Dr. Merrilee Fullerton on Healthcare

http://www.calgaryherald.com/Video+direction/2472656/story.html

Between the HST and the closures of hospitals, the Liberals stand a good chance of being whacked at the polls.

http://news.therecord.com/News/CanadaWorld/article/662650

Dalton et al, figure it out....we are struggling to provide quality health care across the board now..and our population has not peaked in aging--it won't peak for another 20 years.

Along with that we have not reached the trough in decline in tax revenue because of our shrinking tax base. Immigration won't solve the problem.

So the Liberals have created a very uncomfortable spot for themselves. They have created unrealistic expectations for health care through enormous spending over the past 6-8 years and they have created a dead end for themselves with the HST and Bill 8. Very poor long term thinking indeed.

"The premier pointed out that hospital budgets have increased 42 per cent since 2003, and Ontario is spending more than any other province on health care, accounting for nearly half of every dollar it spends.

“What we’ve got to balance is not only the desire of our families to get the best possible health care, but also you’ve got to balance that off against their ability to pay for that,” he said.

“The economy is just not growing as quickly as it has been in years past, so we won’t be able to grow new funding increases as quickly as we have in the past. I think that’s all sensible.”"

R:

The issues are understood by central.

Here, however, are the pressing issues.

1. We have an election to win in les than 18 months and can't share the truth, or risk losing power.
2. We have no one in charge - a new Minister, no effective permanent deputy minister, and tainted staff who went along with eHealth and hiding various salaries in hospital budgets in violation of at least the intent of the law, if not in actual violation.
3. A new DM will take 9-12 months to get caught up.
4. An OOP DM is most likely because of the assault that would occur on internal candidates (did you support the eHealth mess or why didn't you know about the eHealth mess?). There are actually people reviewing applications doing six degrees of seperation from eHealth, and also if they aren't directly attached (and most are), and , if clean, how come they didn't know?
5. Now to have both the Minister and Premier admit that rationing is going on because we can't provide the best care everywhere is not helpful, because it confirms that the government is going to do the rationing and not the "community".
6. The budget situation won't be fixed shortly.

Any solutions to get out of this nutty situation while still maintaining control of the public purse would be appreciated.

oh dear, I'm beginning to sound like Michael Decter with his "no speed limits" concept.

Perhaps I should rephrase the last line:

I'd prefer to get the message across to the public that despite what various vocal unions have to say, our government health care monopoly cannot continue.

In Quebec, they seem to have figured it out after the concrete overpasses began to fall on people. I hope we don't have to wait until that happens for the public to clue in.

this one is for you Andris..whether EMRs improve patient care has largely to do with how much is spent on them in the first place ie if the amount is billions and billions on electronics instead of new hips new knees or new medications or direct patient care, then how can one contrast the benefits of spending on EMRs or not...One would need to know what care was NOT provided and which care was sacrificed for spending on EMRs.One would also need to know the cost of providing the other services instead of providing EMRs and the overall benefit of providing billions of real services instead to say whether EMRs are valuable or not..

How does one measure the value of EMRs in preventing medication errors or in generating data, compared to the value of providing actual medical services or procedures? That is a tough comparison but it would need to be done in order to understand the ramifications of a very expensive EMR system...that should likely be developed through private funding only.

http://www.cmaj.ca/earlyreleases/25jan10-electronic-health-records.dtl

"Anne Holbrook, director of the Division of Clinical Pharmacology and Therapeutics at McMaster University in Hamilton, Ontario, offered a vastly different assessment and urged caution.

Holbrook said her work as principal investigator of COMPETE, a three phase $7.3 million study of electronic medical records (EMRs) in Canada, indicates that they may have some value, but “there’s very little that’s been proven. We need high quality research before we spend more.”

And when it comes to patient outcomes, she added, “there is no evidence that EMR makes a difference.”

The massive financial investments across Canada in systems linking patients and health care providers is being “driven by system needs” and the profit motives of EMR system vendors, rather than any kind of evidence that such records improve patient outcomes, Holbrook said.

“We have not been able to show from the literature that drug interaction problems improve,” Holbrook added. There’s no effect on clinical outcomes, but very impressive effects on processes.”"

repeat:

And when it comes to patient outcomes, she added, “there is no evidence that EMR makes a difference.”

mfo

The solution is before you. Existing policy is to ignore the inconvenient. Certainly no one seems to been enforcing the prohibition of hospital deficit budgets. Part way down the slippery slope, why enforce any existing legislation?

The Canada Health Act is toothless and federal funding will, if it has not already, dry up.

No rationale for improved care with EMR spending. Ombudsman exposing the LHIN. Premier admits there is rationing.

Looks like a free-for-all. Send the marshall out of town until the economy has turned around and "sanity" returns.

"until the economy has turned around"..well that could be at least 5 years and then another decade or so to recover from deficits..

The economy is on shaky ground...

What percentage of Ontario's health care budget is funded by the feds?


"And certainly no one wants to talk about the lengths to which we go to keep the aged and near-dead alive, or about the delisting of certain drugs and procedures from medical coverage and allowing private providers to fill the gap. Mention any of these ideas and the opposition parties, regardless of their ideological persuasion, rev up the fear-mongering among seniors and others, leaving us in the precarious situation where we find ourselves today.

Health care is so effective and so desirable that our demand for it is almost without limits,” says historian Michael Bliss. “Whoever tries to impose limits is bound to be unpopular.” And so we drive toward the horizon as the cliff gets closer every day."

http://www.theglobeandmail.com/news/opinions/this-health-care-crisis-will-require-more-than-savings-around-the-edges/article1446642/

DrK:

Your analysis is basicly correct.

We have controlled anarchy. With those in power, selective enforcing rules, regulation, and legislation as it serves political needs. This is not how a structured democratic system is designed to work. The documented response of the Premier to the unfolding eHealth issue demonstrated that first response is always - "we are right - you are wromg be quiet."

The problem is health is the biggest business of the government, and the government has an ideology to promote based on how they have been elected. They have been elected to provide all the free health care we want. Because the job of the government is to get elected, as long as more votes are obtainable by giving free health care to those who otherwise wouldn't be able to afford reasonable health care, we will remain in a spiral downwards unless we can get more revenue from the supporting tax base.

There are otherways of doing this, but those changes are too dramatic and too threatening to the current structure.

1. Mandate insurance coverage to all - if one doesn't access services, rebates are provided. A life time cap on consumption. Extra insurance is charged if you wish unlimited care. global hospital funding goes - payments tranfer with patient served.
2. Pay per visit out of pocket with reimburshmnet from the pool after bills submitted.
3. All ambulatory care is free - copayment upon hospitalization (encouraging preventive visits to avoid hospitalization.)

These are merely some examples of options - all have been discussed and rejected by the MOHLTC as too difficult to implement.


Lots and lots of people like what's going on., so the need for change remains low, as money still tickles down and keeps a lot of people happy.

We have seen the enemy and the enemy is us.

The plan is good.

http://www.ottawacitizen.com/health/Troubled+health+agency+finds+magic+pill/2492650/story.html

While I have faith in Cameron Love's abilities, I am not sure they are sufficient to overcome the pressure on community resources that is smashing at the gate.

mfO,

Sure, the "enemy is us" but a tipping point must come. Just when is the question.

http://network.nationalpost.com/np/blogs/fpcomment/archive/2010/01/27/jack-mintz-leading-the-way.aspx

"Both demographic and competitive trends will require industrialized economies to invest in more public and private capital and innovation if countries are to boost their productivity. Yet, what we will likely see in the coming years are higher taxes in many countries struggling with their indebtedness. And if these taxes fall heaviest on capital and entrepreneurship, fiscally-challenged economies will be less able to grow out of their debt burdens.

While other industrialized nations wallow in their fiscal mud, Canada should leverage its fiscal advantage to build its competitiveness. Canadian governments are already large enough — they just need to spend more wisely. The federal government could easily balance its $250-billion budget within the next five years by constraining salary increases and program spending to save $10-billion a year. It can also meet future spending challenges by reordering its priorities rather than raising taxes."

Short points on efficiency thing:

1. Interesting article recently (may find link again) on a Penticton medical clinic who reduced appointment booking waits down from several weeks to almost same day by following efficiency improvements based on 'queing theory' based assessments. Apparently most physician offices could benefit from such studies. Who is advancing this $ saving concept in Ontario? Why not?

2. Learned this morning of an Ontario emergency clinic who hired a psychologist to intervene with patients deemed to have no physical cause for symptoms. Offered quick course of pschotherapy leading to a very significant reduction in return visits. not to mention the actual value added of actually ahving helped many patients otherwise sent on there way until next week.

When will every major emergency room in this province be ordered to deploy dedicated psych. staff? If not, why not?

The Liberals will not be picking fights with anybody given their polling numbers. Slow and steady below the radar for as long as possible. A lack of civil service leadership gumption in key ministries is in tune with this overall strategy so Ms. Matthews et al doing their tactical best to advance to game.

HH,

Your item one has been promoted for some time. Essentially the doc(s) work like crazy, extra hours etc to reduce the backlog of appointments until they are caught up and then begin same day or next day appointments. What typically happens is that over time, they begin to fall off the appointment wagon again and have to work like dogs again to catch up and so on and so on.

This isn't really a solution at all, it just makes everybody feel better being caught up periodically.

Point number 2: Almost any physician either in family practice or ER would dream of having a psychologist to deal with some patients. Trouble is that funding for this is difficult to access. In a regular ffs setting, docs would have to come up with this extra cash somehow...not possible with the situation now. In models where government funds additional providers to do this sort of role, more cash is required.

Once again, funding is the real issue. Some groups are given funding for this others are not. You have to be one of the special groups ie CHC, FHT (limited in number I might add because of their additional expense).

http://blog.canadianemr.ca/canadianemr/2010/01/a-hiccup-for-phrs.html

..Alberta is likely to forge ahead with solutions before any other province, pragmatic group that they are.

A must read...enjoy:

http://www.edmontonjournal.com/health/Health%20care%20reruns%20nauseam/2489409/story.html

"If we, as a public, direct our elected officials to create provincial budgets that equate just the health system with being healthy, then our population -- in particular our children -- will continue becoming less healthy."
---------------------------------------

That is juvenile. No one ever, not even Mother Theresa, implied that taking care of the ill would make a society healthy.

Today a senior citizen with a 60 year pack a day habit came to my office with a cervical spinal cord compression, walking with a walker. She got an emergent MRI confirming the nature of her disease and referral to a surgeon.

If the authour suggests that this person in some way failed a "benefit to a healthy society test" and is undeserving, may I suggest that they come forward and tell that citizen that they will be denied care and risk paralysis from the neck down until death?

I think what he probably is referring to is the huge amounts that are spent to preserve a monopoly system at the expense of many other programs that would contribute to the well-being of the population and in particular, children.

If more and more public funding is poured into health care, there is less for all other programs.

I don't think that he meant to imply that an elderly patient should be denied care as in the case you present, eklimek.

It appears that he is pointing out that it takes more than a health care system to provide a healthy population.

this is likely the article HH was referring to earlier:

http://www.cbc.ca/health/story/2010/01/27/psychotherapy-emergency-room-halifax.html

Just wait until one of the patients with "psychological" symptoms dies after being seen by the psychologist......Let's hope the psychologist sees the "regulars" and not patients who have symptoms "not yet diagnosed".

"Ontario spending more money than any other province on health care"---is it really?

How much of the monies is spent on actual health care and how much on the huge bureacratic monstrosity that squats on it---supposedly 'managing' it but really obstructing and inhibiting those at the coal face actually carrying out health and disease care?

Our ponderous, obstructive and dysfunctional system is so top heavy with drones that it's embarrassing.

The trouble is that by going down the wrong path we are consuming time and wasting money when we could have been going down the right path---and we won't be going down the right path untill the last pointy head exhausts the very last alternative to going in the right direction and there are so many wrong headed blind alleys that they haven't explored as yet.

One day we may well find ourselves working in a rational health care system using evidence based methodology untainted by dogma , utilizing what works in the private and public sectors and rejecting that which doesn't work---one suspects that the opinions of those working on the coal face will weigh heavier than the opinions of those far divorced from it with their prognosticating charts and power point presentations when that comes.

Our own hospital which was closed and replaced by a 'modern' one which is staggering along barely holding together was once run by a nurse who ran it a la Florence Nightingale like a well oiled battle ship---she was replaced by an administer who knew his place and worked out of a converted closet with barely room for a desk and chair--- he worked smoothly in conjunction with the Board composed of very concerned citizenry, the doctors and nursing staff, listening to the concerns of all concerned and of the patients---gradually the space occupied by the new administrators expanded and became increasingly plush despite deficits, as they were joined by more and more self important administrators and bureacrats---indeed at one time it was the bureaucracy that had the air conditioning with the patients denied its cooling properties---the Boards eventually were packed with self serving members handed picked from high, and all became deaf to the needs of the patients and completely deaf to the doctors and nursing staff, co opting both compliant doctors and nurses into the hospital bureacratic administration to the detriment of morale of those left at the coal face who are outnumbered by those managing them---coal face doctors and nurses are now gagged from speaking their minds by the new rules and regulations---any dissent on the Titanic has been crushed by those who have golden plated lifeboats standing by if things go awry for them.

The system, in particular the hospital system, as it stands cannot last---the sooner the whole rotten structure is kicked over the better.

I am not sure what this report's conclusions offers which is different from what we had in the early 90's when I started to practice medicine. The doctors worked in the clinic with several nurses. Across the hall was a dietitian, physiotherapist, and across the street was the town's pharmacist. We all got along, consulted each other and often socialized together. The physician was the "care coordinator" and that is where the buck stopped with regard to final decisions after consulting the rest of the unofficial team.


"There needs to be a radical new approach to the training of doctors – with more emphasis on patient-centred care, preventive health care and working in teams with other health professionals, according to a much-anticipated new report."

http://www.theglobeandmail.com/life/health/md-schools-call-for-radical-rethink-of-doctor-training/article1448221/#comments

"I don't think that he meant to imply that an elderly patient should be denied care" - r
--------------------------------

Maybe not. If healthcare is delivered to individuals reductions must be implemented individually. Withdrawal of funding has individual impact.

As always Andris has a monochromatic descriptive style with which I largely agree. The problem at my end money spent administering the money to be spent on delivering care leaves less for delivery.

How much more would be available if it were spent on care?

On a separate note, around the time of the Ontario Cabinet shuffle project funding became scarce.

a twitter friend of mine pointed me to this article on tuition hikes at U of Calgary for medical school.

a $4,000 hike seems a bit steep...and an example of how costs in education will rise as more and more funding goes toward health care. It looks like only the wealthy will be able to afford becoming physicians.

oops, here is the link:


http://www.calgaryherald.com/news/Planned+tuition+hike+draws+fire/2497884/story.html

In the article Canary posted from the Globe, there is discussion about promoting generalism and a greater role for patient responsibility...and yet the changes that are occurring in health care point directly away from this.

Does this mean that the Titanic is changing direction slowly or does this mean that the band is still playing while the ship goes down?

Some upcoming timelines:

So, for those who don't get the timeframes for change:

We are short a Deputy Minister (DM). The DM runs health. He/she must know and coordinate all, and, in the end, approves all decisons.

This appointment is subject to all party review, and rises and falls with the party in power.

Any new candidate will be subject to the new standard of scrutiny - particularly with respect to the politics of LHINs, eHealth, and the burying of the DMs salary (and others) in hospital budgets to get around the rules. They will be asked if they knew about; and if they didn't why they didn't know if they are "in the know" people.

This means very unlikely any current MOHLTC staff will be in, because they all knew and condone the abuse of power. Means very unlikely any senior hospital/CACC/agency currently in Ontraio well be accepted because they are all tainted. Could be senior staff dismissed under the previous two ministers action might be brought back as "good" people who fought against the corruption, but that is unlikely.

Out of Province, within country. There are some candidates out there, but who would move and possibliy be out of work after the next election?

Out of country. All Americans on "no go" list, becuase they would taint public care. European/Far east shortage of applicants.

So any in province appointment will likely come in tainted (thus subject to constnat sniping) if they are from the health field, and any OOP choice has a longer learning curve.


So where we are: short list is being sorted through. Could have appointment within 6 months. Give new guy/girl 12 months to get up to speed. Election. Liberals lose - DM goes. Liberals win - DM stays. So no action of significance in MOHLTC in under 3 years and it could be longer.

Welcome to the plan.

ahhh...a insight like no other, mfO!

How can it be that when we need leadership in health care the most, that there is none in sight?

Oh well, perhaps the work of the DM creates more problems than it solves...maybe...

How is it that the LHINs have any expertise to determine which rural emergency departments should close and which should not? There are no physicians in these agencies and likely no criteria regarding transport times were looked at when the Fort Erie and Port Colbourne EDs were closed rather it was simply a dollars and lack of common sense decision.



"The Canadian Association of Emergency Physicians is calling on the federal and provincial governments to set standards for treatment, including the maximum time and distance of a patient's trip to an emergency department.

In a country that takes universal access to health care for granted, there needs to be a national understanding of minimally acceptable standards for emergency care, said Alan Drummond, a spokesman for the association, in an interview yesterday.

"People shouldn't be winging it with respect to emergency care," he said."

http://www.theglobeandmail.com/news/national/er-doctors-call-for-national-care-standards/article1448573/

'B.C. doctors finding ways to speed patient access' article here FYI

http://www.vancouversun.com/health/doctors+finding+ways+speed+patient+access/2203861/story.html

Realist

1. The article will reveal that the access improvements achieved relied on doing abit more than you suggested.

2. Placing psychologists in emergency department story is about managing emergency department volumes efficiently and therefore preserving resources. Not a investment physician clinics would likely consider as you say. Sorry I misled on the application.

For those lamenting ther fact a bureaucratic layer exists let me ask again: How much of the budget should be allocated to 'adminsitration' in your opinion? How do you arrive at your figure and how does it compare with investment levels in play in comparable insudtry settings?

Just asking because there is a 'baby and the bathwater' tipping point here somewhere.

"So we worked like maniacs to clear off the backlog and then changed to an advanced booking system."

That's pretty much what I said in a previous post, HH.

HH

In order to answer your question, I think we need to determine what does "administration" actually contribute? Doubtless there are needs to be filled, some episodically and some more frequently.

We seem to have a fair number of full time equivalents in the management sector judging by the parking lots filling up 8 to 4. Is this is what the task demands? My previous posts suggested that until absence makes the need to be filled apparent, why are they?

It is a time honoured observation that the value of a "job" is rediscovered during absence. Arbitrators recognize disproportionate numbers returning after absence become unemployed. Even during "holidays" managers want to remain "connected", if only to reassure themselves and others that they are value added.

Psychologists in the ER ---presumably to make the languishing patients feel better and to rationalize the 8 hour wait to be seen after having been triaged two to three times---perhaps they should also be employed in airport terminals to ease public anger as the wait, corralled like cattle, to be pawed over by bored security staff.

Too much of the health care budget [will we ever find out the true figures?] is squandered by layers of administrators/bureacrats whose primary job seems to be to obstruct/impede those at the coal face from doing their job---perhaps they make work for themselves to rationalize their positions.

Parkinson had it nailed and his 'Laws' should be studied by all concerned---and where such violators are detected the hatchet should come out.

Never forget that much of the public sector is actually a welfare system

Back to the plan:

"Mr. McGuinty said he would welcome a coroner's inquest. But he said the "guiding imperative" that is driving many hospitals across Ontario to restructure is the stark reality that the government cannot afford the best health care in every single community."


So we will have threee levels of official care in Ontario. Level 1 will be serving population groupings of less than 250,000. It will include all health services not drawing on a population base of at least 250,000. These will be our "centres of mediocrity" - care is available, but don't expect too much. Second level will be serving population of under 1,000,000. These will be "centres of average care". Not bad care, but could be better.

And of course, centres of excellence, serving population grouping of over 1,000,000.

Fortunately, we have reached an honest stage - we can't afford the best care for all - so we'll triage and hope mediocre works.

The plan is good.

"government cannot afford the best health care in every single community" - DM

"the health care insurance plan of a province must entitle one hundred per cent of the insured persons of the province to the insured health services provided for by the plan on uniform terms and conditions." - CHA

http://www.liberal.ca/en/newsroom/media-releases/17400_liberals-are-working-to-keep-canadians-healthy

At least she acknowledges or eludes to the unsustainability of our health care system and to the need to address social determinants of health in a more significant way. However, she is off the mark about solutions to both of these areas....and it is not to tax more to provide for these increasing needs. The solution is to provide a more balanced health care system by encouraging public to use savings vehicles to purchase more of their own health care. This would allow more spending on social determinants of health.

Spending like crazy on health while increasing spending on social determinants of health will only result in a more unsustainable system.

Physicians retire later than other professions...no kidding.....so pension and difficulties saving for retirement given current economic difficulties across the globe.

http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=media_20091126_e

Incentives will not save the health care system any money even if they do provide improved outcomes.

http://www.nationalpost.com/news/story.html?id=2501283

"The theory is that they were less likely to need pricey hospital care."

This is a good thing. My observation is that preventive measures result in prolongation of life, delay the last six months of expensive/intensive care, and thereby delay one cost in exchange for another.

DrK:


Hmmmm. But the Premier and Minister has publicly declared that the province can and will not support the "best" care to all citizens on uniform terms and conditions.

"the stark reality that the government cannot afford the best health care in every single community."


ain't politics grand!

No wonder people are frustrated and angry.

probably should be on the last journal entry string but what the heck....

Concerns about long term care cuts being a deficit reduction measure:

http://www.oltca.com/axiom/DailyNews/2010/January/January29.html

Minister Matthew's first mistake: probably won't ber last:

Statement on Toronto Grace Health Centre
http://news.ontario.ca/mohltc/en/2010/02/statement-from-deb-matthews-minister-of-health-and-long-term-care-1.html

As soon as the Minister stepped directly into this, she undermined the Toronto Central LHIN, played directly into the strategic hands of the local board and organized labour and set precedent for future interventions across the province.

So what are we to interpret when the Middle-of-Nowhere General Hospital board decides to approach its LHIN to turn over the keys and the Minister does not promptly step in?

Some among us will say that she does nothing and let nature take its course (which should have been done here). Nothing against the Toronto Grace - I am confident that the board and staff do exemplary work in a very difficult environment.

Others will observe that Toronto gets treated preferentially than the Middle-of-Nowhere.

And they would be correct.

I can tell you one thing...it is pretty upsetting for fundraising donors to give to a hospital one day only to see their contributions bulldozed the next.

I still remember walking through the entrance of the Grace Hospital here in Ottawa 17 years ago and seeing all the donor names including very recently added names, only to learn that the facility was to be bulldozed in the not so distant future...and of course, it was.

While no donor expects their contribution to last for eternity, it would be helpful if hospitals who raise millions and millions in funds to keep equipment and facilities up to developed world standards would let their donors know of such plans, otherwise it seems incredibly wasteful.

and nothing to keep Premier Danny Williams from traveling to the US for health care but honestly, if care is so great here, why is he going to the US?

http://www.theglobeandmail.com/news/politics/danny-williams-travels-to-us-for-heart-surgery/article1452524/

"Newfoundland Premier Danny Williams is scheduled for heart surgery in the United States, a move that throws into question his province's and his nation's health-care system.

A source confirmed to The Globe and Mail late Monday that Mr. Williams has left St. John's for an undisclosed destination in the U.S. to have heart surgery later in the week."

Why does one have to be kept captive in one's own country to wait on queues for health care?

Why does one have to "escape" to another country to get timely care?

I am assuming that Premier Williams must have considered going to another province such as Ontario where cardiac care is world class (not to say that cardiac care in NFLD is not worldclass...I simply don't know enough about the care there to comment on it)...but took the option of going to the US instead.

One can only surmise that jumping the queue in Canada, was seen to be the worst of the two choices.

Wonder if he has private health insurance, likely, or if his province is going to foot the bill for his "out of province" care.

Story could have legs.