Who should "play God?"

A CBC News article reports that the Calgary Health Region is appealing a court injunction which lifted a “do not resuscitate (DNR)” order from a comatose patient. Doctors at the Foothills Hospital had ordered the patient not be resuscitated (in the case of cardiac or respiratory arrest) because they felt his brain injury was so traumatic that he would never recover. The patient’s family sought legal intervention to give them time to obtain independent medical advice. Since that time, CBC reports the patient has made “a remarkable recovery” and is now able to speak, read and write.

The Health Region chose to appeal the injunction because it will create ambiguity over who has the final say – judges or doctors. Justice Sheilah Martin, who ordered the injunction, noted that the current law is unclear as to whether doctors or families have the final say. A medical ethicist at the U of C pointed out that if the injunction stands, it will set the precedent that judges have the final say on DNR orders; and judges would therefore have to be available 24 hours a day, to make the decisions that doctors are currently making.

Deciding when to stop treating a patient (or family member) is undoubtedly one of the most difficult decisions for anyone to make. Regardless of your opinion, everyone has to agree that the very last thing we need is ambiguity in the law defining who has the final say in letting a patient die. Currently, doctors make the majority of these kinds of decisions, and some would say doctors are impartial, not emotionally tied to the patient, and therefore best suited to make an educated decision regarding the likelihood that the patient will recover. Doctors however are human, and some patients will undoubtedly defy all odds and recover from the worst of circumstances.

Another CBC article reports the Manitoba College of Physicians and Surgeons has proposed a policy that would clearly give doctors the final say, but require them to give 96 hours notice to the family who would then be given the right to appeal via a second opinion or court intervention. I believe that a policy along these lines (maybe with more required notice) is probably the best option as it leaves most of the decision making power with doctors, but gives ample opportunity for the family to obtain secondary advice and court intervention if necessary. Regardless of your position, “playing God” is not for the faint of heart.

Privatization of Health Care Part 3: Final Thoughts

In the last half decade or so, there have been a few noteworthy studies on how to “fix” Canada’s health care system. I will briefly discuss a few aspects from each that I feel are significant.

• The Fyke Report commissioned by Roy Romanow called for…
• Greater emphasis on quality of services rather than quantity of services.
• Payment of physicians on a salary or contract basis and not on a
  fee-for-service basis.
• Amalgamation of 32 health districts into 11.
• The creation of a 24-hour 7-day-a-week health care advice phone line.
• The creation of an independent quality council.
• Hospital services to be delivered through a smaller number of facilities;
  convert smaller rural hospitals to “health care centers.”
• Establishment of electronic health records.
• Expanding services covered by public funding in the longer term.

• The Mazankowski Report, commissioned by Ralph Klein called for…
• A blending of public, private, and non-profit funding and delivery.
• A reduction in the amount of services covered by Medicare; services to be dropped would be decided by an expert panel.
• A 90 day wait list guarantee for certain services.
• Establishment of electronic health records.
• Expansion of private delivery; however physicians would be required to work a certain amount of time in the public system.

• The Senate Report headed by Senator Michael Kirby called for…
• A new dedicated tax that would raise $5 billion per year for various health programs.
• Government funding of out-of-province or out-of-country treatment if the patient can not receive timely local care.
• Capping of out of pocket drug expenses at 3% of family income.

• The Romanow Report commissioned by Jean Chrétien called for…
• An immediate $6.5 billion cash infusion from the federal government.
• Guaranteed minimum funding amounts that would increase with inflation and the cost of advancing technology/drugs.
• Increased transfers to provinces to expand drug coverage.
• Revision of the Canada Health Act to limit the private sector.

What has resulted?

• Since the Fyke report in 2001, the government of Saskatchewan has…
• Amalgamated the previously 33 health districts into 12.
• Created a Health Quality Council whose function is to evaluate the performance of our health system and make recommendations.
• Created HealthLine, a 24 hour information and advice line where citizens can speak to a registered nurse.

• Since the Mazankowski report in 2002, the government of Alberta has…
• Become the first/only province to implement province-wide electronic health records.
• Allowed private clinics to offer publicly funded services.

• In September of 2004, at a first ministers meeting under Paul Martin, the federal government and provinces reached a deal worth about $41 billion in health care dollars over 10 years. The deal included…
• $3.5 billion over two years for the provinces and territories.
• Guaranteeing a 6% increase in transfers per year.
• $4.5 billion over six years to reduce wait times.
• The development of a national wait times strategy.
• Creating a national home care program.
• Staying true to the Canada Health Act.
  

My Thoughts:
The amount of variance in the four reports (which were all commissioned around the same time, and were essentially supposed to do the same thing) is evidence of the complexity of the situation and the task at hand. It is interesting that the two federal reports both recommended immediate cash infusion and even came up with a similar figure ($5B vs. $6.5B). What’s more surprising is that their recommendations were implemented and even exceeded in certain regards, as the federal government and provinces agreed on $41B over 10 years in health related transfers. Although the two provincial reports both agreed on electronic health records, they seemed to disagree fundamentally on the way health care should be delivered. Mazankowski sought an increased private role while Fyke recommended an increase in publicly provided and funded services over the long term. This difference might be explained by the unique situations in each of the provinces at the time of the reports. Alberta was in the middle of a massive population boom, and the stresses that were felt across the nation, were becoming dire in Alberta, and especially Calgary. Now that Saskatchewan’s economic forecast is looking brighter, it will be interesting to see how our health care system responds over the next decade or so. If Saskatchewan’s population does boom, will we be forced to adopt a stronger private role?

The major challenge right now is to increase the quantity of services that are being provided in a given time so as to bring wait times down to a reasonable level. My position is that maintaining public funding of medical services is absolutely essential if we want to maintain a just and free democratic society where citizens are equal and life is a fundamental right. I have no particular opposition against the private delivery of some or all medical services, provided there are safeguards or economic incentives to ensure equal treatment for all citizens, regardless of the complexity or costliness of their illness. While increasing efficiency is central to reducing wait times, quality must always be maintained at the highest standards – and herein lays our challenge. Electronic medical records and information technology will undoubtedly help improve the efficiency of our health care system – for example couriering an x-ray or a medical record between doctor’s offices seems atrociously old-fashioned in this age of digital files and email (not to mention bad for the environment). Electronic records in the future will also play an important role in public health, as incidence of disease, foodborne illness outbreaks, and population health indicators can be measured and analyzed with the click of a button.

I hope in my lifetime to see (and be part of) real solutions to the problems that are plaguing our health care system. If and when some of the current crises are solved (or at least more effectively managed), the next step I (and Fyke) would like to see is the expansion of services which are publicly covered. Ambulance rides, dental treatment, optometric procedures and prescription drug coverage are all things that I believe should be one hundred percent publicly covered in the future.

Sources:
Alberta Health: Private health care clinics
Alberta NetCare
Saskatchewan HealthLine
CBC News InDepth: Health care

Privatization of Health Care Part 2: Opposing Views

Tommy Douglas on Universal Health Care (Requires Windows Media Player)
(I can only get it to work in Internet Explorer so far)


Canada spends a lot of money on health care... period. In the 2007-2008 provincial budget, health care clocked in at an estimated 41% of total expenses. Total health care spending in Canada – approximately 10% of total GDP – is on average comparable to what other OECD countries spend on health care; however Canada’s percentage of public spending (roughly 70%), is somewhat above the international median.

In previous blogs I have discussed some of the factors that are currently putting strain on our health care system, introduced the debate around privatization and universal health care, and talked about four idealized health care models and how different countries around the world fund and deliver health care.

In 2005 the Supreme Court of Canada struck down a Quebec law that prevented people from purchasing private health insurance to pay for services already being delivered through the publicly funded system. The two appellants contended that the Quebec law violated section 7 of the Canadian Charter of Rights and Freedoms as well as section 1 of the Quebec Charter of Human Rights and Freedoms. Justice Beverley McLachlin and Justice John Major wrote in their decision “access to a waiting list is not access to health care.” Although the ruling applied only to Quebec, it served to open up the door for national dialogue regarding how health care should be delivered.

Dr. Brian Day, the recently appointed president of the Canadian Medical Association (and owner of a privately run surgery centre), believes that private-sector-style discipline is the cure for what ails Canada’s health care system. Hospitals currently receive most of their public funding via annual grants and transfers. Day would like to see funding for hospitals moved to a fee-for-service basis – just as it is for GP’s – so that there is incentive for hospitals to be more efficient, and treat more patients. He would also like to see changes to the Canada Health Act affording privately owned clinics the ability to compete for the right to provide medical services, which would still be funded by the public purse. Day’s vision is therefore to increase private delivery of services, but still maintain public funding.

Dr. Arnold Relman, who appeared before the senate committee on health care, argues that health care is fundamentally different from most market-based goods and services, and it is dangerous to treat sick patients like consumers. Other critics of Dr. Day argue that moving hospitals to a fee-for-service basis gives them incentive only to increase quantity of treatments and not quality of treatment. Hospitals will focus on the quick procedures that make healthy profits, while ignoring the procedures which are complex and expensive.

To me, Dr. Day’s vision of incentive based funding seems like a reasonable way to reduce wait times, and make our current health care system more efficient. The problems that his critics mention could potentially be resolved with regulations forcing hospitals to perform all types of treatments and not just the quick and cheap ones (of course this would add some administrative expenses). Alternatively, hospitals could be entitled to bill the public system at higher rates for performing complex and costly procedures so as to ensure they have sufficient incentive to perform all kinds of necessary procedures.

No one pretends that the question is as simple as a ‘yes’ or ‘no’ on private health care. The fact is that private health care in Canada already makes up a large part of the system, and to some degree anyways, is likely here to stay. What makes studying this topic so difficult is the unending complexity of variables that contribute to overall health and wellbeing, and to the success of a given health care system. We can’t simply look to other countries and say because they allow private clinics and because they have better population health indicators than Canada, their health care system is better and we should therefore adopt their model. Even within Canada, there exists great variability in the challenges to providing health care in different regions and to different groups of citizens.

With wait times in some areas becoming dangerously unreasonable, there is increasing tension between the Canada Health Act and the Charter of Rights and Freedoms. In the conclusion of my blog on privatization of health care I will be discussing major studies recently undertaken on behalf of the government, analyzing the results of those studies in terms of what steps governments have taken, and looking briefly into the future of health care in Canada.

Sources:
Health Canada: Overview of the Canada Health Act
CBCNEWS INDEPTH: Health Care
Financial Post: Don’t Take a Number

My Thoughts on the Leaders' Debate

The topic of health care had a strong presence in the recent Leader’s debate, and is likely a major issue for a substantial amount of voters. The two questions posed to the leaders related to waiting lists, and bringing health care spending under control – two issues that would appear to be at odds with each other. It was a great combination of questions being that both issues are extremely relevant to a lot of Saskatchewan citizens, but it was also interesting that the health care spending question was placed second, after the leaders had proposed their grandiose and costly plans to reduce wait times.
Each of the three parties’ plans to deal with wait times shared some common elements, but contained enough fundamental difference to allow for a lively debate. While each leader acknowledged their own special plan to hire/recruit/train/retain more doctors and nurses, none chose to elaborate any further except Wall who proudly pointed out that his plan was created way back in September, and Karwacki who emphasized his plan was “made in Saskatchewan.”
One of the comments of most interest to me was Calvert’s statement “a universal drug plan will improve wait times.” I’m wondering whether this was a personal opinion, or was something he read in a medical journal, or saw in a study, or maybe just something that he hoped would be the case. According to Saskatchewan’s Surgical Care Network, the longest wait times are currently in the areas of orthopedics, plastic surgery, dental surgery and ophthalmology. In my non-professional opinion, patients who have been waiting for a hip replacement, skin graft, root canal or cataract removal are not likely to skip out on surgery because they can now get a cheaper prescription. On the other hand, while Wall’s version of the drug plan may be more fiscally responsible, what is the logic behind setting the cutoff for children at 14 years? Should wealthy parents of a 14 year old with leukemia be paying less for cancer meds than the impoverished parents of a 15 year old leukemia patient?
In regards to the second health care question, about bringing health care spending under control, it was my feeling that the question was never really answered. Karwacki gave mention of a health/social policy council that he assured would help bring spending under control, but chose not to elaborate. Wall’s answer was the most specific of the three, as he stated the Sask Party would conduct a patient first review of the health care system to determine if health care dollars are really making it to the front line. However, if the review finds that funds are indeed making it to the front line, then I suppose Mr. Wall will have to actually address the question. Calvert sadly chose to deflect the question by suggesting that under the Sask Party or Liberals, private, for-profit health care would eventually come up because “that is where they always go.” Seeing as that the Sask Party’s official platform ensures their commitment to “publicly funded, publicly delivered health care,” one has to marvel at Calvert’s ability to materialize any piece of information that would suit him well, and present it to the Saskatchewan people as if it were a long established fact.

Health Care Issues in the Leaders' Debate

A good portion of the recent Leaders' debate was centered around the topic of health care, with both Lorne Calvert and Brad Wall giving mention to it in their opening remarks. Here is a rundown of the Leader's responses to the two questions specifically about health care.

Health Care Question #1:
Recently a friend lost his father because the waiting list was too long; what is going to be done about this?

Calvert:
While everyone else has been complaining, we have been taking action.
We have setup a surgical wait care network in Saskatchewan that is now being copied across Canada.
There are more doctors currently practicing.
We have decreased wait times significantly.
We have a plan for publicly funded/administered surgi-centers to provide 30 000 more surgeries.
Not just on acute care that we need to focus, providing prescription care to whole population; a universal prescription drug plan will improve wait times.

Wall:
With respect, the answer is not new facilities.
We have a nursing/doctor shortage; that’s why we began in September creating a plan for more nurses and more training seats for doctors.
Similar to Manitoba, we would like to increase doctor training seats to 100.
We need more residency positions in Saskatchewan hospitals so there is a better chance of keeping doctors here.
Our plan is about the front line, that’s what needs to be dealt with.
Unaffordable prescription care for everyone will take hundreds of millions away from recruiting nurses/doctors and dealing with wait times.

Karwacki:
While knocking on doors in my constituency, I came across a mother with a 15 year old son who had to wait until he was 17 to get his knee fixed.
We have a made in Sask nursing shortage plan to make sure we have enough nurses.
We will retain specialists in the province to make sure these waits don’t occur anymore.
We have a plan for 2 not-for-profit surgical centers.
We will take orthopedic surgery out of hospitals, and place it into these surgical centers to ensure there are no waiting lists in this province anymore.

Open debate:
Calvert:
Not a question of either or, we need to concentrate on acute care services, but families need help with prescriptions as a way to keep them out of the hospital.
Drug plan will take up only 4% of health care spending.

Karwacki:
Calvert record is worst in country on waiting lists.
I am concerned that Mr. Wall does not have a plan.
The Liberal plan is to build on the Phike commission and Romanow report to ensure we deal with waiting lists with not-for profit surgical centers.

Wall:
We have a targeted affordable prescription care plan for seniors and kids under 14.
Only the Sask Party has expressed a need to expand the formulary.

Calvert:
Tonight there are 3500 drugs covered on the Sask formulary.
Are you saying in this time of prosperity people do not deserve a universal drug plan?
Are you saying we can’t again lead Canada in Medicare?

Wall:
In this time of prosperity, people have hospitals closed so they have to book emergencies from 8-5 Monday to Friday… that is a priority… wait times are a priority.



Health question #2:
What is your Plan to bring health care spending under control?

Karwacki:
If we do not deal with health care spending in this province, in a decade health care will take up every dollar that we have in Saskatchewan.
By 2017 politicians will have no other decisions to make.
The way Calvert has been spending money, there will be nothing else politicians can do.
We have put forward a health/social policy council that will help bring health care spending under control, to give us best practices, and ensure we do the right things in health care.
We have plan for waiting lists, nurses, a plan that will make a difference and get health spending under control.

Wall:
We will establish a patient first review of the entire health care system if elected.
If there is an item in the budget that accounts for nearly half of the provincial budget, and grows at 8-9% per year, yet waiting list are not getting shorter…
It’s time to ask are those dollars getting to the front line, are they being maximized in terms of patient care, or are dollars being lost to various levels of administration?
This is a question that no one has had the courage to ask.
We need to make sure that resources, precious health care dollars are getting to the front line to deal with wait times.

Calvert:
When Sask/Liberal party talk about sustainability of health care, soon the debate will come to private, for-profit health care, because that is where they always go.
The health care system in Canada is much more sustainable than any private system in the world.
In dealing with growing costs, when we talk about prescription medicine, preventative medicine, education, community based services... that is when we will make the system very sustainable in a publicly funded way.

Open debate:
Karwacki:
It is clear that Mr. Calvert needs a $15 prescription for truth serum, because he is not being straight forward with people.
The province needs to go in a different direction than Calvert is proposing.
The rest of the world is trying to get people healthier, to take fewer prescription drugs, to make sure we practice preventative health care, to make sure we have an education system that gives young people the chance to find their passion and get involved, that we have nurses, pediatricians, and social workers at school to deal with children that are struggling, that need a difference made in their lives.

Wall:
David you can’t take nurses out of hospitals and put them in schools, we have a nursing shortage. Medical personnel are needed on the front line.

Calvert:
Sustainability of health care means keeping people healthy so they don’t need to get to the acute care system.
This means community-based services, and working in our neighborhoods to create that circumstance where people are healthy.

Wall:
Problem is that people wait too long, can’t get to the health care system that they need.
We currently have the longest wait times in the country.
The system – when it is readily available – works for people. The problem is that the system is not accessible, not readily available.

Calvert:
The time that you two have been complaining, we have been acting; waiting times are shorter today.

Karwacki:
They are the longest in the country.

Calvert:
According to the Fraser Institute, your right-wing friends who believe in private for-profit health care.

Karwacki:
We will make sure that nurses in hospitals are fully staffed before we move them into schools.
This is a great opportunity to make sure we retain nurses in the province, nurses getting close to retirement that want a different work environment.

Calvert:
Are you aware Mr. Karwacki that 90% of graduating nurses in Saskatchewan are staying in Saskatchewan, practicing in Saskatchewan, building careers in Saskatchewan?

Wall:
SUN has said we are short 1000 nurses. No one here believes there are any quick answers to that. It is a problem a long time in the making as a result of Mr. Calvert’s neglect of the issue.

Privatization of Health Care Part 1.5: Health Care Around the World

In understanding the debate around the future of health care (with specific regards to the question of privatization) in Canada, it is useful to examine various models of health care in developed nations around the world. It is important to remember that no country really has a universal system of health care. Canada – who some might say comes the closest to universal health care – only publicly funds the most essential services, with non-essential health services such as drugs, dental care, medical appliances etc. being funded by a mixture of public and private finances. Although I will talk about four major health care models, no single nation operates entirely within a single model. In reality, health care in developed nations is incredibly variable and complex, with each country taking pieces from each model to construct their own unique health care system.

The fact that health care systems can be so variable, even among the most developed countries, should be reason for politicians and citizens to keep an open mind to new ideas. For example the term “two-tiered” has almost developed a derogatory connotation in Canada, even though Britain has a two-tiered model and was ranked 12 spots ahead of Canada in the WHO’s 2000 World Health Report. The extreme complexity of health care systems and population health indicators should be noted, and the WHO’s ranking should be taken with a grain of salt; nonetheless it is still a good reason to keep an open mind.

In “Privatization of Health Care Part 1: The Background,” I indicated that Part 2 would focus on the views and ideas of prominent health care policy researchers, politicians and political parties. So as not to lie to my audience, please note this blog is titled Part 1.5, and will serve as a segue to Part 2. The remainder of this blog will be a brief description of the four main health care models, and comparisons of various national health care systems.

Health Care Models:
The health care models below are as described by researchers at the University of Toronto in a report titled “How Does Private Finance Affect Public Health Care Systems?”

• Parallel Public and Private Systems:
• A privately financed system exists parallel and as an alternative to a publicly funded system
• Often the privately financed system will cover a relatively narrow range of services

• Co-Payment:
• Financing of a broad range of services is partially subsidized by the public purse
• The remaining amount comes either out-of-pocket or from private insurance
• Amount of subsidization may be determined by the income of the patient

• Group-based:
• Certain groups of citizens qualify for complete public coverage, while other groups (usually the wealthiest) must rely on private insurance or out-of-pocket payment

• Sectoral:
• Certain sectors within a health care system are entirely publicly financed, while other sectors rely heavily on private insurance or out-of-pocket payment

National Examples:
The information below also comes from the U of T report, as well as the following sources:
CBC News In Depth on Health Care
Dutch Ministry of Foreign Affairs: Health Care
New Zealand Health System - What you Might Pay for Healthcare
Medhunters: Healthcare in the United States

• Britain:
• Most comparable to a parallel public/private model
• Broad range of services publicly covered by National Health Services (NHS)
• NHS is completely funded by general taxation
• Parallel private sector covers a relatively narrow range of services
• The private sector provides many of the same treatments as the NHS and therefore the main purpose for using it is decreased wait times
• Private financing comes from private insurance and out-of-pocket payment
• Dental services and out-of-hospital drugs are partially subsidized by the NHS, and partially paid for by the patient (co-payment)

• New Zealand
• Most comparable to a parallel public/private model
• Similar to the British model in that a private hospital system provides a narrow range of services parallel to a publicly owned/operated system which provides a broad range of services
• Significant co-payment is required for ambulatory care (i.e. seeing a GP, or outpatient services)
• The public subsidizes ambulatory care based on level of income; above a certain level of income there is no subsidy

• Netherlands
• Group-based model which is almost entirely privately delivered, but financed by both sectors
• Three main insurance schemes:
1. Exceptional/Catastrophic insurance covers entire population
2. Sickness Fund covers hospital/physician services, drugs and home care for the less wealthy 60% of citizens and all civil servants
3. The wealthiest group of citizens must pay for private insurance and can only fall back on the public system for “exceptional/catastrophic” expenses
• Since the delivery of health care is mostly private, it is tightly regulated to ensure that everyone has equal access
  
  Note: In the last year Netherlands has somewhat revamped their health care system making it mandatory for everyone to purchase basic health insurance from their choice of provider. My analysis of the Dutch model probably does not reflect these changes since it is primarily based on a 2004 report.

• Australia
• Hybrid system that combines both parallel public/private and co-payment models in an attempt to balance the three sources of health care funding: public, private out-of-pocket and private insurance
• Parallel private hospital system similar to Britain/New Zealand
• Subsidization and tight regulation of private insurance
• Similar to New Zealand, Australia relies on co-payments for ambulatory care, although to a lesser degree; Australia bans private insurance for these co-payments which therefore must come out of the patient’s pocket

• Canada
• Most closely based on a sectoral model where essential hospital/medical services are entirely publicly financed, and all other services have a mixed mode of public/private delivery and finance
• The Canada Health Act stipulates that no private charges can be paid for publicly insured services
• In 2005, the Supreme Court of Canada overturned a Quebec Law which prevented citizens from buying private health insurance for medical services available through the publicly funded system
• In their decision the Chief Justices noted that “access to a waiting list is not access to health care”

• United States
• A complicated mixture of public/private funding and delivery
• Federal law ensures everyone access to emergency services regardless of ability to pay
• Three ways in which health care is funded:
1. As a benefit through employer
2. Through government programs including Medicaid and Medicare which provide coverage to seniors, persons with low income and/or disabilities
3. Through privately purchased health insurance
• Generally regarded as the industrialized nation with the least universal health care system
• Spends more of its GDP (around 15%) on health care than any other industrialized nation
• A U.S. Census Bureau study found that 15.8% of Americans had no health insurance at some point in 2006
  

$150 Million for What??

On day one of the official Saskatchewan election campaign, Lorne Calvert promised a $150M universal drug plan, should his party win the upcoming election. One day prior, an independent research organization at the Fraser Institute released a study showing that surgical wait times in Canada are at an all time high. According to a CBC news article reviewing the study, Saskatchewan has the highest surgical waiting times in the nation, with a total wait time average of 27.2 weeks. On the positive side, Saskatchewan was one of the four provinces where wait times have actually come down in the past few years.

It seems as though a universal drug plan is really not one of the most pressing needs of Saskatchewan citizens at the moment. It certainly doesn’t sound like a bad idea, especially in an age where prescription drugs are becoming more common, more important to general health care, and definitely more expensive. If we are going to have a health care system where everyone has equal access to see a doctor, diagnostic services, surgery etc., it makes sense that everyone should also have equal access to medication, with no discrimination based on financial circumstance. My concern is that it didn’t seem like a universal drug plan was an issue before the election was called. There were however other issues related to health care including surgical wait times and doctor/nurse shortages that have been important and pressing issues for some time now. One has to notice that with a major announcement coming almost every day from the major political parties, the hundreds of millions of dollars are really starting to add up.