How to fix our health care system : Dr. Brian Day

Dr. Day’s Diagnosis
The president of the Canadian Medical Association explains how to fix our health care system
October 23, 2007

Over the years, I have been called names like Dr. Profit and even the Darth Vader of health care. But the goal of the Canadian Medical Association (CMA) — of which I am president — is to help improve our universal system, not destroy it. We want a system that recognizes that patients come first.
Patients in Canada pay dearly both in taxes and out of pocket, yet they cannot access timely care. For doctors, this is unacceptable. And it’s becoming more and more unacceptable to patients as well.
Just over two years ago, the highest court in the land ruled that if the public system fails them, patients have the right to pay for private insurance for medically necessary care. Chaoulli vs. Quebec was a decision made by the Supreme Court of Canada — not by me, not by the CMA. That ruling dealt with a case in Quebec. Similar — and indeed more compelling cases — are coming soon in Ontario and Alberta. The lower courts will be bound to take guidance from the Chaoulli case. Patients should not have to sue for access. Governments must understand that Canadians cannot legally be forced to suffer, and even die, while they wait for health care.
Frustrations with wait lists led me, in 1995, to help establish and become president and CEO of the Cambie Surgery Centre in Vancouver — the first private facility of its type in Canada. The motivation behind our group was simple. Our services were being rationed. Our patients were being shortchanged. Personally, my operating room time dwindled from 22 hours to just five hours per week. That is 10 hours less than the minimum recommended for competence by the Canadian Orthopaedic Association. I had 450 patients waiting for care.
I went into medicine to manage patients, not to manage wait lists. We built our own place to work because the public hospitals would not let us work there. We opened during the tenure of perhaps the most ardent provincial NDP government that Canada has ever seen. Yet our centre spawned imitators, and we have become a valuable part of the B.C. health system.
As a result, I’ve been accused by unions, some so-called consumer groups and even by a single-issue doctors’ group of promoting a “two-tier,” American-style system.
Let me be clear: I am not for an American-style system in Canada.
It is true that I believe in competition. But not the type of unhealthy competition that seems to exist between Canada and the United States in health care. As two of the world’s richest countries, we seem to be in a race to the bottom when it comes to health. Canada’s health system has been ranked 30th by the World Health Organization, and the U.S. was ranked 37th. Why would anyone copy a system that ranks substantially below ours?

It is time to get to work on answering some of the tough questions that patients ask every day. Questions like:
Why are a few selected Canadians — such as workers’ compensation patients, RCMP employees and others — allowed to access faster and better care than ordinary Canadians?
How can crutches for a leg-break victim, or an ambulance for someone who has had a heart attack, or antibiotics to fight an infection, not be defined as “medically necessary” under government health legislation?
Why do public hospitals charge patients for “upgraded” implants and devices, as well as a host of other items that are prescribed by their physicians?

And what is the role of private medical insurance in Canada? Let’s face it. Some 70% of all Canadians already have it — in the form of “extended” or “supplementary” plans. What about the underprivileged 30% who don’t?
Hypocritically, many of those who reject the concept of private insurance have such insurance plans themselves. I have never heard one of them offer to opt out of their two-tier private plan on moral grounds. So let’s not pretend that it doesn’t exist. Let’s not pretend that it doesn’t cover medically necessary services. Instead, let’s figure out how to use it better. Those who speak against private insurance, user fees and co-payments need to recognize they are widespread and deeply embedded in our Canadian system.

We need to act quickly on reform. The Canada Health Act’s five principles still provide a solid foundation from which to work, but we must now reframe those principles to recognize today’s health care realities. The principles were developed over 45 years ago, at a time when there were no CT scanners, MRIs, bypass surgeries, joint replacements and so on.

The CMA, under the leadership of my predecessor, Dr. Colin McMillan, recognized the challenges of putting patients first in the CMA policy paper Medicare Plus. The report was attacked by critics as “another call for privatization.” In fact, it was a call to make the system work for patients, not the other way around.
This is another sad example of how efforts to raise the real issues get lost in the clouds of negative rhetoric. How, then, do we move forward in a practical way to help patients?

We need a system that treats health professionals, hospitals and, most importantly, patients, as value centres — not cost centres that consume an annual budget. Our system of block funding, whereby a hospital receives an annual budget not tied to efficiency or productivity, is unique within the OECD. It is bad for management and bad for patients.
The introduction of patient-focused funding will encourage hospitals to become more efficient and more service-oriented. Patients will become a source of revenue, not a cost. Dollars would follow the patients.

The elimination of wait times will save governments money. For example, consider that the world’s biggest consumers in the $40-billion medical tourism business are Americans. This business has doubled in size this year, as half a million Americans travelled abroad for care. They went to places like Thailand, India, Europe and Russia. By changing our focus, we too could soon tap into that market and reap the rewards for our public system. This is a potentially massive new industry for Canada. A prerequisite is the elimination of our own wait lists.
Since Canada has virtually no non-government hospital infrastructure, the potential income from medical tourism will benefit public hospitals and unionized hospital workers — a benefit that naysayer union leaders should reflect upon.

I also support an expanded role for the private sector. But let me be clear: Canada’s doctors believe that access to quality health care services must be available to all Canadians based on need, not ability to pay.

We also accept that if certain services can be delivered better, faster and at less cost in the private sector, then the private sector must be engaged. Governments have a moral and fiduciary duty to use taxpayers’ resources wisely.

The public/private debate in this country is, in my judgment, largely irrelevant. Much of the negative rhetoric is simply about defending unionized jobs. I understand why union-funded groups, such as various so-called health coalitions, continue to advocate for their members. These groups may label themselves as “health advocacy” groups, but in my mind, they are not. They are, pure and simple, union lobbyist groups, fighting for the rights of their members. That is understandable. It’s their job to advocate for union workers. However, as doctors, our job is to fight on behalf of our patients.

Right now, the single most important factor in improving the system for patients is addressing the extreme shortage of physicians, nurses and other health care professionals.
In 1970, when public insurance was first fully applied to physician services in Canada, we ranked in the top four among developed countries in the number of physicians per capita. We now rank a lowly 24th. Each year, between 1993 and 2004, the equivalent of two full medical schools of graduates has left Canada.
Fifty percent of all newly trained orthopedic surgeons and neurosurgeons leave within five years of graduation. They leave because we can’t offer them the resources they need to work. Doctors graduate with average debts of $160,000, and are forced to factor in their debt as they make career choices. In order to reach the OECD average of three physicians per 1,000 people, we would need 26,000 new physicians in the system right now.

We live in a very rich country. Canadians should not and need not wait for access. Governments have, for too long, looked upon health care as a “black hole” draining its resources. We must all reject that view and understand that health spending can be an investment — an investment that will pay massive dividends for the future.

The doctors of Canada are committed to the cause of renewing health care in Canada. Our system is not working well, but it can be fixed. Let’s fix it. –

Dr. Brian Day is president of the Canadian Medical Association. This essay was adapted from a speech delivered to the Empire Club in Toronto on Oct. 12.

© National Post 2007

See also: CMA’s “seminal paper” sets stage for public/private debate