Owww, Canada
ACROSS THE BORDER, COST-SPIRALING SYSTEM IS ABOUT TO CHANGE —AND MUST
It is the sacred cow of Canadian politics, and those in power who think they will tinker with it do so at their peril. For while the Canada Health Act—the legislation that provides universal health care for all its citizens—is revered by Canadians, paradoxically it is also heavily criticized, as each new survey shows.
The term “crisis” tends to be overused today, but when applied to any medical or health report, people do take notice, as when it was recently estimated that some 5 million Canadians—about 850,000 of whom live in Ontario—do not have a family doctor. One quarter of the entire population is unable to get same-day access to a physician, while waiting lists for various treatments are said to cost $14 billion a year nationally in lost economic activity.
A number of factors have caused our acute doctor shortage, two of which continue to be significant.
Frequently, graduates from Canadian medical schools choose to intern in the United States and elect to stay there when they are fully qualified—not at all happy with the governmental control of incomes in the state-run medical system back home. It is believed that more than 9,000 Canadian doctors work in the United States.
Canadian physicians are compensated on a set-fee-per-medical-act basis but can earn extra income for working nights and undertaking preventative medicine activities. But of those who do complete their internship in Canada, an increasing number then decide to specialize, knowing the long working hours required of the average family physician who must also service a daunting patient roll. A great many physicians have closed their patient lists, accepting a limited number of new enrollments only when existing patients die or move away.
It should be pointed out that while our health care system is a federal program, the responsibility for its administration is delegated to Canada’s 10 provinces and three far-northern territories. This results in 13 bureaucracies employing legions of civil servants absorbing large sums of money, which could otherwise be spent on preventative or curative medicine.
Health care funding is provided jointly by the federal and provincial governments—Ottawa weighing in with a block grant for around 16 percent of expenditures, the balance being funded by provincial taxes (mainly personal and corporate income taxes). Spending on health care accounts for between one-third and one-half of provincial social welfare spending—for the nation as a whole it is around 10 percent of Gross Domestic Product.
Earlier this year, in an attempt to ease the chronic shortage of doctors, Ontario introduced legislation to increase access to treatment by giving many of its other medical professionals the freedom to provide a wider range of health care services.
Under these new rules, accredited nurse practitioners will be allowed to set broken bones, carry out ultrasounds, set casts and provide prescriptions for certain drugs beyond what they are already authorized to prescribe. Physiotherapists will be able to order X-rays, midwives will be able to take blood samples and pharmacists will be allowed to renew prescriptions.
But the government was quick to point out that adding to their workload does not mean these professionals will receive extra income. “We’re talking about increasing other kinds of rewards for these people —there’s a tremendous psychic reward that comes from knowing you can in fact do more than you have done in the past,” intoned Dalton McGuinty, the leader of the governing Liberal Party in Ontario.
This proposal is just one of a number of initiatives introduced by the Ontario government, all aimed at easing the ongoing and vehement criticism of its management of health care in the province. Earlier the administration decided to introduce an Internet Web site that assembled a huge amount of patient data collected from 70 hospitals, listing the waiting times that could be expected for the so-called Big
Five types of treatment that are considered priorities — cardiac and cancer surgeries, eye operations, joint replacements and diagnostic imaging.
At the time this information started to become available, Dr. Eric Cohen, a noted Toronto cardiologist, said, “There must be a higher level of disclosure to patients about what wait times are, what acceptable wait times are and what some of the options are if those acceptable wait times are unable to be met.”
According to Cohen, not only should doctors tell patients how quickly they need treatment, they should also be explicit about the level of risk they face — something that did not always happen in the past.
“It’s our suspicion that many patients have not been aware of how their physician would classify their level of urgency,” he commented. “There could be more communication between the referring physician, the hospital or physician who is providing an invasive procedure and the patient, explaining to him or her the estimated level of urgency for their condition and their recommended maximum wait time.”
The release of all this data is a public relations exercise aimed at making patients feel they can at least take some control of their own care. Being able to pinpoint the areas where the waiting lists are the shortest, it is hoped, encourages them to move around more within their individual province as they seek care. But the idea of entering a hospital or surgical facility that may be many miles away from their own neighborhood is not something that many find appealing.
Nevertheless, traveling to another area for surgery is an option that is available depending on the urgency of the procedure required.
A very recent trawl of the government Web site revealed the often-substantial geographic differences in wait times. At St. Joseph’s Health Center in Toronto, the wait time for breast cancer surgery was listed as 48 days, while approximately 85 miles away at Peterborough Regional Health Center, the wait time was only 18 days.
St. Michael’s Hospital in Toronto listed a wait time of 113 days for its general surgery, while some 58 miles away at Ross Memorial Hospital in Lindsay, one need wait only 46 days.
At Kingston General Hospital, a wait time of 73 days existed for bypass surgery, but 160 miles away, at the University Health Network in Toronto, there was only a 35-day wait.
It is a generally accepted fact that governments are simply not adept at managing any form of business operation—and health care is a business, a very large one. People frequently complain that the system is uncaring and hugely insensitive to individual needs.
Shirley Parent is 71 and lives alone in London, Ont. She suffers from multiple sclerosis and is incontinent, so has visits from home-care workers four times a day — which includes helping her get up in the morning and putting her to bed at night. “On occasion I will get a call from the home-care agency asking if they really need to send someone to help me. I tell them yes, it really isn’t a choice,” she commented. “After one visit to the hospital I was told by the supervisor ‘Shirley, you’ll just have to sit in it,’ referring to the fact that they didn’t think I needed anyone to change my diaper in the afternoon. Supposedly, the government wants us to live in dignity and comfort, and this is how they think.”
Robert Anderson, a 79-year-old grandfather who lives in Burlington, Ont., has colon cancer and takes the drug Avastin, which has destroyed one tumor, shrunk another and kept the largest at bay. He was shocked when he was told the program would no longer pay for this drug because it is the policy of the Ontario Ministry of Health to fund only 16 two-week cycles.
Anderson was given the option of paying for it himself, and was quoted an amount of $1,975 for every two-week cycle. A spokesman for the ministry said it finds Avastin “expensive” but said it would fund the treatment for longer if the drug maker or researchers can provide proof it works when used over longer periods.
Mark Hunt, 30, who lives in the border city of Windsor, Ont., suffers from stage 1V melanoma, a condition very difficult to treat. He underwent bowel surgery in Windsor, but not all of the tumors in his intestines were able to be removed, so he was authorized to undergo additional treatment across the river in Detroit.
Such action is permitted and the expense is covered by Ontario’s health care plan where highly specialized treatment is unavailable within the province. But then the rules changed and authorities told Hunt they will only continue to pay for his treatment if he attends Roswell Park Cancer Institute in Buffalo, which is the ministry’s “preferred provider” of Il-2 treatment for metastatic malignant melanoma and renal cell carcinoma.
Roswell Park is one of several out-of-country health care facilities that have a funding agreement with the ministry. They are selected based on specific criteria, including a cost factor. While Hunt welcomed the continuation of his treatment, he is now faced with an eight-hour round trip instead of simply driving through the tunnel connecting Windsor and Detroit.
Critics have long argued that the time has come for a two-tier health system allowing a private for-profit medical treatment scheme running alongside a government-run one. By allowing doctors a choice of working in either system, it is reasoned, more physicians would stay in Canada and become general practitioners, and some might even return home.
A mounting volume of verbal criticism by both media comment and speeches given by prominent individuals has finally begun to pay off. Highly conscious that there is an enormous sense of frustration with the public health care system at a time when its own costs are spiraling while demand for services increases, the federal government relaxed a number of the rules that underpin its Canada Health Act. Privately run, for-profit medical clinics are now found in some provinces. Ontario has many and Quebec and British Columbia have experienced an explosion in growth, but New Brunswick and Prince Edward Island have none.
These facilities do not offer any type of specialty surgery or red-carpet care only for the wealthy, they simply let Canadians pay for quicker access to the central players in a health care system — family doctors.
Facing long waits under the government-run scheme, Canadians have shown they are prepared to pay for treatment. Christine Crossman, who injured her hip during an exercise class, was told that she was facing a wait of up to a year to have an MRI scan.
“Any wait time was an enormous frustration for me and also the pain I endured,” she said. “I just could not live my life the way I wanted to.”
She opted to visit a private clinic where the scan was performed after a wait of only a few days, and she willingly paid the several hundred dollars it cost her.
As all levels of government in Canada face a declining tax base they seek spending restraint as well as expenditure cuts in the budgets of all departments — and health care is no exception. In spite of recent governmental attempts at this, costs continue to soar. Nothing illustrates this better than a study published a few weeks ago in the Canadian Medical Association Journal, which revealed that in just a decade, cardiac drug costs had increased a whopping 200 percent and could double again by 2020.
“It does raise the question about whether the health care system can sustain this,” said Cynthia Jackevicius, the lead author of the study.
So is our health care system sustainable? The Canada Health Act recognizes that publicly funded health care does not include all possible health care treatments. It uses the term “medically necessary” when defining hospital and physician services it is intended to provide.
Over the last decade, while the provinces and territories have struggled to contain health care costs, there has been much discussion as to how “medical necessity” should be defined, and which services could be deleted from the overall health plan. Inevitably this will accelerate the growth of a two-tier system.
But for the average Canadian, the debate about financial sustainability is not so much a question of whether the country can afford the scheme the way it is structured, as it is of “Will it be there for me when I need it?” The answer hinges on a simple fact — health care is as sustainable as Canadians want it to be.
It would appear they want it a great deal. Various opinion polls have consistently shown that Canadians would pay even higher taxes for greater high-quality medical care.
Discussing this issue, a number of CEOs of international corporations have pointed out that Canada’s system is an economic asset because corporations establishing operations here do not have to factor in health insurance as a part of the cost of doing business.
But while Canadians have come to expect government-funded health care as a right, there is a growing awareness that change is inevitable and unstoppable, and indeed is already under way.
Harry Pope is a freelance journalist who lives in Bowmanville, Ont. He is an observer of the political scene and occasional contributor to Viewpoints.
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