JOHN BARBER February 13 1989



JOHN BARBER February 13 1989

Late last summer, a heart specialist told Charles Coleman, a 63-year-old diamond cutter, that unless he underwent a coronary bypass operation he could die. Four months later, doctors had postponed Coleman’s operation 11 times at Toronto’s St. Michael’s Hospital because of a shortage of beds in the hospital’s intensive care unit. At one point in November, Coleman waited 13 days in a hospital bed before being told to go home again. As the delays continued, members of Coleman’s family said that he appeared to lose his will to live. Finally, eight days after his operation was finally carried out in December, Coleman died. His wife and four children were grief-stricken. But they said that they were not surprised. Recalled Coleman’s wife, Muriel, 62: “He just went to pieces. He was a broken man.” Coleman’s case was not unusual, and the problems of coronary patients across the country are only one highly visible symptom of an underlying crisis that is undermining Canada’s health care system.

Increasingly, hospitals across the country are taking beds out of service, limiting the number of operations they perform and cutting back on other services as governments battle to keep down health care costs, which last year totalled an estimated $50 billion. The spiralling costs have been fuelled by a host of factors, including higher pay and benefits for medical personnel—who make up seven per cent of the nation’s labor force—the soaring cost of high-technology medical equipment—a CAT scanner used to detect internal abnormalities can cost up to $2 million—and the growing number of older Canadians, who are living longer than ever before and who rely heavily on the system. The overall result: an increasingly urgent sense of anxiety among patients and their families alike.

In an effort to cut costs, most provincial governments have clamped down on hospital budgets at a time when many nurses are quitting their jobs to protest poor pay and working conditions. The result has been lengthening waiting lists and a toll of deaths among patients who cannot survive long enough to receive the surgery they need. In Manitoba, six heart patients died last year before they reached the operating room at Winnipeg’s Health Sciences Centre. In Toronto—where an estimated 1,000 people are facing waits of as long as a year for bypass operations at three hospitals—two people have died since December. Last month, long waiting lists forced the city’s highly regarded Hospital for Sick Children to send home 40 children who needed heart surgery.

Hand-to-mouth: Increasing government restraint has angered many doctors, who say that governments are risking lives to save health care dollars. “I'm living from hand to mouth and waiting for disaster each day,” said Dr. Phil Gold, a cancer researcher who is chief physician of the overcrowded Montreal General Hospital. “I don’t know when someone will die for lack of a bed or the proper equipment.” As well, growing numbers of medical authorities say that they now are being forced to ration health care by deciding which patients should be treated first, and which will have to wait—and perhaps die.

The mounting strains on the medicare system have raised the prospect that so-called user fees may eventually be needed to discourage Canadians from making needless medical visits—and they have triggered a rancorous debate among Canada’s physicians and provincial governments. A heated debate is also raging over whether Canada can continue to afford the 20-year-old publicly funded universal system that provides one of the world’s highest standards of medical care. Canada’s federally backed, provincially operated health insurance plan differs sharply from that of the United States—where costs are rising even more rapidly and where millions of people have no medical protection. At the same time, the pressure of rising costs in Britain’s state-run National Health Service last week led Prime Minister Margaret Thatcher’s austerity-conscious Conservative government to propose sweeping changes. They would inject new funding into the system by encouraging affluent patients to pay for superior hospital services.

As health care costs rise, some experts point to the increasingly heavy use of the system by Canadians—including the over-65s, who now make up 11 per cent of the population—as one of the principal problems. According to the federal department of health and welfare, the average number of medical services for each Canadian in 1985-1986 rose to 10.7 from 10.1 in 1983-1984. In British Columbia, the ministry of health said that the number of annual medical services performed in the province rose to 45 million in 1987-1988 from 30 million eight years earlier.

Confrontation: Concern over increased use of the system has focused unwanted attention on Canada’s 48,000 physicians and surgeons. Critics claim that because doctors operate on a fee-for-service basis, they have a strong incentive for treating as many patients as possible. “For doctors, it has been an ideal system from Day 1,” said Dr. Michael Moss, who teaches family medicine at the McGill University medical school in Montreal. “We are paid for every single confrontation with a patient.”

But other doctors point out that their incomes—self-employed doctors earned an average of $97,400 after expenses but before taxes in 1986—make up only about 18 per cent of the nation’s total medical bill. Instead, many physicians say that the fault lies in the fact that Canada’s medical insurance program is based on a “first dollar” system, with no provision for a deductible fee that would force patients to pay for part of their treatment. They add that user fees would solve many, if not all, of the problems. “We’re tired of being scapegoated,” said Dr. Martyn Thornington, president of the Manitoba Medical Association. Added Thomington: “I think it is time the people of Canada realized that the problem is not of our creation.”

Meanwhile, the deterioration in health services across the country is becoming painfully evident. During the past two years, most of the provinces have sought to curb costs by telling hospitals that they will no longer pay for operating deficits. The measures have forced hospitals across the country to close hundreds of beds and limit the number of operations they can perform. As a result, patients in many cities now have to wait longer for operations, while the shortage of beds has forced some hospitals to park patients on uncomfortable stretchers in drafty corridors.

Humiliating: As well, hospitals in some cities have had to institute unusual, and sometimes humiliating, economic measures. Patients in the maternity ward of Toronto’s North York General Hospital are required to bring in their own pillows, while elderly patients in some Montreal hospitals are being kept in diapers because nurses do not have time to help them go to a bathroom.

New Brunswick’s hospitals, which were forced to take about 300 hospital beds out of service after Premier Frank McKenna’s Liberal government tightened hospital budgets, are among the most seriously affected. At Moncton Hospital, some patients are kept in hallways and even in closets, while a total of 2,300 people were on waiting lists for surgery last month. Beverly Taylor, a 31-year-old Moncton housewife, says that she had to wait for more than a year for an operation to relieve a pinched nerve in her wrist. “I just couldn’t believe it,” she said. “It was people everywhere, on stretchers in the hallways, everywhere.”

Rationing: The situation in parts of the Prairies is equally alarming. Following a funding freeze imposed by Premier Grant Devine’s Conservative government, Saskatchewan’s hospitals faced a critical shortage of beds, with 1,870 patients waiting for surgery at Saskatoon’s University Hospital alone. In Winnipeg in 1986, then-Premier Howard Pawley’s New Democratic Party government warned hospitals to expect to have to put a limit on operations because the government would no longer subsidize hospital deficits in 1988-1989. Now, hospital administrators are waiting for Premier Gary Filmon’s 10-month-old Conservative administration to decide whether it will follow suit. Said Rodney Thorfinnson, president of Winnipeg’s Health Sciences Centre: “We are already rationing health care. We cannot always meet the demands people are placing at our doorstep.”

Tighter budgets have clearly placed an added emotional strain on both doctors and patients. Said Dr. Richard Cruess, dean of medicine at McGill University: “Doctors and nurses find it difficult to assure quality of care with dignity and compassion under increasingly difficult circumstances.” For his part, Stanley Alexander, a 52-year-old high-school principal in St-Eustache, Que., said that the six postponements by Montreal’s Royal Victoria Hospital of his coronary surgery were psychologically debilitating. “The waiting affected not only me but my wife and my family,” said Alexander, who had his operation on Jan. 5. “There could easily have been another attack. It could have been fatal.”

Bitter: The spreading crisis is the latest in a series that has beset the system since Premier Tommy Douglas’s socialist government introduced publicly funded medicare in Saskatchewan in 1961. The action led to a bitter 1962 strike by the province’s doctors. National medicare, introduced by Prime Minister Lester Pearson’s Liberal government in 1966, operated smoothly until costs began rising steeply in the late 1970s, just as concern grew over mounting federal and provincial government deficits. Ottawa responded in 1977 by imposing limits on its contributions to provincial health care. As a result, federal medicare contributions in 1988-1989 will total $7.5 billion. That figure, added to transferred taxing powers, is 38 per cent of the total bill—down from 44.6 per cent nine years ago.

Already, some provinces are forcing hospitals to postpone the purchase of expensive new medical equipment. “Montreal has 21 CAT scanners serving a population of about 2-1/4 million people,” said McGill’s Moss. “The Oxford area of England has two, serving two million people, and the quality of neurosurgical care is no worse. It’s a matter of using resources properly.” As well, some provinces are re-examining the value of high-cost prescription drugs. An Ontario task force concluded last April that a drug for treating heart attack victims costing $200 per dose is just as effective as the highly regarded wonder drug known as “tissue plasminogen activator”—which costs $3,000 a treatment.

In another long-range cost-cutting thrust aimed at shifting health care away from hospitals into smaller, less expensive centres, Manitoba and Quebec in recent years have developed networks of community clinics. Last year, in a step that further angered the province’s doctors, Ontario Health Minister Elinor Caplan introduced a bill to allow government funding of nonprofit clinics. Still, some of the most dramatic attempts to control medical costs have centred on the nation’s doctors—who find more and more opposition from bureaucrats and politicians. In Ontario, many doctors still resent federally inspired 1986 legislation that banned doctors from billing more than provincially prescribed fees for medical services. That resentment led to a 25-day strike among many doctors. And last December, Premier David Peterson’s Liberal government rejected doctors’ demands for a 5.7-per-cent fee increase and imposed a pay increase of only 1.75 per cent.

Servants: In British Columbia in 1984, the B.C. Medical Association took Premier William Bennett’s Social Credit government to court after the province attempted to limit the number of doctors who could practise there by restricting the issuing of billing numbers, which allow physicians to make claims. In November, the Supreme Court of Canada refused to hear a leave to appeal, by the province, against a provincial court ruling that the measure was unconstitutional. Those confrontations have fostered a sense among many doctors that they are being turned into servants of government. “Whether we like it or not, we’re workers,” said Dr. Raymond March, a surgeon who is a former president of the B.C. Medical Association. “We’re told what to do, when to do it and how to do it. The politicians keep bashing the doctors and treating us like dirt.”

Still, some health care experts insist that the Canadian practice of paying doctors on a fee-for-service basis is the root cause of the problems. They say that it encourages doctors to see patients more often than they should and to prescribe expensive tests and treatments that sometimes are not necessary. “The number of patient visits to doctors has shot up,” said Montreal’s Moss, who expresses the belief that many doctors, including highly paid specialists, should work harder to discourage unnecessary visits. “We use specialists when we should use family doctors,” said Dr. Michael Rachlis, a health policy analyst who is a member of the Toronto-based Medical Reform Group. “We use health professionals of all sorts when we should be going to our grandmothers for advice.” For his part, Moss added, “It isn’t necessary to go to a specialist for a runny nose, but that’s what some people are doing.”

In a study prepared for Vancouver’s conservative Fraser Institute in 1987, Dr. Malcolm Brown, a University of Calgary health care economist, concluded that medicare cost increases resulted largely from a tendency among doctors to order expensive and unnecessary services. “What is invariably forgotten,” said Brown, “is that they are doing this in order to facilitate the activities of physicians. Doctors tend to perceive hospitals as personal co-operatives and allocate human resources largely in relationship to how these resources affect medical incomes.” Some critics of the present system say that it would be cheaper to put doctors on the kind of system used by the British health service, in which physicians earn an annual fee for each patient on their rolls. There, repeat visits by the same patients do not increase doctors’ incomes.

But most doctors say that they are not encouraging overuse of facilities in the health care system and that only some kind of deterrent fee will persuade Canadians to reduce their use. “This is the thing that bothers me most about our public system,” said Dr. Ian Hastie, chief of emergency medicine at Toronto’s Wellesley Hospital. “People don’t understand what it costs each time they seek care. There’s a misuse of services.” And Dr. Augustin Roy, president of the Quebec Corporation of Physicians, said that most studies show that as many as nine out of 10 people who seek emergency hospital care do not need it—and that only five per cent of cases admitted to emergency wards are actually in danger of dying.

Hurt: Still, deterrent fees are not permitted under federal legislation, and politicians have traditionally avoided proposing a measure that would hurt low-income Canadians most. For his part, Dr. Adam Linton, a professor of medicine at the University of Western Ontario in London, says that user fees are inevitable, and could be made politically acceptable. He added: “There seems little alternative to applying some kind of deterrent at the primary point of contact with the health care system. Perhaps by adding the cost of minor services to patients’ taxable income.”

Meanwhile, most medical experts say that the system is still fundamentally sound—for the time being. “The situation isn’t hopeless,” said Montreal’s Gold. “We’re close to being excellent, but we’re also dangerously close to the abyss—and I’m not at all sure which direction we’re going in.” Still, the spectacle of dying patients and other stresses evident in health care mean that Canadians may soon have to make tough decisions about how they pay for medical treatment—or face a further deterioration in a health care system that is still one of the best in the world.