Better Treatment, Better Care (3)

been used as a lever by federal governments to put the freeze on any

number of policy approaches that provinces might have considered and it's

an ongoing threat because the government of the day will define what reasonable

access means even a friendly government in ottawa to

health care reform tomorrow might be changing four years from now

and that next government might have a different opinion and sections 18

through 21 specifically disallow cost sharing or co-pays and they disallow

extra billing which which is a process we see in countries

like australia and france where a physician only gets partially paid by

the government and individuals are free to top up in certain sectors

i think that's where the real problems in the health act are the rest is less

of a barrier to reform though there are still things we can do to improve on

that that's helpful and here's i guess the real problem is that the provinces

have been so effective at asking the federal government to pay an increasing

share towards health transfers that now the penalty of having the federal

government say we're going to withdraw transfers is so high that that also acts

as a barrier to change i think in the early 2000s or mid-2000s

a couple of us had looked at what the transfers were relative to what the

savings from a cost-sharing program would be based on the rand institute

study from the 1970s which is really the only true trial of how much a

cost-sharing program can save and it was possible in the early 2000s late 1990s

to actually implement reasonable healthcare reform and save enough money

that the transfers could be foregone and the province would still be better off

there is a private shift to patients as well but other policies can further

enhance that benefit but now you're right as those transfers grow it

increases the federal government's hold on the provinces it increases the

federal government's ability to stall reforms that it finds undesirable for

whatever political reason none of obviously what we're talking

about here is is a sound argument against sensible reform it's a political

tool and it's very much it's very much being used in that matter all right well

then let's talk about how they've managed to maintain universality in a

number of high-income countries around the world i think what i always object

to whenever we get into this conversation

is that everyone says oh well we don't want to be like the united states and

there are so many other jurisdictions in the world that we can look to if

universality is something we want to maintain and keep some of the elements

of our system so we're not even going to talk about the united states unless we

have unless we're forced to so let's talk about some of these other nations

and i i and it's a pretty big list australia sweden switzerland france

germany netherlands uk new zealand when you've done an analysis of those why why

did you choose that grouping of nations in particular give us some idea of the

similarities that that would allow us to replicate some of the things that they

do uh going all the way back right around

the roman report in the very early 2000s 2001 we sat down and we decided to just

create a structure of league tables let's see how all of the countries

around the developed world stack up who's doing better who's doing worse in

terms of spending in terms of access to health care availability of services and

then in terms of outcomes and a number of nations stood out in this analysis

sweden switzerland japan france stood out as being leaders in terms of

healthcare outcomes or outcomes from the healthcare process and then we know

there's this other group of countries that have no waiting lists for access to

healthcare it's not to say that you're waiting it's more like scheduling a

haircut or scheduling an appointment for your car they're busy tuesday you're

busy thursday we'll get to the following wednesday we'll do an mri on monday

there's no systemic waiting list or queue of people to be treated ahead of

you and that's uh austria france the netherlands switzerland germany japan

so this subset of countries we decided to take a little closer look and see

what's really going on what do we find in common in all of these countries and

it's incredible every one of the developed world's top performing

universal access healthcare systems has cost sharing for universally accessible

services care is not free at the point of use for the patient which encourages

more informed decision making about when and where is best access to health care

system every one of them has private competition in the delivery of

universally accessible hospital and surgical services all of them in some

cases like in germany it's actually university hospitals that are being

privatized because germany has figured out that when the private sector comes

in the facilities are being recapitalized or being upgraded and

approved for patients and every last one of these nations every one of them has a

safety valve a private alternative to the universally accessible system even

in sweden which might be considered a mecca of socialist thought patients are

not constrained to the universal system they're not shackled to a government

monopoly they're free to seek care on their own terms with their own resources

when they feel appropriate to do so and about the population is privately

insured the access to the private sector is quite low in sweden because the

public system is quite good as far as patient perception is concerned but the

option is always there for them and that is an important option to have let's

stay with sweden just for a minute so i can understand it because everybody

loves to point to sweden as the model for healthcare socialist system i think

is what a lot of people believe it is and yet they've got a lot more

competition and private delivery than we do what was what happened there did they

did they take a u-turn or did they just develop differently did they have some

moment of crisis where they said okay we've got to do things differently or

was it just incremental change it seems to be incremental change and i

think there's a there's a pragmatism there behind these reforms it's it's a

moment of pause where everyone stops and looks around and goes well this isn't

working so we should try something different

the cost sharing has been increasing in sweden it's about 20 or 25 dollars to go

see a doctor um obviously there are exemptions for low-income populations or

exemptions for children exemptions for the elderly exemptions for people's

chronic conditions there are limits on on annual spending every year out of

pocket to protect people from serious health events and to ensure that the

trade-off when people are seeking health care from a doctor is a trade-off

between going out for dinner versus seeing a physician a starbucks versus

seeing a physician we're not trading off eating versus seeing a physician that is

an inappropriate trade-off to be making the swedes have moved into into

privatization activity-based funding of hospital care again recognizing that

there are there are real benefits to having the private sector involved

competitively in the delivery of universal accessible services it's in

stockholm the hospital is called saint gorons it's actually run by a private

for-profit company traded on the swedish stock exchange called capio

and that hospital has revolutionized the patient focus of hospital care and

it's a very competitive hospital that actually helped reduce hospital spending

in sweden or at least enhance the availability of services in sweden

alongside a reduction in spending i think that as sweden moved into

activity-based funding and st burns was a part of that that changed but

activity-based funding takes a lot of the credit here the suites were

available they are able to deliver 11 more health care for one percent less

money just as a result of the transformative reforms and the parallel

sector has always been there in sweden it was never outlawed it was never

forbidden that's something that is is across europe it's always exist

i love the way you've worded that so you get 11

more services for one percent less cost relative to the status quo because

oftentimes the reason why the private sector is treated with suspicion of

those who don't want the system to change is oh well they'll just siphon

profits off the top and the profits will then uh go into the pockets of

shareholders and that's money that could be spent to ex expand services so how do

you how do you how do you address that issue because there's a real

reluctance i think to talk about profit being an aspect of such an essential

service to the the health of our lives i mean i think people maybe it's maybe

uniquely canadian experience that this is one of those areas where you almost

have a pr a national consensus that province should pro profit shouldn't be

a part of it and so ex make the case for for for profit why shouldn't we be

worried about that i think first there's a misunderstanding

of where profit comes from profit is not off the top profit is the residual that

remains after services are delivered and profit is a great motivator it is

what motivates providers to focus on patients to focus on the long term to

ensure services delivered efficiently janus coroner pointed to to a

fundamental difference between government business enterprises and

for-profit enterprises this is not just in healthcare this is in any economic

sector there are any number of studies supporting this

the government can deliver services below standard below expectation and

lose money continuously there's nothing to stop them from doing that

a private operator has a very different set of incentives and structures they

cannot lose money on an ongoing basis they cannot treat patients poorly

because those patients will go to another provider especially in an

activity-based funded system where money's following patients if you don't

look after people appropriately and provide the services they desire they

won't come to your facility and eventually your facility just closes

that's where profit comes in to motivate hospitals to look after people there are

a number of important constructs that have to be in place but there is no

evidence to say that this doesn't lead to a better health care system in fact

there's an abundance of evidence to say that you do get a better universal

access healthcare system universal access healthcare system when you have

private competitive provision of medically necessary universally

accessible services under an appropriate policy construct money following

patients is critical we can't be paying hospitals to exist we have to pay them

air for people and we have to have appropriate constructs and impossibles

in place to ensure that there's enforcement and an add-on to this that

is incredibly beneficial certainly from from the experience of a number of

countries is reporting of hospital outcomes reporting of adverse events

reporting hospital report cards effectively for the public not just by

government but also done by the private sector independently like we see in the

united kingdom and i know we weren't going to talk about them but we do see

the united states where they are leading on hospital report cards and actually

rank hospitals based on how they're looking after patients and there have

been meaningful improvements in patient outcomes as a result of that okay well

since you mentioned america then i will also mention that not all