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, December 01, 2006

Private/Public Healthcare, A Synergistic System

I think the first thing we should deal with in our discussion as to how a private parallel healthcare system would work in Canada, is to look at the idea of guaranteed wait times, since some politicians are suggesting this, as some sort of solution to our long “risk lists” in our health care system. Let us take a case where I need a hip replacement. I am in pain and am developing a stoop because of contractures developing in my hip. I relate to my family doctor that the pain pills he has prescribed are no longer effective and I wish to have a hip replacement. He agrees and refers me to an orthopedic surgeon. I am informed that the waiting time to see an orthopedic surgeon in Alberta (any surgeon who does hip replacements) is six months. The provincial guaranteed waiting time in the province for a hip replacement has been set at three months. Does the time I am waiting to see the orthopedic surgeon count as time “put in”, waiting for my hip replacement? I have already acknowledged, and my family doctor and physiotherapist agree, that I need a hip replacement. So the “system will probably say “No, we only count the time after you see the orthopedic surgeon”. Fine, I take my morphine and stumble around for the six months, finally see the orthopod months later, and he concurs; I need a hip replacement. I am then put on another waiting list, waiting for a slot in the operating room, that is again estimated at several months. What happens when the three months are up on my new waiting list and I have not had my surgery? Do I get sent to the U.S.? India? another province in Canada? Or will I be booked at night on an emergency basis and “bump” someone else who is waiting? If we have that capacity, why don’t we just extend the operating room hours now? What if nothing is done? Who forces the government to honor their guaranteed wait time? Can you imagine the hassle trying to deal with the government bureaucracy?
At the same time I have my problem, my neighbor sees his doctor with a similar problem, but is not sure he is ready for surgery. An appointment is made with the surgeon, as in my case, six months down the road. Is he put on a wait list? He sees the surgeon and is told the pros and cons of surgery but the decision is his. He wants to think about it. Is he put on the waiting list then or two months later when he decides to go for the surgery and signs the papers?
The point is that guaranteed wait times cannot work without a recognized process for the many people that will not fall within the agreed upon parameters, and without a treatment resource outside of the existing public system. If this were not true, we already would have appropriate wait times. A private system would enable negotiations between the government and the private system, to agree upon a price and the conditions to be met, and the protocol to be followed to access the private system when the public system has not met their guaranteed wait time, in advance of the situation. All parties, including the public, would be aware of those terms and conditions and the protocol to be followed. My suggestion would be that the orthopedic surgeon involved could approve the move to the private system if the wait time guarantee cannot be met.
When a parallel private system is allowed in Alberta, it is imperative that companies providing health insurance, be invited to be active in Alberta. These companies would offer full coverage comparable to the public plan, or they may offer coverage that the patient could pick and choose from similar to a “menu” of services. People could review this menu and the cost of coverage and choose the coverage that suits them personally. What would likely happen is that as people get older they would insure for joint replacements if the public system wait times were long, and tend not to insure if the wait times were reasonable. This would automatically, to some extent, control the wait times and cost to the public system. Some people would choose to wait in the public system so their premiums would not go up, some would change their life styles to bring premiums down and within their reach. Patients, as taxpayers with insurance, would always have the right to the public system, or the private system, at their option. The better the public system works, the fewer people will take out insurance.
Timing is critical with this next issue. Although our present physicians must be allowed to work in both systems, it is extremely important for the government to do their homework in advance. A search should be undertaken for physicians who have left Canada and set up practices elsewhere. They should be invited to return to Canada, practice in the public system, the private system, or both. Obviously, the private system will try to attract good physicians into their programs, but they will be looking at physicians in Canada and abroad. The government should focus on those who have left Canada for reasons related to restrictions in practice. Properly approached, many of our native sons and daughters would return. It has always amazed me that we Canadians are so supportive of diversity in our culture, but stick stubbornly to a monopolistic healthcare system. And why do we press for ways of bringing in foreign doctors, instead of looking at ways to recruit back our own sons and daughters who left Canada because of our narrow minded perspectives on health care?
Which brings us to the next point; by having a private system, the public system, its administrators, and the government, will have their feet held to the fire. People will investigate and educate themselves as to what is covered, and what is not covered in the public system, and whether they have a need for additional insurance. People will realize that there are choices to make, and that they cannot be, and should not be, wholly dependant on a government system that has not defined exactly what it is, what it is not prepared to finance, and how it is going to do it.. The importance of life styles is underscored in a private system, adding to patient awareness.
Our existing government leaders in health care continually mention “preventative” medicine, and that this is the answer to sustainability in our Canadian system. Unfortunately, any benefits derived from altering life styles (quitting smoking, exercising, loosing weight, etc) will be many years down the road, presuming there will be enough patient compliance to make a difference. Presently healthcare costs are sky-rocketing, and waiting lists are getting longer, or have not changed. Programs of long term societal changes, to be effective, will necessarily be costly and long term. How will the transition from ever increasing intervention costs and these significant prevention costs be bridged? As previously stated, cost benefit will not be realized for years.
Once again, interim private insurance can bridge the gap. From my perspective, the government’s primary responsibility should be public health with all of its implication. They should be primarily responsible in the areas of pandemics, epidemics, life style issues and preventative health, immunization, neonatal care issues, poverty, food safety, pharmaceuticals, etc; the list can go on and on. The next priority of government and closely associated with the first should be to address the issues that have to do with chronic disease such as diabetes, hypertension, cancer, etc. The last responsibility in healthcare, of governments, should be, on a province by province basis, to provide a safety net for unforeseen medical events for its citizens who are unable to fend for themselves. The idea that we, who are able to fend for ourselves, should be excluded from doing so, is insulting, offensive, and undemocratic. There is absolutely no reason why the private and public systems cannot work together in the “intervention” area of health care.
Finally the issue of healthcare premiums should be addressed. As long as low income people are exempted it is not really an issue. Basically, it is simply another taxation measure. It would be nice if a little ingenuity were used in the administration of this tax. What if rates varied somewhat with life styles? What if those paying the tax (premiums) actually got to pick and choose some health care benefits specific to them and their needs (travel coverage, ambulance coverage, additional drug coverage etc). With the drive to a computerized health record, it would be a piece of cake to implement. But I’m sure someone would find some inequities in such a system. Lord help us if we show some true innovation that may not be 100% inclusive.
The above is a rough draft of how a private health system could be utilized in our present system. It should NOT be considered, in any way, a replacement for our existing public system, as the doom-sayers screech, but an add-on; a tool to be used by those who choose to use it, and by the system, to shorten wait times and give people more control of their lives. Too bad none of the candidates or for that matter, Iris Evens previously, took the time to introduce the subject rationally and objectively. But then again, who is listening?

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