Better Treatment, Better Care (8)

your hospitals and you can choose to go to the hospital on the north side but

everybody knows that hospital charges more and serves the worst food in town

but their medical outcomes are no different than the hospital on the east

side of town that has great food and really looks after their patients and

has a concierge at the front door it's a medicare card taking you to either of

them for exactly the same amount of copay based on what the government is

requiring where would you go as a patient

immediately it changes behavior and i think we under appreciate the the power

of competition in that world well i'm a foodie so you i would

definitely go to the one with the better food let me um i don't want to get too

far down this track we could probably do another whole segment on it but

you've clearly articulated i think why it is the canada health act prevents us

from moving in the direction of some of the more successful universal systems

what i find astounding is that we're now talking about the federal government in

canada taking over more of the

delivery or management of health services that have been in the

provincial domain the discussion of a national pharmacare program for instance

the discussion of a national long-term care approach for instance as after

having this conversation with you i don't want the federal government to go

anywhere near those and so so tell me tell me why this is though like what is

the enticement for thinking that the federal government has all the solutions

when clearly you've just um you've just demonstrated the federal government in

this case is the problem i think the federal government has very

few solutions this is this is politics and this this is is purely politics

healthcare is the third rail i think uh premier klein and alberta many many

years ago said it is always politically expedient to wrap yourself in a flag and

proclaim yourself the defender of medicare i suppose it's just as

expedient to say you're going to be the expander of medicare

we know the federal government is only involved in healthcare as

as a function of the federal spending power

it is taxing more than it needs for its own needs and then or for its own

responsibilities i should say and then transferring those money to that money

to provinces under a certain set of terms and conditions

we could just get the federal government out of it and leave the provinces to

decide because it is their constitutional responsibility it's in

their under the constitution healthcare's

provincial jurisdiction exclusively for decision making

and and let's not forget what roy romano said if you got in a car and drove from

the tip of newfoundland to victoria you go through 10 very different provinces

with 10 different economic realities with 10 different demographic realities

these are 10 provinces that need 10 different policy constructs for

healthcare a one-size-fits-all solution from ottawa is counter-productive it it

one moves decision-making further away from the people who are voting for

government which means we now come into these federal dynamics where ontario and

quebec determine what the federal government wants for places as distant

as newfoundland and british columbia as opposed to populations that are

voting for their premier and their province with their own construct

i think we could take some great lessons from from welfare reform in the 1990s

where provinces were given a free hand they were given open transfers the rules

were taken off and the provinces were given the opportunity to innovate in

reform some did some didn't and they're responsible to their own populations for

that so some systems work better now than others but the provinces can also

learn from one another it's a lot easier for bc to learn from saskatchewan than

it is for ontario to learn from switzerland

we're right next door we can see what's happening we can study it we can travel

quickly and easily i i think there's great magic in having the federal

government get out of the business of health care led it back to the provinces

who are directly responsible populations i don't understand what the federal

government would bring to the table that the provincial government doesn't other

than the ability to tax the entire nation and transfer money to germany

well we should all be wanting to get better outcomes so totally agree with

you let me ask you uh just in sort of our final moments here we so we do have

we whenever we're doing our comparisons we do talk about

nation to nation but as you pointed out we've got we've got 10 different health

care systems more if you include the territories as well but looking at the

10 provinces are you seeing any glimmers of hope

you've identified pretty clearly the things that a province needs to do to

move in a direction of a higher functioning system that gives better

outcome at lower cost where are the bright lights in canada what provinces

are are leading on this front or is the canada health act and the federal

spending power and the threat of losing those dollars so overwhelming that

nobody's really been prepared to stick their neck out

we have seen some tweaks and some changes across the provinces over time

and certainly even within the restrictions of the canada health act

some some policy options are available activity-based funding is as far as the

letter of the canada health act is concerned entirely canada health have

compliance we could change the way we fund hospitals tomorrow

and unless the federal government really wanted to raise section 12 about

reasonable access it's okay under the letter of the candidate health act cost

sharing clearly not private competitive provision of hospital services under the

letter allowed permissible private parallel health care under the letter of

the canada health act allowed there's actually nothing in the canada health

act that says you cannot have a private parallel healthcare system there's

nothing explicit but again section 12 reasonable access rears its ugly head

fairly routinely but if we look across the provinces we have provinces that

have innovated we have saskatchewan which created a central registry for

waiting lists one approach but then they used the private sector to bring the

waiting list down and embrace that approach and they made a meaningful

impact on their waiting list we've seen initiatives in alberta pilot projects

small projects but they've happened in the devon and joint

approach where we used a private facility here in calgary and again

brought the waiting list down quebec has traditionally performed a little bit

better than the other provinces on waiting lists historically and it's a

little more of a european-style healthcare system there's there's a

little more activity there they have that private parallel sector now since

shoguly it's very limited very restricted but they haven't exploded and

got worse waiting times i think that when we look across the nation

when we're trying to pick a winner among the provinces we're trying to pick a bad

apple out of a batch of really bad apples there's really no great

healthcare system in this province even in this country there's really no great

province even in the very best province in this country we are finding waiting

lists that are longer than that in longer than those in any number of other

developed nations national surveys show that canadians wait longer as a nation

than people do in other developed nations around the world we have some of

the longest waiting us for access to care according to the commonwealth fund

so as much as we want to find a provincial example i think we've had

some great experiments we've had a great activity-based funding experiment in bc

that never really turned into anything

massive we had a great experiment in saskatchewan where the private sector

helped reduce waiting lists entirely in line with the experience of countries

like spain and portugal we have yet to see a province say okay this isn't

working federal government you've got to get on board with this because we're

wasting taxpayer dollars we're not looking after patients properly let's do

a sweden let's let's just move beyond this this model let's understand that we

are going to be a better universal system if we reform because we're really

not doing universality well today let me ask you one other concept that you've

written about before that is really stuck in my mind and you alluded to it

earlier is one of the other things that we need to think about is how we have a

purchaser provider

and evaluator split so right now we have the same group that is providing the

service is the group that's given the money to fund the service which is the

group that then oversees the evaluation of how well the service is doing so is

it any wonder we don't have hospital report cards and is it any wonder that

we don't have a hole springing up the surgical suites that are independent of

that system that would hive off some of those dollars so

would any of that structural change be um be disallowed

under our canada health act could you have they're called different things in

different provinces but a health quality council that has the authority to do

genuine real health audits and evaluations and report cards and it's

serious could you then also have a separate spending authority and they

make the decision yeah we'll give money to a private hospital or a public

hospital or a non-profit or a charitable organization but we decide and then you

could still have the traditional services that are run by government run

under the same umbrella but they wouldn't be making those other two

decisions that's sort of how i've been thinking about the structural change

that's needed but is there anything that would be a barrier to that number one

and is there any place where they do that particularly well that we should be

emulating uh i think we can look to germany for

for the great example there's nothing in the canada health effect that would stop

a purchase for provider split again in the letter of the canada health act

section 12 always removes its ugly head but section 12 could be used to stop the

delivery of hamburgers i mean it's that big

when it comes to the purchase of provider split

i think it's a very important part of activity-based funding and a very

important add-on and it is about getting government to where government needs to

be not necessarily where government is the

less efficient provider and where the private sector can play a stronger role

the private sector is a great insurer the private sector is a great provider

they're great at looking after patients the private sector is perhaps less good

when it comes to ensuring that everybody has access to a health care system on

equal terms because that's the role of government

and we need somebody to look after the system and police it and ensure that

things are being done properly and you're absolutely right when you say

government today in canada is the payer the provider and the monitor so when

they pay for care that isn't delivered properly they're the ones who go and

slap themselves on the wrist that is a horrendous conflict of interest whereas

in a country like germany government ensures everybody has access it's a

swiss style health care system where there is private insurers within the

public system government ensures everybody has access to the health care

system or at least the insurance system that's their role they then ensure that