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?

Friday, February 03, 2006

Let's Be Honest.

Yesterday I introduced two medical terms; efficacy (effectiveness of interventions), and fidelity (the extent to which the system provides patients the precise interventions they need, and when and how they need them). It is my contention that we in Canada have become pre-occupied with the availability of the marginal benefits of efficacy (one blood pressure drug being 5% better than the next, an MRI being able to pick up breast cancer 5% better than a mammogram), and have totally forgotten about fidelity (65% of hypertensives not being treated or treated adequately, certain groups within our society not availing themselves of pap. smears, mammograms, etc.). Large scale system design must be recognized and given high priority. Even though the term “fidelity” is relatively recent, the principle was recognized in the 1960s and an attempt to address the issue was the Canada Health Act. Unfortunately the principle of getting good medical treatment to those that need it, when they need it, was high-jacked and replaced with the untenable position that everyone receive and are entitled to the same treatment. As a consequence, the very people the Canada Health Act was to help, has placed them in long lines waiting for interventions. This obviously negates the principle of appropriate treatment for those that need it, when they need it.
A British study suggested that reducing cardiac risk factors had saved 731,720 life-years in England and Wales, compared with 194,145 life-years gained by direct cardiac treatments. Yet only approximately one third of patients in the U.S. with cardiac risk factors, who should be on a cholesterol lowering medication, are actually on one. Our situation in Canada is not much different in spite of our “free” health care system. So, how do we change all this?
It never ceases to amaze me that we as a society and taxpayers, would supply something to all our citizens at great cost to the tax payer and expect absolutely nothing back in return. Our “free” health system in Canada requires minimal premiums only in three provinces, has no limitations or definitions to coverage, no conditions or qualifications for access-----not even basic information about your health. When I was in practice I provided medical information to insurance companies so their client could be insured, notes for schools so kids could participate in sports, sick notes for absenteeism, information to the tax department for special tax deductions, forms for access to handicapped parking, forms and letters for disability claims, forms and letters to Workman’s Compensation, and the list goes on and on. So why aren’t we setting up a system that will screen our population, not to “punish” them as an insurance company would do with high premiums, but to target the people that need intervention and prevention in health matters, and then present them with modalities to health improvement.
To drive a car I need to renew my license every five years for little benefit that I can tell to society or myself. At the age of 75 a mandatory medical is required to continue to drive in Alberta, with possibly a small benefit to society. What if, for discussion’s sake, we think outside of the box and as part of our National Health Care Program, people would have to register for their health insurance through a brief screening program? This could be done by a minimally trained individual---taking blood pressure, waist measurements, BMI, life style issues such as smoking, lipid and diabetes blood work after a certain age, etc. The purpose of this would not be to downgrade these individuals as clients, as insurance companies do, but to upgrade them as priorities in our health care system. Referrals and advice can be given to the person as to interventions available in the public system, and this may well start the process of change. At least the system has identified the group needing intervention. Whether the person avails themselves of the care advised, and what kind of care they access, becomes their personal choice.
Annals of Family Medicine, Inc/05, posted 01/18/06, states: “Fidelity is lacking when patients cannot make known their need for care (e.g. there are barriers to access or communication), when clinicians cannot recognize that an intervention is indicated (e.g. there is lack of time, knowledge, attention or memory), and when the intervention cannot be delivered properly (there is inadequate infrastructure, procedures, safety, coordination, or information). Fidelity has less to do with the properties of interventions than with the functionality of the system that delivers them”. When we look at long Canadian health care waiting (risk) lists, the inability of patients to access a family doctor, and the huge numbers of unidentified patients at risk and untreated in spite of our “free” system, I would be inclined to give our system a failing grade in the “fidelity” category.
If such a system existed, each person could review the basic package plan and decide if they wanted additional insurance for premiums. This would involve people as responsible adults instead of treating them as children. Each person could pick their additional coverage from a list of options as to their personal needs. Some may want the latest technologies----those released in Canada over the past five years. I wouldn’t want abortions included in my package! Additional insurance can be offered by provincial governments or other insurance agencies. The premium paid would be related to your income, and the items in the “menu” would be the “unexpected high cost items” that didn’t fall in the hospitalization and cancer treatment basic plan, and procedures and interventions that had not yet shown their value according to the national Medicare Authority. The above scenario would be an incentive for people to be involved, take some responsibility in their health “determinants”, would define their coverage, and cap to some degree the taxpayers exposure. There could be both federal funds and provincial funds specifically set aside to be accessed in the event of “compassionate circumstances”.
This may be a complex system that I have proposed, but the reality is the present system is not working. In spite of increasing cost and significant rationing, (diabetics have to buy much of their testing equipment) the needs of our chronically ill are not being addressed in a timely fashion, and a huge “population at risk” is being ignored or under treated. At present all I see is governments at all levels simply throwing taxpayers money at the problem with no long term plans in site. No political party seems to have the courage to advise surgery on the Canada Health Act----at the cost of many Canadian lives.

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