Stitches in Time

Stitches in Time

Canadian Governments Should Not Encourage more Private Finance and For Profit Delivery Canadian Pension and Benefits Institute Winnipeg June 15, 2007 Michael M. Rachlis MD MSc FRCPC www.michaelrachlis.com Outline The goals of Canadian Health Policy are equity and efficiency

Private finance and for-profit delivery are incompatible with equity and efficiency We can fix our health systems problems without private finance, for profit delivery, or a lot of new public money What are the goals of Canadian Health Policy?

British North America Act It shall be lawful for the Queen, by and with the Advice and Consent of the Senate and House of Commons, to make Laws for the Peace, Order, and good Government of Canada Canadian Constitution Section 36. (1) Without altering the legislative authority of Parliament or of the provincial

legislatures, or the rights of any of them with respect to the exercise of their legislative authority, Parliament and the legislatures, together with the government of Canada and the provincial governments, are committed to (a) promoting equal opportunities for the well-being of Canadians; (b) furthering economic development to reduce disparity in opportunities; and (c) providing essential public services of reasonable quality to all Canadians. Canada Health Act Whereas

that Canadians, through their system of insured health services, have made outstanding progress in treating sickness and alleviating the consequences of disease and disability among all income groups; that continued access to quality health care without financial or other barriers will be critical to maintaining and improving the health and well-being of Canadians; Canada Health Act Whereas

AND WHEREAS the Parliament of Canada wishes to encourage the development of health services throughout Canada by assisting the provinces in meeting the costs thereof; From the BNA Act through the Constitution of 1982 to the Canada Health Act it is clear that most, but not all, Canadians value: Equitable health care

Between provinces Between different income groups Efficient health care Good government Canada at its best: Social Justice and Efficiency Hon Tommy Douglas Social Democrat

Justice Emmett Hall Tory Outline The goals of Canadian Health Policy are equity and efficiency Private finance and for-profit delivery are incompatible with equity and efficiency We can fix our health systems problems without private finance, for

profit delivery, or a lot of new public money Private finance is inefficient and inequitable Single payer systems have much lower administration costs Single Payers can keep prices down Relying on private finance leads to large numbers of uninsured When people have to pay out of pocket,

the poor are less likely to get needed care Hence, the decision which Canadians have to makeis whether they wish to pay $1.020 millionin 1971 for a programme administered by the insurance industry, or $837 million for a programme administered by government agencies In our opinion it would beuneconomicto spend an extra $193 million. We must chose the most frugal method.

Royal Commission on Health Services. 1964. Percent of GDP US and Canada HC $ as % of GDP 18 16 14 12 10 8

6 4 2 0 CAN US Admininstration as % of Total HC Exp 35% 30%

25% 20% 15% 10% 5% 0% US CAN

S Woolhandler Int J H Serv 2004;34:65-78. Private finance for health care leads to large numbers of uninsured People who are not part of a group often find they cannot get health insurance at any price Private insurers deny coverage to people who are poor risks and are most likely to need care No private insurer would have sold Mr. Zeliotis a policy One in six Americans have no coverage whatsoever

and tens of millions more have inadequate coverage One in two Canadians lacked medical insurance prior to Medicare When people have to pay out of pocket, the poor are less likely to get needed care Access & Income US, Canada, Germany Did not seek

care because of cost (below avg income) Did not seek care because of cost (above avg income) 0% 10%

20% 30% 40% 50% K Davis. Commonwealth Fund 2006 For-profit delivery tends to be

more expensive and delivers poorer outcomes. Therefore, it is incompatible with efficiency, which by definition integrates quality and costs For profit delivery: In general -higher costs, no better outcomes PJ Devereaux et al (CMAJ. 2002;166:1399 1406. CMAJ 2004;170:18171824) For profit hospitals had 2% higher death rates and 20% higher costs

For profit delivery: In general -higher costs, no better outcomes PJ Devereaux et al (JAMA. 2002;288: 2449 2457.) For profit dialysis clinics had 8% more deaths For-profit clinics had fewer and less trained staff For profit clinics dialyzed patients for less time and used lower doses of erythropoietin In the US, 2,000 premature deaths occur every year among dialysis patients using for-profit clinics.

Contracting out clinical services isnt nearly as easy as the advocates claim (Deber 2002) low contestability

high complexity low measurability susceptibility to cream skimming externalities Externalities -- Non Profits are more likely to: expend resources on linking different organizations together to plan community networks engage their communities and enlist

volunteers Provide benefits, continuing education, and training to their staff Outline The goals of Canadian Health Policy are equity and efficiency Private finance and for-profit delivery are incompatible with equity and efficiency We can fix our health systems

problems without private finance or for profit delivery We could have prevented Medicares problems, but we can fix them! Medicare was the right road to take The real problem with Medicare is that it was designed for another time and was implemented as a compromise Costs are not out of control but neither is the system drastically underfunded

We can (and are) fixing Medicare's problems -- The Second Stage of Medicare Medicare was the right road to take Canada & US had same system < 1960 Now 47 million US uninsured Canada spends a lot less than the US but Canadians get more services Canadians live 2 1/2 years longer and Canada has a 30% lower infant mortality Medicare boosts Canadian business

Health care costs: 1.5% of Canadian manufacturers payroll and 9% of those in US Medicare was designed for another time and was a compromise We designed our system for acute care, but now the main problems are chronic illness Douglas originally planned a very different delivery system

Chronic diseases have a major impact Chronic diseases account for 70% of all deaths. Chronic diseases account for more than 60% of health care costs. Our health system has problems managing chronic disease < 30% of Canadians hypertensives have their blood pressure properly controlled

60% of diabetics have gone > 1 yr without an eye exam or a check for proteinuria 60% of asthmatics are not properly controlled Up to one in six seniors is re-admitted to hospital within 30 days of discharge We could prevent most chronic diseases > 80% of ischemic heart disease, lung cancer, chronic lung disease, and diabetes cases could theoretically be prevented

with what we know now This would free up over 6000 hospital beds across Canada Douglas originally planned a very different delivery system Swift Current Region: A regional authority model with a public health focus The Saskatchewan MDs fought off changes to the delivery system The models that were implemented, e.g. Sault

Ste. Marie Group Health Centre and Saskatoon Community Clinic, have proved fonts of innovation Medicare in the crucible: 1945 and Swift Current Region #1 Prepaid funding Services available on a universal basis, with little or no charge to users. Integrated coordination of health care delivery through the creation of a local integrated health region which funded a comprehensive service package

Group medical practice with doctors working in teams with nurses, social workers and other providers. A focus on prevention Democratic community governance of health care delivery by local, elected boards. Health Care Costs are not out of Control but neither is the Health Care System Drastically Underfunded

Percent of GDP US and Canada HC $ as % of GDP 18 16 14 12 10 8 6

4 2 0 CAN US Provincial Health Spending as GDP % % GDP

http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=media_01nov2006_e 8 7 6 5 4 3 2 1 0

Provincial per capita health spending (constant 1997 CAN$) http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=media_01nov2006_e 2,500 2,000 1,500 1,000 500 0

Trend Line Canadian Gov't Budget Expenditures % of GDP http://www.fin.gc.ca/toce/2006/frt06_e.html 50 45

40 35 30 25 20 15 10 5 0 Federal

Provincial Total We can fix Medicare's problems with the Second Stage of Medicare Removing the financial barriers between the provider of health care and the recipient is a minor matter, a matter of law, a matter of taxation. The real problem is how do we reorganize the health delivery system. We have a health delivery system that is

lamentably out of date. Tommy Douglas Only through the practice of preventive medicine will we keep the costs from becoming so excessive that the public will decide that Medicare is not in the best interests of the people of the country. Tommy Douglas

We Could Have Seamless Access to All Services Advanced Access in Ambulatory Care Cambridges Grandview Medical Centre and Torontos Rexdale and Lawrence Heights CHCs have gone to same day servicing Ten MDs in Penticton and Prince George The Saskatoon Community Clinic (20,000 + patients) went on Advanced Access in 2004. Saskatchewan is aiming for 20% of family

practices on AA this year and 100% by 2010 Reducing Waits for Specialty Care The Hamilton HSO Mental Health Program increased access for mental health patients by 1100% while decreasing referrals to the psychiatry outpatients clinic by 70%. Capital Health Edmonton decreased delays for diabetic education from 8 months to 2 weeks by not insisting patients see a diabetologist on the first visit to the centre

Reducing waits for diagnosis Toronto East General Hospital reduced the overall time from a suspicious x-ray to definitive diagnosis of lung cancer from 128 days to 31 day a reduction of 75% Reducing waits for treatment Alberta Orthopedic pilot project From 82 weeks to 11 weeks from family doctor to arthroplasty

Cost neutral Summary: Private finance and for-profit delivery are incompatible with Canadian values of equity and efficiency We can fix our health systems problems without private finance, for profit delivery, or a lot of new public money Lets demand governments and providers deliver the care we deserve!

Courage my Friends, Tis Not Too Late to Make a Better World! Tommy Douglas (per Alfred Lord Tennyson)

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