The recent series on Toronto's Mount Sinai Hospital by Globe writer Ian Brown and photographer Kevin Van Paassen highlighted the importance of major teaching hospitals to the welfare of Canadians. It raises again the issues of how hospitals are funded, and why waiting lists are so unconscionably long.
There is a major problem with funding of our hospitals and, perhaps surprisingly, a fairly simple solution. All it takes is courage and clear thinking - apparently too tall an order for our politicians.
Ontario hospitals, and probably most other hospitals in the country, are funded through an arcane and extremely dysfunctional mechanism called the "global budget." The ministry informs hospitals, after their fiscal year has already started, how much money will be provided for the coming year. The amount of funding is fixed, and it doesn't matter how many patients come through the doors, nor how sick they are; it will not go up. Hospitals are instructed to stay within budget; to do so, they have to decide what to cut next. Despite the fiction maintained by the Ministry of Health and Long-Term Care, to the effect that efficiencies are available, hospitals have long been cut past the bone: The last bit of fat went about 1987. (As noted recently, 40 per cent of ambulance calls are outside the accepted time window, because there is no room for the patients in hospitals.)
In London, Ont., only 40 per cent of the patients who come through the doors of the London Health Sciences Centre are from the London area. The rest come from across Southwestern Ontario: from Windsor to Owen Sound, from Sarnia to Niagara Falls (bypassing hospitals in Hamilton), from Kitchener (despite the existence of large hospitals there), and from beyond. We commonly see patients from Sault Ste. Marie, Timmins and South Porcupine. In my clinic in the past year, I have seen about 15 patients from the Toronto area; in the past few years, I have seen one patient from Miami, two from Prague, a few each from Vancouver and Vancouver Island, and some from Ottawa, Winnipeg, Prince Edward Island and Sidney, N.S. The reason? We are very good at what we do. The penalty paid by patients from London is that they have to wait in line with patients from outside the London area. The worst waiting times for MRI scans in Ontario are in Stratford and St. Thomas, because patients from there also have to wait with Londoners.
Our hospital is a designated regional stroke hospital. Even though I am on call for stroke only 25 per cent of the time, I have had to refuse a few patients a year with acute stroke, or send them back to village hospitals in Southwestern Ontario, because we had no empty beds. I have had half a dozen patients who had strokes while on the waiting list for an operation to prevent their stroke by cleaning out their narrow carotid artery (the main artery to the front of the brain). That operation, carotid endarterectomy, reduces by two-thirds the risk of stroke and death over the ensuing two years, but only if it is done in a timely fashion. The provincial benchmark, accepted by the Ontario Stroke Strategy Task Force, is that this operation should be done within a month; our waiting list is commonly three months and, by that time, much of the risk has already occurred. This operation has not even made it onto the list of priorities for reduction of waiting lists, even though it is much more cost-effective, in terms of improved cost per quality-years of life, than coronary bypass, cataract surgery or hip replacements, which occupy most of that list.
How does this happen? Because choices have to be made. If there is a fixed envelope of funding, then every dollar spent on one procedure is not available to spend on another. This is called "opportunity cost," and it is the underlying basis of the problem in our teaching hospitals. Decisions about how money is spent are not based on cost-utility: They are based on local history, entitlements, personal power, and other irrational drivers of decisions. (Cost-utility is cost-effectiveness adjusted for quality of life. It is probably the best way to make resource-allocation decisions.)
So, how can this be solved? Pay the hospitals for the work they do, and decide what to pay for on the basis of cost-utility. Establish a standard price for all the procedures that are performed in hospitals: a clinic visit for treatment of high blood pressure, an appendectomy, a gall-bladder operation, a coronary bypass, a carotid endarterectomy etc. The list would be 800 or so items long. Then the hospital could open operating rooms, hire nurses and provide the service, and the waiting lists would disappear.
But, you say, that would cost too much - there wouldn't be enough money to pay for everything! Exactly: The politicians have to admit that we can't pay for everything. We need to rank the procedures on the basis of cost-utility, calculate how many of the top-ranked procedures need to be performed, and draw a red line where the money runs out. Above the line, necessary and cost-effective care would be paid for by the public purse. Below the line would be private. This is the best way to obtain the appropriate mix of public and private care.
But, you say, shouldn't everything be paid for by the public purse? Of course not. Not only is it not possible, but it is already the case that governments do not pay for all medical procedures. Cosmetic surgery, for the most part, is already private. What this is about is putting funding of health care on a rational basis that will achieve an appropriate balance of public and private payment for care.
J. David Spence is director of the stroke prevention and atherosclerosis research centre at the Robarts Research Institute in London, Ont.
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