The death of timely health care: a post-mortem

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Appeared in the National Post, December 22, 2015

A few days ago we released our annual report measuring wait times across Canada. Much has already been said about the national results—that we’ve seen no improvement over the past three years, that this year’s wait is almost twice as long as it was in 1993, and that physicians are consistently telling us that their patients are waiting longer than clinically reasonable.

However, not much has been said about how we got here, and why nothing changes.

When the Fraser Institute began measuring wait times in the early ’90s, there were few (if any) alternatives to our report, so it was possible for those committed to the status-quo to simply dismiss our report out of hand. However, as provinces have developed their own publically accessible websites (which still leave much to be desired) and other organizations (like the Wait Time Alliance) published their own findings, it has become impossible to escape reality—the current system is forcing Canadian patients to wait too long for medically necessary care.

While some patients can wait for treatment, it should go without saying that others are waiting in pain, unable to work, and potentially risk having their conditions worsen while they wait for treatment. For every success story of Canada’s health-care system (and there are many), there are perhaps as many heart-wrenching failures.

Let’s be clear: the goal of our health-care system is admirable—universal access to health-care services regardless of ability to pay. The problem is that we are failing to deliver these health-care services in a timely manner.

Let’s examine a few reasons why this may be.

First, there are no pressure valves. When the system fails, patients have no recourse. Private options are few and far between, and they are generally unavailable to the majority of the population. Patients are left with the unhappy choice of remaining on the waiting list, or crossing the border and seeking treatment in a different country. Further, the public system also doesn’t have many options to expand capacity, since provincial governments are already spending about 40 per cent of their budgets on health care.

Second, there are limited incentives to use services responsibly (apart from the dread of having to wait for treatment itself). For example, there is no cost-sharing disincentive to visiting the emergency room or seeking surgical treatment, regardless of how trivial an individual’s concern might be. The abuse of such a system is inevitable.

Third, there are actually incentives to restrict the supply of services. Most hospitals in Canada are funded through a global budget set at the beginning of the year. While this controls costs (to an extent), it actually incentivises hospitals to treat fewer patients in order to stay within their budget.

Fourth, there are too many bottlenecks. Let’s just focus on three. First, as a result of following a gate-keeper system, patients are required to get a referral from a general practitioner to see a specialist. While this is not unusual, it’s inefficient if general practitioners are unable to see which specialist has the shortest wait, and refer accordingly. Second, there is often a significant wait to get a diagnostic imaging scan in order to assess the severity of a patient’s condition. These wait times prevent an efficient system of triage, forcing those with serious conditions to be lumped in with those without, in a long line. Such diagnostic scans should be available almost immediately, on site. Finally, there are many patients stuck in hospital because after they’ve received treatment there is no appropriate place for them to be discharged to. These ALC (alternate level of care) patients likely don’t want to be there, the hospital likely doesn’t want them there, and patients waiting for a hospital bed certainly don’t want them there either.

While the presence of bottlenecks is likely a challenge faced by many systems, the other issues discussed are effectively addressed in countries with successful universal health-care systems. These relatively successful systems generally involve the private sector—either as a partner, or an alternative. They expect some level of cost sharing from patients—exempting the poor and chronically ill, and placing annual caps on levels of contribution. And they generally fund hospitals based on the amount and complexity of their activity.

Importantly, they do all this not in spite of their commitment to universal health care, but because it helps them better deliver on that promise.

In Canada, we unfortunately focus on the preservation of the Medicare system, and expect patients to adjust accordingly. Instead, we need to focus on the patients, and adjust the Medicare system accordingly.

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