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, November 17, 2006

Dr. Lyle Oberg on Health Care, Some Good Suggestions.

I suppose the fact that Dr. Lyle Oberg was a busy family doctor in the Brooks area of Alberta, does give him a distinct advantage in discussions on health care. He correctly identifies the problems with regard to the sustainability of health care in Alberta, quoting budget increases from 3.3 billion in 1994 to 10 billion at present. This is reflected also in the proportionate increases in the relative increase that health care takes in the provincial budget expenditures. As the population ages with the relative proportional increase in the geriatric population, we can expect health care spending to continue to grow out of proportion to taxation revenues, inflation, etc.
Dr. Oberg presents his “vision” in a five point frame of reference.
1) Guaranteed access.
Since not having access means not having health care, this is pretty basic. Guaranteed wait times have been discussed for some time now, and the principle has been approved by both the Canadian Medical Association and the Alberta Medical Association. At present I have seen little movement on the part of governments to introduce legislation to this effect. Personally, I think it is one of those “feel good” solutions that are almost impossible to put in place. First, there must be a recognized authority on specific wait times that would be appropriate. I recall seeing a rough draft of such a recommendation that said forty eight hours was an acceptable wait time for patients with a fractured hip. There are excellent studies in the literature that show increased morbidity and mortality after waiting times of twenty four hours, for a fractured hip, are surpassed. The second problem with guaranteed wait times would be the complexity of monitoring and implementing such a system. The third problem is that provincial governments do not have the capacity (either facility wise or personnel wise) to meet even semi-reasonable wait times. Problem four is, since we don’t have the capacity, where do we send the people who require a treatment and have surpassed their guaranteed waiting time? Will the government be penalized in any way for not meeting their “guaranteed” waiting time? How do you punish a provincial government? Do we want Ottawa to do it by with-holding transfer monies? If so, there will have to be Federal and universal Provincial agreement on both, what comprises a guaranteed procedure under the Canada Health Act, and what the time frame should be for any and every procedure that is guaranteed.. Dr. Oberg suggests that the accountability will rest with Albertans in provincial elections. Perhaps that is the simplest solution.
2) Public guarantees.
Dr. Oberg recommends that doctors be allowed to practice in both the public and in a private parallel system. He doesn’t spell it out, but this would infer that he would approve of patients being able to apply for health care insurance, and would allow health care insurance companies to be active in Alberta. This, in itself, is a step forward. This will push the public system to identify the procedures they cover and do not cover, and the time frame that they are prepared to back. The public will demand it in order for them to decide as to whether they spend money on additional health coverage. The longer the waiting lists, the more privately insured people there will be (thus shortening the waiting lists); the shorter the waiting lists, the fewer the people signing up for private insurance. Dr. Oberg’s idea of forcing doctors to work seventy five percent of their time in the public sector before they can work in the public sector is simply not workable. Administration of such a system would be a nightmare. What are we, as practitioners, to do; I will be working in the public sector from January to September inclusive, but won’t be available to the public sector in October and November because I’ll be in the private sector? I don’t think you have thought this one out clearly Lyle. People don’t like being forced into situations that they do not wish to be. Studies show that only five percent of physicians would want to practice in the private sector. Likely this group could be augmented with active recruiting of Canadian physicians who have immigrated to the U.S. over the past fifteen years. The majority of Canadian physicians have indicated a preference for staying in the public system. If our governments treat them right, there should be no problem allowing physicians practice where they enjoy their work. The majority of physicians practice medicine because they enjoy the work!
3) Enhancing patient choice
Choice should be a “given” in a democratic country, but with privilege, there should be responsibilities. Studies have shown that when the patients have to make choices, they tend to inform themselves as to the pros and cons of their potential choices. The possibility of a parallel insurance system will, of itself, be a stimulus for people to look at cost effectiveness. It will bring about more investigative searching on the part of patients, to look at various forms of interventions and preventative therapies and their benefits (the private system usually gives premium breaks to patients with healthy life styles, the public system will have to look at alternate ways to encourage and motivate healthy life styles). It brings alternate care providers into the equation (homeopaths, chiropractors, podiatrists, etc.) without forcing the patient to pay out of pocket, and at the same time, not be a burden on tax dollars. Some European health care systems have included some of these services under the public umbrella, as we in Alberta have done to some degree with chiropractic and podiatry.
Basically, the increase in patient choice must take place in a more free market environment if it is not to be a drain on the provincial government’s tax-payer funded budget.
4) Proactive solutions
Here again, one of our candidates brings up preventative medicine and promoting healthy life styles; however he distinguishes himself from the rest with some important methodology. He correctly points out that managing chronic disease is the key to preventative medicine’s cost effectiveness. In doing this we need to think of chronic disease in a broad sense; not just those people who are symptomatic such as patients with arthritis, diabetes, asthma, etc. The greatest benefit would be to capture those people that are asymptomatic and before they experience the complications of their chronic disease. Hypertensives, the obese, the hypercholesteremics, the smokers, etc, fall into this category. This group of asymptomatic chronic disease patients need to be involved in a very direct way to change their life styles and intervene when appropriate. With the help of electronic technologies, registration and tracking systems for those people at risk could potentially be a real winner, treating the right patient at the right time with the appropriate intervention. (I believe that money spent on generic T.V. commercials directed to the public at large is money poorly spent). To my knowledge, Alberta, at present, is investing millions of dollars in such tracking pilot projects in chronic disease. This is one of the few bright lights in preventative health since immunization programs were introduced. I encourage strong support for these preventative pilot projects and trust this is the area that Dr. Oberg is referring to.
5) Equitably Sharing Costs
Health care premiums are simply another tax, so I agree with those candidates, to some degree, that they should be eliminated. If the premium system were implemented in a different way, there could be some advantages. What if there were variable premiums, dependant on life styles? What if your premiums were determined by B.M.I., blood pressure, smoking, activity levels, etc. (and don’t give me the garbage of taxing the ill; it is RARE that normal blood pressures cannot be achieved with proper intervention). Money seems to be a universal incentive, and cost a universal disincentive. Note the use of fines for speeding, not using seat belts, wearing helmets, and more recently in Calgary, for spitting on the sidewalk. Let’s get consistent.
So, Dr. Lyle Oberg, you have done the best of the bunch in the area of health care. I guess my concern is that you have been in cabinet many years, and there is little evidence of your input. As premier, will you have the courage and determination to move from the present point of stagnation (and back-sliding from world standings perspectives), to a more truly innovative, thinking “outside of the Canada Health Care Box” position?

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