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?

Tuesday, September 05, 2006

The "Shell" Game, Dumping Health-care Needs Into The Community

Recently Dave Rutherford had the CEO of the Capital health Region (Edmonton) explaining what a good job the various Health Regions in Alberta were doing, and I suppose indirectly, justifying the salaries administrative types make. Calgary Health Region’s senior vice president of people and learning (don’t ask me what that means), Margaret Munsch, said in Thursday’s Herald that “The compensation reflects their accomplishments as individuals”. So let us take a look at the accomplishments of administrative types at all levels of health care in this province (especially Calgary).
1) Wait times in our emergency departments have grown drastically. Ten years ago we were upset at waiting times of one and one-half hours. Today wait times exceed four hours.
2) There have been longer waiting times for various surgical procedures such as joint replacements.
3) There has been an increase in waiting times for specialty consultations.
4) There has been an increase in waiting times for diagnostic investigative procedures. There has been an increasing delay in many cancer treatments.
5) There has been a decrease in family doctors (and specialists) doing obstetrics.
6) There is a drastic decrease in family doctors with hospital admitting privileges.
7) There has been an increasing proportion of the government’s budget going to health care during this same time (out of proportion to inflation and population growth).
8) There is a drastic shortage of family community doctors (now in Calgary alone estimated between 200 to 300 doctors).
9) And there has been a very impressive increase in the salaries of administrators!
But our administrative friend from the Capital Health Region states that innovative ways of providing medicine has occurred.
1) Hospital stays per procedure or per disease treated are decreasing.
2) More people can be treated as out patients.
3) The cost of hospital care as related to the total health care cost in the Regions is going down (didn’t mention that the cost of community care is skyrocketing, which is of course the other side of the cost equation).
And the above three statements are absolutely true; but what isn’t being said is:
1) By downloading patient care from hospitals to the community, we have conscripted the loved ones of the ill as care givers, and their beds as treatment beds. This is cost effective because instead of $1000.oo a day for a hospital bed, the family takes on the care of the patient with minimal support from the system, eg. palliative care and home care nurses drop by periodically and the region will kick in up to $3000.oo a month to beef up care for palliative care patients (a savings of 27,000 dollars per month per patient).
2) Home treatment programs aren’t assessed as to patient and family impact (someone taking their holiday time to care for a sick family member, someone quitting their job to care for a dying family member, the stress and exhaustion of family members staying up day and night to care for their dying loved one, etc.). I’m not saying that care in the community is not necessarily appropriate. I’m saying that it is not adequately compensated, and the system is taking advantage of the loved ones and the community care-givers!
3) Early discharge is not being critically assessed as to patient and family impact.
The problem is that by downloading health care NEEDS into the community, no tools are being used to measure the impact of the innovative “cost effective” practices that we herald as advances. In hospitals we are able to look at waiting times in the emergency departments, hospitals putting patients in hallways, surgical wait times, etc. In other words tracking and visibility is easy and unavoidable. Ten years ago I strongly recommended using “known “tools” for tracking health care needs in the community on an annual basis, to see the impact of the changes being brought about in the Calgary Region (this was being done by some of the consumer groups in the U.S. to monitor the activities of HMOs in the U.S) To my knowledge this still is not being done by the Calgary Region (What independent consumer groups in Canada and Alberta are tracking health care provision here?). In effect what we have here is a “shell” game ----- “Bet you can’t find where the sick people are?”
The process is simple and is comprised of a questionnaire sent out to a random, statistically significant number of people in the Region. The questions would be as follows: IN THE LAST YEAR
1) Have you been ill?
2) Did you see a doctor?
3) How long did you have to wait?
4) Were you investigated?
5) How long did you have to wait? a) in the Laboratory b) for a diagnosis, c) X-ray, Ct scan, MRI, specialist.
6) How would you rate your experience?
7) How much time from work did you miss?
8) How much time was needed from other members in your family (or friends) to attend you or assist you?
9) Are you still having problems?
10) Have you had pain?
11) How would you rate your pain (from 1 to 10 with one being little pain and 10 being the worst pain you can imagine).
12) How long did you have pain for?
13) Do you have a family doctor?
14) How far do you have to book ahead for a complete check-up?

You get the idea? There are standardized “tools” (much better than my effort above) that have been used for years and reflect the community “burden” of health care needs similar to emergency wait times, surgical wait times, etc. To my knowledge this is still not being aggressively pursued. Think about it; health care needs are being put into the community where no-one can see the impact------except of course, those poor unfortunates that happen to become ill (and their families), and are deemed to “not need a hospital bed”.
Don’t get me wrong, many cases are more appropriately treated in the community. But in the face of an increasing shortage of family physicians, an increasing population, an increasing percentage of seniors, and increasing health care costs (which, it seems, providers and provinces are all trying to contain), wouldn’t it be nice to know how we are coping in the community with the most vulnerable in out society. In this case, what you don’t know may in fact “hurt” you! Available acute care beds in Calgary have dropped from 3.3/per 10000 people to 1.8/per1000 people. The health care needs of the people of Calgary have actually been increasing per 1000 population with increasing age, obesity, diabetes, etc. The people that once were treated in hospitals are now treated in their community. Do the highly paid administrators know how well the chronically ill, poor, and frail elderly are doing in the community? Does anyone besides the sick patients and their families know how well they are coping? After all, the Health Regions and
their administrators, are responsible for all health care provision in their regions, directly or indirectly, not just the care and budgets and care in the hospitals. And from what we can see from a community health care and access perspective, most of us wouldn’t consider it worthy of the increases given.

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