Public and Private Medical Systems Can Be Synergistic

Now we get into the fun part!!! Today we will discuss: B) Areas of health care change and innovation that may well contravene the Canada Health Act. These are the areas that probably never get explored in the MSNM because very vocal lobby groups raise the negative side of the equation to public awareness, but little discussion occurs as to the positives.
1) Doctors being able to work in both the public and private systems. Probably the public doesn’t know that in some provinces there is a “cap” put on doctor’s earnings. This means that effectively some doctors (even family doctors) who work hard are penalized for their productivity; the more patients they see, the less they get paid for their additional work. This is a definite disincentive to work to capacity. If they were allowed to spend additional time in a parallel private system, they would be fairly remunerated for there additional work, and more community needs would be addressed. The more patient needs that are addressed in the community, the fewer patients show up in the emergency departments for treatment.
2) Surgical waiting lists comprise an “at risk” group of patients, and at risk patients are more likely to end up in the emergency department. This is true of cancer patients waiting for investigation and/or treatment, joint replacement patients who are more prone to falls, etc, or patients waiting for coronary by-pass surgery. Many presently practicing surgeons in Calgary have limited operating room time, and many surgeons who possibly would come to the Calgary region do not do so because of lack of operating room time. Allowing surgeons to work in both a private and public system would make full use of the existing highly trained physicians, would entice surgeons to come to this area despite restricted access to public funded operating rooms, would shorten wait times, and by doing so, reduce visits to the emergency departments by these high risk patients.
3) Allow insurance for “covered” investigative procedures and treatments (in a private parallel system).
a) People waiting for investigations such as C.T. scans, MRI’s, and other investigative procedures, are usually getting these procedures done for medical reasons. They comprise a community group of patients at risk, who are more likely to attend the emergency departments of our hospitals than the average patient who does not have medical concerns. The faster these patients are dealt with and their medical issues addressed, the less likely they will frequent the emergency departments.
b) As in “(#2), access of treatment, through insurance, takes patients off treatment lists in the public system, and by shortening the “wait” times, reduces emergency department visits.
4) Allowing a private, parallel, health care system.
a) This could entice thousands of doctors and other health care providers who have left Canada over the years, back to Canada. More care providers in the community will decrease the need to visit the emergency departments.
b) Insurance for various “services” of health care, that are in short supply at present, will be taken up by the people who can afford to do so. This will take these patients off of the wait lists in the public system with benefits to both the private and public patients. Further, the care of the insured patients will not be coming from the tax-payer funded public system. As the waiting lists shorten in the public system in various areas of service, the patients will decide whether they wish to carry insurance for a particular service. As an example, if waiting times for joint replacements are two years, I would probably take out private insurance coverage. If the wait times for joint replacements are six months, I likely would not take out private insurance coverage. At all times this system will give options to the average Canadian (right now only the very wealthy have options), and at the same time have an ongoing effect on shortening the waiting times for many procedures in the public system. Keep in mind, the public system will still be there as it is today, with appropriate emergent and urgent care (and should be more accessible).
c) Privately owned and operated facilities could be established in this environment, but the finances for these operations are completely paid for by the insurance carriers. If, on the other hand, it is expedient (by virtue of cost benefit or demand) for the public system to “farm out” certain procedures, the private system acts as a resource and a possible safety valve at times of critical demand (disasters, epidemics, etc). On the other hand, the public system may be able to compete very effectively in providing certain privately insured patient’s services. This could be a financial benefit to the public (tax payer funded) system. After all, the proponents of the public system continually state that they provide services more cost effectively than private systems.
5) An interesting thought is for the government to actually be one of the insuring companies. They already have a premium system in place. People could either take out separate policies with them that would give them access to private facilities or simply “beef up” the existing universal health care system in such a way that it complements their individual needs. I personally don’t need abortion coverage, but I would like better “portability” coverage.
All in all, significant and major changes are necessary in our health care system (we are running out of band aids). In spite of ever increasing proportional cost to our governments disposable, tax payer funded budgets; huge new money is needed within the system. We need to make a decision; do we increase government’s taxation significantly, or do we devise a system where, in return for slightly better access to elective and non-urgent care, those that can afford it will take some of the pressure off the system. I personally, always opt for systems that provide personal options, consumer input and control. And I see no reason why the public and private systems can’t work synergistically.

A Prescription For Decreasing Emergency Department Demand.

I think it needs to be stated at the beginning that there will always be some public discontent with health care systems, just as there is always some discontent with life itself. As I’ve stated before, all normal creatures move to and desire survival and comfort, so just determining the parameters of Health care”, yet alone society’s obligations to its citizens (as opposed to personal responsibilities) in this area, presents enormous controversy. The purpose of today’s blog entry is to show that no matter where you stand on most health care issues, improvements can and should be made to the present system. I will discuss solutions that fall within the Canada Health Act and solutions that fall outside of the Canada Health Act.
A) Solutions within the Canada Health Act.
1) Graduating more medical, nursing, and technical practitioners. This is a given; however, unless we retain these practitioners, the money invested in them has been wasted (Retention of practitioners is a topic in itself and will be addressed separately. Basically it involves giving more autonomy, independence and control over a myriad of working conditions, to workers in the health care field). This solution lends itself to “long term” approaches since training time for various professionals in the health care field varies from four to fourteen years.
2) Fast tracking the qualifying foreign graduates is given as a solution but is far more complex than the general public perceives. Matters of language, training, attitudes, beliefs, social customs, and many other factors come into play. Doesn’t it make more sense to try to recruit back the thousand of Canadian graduates that have sought employment in other countries? To do that we have to look at the reasons they left, and address those issues. Providing a more “comfortable” work environment for health care providers in Canada could start a significant and immediate return to Canada of many of them.
3) Put incentives into the system that encourages doctors and other health care providers to look after sick people outside of the hospital and emergency department settings. At present there are only negative incentives in the community for caring for the chronically ill, acutely ill, complexly ill, and frail elderly. At present a community physician, by limiting their practice to trivial episodic care, can generate 200 to 300% more income than a practitioner doing complex ongoing care. My suggestion would be that for the next five years all fee increases be applied to increasing the fees for complex care. If the fee for seeing a diabetic seventy five year old with pneumonia was five times more than seeing a twenty year old with a sore throat, we would see a renewed interest in the care of the sick and elderly. When I retired one of my elderly patients with Parkinson’s disease was interviewed by several family practitioners as a prospective patient and rejected on the basis that” the practitioner was not THAT knowledgeable about Parkinson’s Disease”. I would suggest to you that most “interviewing” done today to see if there is a “patient/physician fit” is primarily done to see how time consuming a patient may be, and whether taking them on as a patient would be cost effective. Perhaps if the complex/ill patient visit paid five times what a “routine” visit paid, there would be competition for the seriously ill patients by the community physicians. As a consequence these patients would show up in the emergency department less frequently because a physician actually seeks, assumes, and takes responsibility for their care in the community! The same principle should apply to the medical care in extended care facilities in the community and to hospital care.
4) Use and payment of “physician extenders”.
At present, if a group of physicians hire a physician extender, nurse practitioner, etc, there is no payment system in place to recapture that provider’s salary. Years ago, dentists found that adding an hygienist to the office practice was both cost effective and a benefit to their patients. A registering system for qualified physician extenders/nurse practitioners should be set up and a payment system for their services undertaken. This payment system could be part of the “Medicare” System, private, or a combination of both. This addition to an office setting would enable physicians to direct their TIME to the more seriously ill, as well as increasing their capabilities in dealing with the more seriously ill. The end result will be better access to care in the community, better use of the physician’s skill and training, and fewer visits to the emergency departments.
5) Fast tracking of community patients who are of considerable concern to their community family physicians. This basically means that community physicians who take on the care of patients who are seriously ill, and/or have special needs, must have better access to resources. For example, as long as the emergency department physician can get an MRI the same day and the community physician can’t get an MRI for the same patient for two months, patients of concern will be downloaded to the emergency departments. As long as emergency physicians can refer directly to cast clinics and community physicians can’t, telephone triaging of traumatic injuries directly to emergency departments will occur, and these people will not be seen or cared for in the community by community doctor’s offices.
6) Having physicians do the triaging in the emergency departments, and fast tracking those patients that have the greatest medical needs.
Physicians are trained to diagnose illnesses and know the consequences of the various diagnoses. Priority must be given in the public system to those individuals in an emergency department that may come to harm. Those that will not come to harm will have to wait or be seen in the community. Some of our emergency departments have accepted and implemented the U.S. Hospital System of fast tracking minor conditions. This is wrong on several fronts. In the American system, hospitals MAKE money from seeing minor conditions in the emergency departments. In our Canadian system, it takes from the hospital budget and takes the time of personnel that should be attending to the more critically ill. Today, only a small percentage of patients use the emergency departments for trivial complaints. If we shorten the waiting times for trivial complaint, more and more people will use the emergency departments inappropriately.
7) We must develop more capacity in community facilities (both physical and care-giver), to deal with patients that do not need the acute multidisciplinary approach of a full general hospital. This entails transitional care facilities (patients simply slow to get well enough to return home), rehabilitation facilities, palliative care facilities, etc. This has been done to some degree, but has been marginalized and not supported sufficiently with appropriate diagnostic and financial care-giver support. This type of a program is both medically sound (if done properly), and cost effective. It is imperative, however, that the care givers in these settings are given the tools, autonomy, and financial rewards for their complete buy-in. The Calgary region has attempted to implement some of these ideas, but since there has not been financial and medical back-up for them, most care givers view these attempts as “dumping” into the community. As such, there is continued resistance on the part of community doctors. If this were to be done properly, with the appropriate incentives, many acute treatment hospital beds could be freed up for emergency department admissions, and patients could be triaged directly to these community physician/facilities, by the emergency physician.
The above suggestions are only a few that I think would improve the provision of health care in Canada within the terms of the Canada Health Act. Most of these suggestions are based on the premise that if we pay people for what they do, we will get a better return for our taxpayer dollar. The present system IS NOT a fee-for-service system; it is a fee for visit system. As such practitioners are rewarded financially for taking the least time and the least responsibility for a “visit”, and penalized financially, time wise, stress wise, and from a medico-legal perspective, for looking after complex and significant health problems in the community. In most areas of our society, people get paid for what they do; whatever and whoever decided medical caregivers can and should be treated differently?
Since this dissertation has gone on long enough, I will make suggestions that may well fall outside of the Canada Health Act on my tomorrow’s blog. Any comments or questions are welcome!

Innovation/Cost Effectiveness Equals Emergency Room Crises.

I suppose it will be interesting to see where the Health Quality Council of Alberta goes with their assessment of Calgary’s emergency departments; but I’m not optimistic that anything good will come of it. To really look at emergency services in Calgary, one has to understand that emergency services are only one part of a continuum of health services (although one of the more visible parts), that ranges from the care of relatively healthy people in the community, aged and chronically ill, people with assisted living and aids to daily living in their homes, institutionalized people with assisted living, transitional care, rehabilitation care, long term care, and palliative care, in combination with community health care providers (family doctors, home care, E.M.S, palliative care providers, etc), to the care of people in the intensive care units of our Acute treatment hospitals. The demands on the emergency departments of our hospitals, to a great extent, reflect our failures in the community as a whole, and in the care and discharge processes of our hospitals. In short, the innovation and striving for cost effectiveness that has taken place over the last fifteen years. Do we really think that a government appointed body is going to point a finger at “innovation” or cost effectiveness? Now I’m not saying that all that has happened is wrong; I’m just saying it was predictable and could be expected.
Let’s start with the healthy people in our society. They impact our emergency departments because of accidents, acute illnesses, anxieties, etc. The truth is that this group is actually decreasing its demand on emergency services. As we put in helmet laws, seatbelt laws, and safety standards in the work place, as a group, the healthy people in our society are taking a smaller toll of our emergency resources. Contrary to popular opinion, only a small fraction of the visits to emergency departments these day are from people who are there inappropriately. So far, so good!
But lets take a look at where innovation and cost effectiveness has taken us in the care of the aged, chronically ill, and others needing more ongoing interventions.
1) To be more cost effective, smaller community laboratories and x-ray (diagnostic imaging) facilities were shut down and centralized. In itself, no big deal for the healthy and mobile, but a huge factor for both the community physician and the aged/chronically ill patient. Rather than inconvenience a patient with pneumonia by trying to assess their risk in the community, it was expedient for the community physician to simply send them to emergency departments.
2) Stratification of patient care became the champion of cost effectiveness for those that needed on going care. The community physician no longer determined the level of care for the patient. A placement assessor and coordinator determined where a patient would get the most care (often rightfully most appropriately) for the health care buck. Each patient was given the maximum care with the minimum cost (services). This is good and well, but since the aged and chronically ill are a quickly changing group with regards to their needs, and since the facilities where they were placed did not have the capacity to assess their needs, little change was required to warrant a trip to the emergency (this of course was aggravated by lack of diagnostic community resources, see #1).
3) Early discharge from hospitals to communities with decreased resources in the communities precipitated the revolving door syndrome----- the patient was discharged in the A.M. and because of a multitude of factors (communication, follow-up, community resources, lack of community physicians, etc), the patient would be in the emergency department the next day.
4) Stagnant fees for family doctors, lack of visible appreciation for those that put out extra effort (charged parking for seeing their patients in hospital), did continuing care, nursing home care ,etc., forced family doctors to look at their practices in a cost effective way. This resulted in many dropping hospital privileges, nursing home privileges, restricting geriatric care and any other care that was time consuming. Many took on walk-in clinic care that gave more control over their lives, but did less to address ongoing or complex care issues. I tried for years to encourage the family doctor’s fees committee to build in incentives for doctors to take on more complex care, to no avail. At present, seeing a diabetic patient with heart and renal failure and pneumonia pays the same as seeing a healthy twenty year old with a sore throat. In Alberta, we get less that $2.00 more for seeing someone over the age of 75 years. So if we see someone in the office who is aged and ill, and will require time to assess properly, the reasonable thing to do for the physician, from a cost effective perspective and a malpractice perspective, is to send them to the emergency department (and considering all aspect of access to community resources, probably best for the patient as well).
5) Centralizing services for patients such as cast clinics at hospitals. For years many community physicians looked after a wide range of patients with fractures. With limited access to community diagnostic imaging, doing these things in my office became impractical. When I attempted to refer to the cast clinic I was told to send the patient to the emergency department (where the physician simply looked at the X-ray that was done and sent the patient to the cast clinic). With such a system in place, why would I even see injuries in my office, yet alone inconvenience the patient by sending them for an X-ray, having them bring the X-ray to me, and then sending them to the emergency department (where they have X-ray capabilities). If a patient phones the office with what sounds like a significant injury just triage them directly to the emergency department.
6) As emergency departments became busier, they soon realized that many of their visitors fell into the “revolving door category” due to inadequate placement, follow up, community resource access, etc. Soon emergency departments were given priority and resources to deal with home care, palliative care, mental health, placement issues, social service, and numerous resources that as community physicians we had difficulties accessing, but realized would be a benefit to out patients. Subsequently, when these patient needs presented in out offices, the best way to access these resources and benefit our patients was to send them to the emergency departments.
7) Lastly, and very importantly, patients cannot stay in the emergency departments for extended periods of time. This is due to lack of physical capacity and manpower capacity (once you are admitted to the emergency department a physician must be responsible). This means that at some point you must either go back to the community (and/or its institutions) or be admitted to hospital. Admitting to a hospital bed is dependant on two factors: a) availability of a bed, and b) availability of a physician who will agree to take on your care. Since we now have 1.6 acute treatment beds per 1000 population compared to 3.3 acute treatment beds per 1000 population fifteen years ago, and since most family physicians have discontinued hospital practice, the emergency holding beds frequently are taken up by patients requiring admission.
The above are but a few of the factors affecting our emergency departments, but constitute a significant impact. In short, there is a huge increase in acuity of illness and need for intervention in Calgary’s communities as a whole, and an abysmal lack of community resources. I find that, for the most part, community physicians feel they have been abandoned in our health care system, and are in survival mode. Since the emergency departments of our hospitals simply reflect the acute care needs of the community, it will be interesting to see what the Health Quality Council of Alberta will come up with, but as I said earlier, I’m not optimistic.

Emergency Department Services in Calgary.

So the Board of the Calgary Health Region is bringing in the Health Quality Council of Alberta to examine, assess, consult, mull over, deliberate, and generally pontificate, over Calgary’s Emergency Department problems. Great; a government appointed Board is asking another government group to look at (aka rubber stamp) what is being done at present and make the usual recommendations to solve (see Jim Dinning’s suggestions: innovate, explore, more of the same) our emergency health care crunch. Sounds like a make work project to me!
Keep in mind that it wasn’t that many years ago that a costly and quite extensive consultation process took place to look at the health care provision in the Calgary Region. Come to think of it, this may have occurred shortly after Jim Dinning and Jack Davis were sent from Edmonton to get things in order down here. The word on the street at the time was that Calgary didn’t have a health care provider problem; there was simply an erroneous “perception” that there was a problem. Well, during Mr. Dinning’s two and one-half years as the Calgary Board’s Chairman, costs escalated, as did waiting times in all areas. I suspect even at that time Mr. Dinning realized that the present monopolistic public system was unsustainable. Could this be why he left the post after only two and one-half years (before the present crunch) with nothing gained functionally? On the other hand, as an ambitious politician, he could leave early and still, using the universal health care mantra as the universal “get elected” tool, present himself as the savior of our universal public health care system.
At the same time, as the government (through the Calgary Regional Board), is dishing out more money to get another government body to give an opinion on ongoing and long-time problems, we find out there has been a million dollars spent on ads, booklet design, consultations, etc, on what they had previously termed the “third way”. Now the opposition parties call this propaganda, and squashed that process through the help of the MSNM and Medicare lobby groups. Personally, if some of my tax money went to putting this together, I would like to see it. One of the strident cries of the advocates of Medicare, against the “third way”, was that no one knew what it entailed. So let’s have a look at it. Seems to be a bit of indirect censorship going on; on one hand they are saying no-one knows what the government is talking about regarding the “third way”, and on the other hand they say the public shouldn’t see what was put together and the money was wasted. Maybe, just maybe, there is and was some information in that million dollar expenditure that is credible.
The facts are simple: in spite of annual funding to the Calgary Region from the government (since the beginning of Mr. Dinning tenure as Chairman), surpassing the annual combined inflation rate and population growth, there has been an increase in waiting (risk) in both our emergency departments, access to procedures, hospital beds, and diagnostic tools. In spite of this and an ever increase in government’s budget going to health care, the policy makers, opposition parties, and “would be” premiers, refuse to even discuss alternatives. One of the truly stupid comments that I have heard regarding the non-sustainability issue is “More money isn’t the answer”. Of course it is! If money didn’t provide better access to health care, why all the paranoia about the wealthy getting better access if there were a private system? Why do many high profile people get opinions and service south of the border and from private sources in other provinces?
A common comment made now in Alberta is: “With all our surpluses, why isn’t the Alberta Government putting more money into Health Care? Here are some of the answers:
1) At present there is a shortage of doctors, nurses, technicians, etc. Alberta could probably afford to give them all a fifty percent raise. I guarantee this would do several things. a) Bring in a good supply of these people from other provinces, b) Create a worse shortage of these people in other provinces, c) Create significant hostility in the people and administrations of nine Canadian provinces, and d) bring about federal taxation policies that would take away Alberta’s ability to lure workers from other provinces. This can be already seen to some degree with our “bribing” of construction and oil field related workers from B.C. and Ontario.
2) If workers in the health care field were to get a fifty percent increase in their income, what do you suppose workers in education and other public services would want? Suddenly there would be a huge inflationary effect on salaries throughout Alberta.
3) Keeping in mind the above scenario, what would happen, if, in the aftermath of this, Alberta’s revenues from non renewable resources were to drop or a change in federal taxation evened the playing field between provinces? I doubt very much we would be happy with a deficit budget or a fifty percent decrease in salaries.
Realistically, Alberta has to use its resources revenues in such a way as to not significantly disadvantage Canada’s other nine provinces. We could though, do some health care provision that is costly (may mean we don’t get federal funding), but truly innovative. With careful monitoring of process, outcomes and cost effectiveness, we may be able to show the way to true health care reform that would benefit all Canadians.

AIDS Conference, A Missed Opportunity

Is there nothing in today’s world that is not a political opportunity? Forty million people in the world today are infected with the AIDS virus and sentenced to declining health, suffering, and eventually, an early death. This is indeed, a humanitarian disaster. One would think that a conference supposedly designed to rally all of mankind to eradicate this disease would bring thoughtfulness, intelligence, compassion, science, innovation, and in general, all those things that pull people together in the face of this ever increasing threat. But no, the major coverage in the MSM pertains to whether Our Prime Minister attended or not.

I suppose it is inevitable. Politics is about power, control, and influence; doing what is right places a distant fourth. Internationally, some highly placed people couldn’t resist a jab at our Prime Minister, and refused to come because he wouldn’t be there to welcome them. Certain movie stars had to have their two-bits worth of say, a past president of the U.S. had to take advantage of the “photo op.”, and Mr. Gates appeared as a major philanthropist. I would have thought the person most deserving to be on the international stage would have been Mr. Gates. If a half billion dollars for the cause doesn’t give you some air time, what does (although I understand the crowd was more appreciative of his money than his advice)? Our Federal Opposition Parties saw Harper’s absence as an opportunity to better their lot, and the MSM, still smoldering over their loss of control over the Prime Ministers Office, joined in frequently with similar criticisms. I heard little during the days of the conference of any worthwhile scientific medical information.

From my perspective, Canada’s Health Minister, Mr. Clements, and Canada’s International Co-operation Minister, Josee Verne, were Canada’s appropriate representative attendees. From a political correctness perspective, Harper could have attended, but haven’t Canadians had enough of politicians doing the “photo-op” thing. Had Harper gone, I imagine the spin from the MSNM and the opposition would have been “usurping minister’s jurisdictions, micromanagement, etc.

The only good medical information that I was able to glean from the News media took place during an interview before the conference began. Two well respected scientists spoke of AIDS, its impact world wide, the various approaches to treatment, and the future hope for a cure. Some of the information that they presented wasn’t new to me as a physician:

1. A significant rise in AIDS in Canada is being seen in heterosexual women (no mention was made that primarily this is due to bisexual and other unfaithful partners).
2. Drug usage is the main means of transmission in Canada and the U.S.
3. Sexual activity is the most common means of transmission in Africa and most other countries.
4. Aggressive treatment can lower contagiousness and spread.
5. The resurgence of tuberculosis is largely related to AIDS, and the development of resistant strains of T.B. likely related to the difficulties in treating people who are immuno-compromised with multiple antibiotics.

What I found interesting, from a medical perspective, was that of the 40,000,000 people in the world with HIV infection, only 10,000,000, or ¼ are under treatment. The experts being interviewed felt dramatic progress could be made if all were under treatment, since this would decrease contagiousness. Further, progress in immunization offers hope for the future.

Unfortunately, I am not nearly as optimistic as the specialists being interviewed. HIV infection, like cardiovascular disease, is inherently bound to human nature and human activities. When Mr. Gates tried to address some of these issues at the conference, he apparently was booed. If all the appropriate medications were available to all the people in the world today who have HIV, and there was immunization that was 100% effective to all the others, we would still have an AIDS problem. After all, in Canada today, we have antihypertensive medication that is effective in 99.9% of the hypertensives, but only ¼ of hypertensives are treated to target, with the result that many, many Canadians die an early death from strokes and heart attacks. They may not show the wasting, skin lesions, etc. that AIDS patients do, but dead is dead! We have the best food in the world available to us, but we eat junk food! We know how, and have the means to treat most cardiovascular risk factors, but only 20% of Canadians get adequate exercise, only twenty five percent of those who need their cholesterol problems addressed, do so, and there is actually an increase in teen-age girls smoking. As I’ve stated many times before, the scientific knowledge and capability is extremely important, but cannot achieve the desired benefits unless there is good fidelity (system of application) of that knowledge and a buy-in by the population. But how close are we to addressing this issue when even referring to root causes (the human behavior element) provokes booing?

Canada Health Act, Portability, The First Casualty.

In today’s Calgary Herald and on Rutherford today, Gerry Brissenden, president of the Canadian Snowbird Association criticized the Provinces (and Alberta in particular) for its policies pertaining to traveler’s medical coverage. For all intense and purposes, they don’t cover you. This, as pointed out by Mr. Rutherford, contravenes Canadian Law.
It should be pointed out that: 1) This has not always been the case, and 2) all travelers are affected, not just snow birds. When we first enjoyed our Universal Health Care system in the 1970’s people were covered for acute illnesses that occurred when traveling abroad, but as time went on, and our access to resources in Canada diminished, people began having procedures done in the U.S. that did not represent an Acute Event; in other words, having medical issues attended to that were of a more chronic, but urgent nature, and that they had lengthy waits for in Canada. Snowbirds, being primarily a geriatric population who were impacted most by waiting lists, were the worst offenders.
From the Provincial Government’s perspective, they saw this as an opportunity to decrease their health care costs, blaming the “queue jumpers”. Accordingly, they all got on the band wagon, and defied Canada Health Act pertaining to “Portability” (Keep in mind, one of the selling points of the Canada Health Act had been “You can travel anywhere in the world, and not worry about your health care coverage”). Not surprisingly, there was not much of a public political backlash from this new policy. Since all provinces got on the bandwagon, and the snowbirds were viewed as a more affluent and privileged group, the general public had little sympathy. Besides, the idea of preventing queue-jumping politically was a winner, as it still is today, by a segment of the population. Using the argument that these procedures were cheaper done in Canada and that money spent for health care is better spent here than in the U.S., there was hardly a ripple of objection to this policy. It should be noted, however, that this was one of the first policies of provincial governments to “ration” health care provision, and contravene the Canada Health Act.
For that matter, I, like many in Canada, do not see this as the biggest problem in our health care system, and frankly, I don’t think that Mr. Gerry Brissenden and the Canadian Snowbirds association have the chance of a snowball in he—of changing things. Granted, by abdicating their responsibilities, the provincial governments have sentenced the very frail and elderly, the poor, and the chronically ill, to be confined to Canada for the rest of their lives, but worse things, at present, are being done to them in our health care system. They could possibly file a class action suit against provincial governments for costs incurred over the years, but voluntarily, provincial governments aren’t going to start paying money to other countries for health care. There just isn’t the political support. They could change the law, but starting to monkey with the Canada Health Act (Federal) could open the door to further changes, and politically to date, that has spelled political suicide. The Canadian Snowbird Association should be grateful that they can obtain insurance to cover events south of the forty-ninth parallel (although that is not true of the frail elderly, chronically ill, and the poor); when they are here in Canada, they have no insurance option for coverage, and will be put in an “ at risk, but treatment not available at present” queue. In an environment of longer waiting lists (risk lists) and more rationing of care coverage (and no availability of insurance), the public has greater things to fear from our Health Care System than lack of travel coverage.

Canada, Honest Broker

I’ve made it a point in the past to blog on medicine since I’ve spent forty years submerged in medical practice and medical politics. I recognize that international politics is a very complicated field and that I rely almost totally on various news media for my information (a very precarious position at best). The fact remains that all of us have a point of endurance that we cannot tolerate; and if we do, our reactions may well not be termed a “measured response”. Well, I have reached that point, and indeed, this may not be a measured response. You could probably call it a rant.
Could someone please tell me what an “honest broker” is? One definition I found was: “a mediator in international, industrial, etc. disputes. This definition does not seem to include the vital parts of the definition of “honest”------“held in respect, credible, truthful, will not lie or cheat, be free of deceit, genuine, etc”. “Broker” in the older dictionaries is defined as one who “is paid a fee or commission for acting as an agent in making contracts or sales”. I suppose then that Mr. Maurice Strong could be called a broker in the “food for oil” disaster (Iraq/UN) but I’m not sure Canada wants to be identified with that adventure. Some more modern dictionaries define “broker” as a “mediator”, during negotiations. Fair enough, let’s go with the definition, as meant by the opposition parties (and the MSNM) pertaining to Canada’s position internationally to mean: “A credible, respected, truthful, mediator in international affairs. They claim that has been our traditional role.
Well, I’m not sure how far back is termed “traditional” but it seems to me Canada entered World War 2 before the U.S., and seemed to take quite a definite stand on the issues at the time. I also find it hard to associate the Liberal party (after the ADSCAM thing) with “credible, respected, truthful, etc.; or for that matter, Mr. Layton and his wife who lived in subsidized housing while they were both “alderpersons” for the city of Toronto, or Mr. Layton when he proclaimed that he was not aware that the Nationally known Scholdice hernia clinic was not a private facility. But you say, those are human frailties and nobody is perfect. I agree. Unfortunately, on the world stage many things are factored into our credibility such as our leaders, our international friends, who we do business with and even our neighbors. And if we are really honest, we would have to admit that much of how we “feel” about someone or something has to do with our perceptions of them. Our leaders and their behaviors will give the perception of credibility, or lack thereof, both nationally and internationally.
So let us take a look realistically at Canada being an “honest broker” in the Middle East------specifically between Hezbollah/Iran and Israel, keeping in mind that we must be perceived and acknowledged as being a credible, truthful, and respected mediator.
How would you feel if the mediator appointed in a dispute that you had with someone in Florida, lived next door to that person? You also found out that they holidayed together, worked for the same company, and were both Baptist. Let’s be honest, Canada could bomb the U.S. and the Hezbollah and Iran would still perceive us as being pawns of the U.S.A. and the bombing a political manipulation. Good grief, a percentage of Canadians feel that way, and some of the news media may support that position.
Mediators in disputes should have no strong convictions over the issues involved to be truly impartial. Is that possible for Canada? Canada has declared Hezbollah a terrorist organization and we recognize Israel as a Nation. Do Canadians really back a terrorist’s organization that invades, murders, and kidnaps citizens of another nation, or for that matter, on a frequent basis, lobs rockets into public places intentionally? Can we, as Canadians, truthfully say that we can be and are impartial about Hezbollah and Iran wanting to “wipe Israel of the map”? If that be true, I am ashamed to be called a Canadian.
I believe that if Canada is to be seen and acknowledged as a credible, truthful, and respected mediator we must make known our values to the international community, and we must be prepared to embrace them, take responsibility for them, and when necessary, make sacrifices for them. We do not believe in genocide, we do not believe that terrorist groups should provoke wars and target innocent lives to further their cause, we believe that a nation and its people have a right to live in peace, but we believe that when a nation and its people are threatened with extermination, that nation has the right, yes, the responsibility, to take the actions necessary to preserve the lives of its citizens and its identity as a nation.
Did previous federal governments of Canada delude themselves into thinking they would be credible and respected internationally for standing for NOTHING. Has this been the reason for progressive and substantial decreases in funding to our military? After all, if there is no cause worth fighting for, why spend billions of dollars for a military. It would seem that someone decided to use the term “honest broker” to justify our position of “standing up for nothing”. On an international level, the United Nations is to be the “honest broker” in International disputes; that was its founding purpose. Unfortunately, it has not fulfilled its mandate. Could it be that it has lacked the ingredients to generate credibility and respect? Could it be that their inaction speaks louder than their words?
Canadians have lost their pride. Prime Minister Harper may well be wrong-----Canadians in fact do run and hide in the face of standing up for our values, or is it that we already have no values worth fighting for. In fact, we don’t even seem to have values worth supporting (Quiet, Harper, you may offend someone!!). Personally, I would rather be respected for the things I believe in and which I am prepared to back, than my lack of conviction on all matters.

Lives Lost, Which Are Justified?

Wow, we are now looking at rationing Emergency Medical Services in an effort to make it more cost effective. A recent article in the New England Journal of Medicine (according to the Calgary Herald’s Aug. 3rd, edition) reports that by using three simple criteria, EMS could reduce by two thirds the number of cardiac arrest patients taken to hospital. Notably, this is not because they have “saved” them, but rather a decision would be made that attempts to resuscitate them ‘would be futile”, so why waste the time and effort. If I read the article correctly, the term “futile” is equated to a success rate of 0.5%. In this article, a Dr. Laurie J. Morrison states that in a series of 1,240 cardiac arrest patients, three percent were successfully resuscitated. Two thirds of these patients could have been taken to the morgue instead of the hospital, and the system would have saved the time and expense of attempted resuscitation and transport to the hospital. The loss of life would have merely been 0.5%; approximately one in two hundred. Am I reading this right? In a given life and death situation, it is acceptable to loose one in two hundred people without trying?
The article states that 300,000 Americans die of cardiac arrest each year. Comparing populations and the fact that our life expectancy in Canada is not much different in Canada, somewhere around 30,000 Canadians likely die of cardiac arrest each year. By using those magic three criteria, we could have saved our time, energy and transportation costs on 20,000 of them. So what if 100 would have survived with appropriate intervention (0.5% of 20,000), look at the money being saved!
On the other hand, we Canadians seem to think that intervening and transporting 14,000 Lebanese/Canadians (at great expense) from Lebanon, following the death of four Canadians, was a must. We are aghast at the fact that 17 soldiers have died attempting to bring peace to Afghanistan this year; but sacrificing 100 lives annually for our “Universal Health Care God” is presented in the Calgary Herald with the positive spin headline “New rescue test IDs futile cases” and “Lost causes can tie up ambulances, ER departments”. And so the rationing of health care services in Canada continues and a blind eye is turned to its casualties. Hopefully, when you call the Emergency Medical Services to attend your father/husband/brother/mother/sister/wife’s cardiac arrest, the EMS will give your loved one the benefit of NOT applying those three cost saving criteria!