By André Picard
Canadians tolerate a health system that is difficult to access and only covers part of their needs. André Picard asks what will it take to shake the complacency? —— Prepared as part of the 2011 program of the MUHC-ISAI
The most popular buzzwords in health care today are “patient-centred care.” But how can care possibly be patient-centred if the patient does not have a voice? “What do patients want?” is a fundamental question that should be guiding reform of the healthcare system. But it is a question we rarely ask.
What patients want can be stated quite succinctly: They want quality care, delivered promptly, safely, respectfully, affordably and equitably from birth to death. Yet, we do not consistently live up to those standards, either on an individual or collective level. So what are the barriers? Are they financial; technological; administrative; legal; political?
We spend an inordinate amount of time moaning about healthcare spending. There never seems to be enough money. But enough money for what? Canada’s health system seems remarkably devoid of goals. Even though the polls tell us, time and time again, that health care is the number one concern of Canadians, they never seem to probe expectations.
For $200 billion a year — $5,800 per capita — there is no reason we should not be able to deliver basic care that is prompt, safe, respectful, affordable and equitable. Yet, the care covered by a publicly funded insurance program cannot — or, more precisely, should not — be unlimited and open-ended. We need to make choices and we need to develop sound mechanisms for making choices.
Until we start choosing and defining what’s covered by Medicare and what is not, we cannot honestly say that money is lacking. Rather, it is direction — vision — that is lacking.
Where do we fall short?
The quality of care in Canada is superb; it compares favourably with the care delivered anywhere in the world. We have health professionals who are second-to-none, and the latest technology in our hospitals. We tend to skimp on infrastructure though; far too many of our institutions are old and unwelcoming. And our infostructure is even more out-of-date; society is living in the era of instant communication while the health system is mired in the Stone Age.
We tend to obsess about numbers and pay far more attention to quantity than quality. Do we have enough doctors; nurses; clinics; hospitals; nursing homes? Again, those fretful questions are impossible to answer until we establish clear goals for what we want to achieve. One thing that is certain, though, is that we do not have the staff mix quite right: Nowhere near enough health professionals work to their full scope of practice.
While the quality of care is great, you only benefit if you can access the system. Getting treated promptly is increasingly difficult, and the journey is often fraught with peril. The wait for care is too long: We wait too long in the ER, too long for elective surgery, too long for a doctor’s appointment, too long for a bed in long-term care.
Delivering care safely should be paramount; otherwise, quality is illusory. One in 10 hospital patients suffers from an adverse event, or medical error in the vernacular. As many as 24,000 Canadians die from medical errors each year, making them a leading cause of death. That is not good enough.
What about respect? The vast majority of health professionals are kind and caring; many go far beyond the call of duty. But the system does not make it easy to be respectful: We underinvest horribly in support staff. Many doctors, nurses and other professionals are overworked and overwrought. The system values and rewards volume, not results.
How long are you kept waiting when you arrive on time for your doctor’s appointment? When you walk down the hall of a hospital, does anyone actually look you in the eye? When frail elderly patients are placed in long-term care, is it close to family? Do we ensure death is dignified with palliative care? When something goes wrong with your care, do you ever hear the word “sorry”?
“Customer service” is not a term you find in the Canadian healthcare lexicon. Navigating the system is far too complex; getting answers to simple questions nearly impossible. That is largely an administrative failure, and reflects the fact that our health system is structured, first and foremost, to meet the needs of providers, not customers (or clients, or patients — the debate about terminology can be left for another day.)
Viewing Canada’s health system dispassionately as an outsider, it looks pretty mediocre: it is expensive, unresponsive, not particularly safe and exceptionally inefficient.
Medicare beyond the myth
So why do Canadians put up with it? Why are we so passive and undemanding?
The two most common answers to that question are: a) because it is “free” and b) because the alternative is worse. Neither is even remotely true. But they are potent myths. Mythology may be the single biggest barrier to reform of the Canadian health system.
How often have we heard politicians utter the phrase “Medicare is what defines us as Canadians.” This is nonsense. Medicare is not an identity; it is a public insurance plan. The principal benefit of public insurance is that it is cost-efficient: Pooling risk among millions of people makes good business sense, and a single-payer system cuts down on bureaucracy.
So let us start by de-romanticizing Medicare and appreciate it for what it is: an efficient insurance plan. But let us also recognize that it needs to be cost-effective as well as cost-efficient. And that means parameters and management.
To manage Medicare effectively, we need a sound legislative foundation, good oversight (administrative and political) and an engaged public. What we do not need is an attitude of resignation — that what we have now is the best we can do and that all change will be for the worse.
On the legal front, we have the Canada Health Act (CHA), a well-meaning but outdated and not particularly effective law. There are those who like to blame the CHA for all our woes, but that is giving it too much credit.
The strong point of the law is that it spells out the so-called principles of Medicare — public administration, comprehensiveness, universality, portability and accessibility. The reality is that the word “principles” does not appear in the CHA. The five items enumerated are actually prerequisites for federal funding: nothing more and nothing less. The original purpose of the Act was to assimilate several rules and regulations that accumulated over the years and try to ensure some semblance of equity in the delivery of health care from coast to coast. Let us not, then, pretend that those “principles,” or the law itself, are the ultimate articulation of Canadian values.
The CHA prevents nothing except perhaps extra billing by doctors. (Let us not forget that was the practice the legislation set out to end in 1984.)
Despite the mythology, the legislation does not outlaw private health care, or private insurance, or user fees or anything else. What it says is that provinces/territories that don’t respect the prerequisites in the law can have their federal health transfers withheld. (In practice, less than $1 million is withheld each year on transfers of close to $40 billion, despite widespread violations).
Hoist by our own principles
The “principles of Medicare” act as velvet handcuffs, comfortable (especially for some entrenched interest groups) because they preserve the status quo, but powerful barriers to innovation. And the status quo has become exhausting and frustrating because, increasingly, we are failing to give those principles meaning in the day-to-day delivery of care.
The most troublesome aspect of the CHA is its implied definition of “medically necessary.” Under the law, Medicare must cover “medically necessary” services, which are described as being hospital and physician services. That was adequate in the 1950s and 1960s when Medicare was being fashioned. After all, in 1961, when Medicare (read physician and hospital insurance) became a national reality, the median age of Canadians was 25; the role of doctors was to treat “boo-boos” and infectious disease, and to deliver babies; hospitals were places you went for treatment of grave injuries or acute illness, and were often places you went to die.
Today, the median age in Canada is 47. We are an old society and the vast majority of healthcare spending goes to the treatment of chronic illness. Yet, the system is still structured to deliver acute care, and the public insurance system is still structured to reward acute care treatment.
Today, the notion that hospitals and physicians are the only medically necessary services and prescription drugs, home care, long-term care and so on are not is positively retrograde.
Absolutes and maybes
In reality, all provincial health/territorial insurance plans cover far more than the “necessities” but there are still two distinct classes of public coverage: the absolutes (doctors and hospitals) and the maybes (everything else). This bifurcated payment scheme is what distinguishes Canada from every other health system in the developed world, and not in a good way. In Canada, about 70% of health care is covered by public insurance ($135 billion this year) and 30% ($57 billion) is paid with private insurance and out-of-pocket payments. Yet we cling to the myth that we have a 100% public system.
The most harmful myth we have embraced, though, is the belief that doing things differently would be a lot more costly and inequitable. Do we want a health system like the U.S., where millions are underinsured, and millions more are uninsured and can be bankrupted by a routine medical problem? Where annual health insurance premiums cost as much as a new car?
The menace is raised — explicitly and implicitly — every time there is even a whisper of reform. We cannot seem to shake the star-spangled bogeyman.
As Canadians sit in interminable waits in the ER, in the doctor’s office, in the queue for elective surgery, awaiting a bed in a long-term care facility, they too often utter a mantra: “At least we’re not in the U.S.” Politicians have largely bought into this, perpetuating rather than challenging the myth that the only alternative to our current medicare system is the U.S. non-system.
Don’t look south
We have to drag ourselves out from the menacing shadow of the elephant to the south and look elsewhere for inspiration, to Europe specifically, and create 21st-century Medicare. In most European countries, wait times are largely unheard of, the range of services offered is broader and costs are lower, yet over 80% of healthcare services are paid out of the public purse, significantly more than in Canada. How do they do it? By having a mixed private-public system across the board, rather than a bifurcated private-public system with doctors and hospitals on one side and everything else on the other; by strictly regulating private insurance instead of outlawing it; by placing far more emphasis on quality of care than quantity of care; by measuring, and valuing, results.
In Canada, we have for far too long deluded ourselves into thinking that the structure of Medicare was handed down from the heavens on a stone tablet (with Tommy Douglas playing the role of Moses), and we have treated the CHA as the New Testament.
Europeans are not constrained by this sort of mythology. There, politicians and policy-makers have responded to changing demographics and public demand and, as a result, public (and private) health insurance has evolved with the times.
In Canada, we need to adopt that pragmatic, consumer-driven approach to make Medicare a living, breathing entity.
Doing so may require some legislative change but, above all, it requires a major cultural shift. The health system has to stop existing for the sake of the system and start existing for the sake of the patient. We cannot be afraid to change, even if there will undoubtedly be some bumps (and maybe even some failures) along the way.
“What do patients want?” needs to be the mantra guiding innovation and change. And patients themselves have to become, well, more impatient.
Quality care, delivered promptly, safely, respectfully, affordably and equitably is within our grasp. But getting there will require leaders.
In Canadian health care today, leadership is there for the taking. Who is going to take up the challenge?