgical units always needed a 10% vacancy, Medical Units a greater percent vacancy, and Pediatric Units even a greater percent vacancy. This was determined on the probability of medical events occurring that would require appropriate acute care (hospital) beds. The present situation is that most acute care facilities run at near 100% capacity most of the time!
This means that to a large extent physicians are making decisions based not on absolute scarcity but relative scarcity. We base most things on a risk basis; emergent, urgent, semi-urgent, and elective. Family physicians are encouraged at all levels (teaching universities, continuing medical education, regional administration, etc.) to think in a cost effective manor and to prioritize both medically (risk) and from a cost perspective. Emergency physicians must stratify the patients so those at highest risk can be admitted to scarce medical beds. Intensive care physicians often determine which patient, of a multi-car crash, most critically requires the last I.C.U. bed.
An argument could be made that this is their job (they are the best trained to make those decisions) IF the funding available, as in the case of organ donors, was an absolute, but it is not! Government funding to health care is relative and determined along with many other priorities including, but not limited to, infrastructure, tax cuts, education, and many other social programs. Why then has the medical profession bought into this monopoly? To some extent I think this was a case of the governments saying: “We are going to do it with or without you and you know we are going to screw up”.
Canadian courts certainly have for years told physicians that their primary responsibility is to the patient. The excuse of “lack of resources” has not stood up in a Canadian Court of Law as a defense for a medical practitioner. We have been told by judges that patients who are waiting on “lists” are at risk and should be told that there are private services available to them in Canada and the U.S. More recently the Supreme Court has stated that the Quebec Government must provide options for its citizens when waiting lists impact their right of self health determination. Calabresi and Bobbit in “Tragic Choices” stated in 1978: “Scarcity is not the result of any absolute lack of a resource but rather of the decision by society that it is not prepared to forego other goods and benefits in a number sufficient to remove the scarcity”. It should be noted that this scarcity has only become more acute with time. Society must ask the question, as its members stand in long medical lines, if it wishes to continue allocating tax resources in this manner. The Medical Profession must ask its-self if ethically it can continue to condone being advocates for a monopolistic system that continues to allocate health care as an ever increasing scarce resource, or return to the premise that we are advocates for the patient above all other ideologies.

Perhaps Size Does Matter

On Friday, Jan.13/06 I spoke of the success of the Calgary Regional Palliative care program that was the product of initiatives on the part of concerned people with regard to specific health care needs in the community. To some extent, some initiatives are continually going on, but these are in the form of money raising projects that supplement our government health care system. There seems to be a myriad of “fund raisers” and charities that are described by the organizers as “essential” to our health care system as we can tell by the many phone calls we get and the many lottos that seem to go on endlessly. These projects add an important dimension to our public system, but in themselves are not innovative but rather of a philanthropic nature.
A new and exciting event, I believe, is the advent of non-profit community funded palliative care facilities. These are totally outside of the government funded health care system. The exciting thing about this initiative is not necessarily because it is outside of the system, but rather that it was initiated by community need, medical and other care givers, concerned and compassionate people in the community and surrounding area. The land was donated; the roadwork and building site preparation was donated, and many other businesses contributed their services to the project. Fundraising has been incredible. My understanding is that this is a $6,000,000.oo project of which over $3,000,000.oo has been raised in two years. When completed it is hoped it will be run free to the people needing it, as a community program through fund raising. When relating this to a retired business man from Ontario, he told me a similar facility had just opened in his community.
Centralization, cost effectiveness, and a big business approach have been the pillars of our health care system to date. Would de-centralization and a grass roots small business approach have been more appropriate? Would a combination of both been more appropriate? In a monopoly it has been my experience that service becomes sacrificed for cost. In our present huge health care monopoly we have lost the tremendous energies, knowledge, volunteerism, and input of our health care providers, small businesses, and the people at large in the community. The present “Universal” health care system uses the community to raise money and hide health care needs. We should ask the question; is it ethical on the part of the Government of Canada to with-hold transfer payment from provinces if they disallow private health services and private insurance? The Supreme Court of Canada has ruled that the Government of the province of Quebec has denied its citizens their basic rights. Have physician’s organizations such as the Canadian Medical Association and the provincial Medical Associations been delinquent in not speaking up more during this process over the past twenty years. Is it possible to be an ethical physician with-in the system today? We will look at it in my next post.

Palliative Care, A Caregiver/People's Initiative = Success

By now anyone reading this blog site will have come to the conclusion that I believe firmly that economics has driven the health care agenda since the mid 1970’s, and they would be correct. When health care costs rose annually faster than the GDP, inflation, and population growth, it was perceived by most politicians early in Medicare’s history that it was not sustainable. When Calgary citizens and doctors became unhappy in the early nineties, the Alberta Government sent senior bureaucrats from Edmonton with the message that there was not a health care problem; there was only a “perceived” health care problem. When this idea was rejected, the new mantra became: “patient orientated and patient focused”. At this point I became very concerned because my experience in buying horses had told me that the seller usually represented the worst feature as the best feature. The theory was that you can see the good features, so, if we can only defuse the negatives the average “buyer” would go for “the package”.
Meanwhile, in Calgary a very positive movement was growing. Caregivers in the field of Palliative care were aware that surveys in the/90’s indicated that 60% to 70% of Canadians wished to die at home if possible. These care-givers were also of the belief that the goals and objectives of the patient, after full disclosure and discussion, should be the primary “driver” of the care given. This movement was not cost driven but compassion driven and was a “grass roots” endeavor by care givers from various levels of the health care team. The Calgary region was approached and agreements made in an environment of cooperation. The Region benefited by freeing up expensive acute health care beds (hospital beds) and the community benefited by obtaining resources in place BEFORE the program was actually implemented. Unlike the above scenario, note that the increase in home care was precipitated by early discharge from hospitals, and inability to access hospital and nursing home beds but did not have the buy in of community physicians and care givers because of inadequate resources in the community.
Some physicians saw the development of a palliative home care program (a minority), as an intrusion into their community domain. Most of us, some who were already doing home palliative care, were ecstatic. Planning and focus groups were held jointly with the Region, community care physicians, palliative care specialist, nurses, other care givers, and any interested parties, including the public. Dying at home, with dignity, slowly became a reality for many Calgarians.
Much has been said about the need for health care providers to work as a team. In Calgary’s Palliative care program the physicians in a certain area of the city consistently worked with the same palliative care nurses and palliative care specialists. We developed confidence, pride and trust in each others work, expertise, and contribution. On one occasion I recall a palliative care nurse answering my call while she was in a facility having her own personal mammogram performed. She new I would not page her unless I thought it was urgent. Compare this to trying to get urgent attention for a new “home care patient”. First, I would have to contact an “intake worker” who would want me to spend at least 15 minutes providing information including such things as whether anyone smoked in the house. The case would be assigned to a home care nurse that I probably didn’t know. I was given no time frame as to when the patient would be seen.
I think the success of the palliative care program in Calgary is a good example of what ingredients are needed for innovation to work in health care. There has to be a perceived need and that need has to be patient driven, not cost driven. There has to be “buy in” on the part of care givers, and for that to happen the care givers and patients must be empowered to pursue common goals and objectives. A by-product of a good innovative project is that it would have a cost savings or be cost neutral, but in health care, the primary driver for innovation should not be and cannot be cost driven!

Volume and Low Cost, The Walmart Solution

As health care provider shortages became an increasing problem and the demand for treatment became greater, new efficiencies were needed. This gave birth to the concept of health care programs. To my mind, programs did two thing very well: perform the most units of care at the lowest cost (this is why it was put in place), and get the most units of work out of the health care providers involved. Unfortunately, when the programs were in the planning stages there was no input from family physicians. This resulted in no plan as to how to integrate the community physicians and their patients with the programs. Previously community physicians would use, for instance, a defined number of consulting cardiologists. The long term care of a considerably ill cardiac patient would be followed collaboratively over the years by one cardiologist and one family physician. This disappeared, and the community physician would have to simply use the cardiologist on call for the program if the case were urgent, or refer to a program with a long waiting list and the patient would be seen by the cardiologist working that day. Since the cardiologist on call rotated every seven days, a patient hospitalized for 8 days could have three different cardiologists during their hospitalization. In effect the patient was a “client” of a program, not a patient of “a” doctor. This of course led to more “generic” care and less personal care.
To aggravate the situation, different programs were set up in different hospitals throughout the city of Calgary. Conceivably, I could have two patients in each of three different hospitals, making it impossible to make hospital visits cost effective. In the last years of practice I gave up hospital privileges like many of my colleges. This further separated community patient care from institutional care.
The health care providers in programs did the best they could but soon they were over-run with demand. The combination of early discharge from acute care (hospitals), the inability to admit patients to hospital beds, the lack of long term care beds (governments had put a moratorium on building nursing homes) and the inability to access investigation in the community, flooded the emergency departments and the programs. Soon the need for triage people and intake workers as a buffer to demand and a coping strategy for emergency departments, home care, and programs became apparent and were put in place. The net result ----- another hurdle for community physicians in trying to get the care they felt their patients needed.
Although programs were not a bad idea, they were not properly thought out with patient continuity in mind. They were a “big box store” solution, a volumes solution; and were designed for the most commonly ill, not the most ill in our society. Communities became the “dark hole” where health care needs accumulated and community physicians were left to cope. More family physicians left Canada, more stopped taking new patients, more retired at an earlier age and more medical students simply chose not to go into family medicine. But from a government perspective the needs in the community were invisible and didn’t make newspaper headlines, so Canada could continue with it’s illusion that we had the best health care system in the world! Good patient care had lost its’ priority, replaced by system survival.

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Health Regions Fiddle While Health Care Burns

During the /80’s and /90’s many attempts were made to control costs, often not well thought out. I was one of the many primary care physicians who would get a letter almost annually reminding me that my profile for ordering investigations on my patients was two standard deviations above the norm. I never received an answer when I inquired who my peer group included and if doctors that were two standard deviations below the norm were also receiving a letter! Obviously this was an attempt to decrease patient investigations and cost.
The Alberta government then thought educating the public on their consumption of health care dollars would curtail usage. A statement was sent out annually to individual Albertans itemizing the costs paid by the government on the patient’s behalf. This was discontinued after a few years for three reasons: it raised issues of confidentiality, it wasn’t working, and it showed how little of health care costs actually went to physicians. My patients would often say: “You mean to tell me that while I was in the hospital I ran up a bill of $5,000.oo, you saw me every day and you only get $129.oo? The bottom line, the program moved public support towards the doctors and didn’t help during negotiations with the profession.
As previously mentioned, the investigation of patient’s complaints was one of the large consumers of health care dollars. The Calgary Regional Health Authority approached the problem by actually becoming a part owner of the labs in Calgary. This gave them considerable influence and before long many of the smaller laboratory outlet services were shut down. Soon long line ups developed in the remaining laboratories. By controlling fees for diagnostic imaging (X-rays, ultra sounds, etc.), governments soon forced the owners of these services to close their smaller operations and centralize as well. Waiting time for these services grew.
The above change in services in the community had a profound effect that was not anticipated by the Region. I, as a physician, no longer could send my elderly patient suspected of pneumonia down the hall for a blood test and chest x-ray. They may well have to travel miles and occasionally to different addresses. Instead of having results in minutes it would take hours or days. Injuries also could not be dealt with quickly because we no longer had X-ray facilities on the premises. For compassionate and good medical practice reasons, primary care physicians began sending more and more of our sick elderly patients, our injured patients, and our urgent and semi-urgent patients to the emergency departments of the hospitals. As access to specialists and investigative modalities worsened, emergency department became swamped. Was this predictable? Of course it was! How are the health regions dealing with situation? They are developing medical clinics (Health Region owned and managed) with laboratory and diagnostic capability and hire physicians to work in them. These new clinics offer the same services that were provided by the physician run clinics-----they just cost twice as much to run!
Re-inventing the wheel at twice the cost is now described as the solution to health care sustainability.

Doctors and Nurses Flee Canada

As part of downsizing acute care, thousands of nurses and administrators were fired in Alberta. The Unions insisted senior nurses not be released and as a result Canada lost several years of recent graduates in nursing. These young people would be working today in our system. Instead they have retrained or fled the country. Many of the senior nurses have since retired. Most of the administrators were quickly rehired to deal with the chaos that existed at that time in our health care system.
In medicine, particularly family medicine, there was a sense the government, in their re-organization, considered us superfluous. The Barer-Stoddard (neither were physicians) Report that came out in-the /80s stated there was an overabundance of physicians. The Alberta Medical Association Manpower Committee predicted dire shortages of physicians by the year 2000. Naturally, the physicians were ignored, they supposedly had a vested interest. The Fraser Institute Forum, 1999, “The Doctor Shortage, Part 1, states that decision has cost Canada $1,000,000.oo dollars a year.
During this time, Health Organizations in the U.S. published several studies that showed the cost effectiveness of family doctors. Unlike their Canadian counterparts, hospital administrators and H.M.O.s in the U.S. actively recruited Canadian family physicians. They used words such as dedicated, ethical, hard working, selfless, and patient orientated to describe Canadian family doctors. They paid university debts, moving costs, and many other perks. Being respected, wanted and valued in the American system was such a unique experience for Canadian family doctors, they moved to the U.S. by the hundreds. I believe last year was the first year in twenty years that we in Canada realized as many physicians returning to Canada from the U.S as leaving for the U.S. Is this because the U.S. Health Organizations have become more controlling and Canada is looking at alternate provisions for care, including outside of the Canada Health Act? Perhaps the solution to our health care provider shortage is to provide numerous options including a private system. Perhaps, instead of depleting providers in the public system, a parallel private system and variations thereof, will actually replenish it!

GOVERNMENTS PANIC

All levels of government, federal and provincial, were running deficit budgets as we entered the 1990’s. In spite of efforts to date, nothing had slowed the continuing climb of health care costs. In Alberta during the /80’s, interest rates, inflation, and bankruptcies were high, oil prices and government revenues were low. I think already at that time there was a realization that the present situation was unsustainable. With this knowledge in mind and knowing decisions would have to be made that would be very unpopular, the Alberta government set up health regions and appointed a board to replace existing hospital boards. Hospitals were the largest part of the health care budget and doctors had far too much influence on their local hospital board. As one administrator complained “my job is h--l, doctors act as though all these decisions are a matter of life and death”.
One of the first things the Calgary Regional Health Authority did was to hire a large accounting firm to adopt a “business approach” to health care in Calgary. This resulted in the Calgary General Hospital being demolished because it was presumably too expensive to heat. It also resulted in the Holy Cross Hospital being sold for approximately 4.5 million dollars when 4 times that amount had just been spent on renovating the Holy Cross Hospital, including a new efficient heat exchanger unit. During this time, the Salvation Army’s Grace Hospital was also taken out of public service and became privately owned.
A true “the sky is falling” routine! Calgary, prior to these changes, had 3.2 acute treatment beds per 1000 population. Recommendations by experts at the time (self appointed?) said there was 20% “fat” in the system. At the present time, in the Calgary region, we have 1.6 beds per thousand population. It would seem we went past the “fat”, through the “muscle”, and are now into the “bone”.
Is it any wonder that waiting lists (actually risk lists----because while you are waiting you are at risk!), have doubled in the past 12 years?

Physicians response to government control

As governments tried to control rising health care costs by micromanaging doctors, physicians made changes needed to maintain their incomes. As a small business, services provided had to be looked at as to cost, time, and remuneration. Most physicians continued to provide services that were not cost effective out of a sense of obligation to patients. Since there were still plenty of physicians in Canada and some competition for patients, some services were seen as a "lost leader". Many physicians hung on to the idea that the government simply "didn't understand the situation" and if they continued to try to "educate" the government, things would turn around.
By the late /70s and early /80s however, there was a realization on the part of primary care physicians that they would have to cut costs. One of the first services to disappear were house calls. The physician driving to a residence to see a patient was clearly a "waste" of time and a patient convenience. Further if a diagnostic mistake was to be made, it would more likely happen in the patient's home than the doctor's office with proper facilities. This was followed by physicians not assisting in ther patient's surgeries and by the late /80's more and more family doctors were giving up their hospital priveledges. Most of these services traditionally had not been cost effective, but with cost going up, the fee schedule basically controlled by the government, and a growing wedge between physicians and their patients, a process started that would reach its' peak in the nineties and which continues today ---the disappearance of Canadian Family Doctors.

Innovations of the /70s and /80s

For the first few years of "Medicare" in Canada, physicians were generally quite pleased. Being human, they didn't miss the burden of talking about their fees with patients who had no coverage. They had no collection losses and their billing system was reduced to a one payer system. In the first year alone they probably realized a 15% increase in take-home pay. These things served as the "hook".
The provincial governments were not nearly so pleased. Physicians started to do more depth investigation into patients complaints. Patients saw the situation as a virtual medical "candy store" which they could access and use to solve all concens and discomforts. In a few years provincial governments saw the cost of health care rising significantly above the GDP and inflation. This in the face a slow but progressive withdrawal of support in the form of federal transfer payments to the provinces.
The political response to this was salary control to the doctors. True negotiations never really took place between the medical organizations and the provinces. The threat of strike on the part of physicians never really affected the government and sat poorly with most of us. In fact governments saved money if physicians were on strike and strikes helped drive a wedge between doctors and their patients. During the twenty years of the /70s and the/80s only four or five adjustments made in Alberta to the fee schedule kept up with inflation. Changes in the rules such as paying for a visit instead of the service meant that physicians could charge a maximum for a visit, regardless of the number of services rendered or time spent with the patient. Certain services were rationed to only so many per year.
During this time hospital administrators had to cope with funding at the discretion of the provincial governments. They bought into the idea that sick people did not generate costs, doctors did since they admitted the patients and ordered the tests. Hospital admitting priveledges for family doctors were restricted to a certain number. Compare that to the present state where regions are crying for physicians to take on hospital priveleges and occasionally patients stack up in emergency departments when acute care beds are available but there are no doctors to take on their care. "Innovation" at the time was mainly comprised of micromanaging doctors and their activities as cost controlling measures. Certainly, governments thought they had control of the situation in the late /70s when one Alberta Cabinet Minister(attorney general at the time) told me privately: "We would be fools to salary doctors. We would immediately need 30% more doctors. The way it is now we control the purse and the fee schedule, you have to work harder and harder to meet your expences or you take home less money at the end of the day". This idea that doctors were the cause of rising health care costs finally culminated in the late/80s with government enforced decreases in Medical School training and hospital residency positions.
My science teacher taught me in grade school that: "for every action there is an equal and opposite reaction". Tomorrow I will discuss the physicians reaction to these controling measures and being put in the position of the "bad guy" in the equation.
Dr. Al Wilke

AT THE BEGINNING

I started family practice in Medicine Hat, Alberta in 1963. At that time there was no Canada Health Act. There was however, total hospital care coverage and cancer care coverage. Doctors' fees were covered by insurance plans such as London Life, Medical Services Incorporated, welfare, Federal coverage(R.C.M.P.) and about 5%to 10% of my practice did not have coverage for doctor visits. Keep in mind, as I said, everyone had cancer coverage and hospital coverage. I wrote off 10% to 15% of my billings every year.Some of the people in my practice suspected that I "underbilled" them, but no-one was ever made to feel ashamed of their financial status.
Alberta and Ontario were the last provinces to sign on to Universal Health Care and in 1969 Canadians had what they thought was going to be the best health care system in the world. They were told that they no longer had to be responsible for their health. They did not have to think about "should I see the Doctor, have a house call, or get a second oppinion". They were told they were entitled to these things on demand. They were told government would look after the old, the poor and the chronically ill---infering that this group was not being looked after by the present medical system and doctors. They said no-one would lose their homes because of medical debt. In my 5 yrs. of practice before the Canada Health Act, I knew of no-one who even lost a tetevision set because of medical bills. At that time governments were already using "American Medicine" as a boogey-man to support the Canada Health Act and garner votes.
What was not said was that in 1969 Canada already had a much different haelth care system than the U.S., that physicians in Canada, like Canadians as a whole, were much more compassionate than their U.S. counterparts, and that by effectively conscripting physicians into a "one payer" system, physicians in Canada became Civil Servants. The expression " he who pays the piper calls the tune" would from 1969 on, continue to erode the Doctor--Patient relationship and eventually remove physicians as advocates for the patient and make them advocates for the system. Terms such as "Gatekeepers to the public purse" would have horrified physicians when I graduated. This now is considered to be one of the primary functions of primary medical care.
During the hepatitis inquiries the question was asked; "When physicians become buisiness men(make recommendations based on someone elses bottom line, e.g. cost effectiveness) who do we the people turn to for medical advice?" On this blog site I would hope to encourage some true discussion of issues pertaining to health care in Canada. Perhaps we,the people, can redirect health care and our tax dollars where they should be in a "just society",--caring for the poor, the frail elderly, and the chronically ill, and puting in place incentives that are not counterproductive.
Dr. Al Wilke.