What's Wrong with Healthcare?

Thinking inside and outside of the healthcare box. After 41 years of family practice, what's happened to Canada's healthcare system?

Sunday, February 05, 2006

Government Accountability

I have often wondered why Dr. Rachlis and others have pushed preventative medicine as the savior of our present health care system. During my training in medical school 40+ years ago preventative medicine was taught extensively. As I recall, we had a huge text book called “Preventative Medicine” that coincidentally had, I believe” a bright green hard cover. The problem over the years is that the evidence we have on many preventive fronts doesn’t confirm that education in itself is terribly effective. There seems to be a matter of “ready-ness” for change which is multifaceted and until that point is reached, education basically “goes in one ear and out the other”. When people have arrived at that point of readiness, education is very cost effective. Until they reach that point, we are preaching to the unconvertible.
Don’t get me wrong, education is necessary, but what system is in place to identify and direct education and resources to those that are “ready” (cost effective), and not direct education and resources to those that are not ready (not cost effective)? For that matter, what resources are we using and what system is in place to help people move along the various stages to readiness? There certainly has been a groundswell of graduates in Health Science from our Universities in the past 15 years. Has the promotion of prevention been a “make work” project for this special interest group? Certainly, I have not seen good scientific evidence, combined with a system of administration and good cost accounting to show the advantages in detail.
Smoking is a good example. Although we know that smoking is detrimental to the health of Canadians, the net financial effect to our society may be a plus as pointed out in W. Kip Viscusi’s book “Smoke Filled Rooms”. Studies on alcoholics showed that the initial investments in education was very cost effective, however the continuing expenditure of money yielded poor results.
Obesity is looming as one of the great health costs to Canadians in the future. Evidence is undeniable that increasing obesity will lead to increasing diabetes, heart disease, strokes, dialysis, etc. Unlike smoking in which society “recaptures” health care costs through tobacco taxes, there is very little benefit to society from people overeating. There is a plethora of “diet educators”, diet books, and diet programs available in our society to address obesity, yet obesity continues to be on the rise----- not a great endorsement for education being a solution to our “cost crises” in health care. In fact, our courts are taking away the negative incentives that may help people to change their eating habits or get help. Keep in mind, societal pressure has played a significant role in decreasing smoking.
I believe that the application of certain systems in Canadian health care will have a far greater impact on the health of Canadians than education. Unfortunately, good application (fidelity) of good health intervention programs may in fact cost more, both on the short term and on the long term. But the question we must ask as a society: “Is our goal to save money, or is our goal to provide the best health for the most Canadians within the framework of competing interests?”
Previously I mentioned a pilot project that was effective in reducing emergency room visits and providing better asthma control. The basic ingredients of this program were a) identifying the individuals with the disease, b) a close monitoring system, and c) a strong reminder system. Reminder systems have been shown to be very effective. Dentists and many other people service industries use them. If Canada had a universal health registry system like we have a motor vehicle registry system, with some basic screening every five years in certain age groups, we would be identifying the people needing preventative intervention, perhaps reminding them annually of that need (enhancing readiness), monitoring to some degree every five years(their progress), providing information to those that require it, and intervening appropriately to those that are ready through appropriate referrals.
Would this decrease cost? Probably not. People would live healthier but may require more preventative medications and preventative measures, but we as tax payers would keep them around as tax payers and know that our tax money is being well spent. Life expectancy would likely increase and with that increase, the increasing costs that go with more home care, long term institutional care, and end of life care. Like many other areas within our society, the Canadian taxpayer is looking for accountability. Our Universal Health Care System must re-examine its purpose and focus. We must stop worshipping our false god “Medicare” and address the health needs of Canadians at risk, the long lines of Canadians waiting for access and/or treatment, and the truly vulnerable within our “just” society. Without meeting these basic needs, we cannot be called a compassionate society!


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