The result was predictable. Big new contributions to a public system are going to be gobbled up disproportionately by the providers, in this case doctors and nurses and administrators. They are the most motivated and best mobilized to take the new money, which they did.
Physicians’ and nurses’ remuneration have to be held to the rate of inflation for a decade. The move to change physicians’ pay to blended remuneration based on a mix of fee for service, salary and quality outcomes for patients should continue. In exchange for the large public subsidy for their education and the handsome remuneration they receive, physicians have to agree to work more hours (and in groups) that are convenient to patients rather than to themselves.
Patients, after all, are not organized. They arrive as individuals in the system, whereas the providers are organized in associations or unions, and have structured the system to their convenience over a long time.
Today, every government report on health care insists that the system must be “patient-centred.” Every political speech uses the same rhetoric. If the system were truly “patient-centred,” every official utterance about the system would not need to repeat the cliché.
The Romanow commission a decade ago naively argued that heaps of new money would “buy change.” Instead, the money bought time, but little change. Wait times in five designated areas – cataract surgery, joint replacements and the like – did come down somewhat, but at a cost much too high to justify the results. More change actually occurred when funding was restricted in the mid-1990s.
Three objectives now beckon: to enhance quality, improve timeliness of care, and tilt down the cost increases. Achieving them will require changes to many aspects of the system, starting with de-emphasizing hospital care, wherever possible. A bed in a hospital, or a patient treated in emergency, costs more than care provided in clinics, nursing homes or even at home. Our system, originally built around hospitals, has to be “de-hospitalized” so that hospitals can do what they are best equipped to do: provide acute care.
As well, under the current system, hospitals struggle to handle as many patients as their budget allows. Instead, they should be rewarded for how many patients they see, and the outcomes that result.
The Canada Health Act, contrary to popular view, does not prohibit private delivery of health-care services. The act says only that health care has to be administered publicly; it is silent on how services are delivered.
Moreover, the civil servants who drafted the fact later wrote an interpretive manual (published for the first time in my book, Chronic Condition) explaining what each clause meant.
They wrote: “The Act cannot be interpreted to mean that services cannot be provided on a for-profit basis. It simply means that the organization, commission or agency that administers the provincial plan cannot record a profit on its operation.”
As part of de-hospitalization, private clinics for repetitive surgeries and testing should be encouraged, just as private providers of long-term care, in-home care and nursing homes should be welcomed, provided that they are regulated and monitored by the state and can provide lower costs. The state should be agnostic about who provides service, as long as the state pays.
Observers of health care have championed for years the need for more nursing and long-term-care facilities. If we wait for cash-strapped governments to build them, we will be waiting too long, and far too many hospital beds will be occupied by the frail elderly, at great cost. Private-public partnerships should start immediately getting on with the job.
And if hospitals have unused capacity in operating rooms, as many do, they should be able to charge patients to have surgeries done more quickly in rooms that would otherwise sit idle – with the money earned put into the hospitals’ budgets – and to bring patients from abroad to earn money.
Before any of these, and many other changes, can be considered, Canadians need to think about medicare as a program, not an icon. We need to understand its costs and what those costs are doing to other programs. As our population ages, we should begin to think about intergenerational equity, not just horizontal fairness.
Our system has undoubted assets and solid underlying values, but it is not meeting the value-for-money test. So we need to shuck off ideology and fear and open our minds to the changes that will make health care better.
Jeffrey Simpson is The Globe and Mail’s national affairs columnist. This essay is adapted from his book Chronic Condition, published this month by Penguin Canada.