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?

Wednesday, April 05, 2006

Medicare, Canada's God, Religion, and Identity.

I hate going to continuing medical education seminars! I’m not sure what the purpose of these events is. For the most part the speakers tell us things we already know, and show us in very specific terms that we are not doing the things we should be doing but almost never address the reasons we are not doing them. I suppose that may be a separate scientific session, although I can’t ever remember a seminar that asks the question: “Why are we as practitioners NOT doing those things we know we should be doing”? Filling us with knowledge and then pointing out what a miserable job we are doing (without determinating the reasons for poor compliance) isn’t the stuff that generates enthusiasm about attending the next seminar.
On previous blogs I have pointed out the vast reservoir of people in Canada that are at risk for cardiovascular complication and (for whatever reason), are not being treated. This has been referred to on previous blogs as a lack of fidelity in our health care system (getting the right treatment to the right patient at the right time). On April 6/06, at the University of Calgary, I attended a medical conference on osteoporosis, a chronic condition of decreased bone density combined with increased bone fragility, common in elderly people. It is estimated that this disease costs Canada’s health care system approximately 2-3 million dollars a day, without consideration of the pain and suffering endured by those patients who sustain fractures. I would think that the supporters and designers of our health care system in the 1960s had this disease in mind when they said the health care system should protect the poor, the chronically ill, and the frail elderly since many osteoporotic patients qualify for all three criteria.
There are many aspects to addressing this disease. It is two to three times more common in women than it is in men. With the recent trend away from hormone replacement therapy in post menopausal women, we can expect a surge in osteoporosis and its complications over the next 10 to 20 years. Most people are aware of fracturing as a complication of osteoporosis but few are aware that the mortality within the first six months of a fracture can be as high as 20% or higher, depending on the bone fractured and the age of the patient. With the cost, pain and suffering, and mortality rates in mind, one would think this would be an ideal area for our health care system to shine----not so.
Many preventative therapies are suggested. Adequate calcium and vitamin D intake, weight bearing exercises, avoidance of smoking and glucocorticoids, and using hormone replacement where appropriate, are all useful measures of prevention. Risk stratification can be useful (e.g. low body weight, family history, smoking history, excessive alcohol intake), but by far our greatest neglect in our health care system is the patients over 50 years of age that present with a fracture from relatively minor trauma (defined as a fall from a standing position or less). In this age group, 70% of patients presenting with a wrist fracture will have osteoporosis and need specific drug therapy; for hip and vertebral fractures the figure is closer to 90%. In Canada, the best figures that we have is 1/3 of the patients that should be treated with specific therapy are actually treated appropriately, and after one year the results are even more abysmal.
Unlike cardiovascular risk, where the identification of those that require screening can be a problem, identifying group at risk for repeat fracturing is simple; they present to the physician with their first fracture. What could be easier?
If a patient over 50 years of age presents with a fracture, part of the work up on this patient should be a bone density test to determine if this patient had a fragility fracture. If their bone density reveals osteopenia or osteoporosis they should be treated with specific medications----it’s that simple. When I retired 2 years ago, some provinces didn’t have the capability to do a bone density test. If we treated all patients over 50 years of age that presented with a low impact fracture, 10% to 30% of patients who wouldn’t need medication (depending on the fracture), would be on an expensive medication with the inherent risk of possible side effects.
The various lecturers had excellent statistics to show the cost effectiveness of doing the bone density measurements on patients presenting with low impact fractures. Since this group of patients have a two to three fold risk of having another fracture within one year and since appropriate pharmaceutical treatment can reduce the risk of repeat fracture by 40% - 60%, it would seem that this is a group of patients that a) meets the criteria that our system was meant to look after, b) is easily identified and c) can be cost effectively treated.
So why are we not treating them. The answer is simply that our system has poor fidelity (treating the right patient, at the right time, with the right treatment). We are preoccupied and paranoid with equality issues instead of focusing on the issues that pertain to the poor, the chronically ill, and the frail elderly, as the system originally was intended. The system has been high-jacked by the Friends of Medicare and other special interest groups (e.g. unions), and there seems to be a serious lack of leadership on the part of physicians to assist governments on refocusing on the poor, the chronically ill, and the frail elderly. How can we call ourselves a compassionate society when we support a monopoly that demands inclusiveness of people who have the capability of looking after themselves (at great cost to the system), at the expenses of those, through age, misfortune, or chronic illness, are unable to look after themselves. We have made “Medicare” our god and our religion. We have become totally dependant on it (it is a monopoly), pray frequently while we languish on risk lists, and don’t understand when our prayers aren’t answered. The fanatics, supported by special interest groups and the main stream news media, choke off any constructive discussion as zealously as any religious fanatic. Unfortunately, the carnage, although present, is not as evident. It exists all around us, in our friends, neighbors and relatives. It is the carnage of neglect, of apathy, and indifference. It is the carnage brought about by self interest, paranoia, and fanatic idealism. But we, as a society, keep it invisible and pretend it doesn’t exist within the system; and we physicians can live with it, just don’t go to any continuing medical education seminars.

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