Poking the beast – “P” word missing from reform talk

The problem with discussing health care sustainability is there is no definition of what that means. Data would suggest that our health care spending is not out of control – the so-called cost curve has already been bent. Past increases appear to have occurred in sync with economic growth, the exception being the economic crash of 2008. Clearly those who are worried about sustainability are not equating it with affordability.

Across Canada the average increase in provincial health care spending this year is 2 per cent – hardly a matter of excess especially when one considers aging and population growth.

While Canada has done better than just about every other country in the OECD in controlling health costs, it has often come at a difference kind of price given quality issues that persist.

This week the Conference Board of Canada is hosting a two-day conference in Toronto on health care sustainability. Next week the discussions will be sure to spill over into the Ontario Hospital Association’s annual get-together at HealthAchieve. We’ll be at both.

Earlier this year health policy analyst Steven Lewis and former Cancer Care Ontario CEO Dr. Terrence Sullivan issued a paper on how to keep the cost curve bent.

Among other culprits the two put the finger on the fee for service structure – essentially an incentive to do more regardless of how appropriate the interventions are.

The same applies to Ontario’s new hospital funding formula and outcome based approaches. Some may be surprised to learn that the “outcome” funding is not based on whether the patient leaves on their two feet or in a body bag, but on how many procedures are actually performed. That sounds a lot like fee for service to us.

The authors write that governments are “repeating the error of equating activity with productivity.”

“They have encouraged hospitals to be more efficient but penalized them for successful secondary prevention that reduces the demand for more procedures.”

We all know that while many Canadians struggle to access needed health care, many more Canadians are undergoing interventions that simply make no sense.

In 2010 the Canadian Association of Radiologists issued a report suggesting that as much as 30 per cent of diagnostic testing was unnecessary.

Surprisingly absent from the recommendations of Lewis and Sullivan is the “p” word – privatization.

The nature of for-profit health care is to do more to increase profits, not less. No private company seeking profits sets out to do less because that often equals less return for shareholders. Yet in Ontario we have seen a proliferation of private for-profit care. It is more than half of all providers in both home care and long term care. Almost all independent health clinics are for-profit. We are seeing the emergence of more for-profit diagnostic clinics primarily in the urban areas of the province. Former Premier Mike Harris opened the door wide to for-profit community lab testing. The corporations behind these for-profit providers have a presence at Queen’s Park and new policy initiatives, such as a new form of remuneration being tested in home care, suggest the government is listening to them.

On a very basic level, for example, you have to ask yourself why the a cash-strapped government like Ontario is willing to pay as much as a 50 per cent premium on lab testing to keep it in private hands and simultaneously undermine the efficiency of hospital labs?

Past studies have shown that doctors who own their own diagnostic clinics tend to prescribe more unnecessary testing. Yet who is monitoring these referral patterns in Ontario? Can we at least not flag the outliers and suggest an intervention?

Why did it take governments so long to recognize the extraordinary high price they were paying for pharmaceuticals? The authors point out that the sky didn’t fall when Ontario capped generic drug prices to 25 per cent of the brand name alternative. Evidence would suggest they could go much further. At the most recent Council of the Federation meeting this summer there was agreement to reduce reimbursement for six popular generics to 18 per cent of brand name pricing.

Provinces like Ontario need to realize that they are often penny-wise and pound foolish in the way they allocate resources. That includes delisting of rehab and support services.

“Canadian Medicare has effectively deinsured home support and community rehabilitation,” write Lewis and Sullivan. “Deferring maintenance costs exact an enormous and partly avoidable subsequent cost.”

The authors note that when a frail elderly person walks into ER with an impending heart attack, the system is willing to spend tens of thousands of dollars for tests, surgery and hospital stay. “However, that is often the same person who languishes at home, mildly depressed, isolated, physically inactive and malnourished – someone for whom the system refused to spend a few hundred dollars a month on home care to prevent the catastrophe that ended up in the emergency room and the operating room.”

Sullivan and Lewis have ten strategies to address bending the cost curve, including recognizing the “needs curve” is the best way to bend the “cost curve.”

Critical to them is primary care reform, noting the family doctor of the future “should be part geriatrician, part chronic disease expert, part mental health coach and an excellent team player.”

The two speak about the need for honest discussion on health care reform, yet clearly they are reluctant to talk about privatization as a driver of health care costs. Perhaps they know that in this conversation many are still reluctant to poke the beast.

More on this later in the week.

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