Ontario government suggests that an online University and allowing more international students to assist in funding the higher education system will bring in much needed revenue.

BC's Kevin Falcon indicates that allowing medical tourism is another way to generate much needed revenue.

The recent federal Budget 2010 will maintain federal transfers to the provinces for health...a key difference from the 1990s with Paul Martin's Liberals at the helm. Despite grappling with a huge deficit budget and infrastructure/stimulus spending, the current federal government is prepared to "pay on", at least for this year.

There is discussion in the back rooms of how to bring in a national Pharmacare program either by a CPP type program or through some other mechanism of federal funding. If you thought health care was unsustainable now, just wait for that plan!

All of these issues surrounding taxation and education and health care costs are exacerbated by Canada's low fertility rate in all provinces except for the territories which have a much higher fertility rate than the national average.

And if we look carefullly, the trade off is between "paying now" or " paying later". There simply isn't any other choice. We can raise taxes, look for other funding revenues or create a larger tax base either with more productive people in more productive companies.

Babies, or lack thereof, are very much a part of the equation. Quadrupling immigration will not be sufficient to change the "dependency ratio" or the "providing ratio" as some like to call it.

There are many reasons why Canada's birth rate is falling but interesting that the US birth rate is not despite their private insurance/employer-based health care.

Does higher taxation play a role in declining birth rate? I'm not sure but often financial reasons are given for putting off having children or having none at all. Raising children is expensive. 

In days gone by, families were expected to care for their loved ones in their senior years, for the most part. Some long term care existed but frequently, a senior family member would be cared for by at least one of his/her offspring and sometimes shared around at various times of the year. This was seen to be an obligation. There was no expectation that government or tax dollars would provide all the necessary care long term.

Now, government intervention is expected at all levels of care. We expect to pay taxes and have all of our needs cared for. This is impossible because of simple realities. There are not enough people to pay all of the taxes necessary to provide the care.

There is a VOLUME issue. Not enough tax paying base. Too many people consuming the care.

What to do?

Keep personal taxes low to encourage more families to have more children.

Keep business taxes low to encourage entrepreneurship and less reliance on government for employment.

Give more tax incentives for people to have more children.

Give more tax incentives for people to care for their own family members.

Continue to heavily subsidize post secondary education including apprenticeships.

Do NOT increase public expectations for a national pharmacare program.

Have an honest dialogue about what can be funded in the public health care system and what cannot.

Be frank about the need for more self-care and more savings for individual future health care...But NOT a CPP type plan! Please NO!

I encourage readers to check out the Comments....unlike most other blogs, this is where the real interesting conversation goes on!

Take care. Happy Reading. Enjoy some R & R!

Tough choice.

The Alberta spending spree attracts my attention mainly because it shows a province deeply challenged by a deficit that is likely to linger even though we all know the Alberta economy is one that adheres to the boom/bust/boom cycle. Difficulty is knowing exactly when the boom will hit again and if you are one of the patients left behind in the bust cycle.

With announcements out of Alberta recently that health care funding will be increased substantially in this year's budget...an increase of 17% I believe over last year's budget, it seems that the approach is destined to break the bank in the shortest possible time.

Is this a plan to give the public what they want and see what happens to all other sectors and the public's reaction to pot holes, crumbling infrastructure, and an education system that doesn't meet the needs of a modern world?

Is it a plan to bring in more services offered through  private providers but funded with public money?

Is it a move toward more private provision overall?

My answer is "yes"...and it's about time.

See the link to the Edmonton Journal article. Unless the public understands the trade-offs between monopoly public health care and everything else, we are destined to a paralysis in transformation. The more things change, the more they remain the same scenario is not an option.

I leave you with one question:

Why are nursing unions so set against private provision of care in addition to a public health care system when they are the first to be laid off when the going gets tough in public health care budgets?

Any rational thought that any of you could provide on this would be helpful but then again, some things simply defy logic.

Of course, tens of millions were thrown at neurosurgical cases in the past couple years in an effort to create an improvement but in my own estimation, nothing has really changed. I still wait for months...a year in some cases...for a neurosurgical consult in cases with positive MRI findings. I still have referrals rejected because the fax back reads "due to focus on cancer cases, cervical and lumbosacral cases will not be seen".

I do note that what did change after some money flowed was that neurosurgeons were suddenly quiet.

Looking ahead to an aging population and a population with increasing obesity, diabetes and cardiovascular disease, with all the inherent cerebrovascular complications such as stroke and MIs, it doesn't take a rocket scientist, or even a LHIN administrator, to figure out that things are going to get nastier.

I have copied the post almost in its entirety and hope that it provides a deeper understanding of how poorly our system is equipped to meet the needs of the future, not to mention now.

I will also have a look for Mr. Smitherman's comment.

Here is the post from eklimek:

"I am grateful the discussion is in the press about the shortcoming and unsustainability in providing service.

As some of you probably know there is a telephone communication system called Criticall in Ontario. It is used when an emergency requires treatment not locally available.

In years gone by, when there was surge capacity, it was very helpful in connecting the sending and receiving clinicians and assisted in finding emergent care somewhere in the province. Now with no excess capacity pretty well anywhere clinicians begin to view it as becoming just one more hoop.

Here is how it works. Since Criticall does not know the actual provincial bed availability for the needs of the patient (e.g neurosurgery) , it literally telephonically hopscotchs across the province sequentially ringing up on call neurosurgical services.

Reflect for a second on this. Say you are on call as at the potential receiving end. You also know there is no ICU /NICU or surgical capacity on site because you just took the last bed with the last case. Nevertheless you get called. You are obliged to respond, listen to the story, may choose to give telephonic advice for which shared liability is engendered and still must refuse to accept the case because you lack the capacity to treat the problem. All this, let's say, at 3 or 4 in the morninng.

Meanwhile, on the sending end, typically after 3 or 4 refusals for "no beds" over a similar number of hours of repetition and telephone tag with serial oncall services, the conversation turns to out-of-province care. Of course the alternative is to start over from the beginning, just to see if the bed situation has changed in the last 6 hours.

The new wrinkle is interposition of a medical director near the outset of the process if the patient is to leave the home LHIN. Who knew we really needed another noncare provider in this process?"

Thanks for putting it so plainly, eklimek. As health care in Canada sinks, the band leaders play on....except of course when they are trying to enter the life-rafts destined for the US.

Please feel free to go back and visit the previous journal entry. I'll be checking for comments over the next few days. I've left some info there on wait times in Alberta and on the new iPad. Interesting developments..

But while I was fishing for information on how Alberta is planning its strategy for health care (and I do like to check in on Alberta because I've found Albertans to be very pragmatic in their approach to many things), I came across this video which I'll link to in the comments section.

It is nice to put some faces to names that we hear so frequently but also to understand that the term efficiency in health care has little or no meaning because it cannot be reliably measured. Accountability is what we really need to be considering to forge new health care options and I'm glad to see some politicians somewhere in Canada have figured this out.

Without going on further, have a look and listen to this video that describes the new Alberta Health Services Quality and Patient Safety Dashboard ...sounds flashy and you may think it is the same old, same old, just repackaged but I get a sense that we are finally moving on from the ill-defined efficiency quest and instead to a more distinct measurement...

And if I hear any more about seemlessly providing the continuum of health care services while working together to achieve a more efficient health care system....well...I'll have to excuse my gag reflex......

I still remember the calls of an elderly patient with dementia who used to call out to me as I walked past. By virtue of my female gender she would call out "Nurse! Nurse! Nurse!" and although times have changed , in those days most nurses were women. The first few times, I stopped to see what the commotion was all about thinking that there was something wrong and hoping that I could be of assistance. The nurses across at their station later told me that she did that all day long to whomever walked by and despite all of us feeling somewhat guilty about the limited time we had to tend to her, we had come to the realization that she called out as part of her routine and that after assessing there was no immediate need, we would go about our business as necessary.

This may sound cold and uncaring but the reality was that she needed to be somewhere more homelike and have the stability and structure that daily routines could have provided her. Clearly, there were no relatives capable of taking her home or she would have been discharged long ago. But sending a patient with dementia and incontinence home or even to a nursing home is not really in the cards as most social workers will tell you. They need more care than can be delivered at the usual settings.

I still remember her and many like her. In those days, patient were often restrained for their own safety but thankfully progress has been made on that front.

The reality staring us in the face is that this scenario is playing out in hospitals all over the country to an even greater degree than 26 years ago. The issues associated with alternate level care patients are still not adequately addressed. Yes, 26 years have passed and by all accounts the issues are more widespread than ever before despite ongoing efforts to address them.

Now, Aging at Home Strategies are proposed to assist seniors in staying in their homes. There appears to be little understanding of the fact that there is usually an acute event that brings an elderly person to hospital leading to that person languishing in a hospital bed once their acute care is provided.

The acute event occurs whether the patient has assistance in their home or not. Acute events are often a fall or a cardiac event or an infection that comes on quickly or is resistant to treatment  for some reason (often related to diabetes or the fact that the patient has some degree of dementia). Aging at home strategies will not stop these acute events from occuring. They occur because of the frailty of the elderly person and are associated with aging.

More family physicians and more community care will not stop any of this from happening despite what Health Minister Deb Matthews proclaims.

It seems I am not alone in my thinking. Please see the link to a letter to the editor in the Ottawa Citizen this morning. The writer gives a very good overview of the problems we are facing in local long term care. The same problems repeat over and over across the province and the country.

Minister Matthews is practicing wishful thinking....and that doesn't provide health care as far as I know.

Enjoy any sunshine you can get over the next few winter months here in the land of ice and snow and generate some Vitamin D!

Have a Happy Day...

How much of anything is too much?

How much of anything is too little?

As developed countries leap into action speeding aid to Haiti, I hope that there is sufficient organization on the ground to get the water and food and supplies to those who need it.

Meanwhile, back in Canada several statistics are worth pointing out:

* 37% of adult Canadians are overweight

*24% of adult Canadians are obese

* the number of Canadian teenagers ages 15-19 with a waist circumference indicative of high risk for health complications has tripled since 1981.

* the number of young adults ages 20-39 (is 39 a young adult I ask! really?) with waistlines putting them at greater risk for health problems has more than quadrupled.

*over the next five years, Canada's labour force is expected to shrink, reducing Canada's economic potential to its lowest level in nearly 40 years

*less revenue for the federal government means a $18.9 billion "structural deficit" by 2013-14 according to a report released by the Parliamentary Budget Officer, Kevin Page.

* "You can't fix the demographics. Even significant changes in immigration policy are not going to change fundamentally those demographics."-Kevin Page

*"Canada's potential growth rate is going to decline, because labour supply is going to decline in the years out, and that's going to have an impact on government revenues, and over time, that is going to have an impact on government expenditures."-Kevin Page.

* Canada's potential growth in GDP is anticipated to slip to 1.7% in 2014 even if productivity returns to historical average.

*in the 1990s and early 2000's potential growth rate was nearly 4%

*Dalton McGuinty's full day kindergarten for 4 and 5 years olds is expected to have an annual cost of operation of about $1.5 billion by 2015.

*"..while national and provincial revenues are crashing down, provincial spending continues to soar"-Terrence Corcoran

* federal transfers will jump from $30-billion in 2002 to a projected $62.3 billion in 2014-15....money the federal government may not even have.

And while we count on government to provide all kinds of health care and social programs and security and counter terrorism,  and while a culture of dependence is not only anticipated but encouraged, the true "givers" amongst us are diminishing in numbers:

*a recent Cardus study, "A Canadian Culture of Generosity", shows that fewer than 30% of us now account for 85% of total hours volunteered, 78% of total dollars donated and 71% of all civic participation.

*the primary civic core of about 6% of the population does about five times its proportionate share

*a secondary group of 23% of the population does about double its share.

*"Unless action is taken by government to support these behaviours and the charitable institutions that underpin them, the work they perform will increasingly fall to governments that deliver them at a much higher cost to taxpayers."- Ray Pennings, senior fellow and director of research for Cardus

Here in Canada, it appears that we eat too much, exercise too little, give too little, take too much...and nobody calls us on it, especially not policy makers because to call it like it is would be too politically risky and well.... unpleasant.... and maybe even unCanadian.

We really do need a Canadian backbone and at somepoint we are going to have to lift the excess weight and find it.

I'll post the links for the stats I've mentioned and please consider making a donation to a relief fund for Haiti.

Appreciate your day!

Short term planning is all very expedient and politically correct and even necessary to some degree but the  trouble is this usually leads to a culture of IBGYBG ("I'll be gone, you'll be gone").  I give full credit to the Economist's Matthew Bishop for this acronym and it is possible he found it somewhere else but for now I'll refer you to his article in The Economist, "The World in 2010- Now for the long term".

What about the here and now? Most assuredly, we must deal with realities at hand and decisions meant to improve current conditions are not only needed but quite noble. But misplaced nobility is not usually a good thing and has all kinds of unintended consequences driven by fully intentional and usually self-serving motives.

Heading into 2010, my hope is that health care leadership will understand the stark realities of a new economic world and the new financial realities facing our country and our Canadian health care system.

We cannot continue to spend the way our politicians have spent in the past several decades. This is not to say that public health care in Canada must be scrapped-definitely not--but we must understand that good citizenship requires more than paying taxes to government to have it spend it for us in a way that it sees fit.  Good citizenship at all levels requires more understanding of how to be a responsible consumer or maybe even a "frugal consumer" of health care.

This "responsible health care consumption" will require education and expectation of the public regarding the new realities.

Let us not avoid uncomfortable short-term decisions but take action knowing that they must be part of the bigger long-term picture.

An article by Paul Vieira in the National Post today, "T is for Taxes", is well worth reading and refers to Generation T, where T stands for tax. The article describes what many Americans may be looking at in the future as value added taxes are looked upon as part of the solution there.

Although Canadians may not see the same sad face staring back at them when it comes to looking at their financial situation squarely in the mirror, we must similarly be aware that our fate is tied directly to the US.

If the past decade was the "Decade from Hell" as Time Magazine has described....pack some ice, the next 10 years are likely to pose some challenges that will require cool heads and long term vision.

Happy reading and try the twitter link!

The humming of this kind of cost savings thinking can be heard across the province as hospitals face a stark reality of insufficient government funding to cover their costs. Even with a 2% increase, many hospitals will still be in a deficit position--illegal according to Ontario law.

Hospitals are bound by law to balance their budgets but that doesn't seem to stop them from running deficits and as pointed out here on this blog, the solution is usually to appoint a supervisor who comes in, looks around, pulls a political lever for more cash, and down it comes from the government heavens.

Trouble is, not only are there not enough "supervisors" to appoint across the land to the dozens of hospitals in financial bind but there isn't enough cash either, federally or provincially, to be bestowed on any hospital willing to give up its control to a political appointee.

That makes it tough. The usual "plan" won't work and it might even start to look like a standard routine!

So on to Plan B. Plan B is to freeze the wages for public servants and it seems our Champlain LHIN CEO, Dr. Robert Cushman is onside with this approach with numerous quotes by him to this end reported in a variety of media sources. He suggests that ALL health care employees, union and non-union, should share in the freeze.

I'm betting that Plan C or D or E will be to reduce the number of LHINs and hence their CEOs and staff and then we'll see who is calling the shots.

I'm told that salaries of hospital staff eat up about 70% of a hospital budget, give or take, and perhaps it makes initial sense that holding the line on salaries will get us through a health care economic mess. However, the magnitude of the problem is much greater than will be solved with freezing the wages of hospital staff for a year or two.

Maybe for a year this strategy would help but how long can one freeze the salaries? Indefinitely? Because the uncertainty of the Ontario economy is very real. It is unlikely that we will emerge to see the economy churn along brightly as it did between 2003-2008. It ain't going to happen.

Another solution must be found. It isn't increasing taxes either.

One reporter suggested that it is time for two separate taxes- one to be applied to health care alone and the other to be applied to the other  of the requirements of the province.  In this scenario however, while health care costs continue to rise, the taxes for this stream will continue to rise significantly over the next 20 years outpacing inflation and growth in GDP-not a solution either.

The only way to hold the line on health care costs is to reduce patient services which isn't palatable at all for the politicians.

Sounds like a catch-22. The province can't afford to continue deficit spending, not with the potential for its credit rating reductions and associated increased costs to borrow. It can't afford from a political standpoint  to continue to raise taxes or cut patient services for fear of voter wrath.

In an insidious way,  more costs will be borne by the patient out of pocket whether it is for long term care or for paying for an MRI accross the border or for medical tourism.

Before we go to comments, I'd like to congratulate Ray Hession, a long time family friend, on his appointment as eHealth Chair. My husband was Chair of the Ottawa Hospital Foundation at the same time Ray was Chair of the Board at TOH but the family link goes way back. I have no doubts about Ray's capability but I wonder if anyone can tame the eHealth beast.

Interesting times.

Once again, thank you for taking the time to add your commentary. The insight is illuminating and thought-provoking and I anticipate more friendly discussions heading into 2010!

Best wishes to All over the Holidays---I'm going to keep a vision of sugar "health care" plums dancing in my head and try to stay Merry!

Cheers,

Merri

Overall, giving patients access to their records isn't easy currently and there are many groups vying for a foothold in this area. We've talked about them here under various headings but mHealth deserves to be brandished and waved about because it is a relatively inexpensive way to bring about a cultural shift so badly needed. Government does not need to be the payer for this.

Empowering patients to take more control of their chronic disease such as diabetes or hypertension or renal disease is a complicated task but it doesn't require spending billions of dollars on eHealth strategies that are entrenched for the benefit of many who are not patients at all.

How do we steer away from  enormously expensive eHealth programs?

Some say we should just keep shovelling. I say it is time for a remake,... a redo...a major revision to our thinking and a change in focus toward mHealth.

Some say mHealth can't exist without a robust eHealth system and I disagree.

mHealth can exist on its own and as the disruptive technology of  smartphones evolves, hopefully  the short-sighted mantra of  "spend, spend, spend" at eHealth will fade. What is the likelihood?

EHealth will not save money in my opinion and there is growing evidence that it won't.

MHealth on the other hand has enormous potential to get patients off their government dependence and provide improvement to outcomes.

I have taken the liberty of attaching an article by Christina Spencer at Sun Media on a report regarding private options that seem to be favorable to many people.

Kudos to Christina for bringing light to this.

Just in case you are feeling bombarded by my mHealth messaging, I promise to write about something different next journal entry.  To be honest... it probably won't matter since we usually come back to recurring themes. That's OK...it means we are "distilling" and the common themes that emerge are the issues that do need attention.

Thanks again for reading. Do try my twitter link as well as checking out some of my twitter brethren...Dr. Barry Dworkin's site is a "must-view".

One of the interesting things about the H1N1 pandemic here in Ontario is that it points out how our health care system has barely been hanging on. We've cut beds and providers over theyears and the powers that be are still on a binge of decentralizing care (seems we did the "centralizing" binge a decade or so ago and now it is time to reverse the process!)

All those alternate level care patients...OUT. All those dialysis patients...OUT. All those cardiac pacemaker patients...OUT. It seems keeping everybody "out"  of hospitals and tertiary care centres these days is the solution for at least a few LHINs trying to manage budgets that are not realistic. I guess nobody told the LHIN chiefs that the cost of off-site infrastructure is likely to be higher than centralized care...but nevermind...Meanwhile the feds and provinces claim that eHealth will amount to billions of dollars in savings for health care annually---not likely.

Lorrie Goldstein of the Toronto Sun has written an excellent article in the November 12 paper. He describes how successive governments have  managed to avoid providing the resources necessary for public health to do its job well. So far with H1N1 we have managed to avoid the bullet but he makes a serious prediction.

Yes, public health needs many more resources as germs evolve and Mother Nature challenges our abilities to maintain our population health during various outbreaks inside or outside of health care institutions.

The solution is to revamp the spending pyramid. Patients should be paying more for lesser health related problems through tax free savings accounts and private insurance while government spends more on public health and catastrophic care. Miscellaneous pieces of health care should be funded in a greater proportion by individuals.

I've provided the link to Lorrie Goldstein's piece as I did not want to copy it in its entirety...and it deserves to be read in its entirety.

Thanks Lorrie.