Why the changing of the guard in other provinces?

Clearly, the provinical health portfolio is a toughy and not for the faint of heart. The complexities of the health care system are vast and attempting to solve one problem undoubtedly ends up with others springing up like bad weeds. There are just so many groups that are accustomed to having their usual share of the pie that creating any kind of unknown such as more options for self-pay just seem to  shake the foundations of their existence. This is unfortunate since we do need to boldly go where others have gone already  but perhaps with a slight Canadian twist.

Looking at the push for the US to spend over a trillion dollars in the next 10 years on developing a more universal system, the billions we spend here in Canada seem relatively less significant. But careful with this thinking because as a much less populated country with a potentially shrinking tax base we are heading for much more difficult times. This is my way of saying "you ain't seen nothin' yet".

This is quite possibly why we will see provincial health ministers changed on the fly....except in Ontario where we apparently like to keep them around for as long as we can. It helps deflect blame from those at the real helm  and changing too quickly could create the appearance of indecision I suppose. But government really has no solutions anyway in my opinion, so maybe it really doesn't matter who gets made the scapegoat in the end as long as somebody takes the fall.

Mary Schryer has taken over from Michael Murphy and she will have her hands full trying to patch up the mess that has been created by the government"s unwillingness to honor its deal with physicians there. The New Brunswick Medical Society has threatened to take the Government to court over its refusal to follow through with the negotiated contract.

Her background is as a financial planner and director on the board for the Atlantic Health Sciences Corporation. Sure will be interesting to see if the docs let the government off the hook or if the new Minister can manage to smooth things over. It will be a dangerous precedent if negotiations in good faith stand for nothing.

In Nova Scotia, Maureen McDonald takes on the Health portfolio....a former social work professor at Dalhousie. Evidently, governments shy away from having physicians as health ministers...better to let every other group have a stab at it. Has a physician ever been a Health Minister in Canada? Don't think so.

And last but not least, BC's Kevin Falcon steps into the fire and hits the ground running even if it is with his foot in his mouth. Comments he made about private care have quickly been "clarified" and he speaks of the need for innovation in health care......I hope this doesn't mean just switching to superboards with multi-million dollar deficits as in Alberta....because I have a secret for you: this isn't a solution.

The more things change the more they stay the same and nobody, well almost nobody, has the guts to tell the public that they must have a greater part in making sure we have a strong public health care system which includes allowing more options for self-pay.

His comments were positive and included mentioning that primary care physicians need to have incomes more in keeping with specialists to make primary care more attractive. He also suggest that patients should have choice over which insurance plan works best for them....a marketplace for insurance products would be formed.

When questioned about a government insurance plan by former President Bush's health care staffperson who oversaw Medicare during the Bush era, he was asked about how the program would work if trillions of dollars were needed. If I recollect right, his response was something like "it won't be easy". That is the understatement of the decade.

In any case, it does appear he values primary care physicians and tens of thousands more will be needed in the US in the near future if plans for coverage of the uninsured is going to happen. We've talked about this before on this blog and numbers now seem to indicate that the US will need between 40,000 and 130,000 more primary care physicians. I hear a loud sucking sound.

This is occuring as our own College of Physicians and Surgeons of Ontario is bringing in more regulations of the medical profession here in Ontario that will likely lead to migration south of medical students and physicians, eager to throw off the shackles of a an apparently politically driven College that would appear to take its orders from the Toronto Star.

But enough about the changes in the US....it may not have the funding to create the changes required but I must say that Obama knows how to talk the talk.

In one of may last posts on the previous journal entry I provided a link for a case of a young woman stricken with neurofibromatosis and whose life is at risk yet OHIP is refusing to pay for an experimental treatment which is her only hope for survival. Now compare this to  the $2,700 per day fees that some consultants where charging for the eHealth work (and don't forget the tea and cookies) and to the billions that eHealth will spend on developing universal EMR/EHR which may never save any money at all.

One wonders if Ontario's health care system really exists for the right reasons. Is it a political tool used for some but not for others and for some diseases and not for others? It would certainly seem to be the case.

So along comes Kevin Falcon, British Columbia's new Health Minister who is reported to have said that he believes patients should be able to use their own money to buy expedited health care in the private sector as reported in today's National Post article, "Minister Backs Private Care".

Finally--a politician that is not tying himself to the mast of the listing good ship "Monopoly Public Health care" and who probably realizes that government cannot be the provider of all medical care and in fact, is not.

Some pertinent quotes from the article:

"I don't have any philosophical objection to it....What we have to do is improve the public delivery of services".

"I do not have any objections to people using their own money just as they do for dental care or sending their kids to private school."

"I think choice is a good thing and reducing it is not a good thing."

Well I'll be.......

What can I say?

Entitlement, Feeding at the Trough, No Accounability, Nepotism, Hypocrisy.....and on an on.

Disappointment isn't really an adequate description for the degree of buddy buddy business going on here.

While I recognize that health care and eHealth are exceedingly complex, I would have hoped that the leaders at the top could have set an example.

Dr. Alan Hudson threatens to take funding from hospitals that cannot meet their ER Wait times numbers and yet apparently is involved in awarding hefty contracts to consultants with little or no accountability.

And Pricewaterhouse Coopers, the same firm that looked over the system within the last year is going to find something wrong with the mechanisms of awarding contracts at eHealth? I think not.

I encourage you not to let this drop. Our leaders must be held accountable in one way or another.

You want to spend $26 billion on eHealth like they did in the UK?

Whether it is reports on "female physicians less productive" (whatever productive means) or possible diagnostic errors from Saskatchewan (not all docs are the same and not many driving taxis despite the medical mythology that exists), or nurses taking the lead in private provision (now there's an irony--see the May 26, 2009 article in the National Post on home care-"Health-care's prescription), medical news is definitely in the public eye.

Unlike decades ago, when if you didn't read it in the newspaper or hear it on the radio (or from a talkative neighbor), news didn't really exist, we now have an age of information at our fingertips and a wealth of knowledge being spread amongst the masses (albeit not always accurate knowledge).

Despite Medicine's past paternalism, the delivery of medical care is changing in this New World where just about anybody can research a disease, understand the presenting symptoms and find the available treatments. Just don't ask a patient to be able to put this into  context necessarily or to safely choose the treatment. Because without the background of experience and the training that includes seeing thousands of patients, it is not always easy to put the pieces of the health care puzzle together.

People like Dr. Hudson willl state that other providers are needed to do more of the mundane tasks of a family physician and I quite agree  despite not believing that this will be a cheaper alternative. Nurses and PAs and dieticians could certainly monitor various chronic conditions and this could be quite helpful. Ultimately though, I think it should be the patient's choice as to who "pilots" their care (credit to Andris and eklimek for this concept).

As chronic diseases lend themselves to monitoring by various providers, we still need specialists and family physicians to put medical science into perspective for the patient and the team. It is not sufficient to know that all diabetics should have an annual eye exam, foot assessment, and monitoring of various health parameters. One needs to know how one aspect of treatment will affect another and when a symptom or sign should be a red flag instead of just another line on a patient's list. And don't forget the human need for emotional support, human touch and trust.

With this in mind I read with great interest, The Economist, April 18th edition, "Medicine goes Digital" and if you can go back in the Economist Archives it is well worth the read.

The space on this journal entry can't do it justice but it provides the scope of the changes that are coming. I for one, cannot see how government is going to afford even a small percentage of these changes. I'll list the  the links in the comments section.

Titles of interest from the April 18th edition of The Economist:

HIT or miss: Health reformers have long wanted to digitise medical records. They are getting closer. Page 4.

Flying blind: Digital medicine will improve medical care-and it may possibly revive drug discovery too. Page 6

Getting Personal: The promise of quick and cheap genome sequencing. Page 9

A doctor in your pocket: Developing countries are using mobile phones as a way of leapfrogging to personalised medicine. Page 11

Fantastic Journey: Medical technology is making medicine more portable, precise and personal. Page 15

Health 2.0: The arrival of digital medicine is already empowering patients-but will it also lead to better health? Page 17 (of course, you could probably tell that this one interested me the most..."the shift towards patient empowerment is 'unstoppable'"......and with this must come increased responsibility)

Coupled with these changes is the advent of more private involvement in the health care world. There is simply no way for government to fund every last bit of technology. It doesn't even do it now.

Where will technology take us? To more access for patients and likely more choice along with more patient responsibility and individual funding of personal health care segments.

I've mentioned American Well before and its Hawaiian endeavor to bring online visits to appropriately replace office visits. One study examined the potential for online care.  The areas focused on were non-emergent care replacement, acute physician office care replacement; and maintenance physician office care replacement. The study was followed by the extension of "Milliman's Care Guidelines for Online Care"TM which are evidence-based clinical guidelines spanning the continuum of care including chronic care and behavioral health.

Most recently, a collaborative of physicians created "Decision Guides for Online Care" which supports providers when a patient presents online with a common complaint such as abdominal pain, headache or earache. More details on this can be found at American Well's Online Care Community in an article by Roy Schoenberg called "Developing Guidelines for Online Care".

So...health care is about to make a huge leap......take a big breath but don't close your eyes.

Happy reading and I'll post as many links as I can. Enjoy the day!

Now don't call me reckless....I do understand the severity of the situation in general but there are lots more likely things to kill you right now than H1N1. I do agree with limiting the spread initially and I can see why Mexico has imposed the restrictions it has. Very sensible.

I suggested a few years ago when I sat on a Trans Atlantic flight with a traveller behind me who sounded like they were about to cough up their bowels, that passengers who were coughing be given masks. The air hostess seemed to think it would be insulting to the passenger involved but really, to think that people travelling sick like this should be ignored by responsible parties is an attitude that belongs packaged away in some musty dusty old place.

I do recollect that the plan here in Ottawa was sadly lacking in common sense when it first rolled out. There was no plan to close schools or stop public gatherings and in fact, the concept was to have people who thought they might have the pandemic illness to come to community areas to be assessed...so if they didn't have it before, they would probably have it after being around many who did! Not very sensible to me.

So here you go, H1N1....talk all you want. Next topic is The Economist, April 18th edition...a must read!

One of the comments on this topic was eluded to in the last journal entry Comments section and it is a poignant reminder that the better we get at treating disease, the more government will need to spend in health care.

Last May, chemo wait times were stagnant despite large increases in funding. This May, they are rising and increased funding given Ontario's financial circumstances is questionable.

"We are victims of our own success", was the comment. Patients are living longer with their cancer because of new treatments and new medications and thus are chemo-treatment repeaters. I'm grateful that this is an option for patients but I cringe a little when I think of the repercussions of a goverment monopoly health care system in which patient responsibility is  largely ignored as part of the solution but in which rationing is rationalized by the use of "evidence-based" medicine and "best-practices" which are really buzz words for limiting patient's options in a constrained system. And anyhow, it looks like the UK's NICE system of evidence based medicine actually ends up costing more. Don't ask me how.

Let's be honest about this. If government cannot afford to provide care and treatment in a timely way or to the satisfaction of the patient, then it would be fair not to promise this in the first place and to allow patients to plan ahead. But that would take more responsibility and it seems nobody expects this from patients.

That is a big problem  no politician seems to have the courage to address.

Having lived in Alberta for a number of years, and understanding the independent mindset that generally exists in the Wild West as well as the boom/bust cycles that seem to create a perpetual whirlwind there, it is almost expected that change will come from such a province. The other province offering up change is, of course, Quebec. I don't mean "transformation" because only  Mr. Smitherman knew what was truly meant by that. I mean real change--- maybe even an evolution/revolution toward more patient-driven care. This change can  occur if patients engage in the responsibility of their own care creating a cultural shift supported by new communications technology and a public health care conscience. If only the system would let them.

It can be argued that Alberta doesn't have a provincial sales tax and this could easily be instituted to offset the rising costs . But things are never that simple when it comes to health care as the authors of this report conclude. Several solutions are presented and not one appears to be "just add more cash to the pot" because....to share a little secret....... the health care pot is not bottomless despite what many well-intentioned doctors seem to believe.

The recent downturn in the economy co-incides with increasing expectation and demand for health care along with  pharmaceutical advancement and technological change that the report touches on. Although ageing in itself is not the main problem for sustainability, it is the various new forms of care and treatments  that an ageing population expects that will be the cost driver.

So despite being just another report on the sustainability of health care in Alberta, I think that this time there is more urgency involved. The big health care train rolls very slowly and we need change faster than the bureaucracy can provide. Not only is health care changing, but the pace of change external to health care is happening at an even faster pace. How to keep up?

And I have to ask:

If Alberta, a "have" province, cannot sustain its level of spending on public health care, how is Ontario, a "have-not" province, going to manage? Surely, not just by shuffling  some federal money around and it doesn't look like the manufacturing sector is going to make a come-back in Ontario anytime soon. Will Ontario be relying on other provinces running deficit budgets to bail it out in equalization payments or are we all going to rely on Saskatchewan? The whole situation looks somewhat precarious.

While Mark Carney pumps out more virtual money and interest rates are held to an all time low, some uncertain times are ahead across the country.

Pertinent points from the report:

First the report summary-

"The long-term fiscal sustainability of Canada's publicly funded provincial health care systems is under pressure from an aging population, expensive technological advances, and expanding coverage that is pushing up against constraints on provincial government revenues. Alberta, for example, enjoys the benefit of energy royalties, but the volatility of this bounty has been high-lighted by the recent collapse in energy prices and the loss of upwards of $6 billion in resource royalties. Other provincial governments enjoy more stable sources of revenue but are constrained in their health care choices by heavier tax burdens and larger public debt loads. This paper examines the challenges faced by governments as they attempt to satisfy the needs of the public today, without compromising the needs of future generations."

-projections of real capital spending on public health care in Alberta over the medium term out to 2030: between $5,339 and $14,215, soaking up between 32% and 87% of total government revenues

-growth of spending on non-medicare categories such as drugs, capital and all other health expenditures are growing faster than either revenue base or the economy. Traditional core medicare areas of physician services and hospitals are not.

-options for sustaining provincial government health expenditures include: choosing what other government programs could be allowed to grow more slowly, what tax rates could be increased to cause the revenue base to grow more quickly, and what health programs currently provided by the public sector could be provided privately

-a portfolio of policies that combines these solutions likely would be a pragmatic policy outcome ensuring the fiscal sustainability of Alberta's public health care system can responsibly provide for future welfare of its citizens.

I'll post the link to the report in the comments section as well as a link from the National Post article by David Gratzer from April 22.

Just when Ontario will produce such a report on sustainability is to be seen. In an era of increased accountability and transparency one would think it would be forthcoming...but shhhhhh, maybe we just don't want to know.

Happy Reading!

It is also a big, deep money pit into which government may potentially pour billions and billions of dollars without very much at all to show for it. We have already seen how money bled from a variety of organizations that have since been reincarnated. Intentions were good, it's just hard to get going.

Having said this, I am not against IT changes for health care. They must come. I even believe that we will stumble along spending more money than we'd hoped and making costly mistakes along the way. But we must move forward. The world has changed along with patient expectations and we must start somewhere.

The difficulty I have with the IT spending spree is that there seems to be little room for ground up innovation--the kind of innovation that is spawned by physicians having the freedom to innovate on an independent level to provide service that patients need and want. This approach helps eliminate the costly middle infrastructure that not only adds to the cost, but that delays implementation.

We know that it takes about a decade to change very much in health care. As innovative ideas trickle through the various levels of bureaucracy, some meet their demise because they don't mesh with a government driven agenda. Others meet their demise because they can't hope to meet the archaic vision of various provincial  physician regulatory bodies or even because the public insurance computer systems are so antiquated that they can't be made to accommodate modern requirements.

But during all this evolution, we miss the simple communication tools available easily to many of us, both patients and physicians, right now.

At a House of Commons Hearing on Human Health Resources last week, it was clear to me that some MPs are serious about their responsibilities. Others are not. As a witness at the hearings, I was given the opportunity to ask the other witnesses from various groups questions regarding human health resources. To some this might appear quite strange...witnesses being given time to ask witnesses questions. It isn't the usual process that is for sure.

I am left wondering:

Did the MPs want to provide a courtesy to the witnesses like myself?

Did they not know enough about the subject to ask analytical questions?

Had they not followed the presentations well enough to be able to ask questions?

Why this deviation from the usual protocol?

Please do not misconstrue my comments and questions as disrespectful of the MPs and the process. I am merely trying to understand just how BIG the knowledge vacuum is........and I think it is very, very big indeed.

After attending a session at the Rideau Club the week prior at which Keith Martin was also in attendance, I was comforted to read his comment in the National Post Full Comment section April 7 in which he denied our health care system was the "best" in the world. He even admitted that significant change is required. It was a breath of fresh air particularly from the Liberals who seem to be tied to the mast of a sinking health care ship.

Yes, change must come. We need less regulation that stifles innovation. Hang on, please don't trot out the lack of regulation that led to the demise of the US economy. The whole sub-prime mortgage fiasco there was created by  government that encouraged banks to sell products that had no feet to stand on and is not a result of capitalism gone bad.

In health care, we need to find the balance between over-regulation that smothers innovation and patient-driven care vs regulation that could be beneficial and spawn new ways of approaching patient care.

I suspect that as time goes on and the iGeneration begins to need health care in larger amounts, that the system will embrace change. Just look at Jay Parkinson, Hello Health and Myca (Toronto based by the way).

In the meantime, our health care system will shuffle along, not too different from some of  the aging patients we see----unable to adapt quickly and  uncomfortable with  change.

One cutsie headline reads "Ontari-owe", and another conjures up images of the dirty thirties with rusted out tractors in fields of dust, "Big spending, rusty economy".

As one faithful reader pointed out in the last journal entry, Glen Hodgson of the Conference Board of Canada  suggests that "A lot of people would like to return to the Old World" but the Old World is gone. "This is a catalytic moment for the province," he said and "needed tax reductions would not see the light of day until Ontario decides what to do about health-care spending, which is growing at an annual clip of 8% to 10% and is the single biggest expense item in the budget."

It is clear to me that what we have so far in health care transformation is not patient driven. Government sells the changes as patient centred...but let us not delude ourselves. Taking tax dollars, delivering some form of rationed health care while we pretend we have universal, portable, equitable, comprehensive care doesn't make health care patient-driven. Just because it is seen to be "free", doesn't make it patient-driven.

The public is going to have to understand the cold hard facts at some point in the very near future. Right about Now would be a good time.

Tim Hudak, a contender for the provincial PC leadership points out several facts:

*It took from Confederation to 2002 for the Ontario government to take the provincial budget to $68 billion

*This year Dalton McGuinty will oversee spending skyrocket past $100-billion

*Ontario's debt burden is more than $170-billion

*Program spending has increased 50% to $87.4 billion, or 8% per year, since 2003

*the Liberals have installed excess spending that now exceeds $17 billion a year-spending that will now drive the province into serious deficits

*experts like Warren Buffet are warning that a return to high inflation could result from quick-fix solutions ending in skyrocketing borrowing costs and deepening the financial hole

*Public services, especially health care, are only beginning to grapple with the surging demand and increased costs stemming from the retiring baby boom generation

Hudak suggests we need to cut taxes, reduce red tape and make government more productive, responsive and efficient.

I would suggest that all three options above are necessary in health care but instead we have seen more government driven transformation that involves more red tape, more taxation and which has resulted in a complacent physician work force content to believe that they will be taken care of and lulled into their roles as gatekeepers for government.

Doctors for Medicare is a prime example driven by the concept that what is needed for improved health care is more taxation and that the rise in GDP will sufficiently offset the costs of future health care. How wrong they are likely to be.

What is needed is for patients and the public to fully understand what is ahead and to prepare and take responsibility. Now if only somebody would tell them.

Richard Florida, McGuinty's advisor, may well believe that the future of Ontario is in creative endeavors. He may be right but as long as we cling to the old way of doing things and the old structures in health care that stifle creativity and are government driven, we are destined for a downward spiral. Ontari-owe may turn  into Ontari-ouch.

Thanks for reading along and Happy Spring!

The concept behind the new web-site is that the public is given an opportunity to provide their input and their solutions. Didn't we go through this with Romanow's marvelous adventure almost a decade ago? Seems to me we did...but we are back to the drawing board.

The mantra appears to be that patients have the solutions. Well, the Council may be partly right in the sense it is not the system that holds the solutions but patients themselves.

As  we watch the cost of health care rise along with wait times despite billions of dollars in health care "bail-out" packages, I am concerned that there are still individuals within the health care system clinging to the idea that we can afford all health care needs coming our way. Or perhaps they just need their hospitals to live to see another day.

It really looks like a rather slow and uncomfortable death, for patients, for politicians and even for physicians.

If the Health Council of Canada and the government are going to use the web-site as a way of saying to the public "we did ask for your input...there were opportunities for you to contribute your dialogue....but we still don't have the money to pay for everything that is needed" then fine. If they really think they are going to find solutions by looking at the system in the tunnel vision fashion they are using then we are likely to meet with failure again.

When LHINs fail, after the CEO heads fall, we will see how many years the politicians can keep up with the rhetoric. Maybe about the same time that Obama's shine begins to fade. Reality does hurt sometimes.

Sorry for the delay in getting another journal entry up and going. Perhaps you don't care but I do. I am looking forward to having a little more time in the not so distant future to do what I enjoy, including posting here on this blog.

Best wishes and thanks to all for your contributions,

Realist