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Physicians and public health care advocates protest outside the Cambie Surgery Centre, a private health clinic, against the clinic's extra billing practices in Vancouver, British Columbia, Monday, August 20, 2012. (Rafal Gerszak For The Globe and Mail)
Physicians and public health care advocates protest outside the Cambie Surgery Centre, a private health clinic, against the clinic's extra billing practices in Vancouver, British Columbia, Monday, August 20, 2012. (Rafal Gerszak For The Globe and Mail)

Review: Non-fiction

Fixing a Chevrolet health-care system that comes at Cadillac prices Add to ...

  • Title Chronic Condition
  • Author Jeffrey Simpson
  • Genre society
  • Publisher Allen Lane
  • Pages 392
  • Price $32
  • Year 2012

Award-winning author and Globe and Mail national affairs columnist Jeffrey Simpson has taken on a daunting challenge in Chronic Condition: Why Canada’s Health-care System Needs to be Dragged into the 21st Century.

Leveraging his public-policy perspective, gained over decades, Simpson seeks to shake up the status quo by presenting some cold, hard truths about medicare, our most beloved “Canadian value.” He traces our current health-care system to its roots in Saskatchewan and exposes many unintended consequences of decisions taken a half century ago, including the fact that our “doctors and hospitals” approach to funding means our system lacks breadth and struggles to meet needs at the community level, especially in an aging society. It’s a system that produces mediocre outcomes despite being among the most generously funded anywhere.

Simpson’s recounting of the essential role of Tommy Douglas reminds us that the “doctors and hospitals” model fell short of the vision espoused in Douglas’s time, a vision that included dental and pharmaceutical coverage as well as a healthy dose of personal responsibility on the part of citizens.

The high drama that unfolded in Saskatchewan might help to encourage a politician to stiffen his or her spine, speak truthfully and make serious proposals to renovate medicare, as the book practically pleads. Yet those prospects are dimmed by Simpson’s descriptions of a health-care system dominated by provider special interests and a public that lacks the knowledge and smarts to debate the future, relying heavily instead on emotion and slogans.

Simpson’s analysis of the power of entrenched interests is well founded, and he exposes the hard truth that behind the phrase “patient-centred care” is the reality that the health-care system is organized for the convenience of the providers. How else to explain the fact that more than 90 per cent of care is delivered from 9 to 5?

His examination of the fiscal creep of health care at the expense of other crucial programs ought to engender fear on the part of the young that their future is being spent on the demands of today.

In making his case that Canada’s health-care system is a Chevrolet at Cadillac prices, Simpson relies heavily on comparisons with other health-care models. But his decision largely to ignore comparisons with the United States because it is a global outlier seemed to me rather too convenient. I accept his point that health-care models from Europe and Australia, for instance, are more similar to the Canadian model, so how we stack up against them is highly relevant.

However, our proximity to the United States is most certainly a huge influence on high rates of compensation for doctors and nurses, one of the three remedies that Simpson argues we must most urgently address. He compliments the Swedish model of health care, but would Sweden get away with paying their doctors $80,000-$100,000 (not much more than we pay some of our registered nurses) if Stockholm were a three-minute bridge crossing from Detroit, and mostly spoke the same language?

Now for a look at Simpson’s three remedies for health care. Simpson rightly chooses to focus on the three biggest cost centres: doctors at 14 per cent, hospitals at 29 per cent and pharmaceuticals at 16 per cent.

Doctors

Simpson points out that at an average annual compensation of $390,000, Canadian doctors rank in the top five globally. He argues that over the next decade physician compensation needs to be capped at the rate of inflation and suggests that user fees should be considered as a strategy to reduce demand. On the issue of a fee-for-service model, he quite rightly points out that the long delays patients experience could be addressed by more doctors working in group practices.

I found these suggestions rather more incremental than transformational, and I think that Simpson too easily dispenses with the idea that nurse practitioners can replace doctors at the primary-care level. While it’s true that there are relatively few NPs in Canada, it is also true that their training period is short and this approach could produce big savings quite quickly.

Hospitals

Simpson’s remedies are highly transformational and rely on a clear understanding of how decisions taken back when medicare was formed impair performance today. His advice concerning the need to unshackle regional health authorities, to give them real power, including over physician payments, and hold them accountable for performance, is prescient.

He focuses on “dehospitalization” of medicare, the long overdue process of getting certain services, procedures and surgeries into the community where they can be delivered more conveniently and less expensively. His myth-busting about the overused and incorrect argument that the Canada Health Act prevents such transfer of services is refreshing.

Pharmaceuticals

Discount retailers take advantage of volume purchasing to pass cheaper prices along to consumers. This tantalizing bit of low-hanging fruit offers the promise of billions of dollars in savings. Provinces and Territories should take advantage of volume pricing and the opportunities to align drug formularies offer further cost savings and more than a bit of political cover. There’s an obvious role for the federal government, too, given that Health Canada runs the drug-approval process and Parliament establishes the rules for patent protection.

Perhaps the greatest contribution Simpson makes in this book, though, is in defining “private.” In the phony war that occupies far too much of the health-care debate in our country, foes of change like to pretend that private means two-tier. It doesn’t, and Simpson persuasively distinguishes one from the other.

Chronic Condition is a great guide to models from around the world to be considered for reforms in Canada. Readers will find the lessons of history, global comparisons, abundant domestic data sets and the wisdom of one of Canada’s foremost commentators to guide them.

George Smitherman is a recovering politician who was Ontario’s minister of health from 2003-2008.

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