NATIONAL

WAITING FOR A REVOLUTION

JOHN GEDDES December 31 2007
NATIONAL

WAITING FOR A REVOLUTION

JOHN GEDDES December 31 2007

WAITING FOR A REVOLUTION

Wait times have gotten better in a few areas. Can this be extended to health care as a whole?

NATIONAL

JOHN GEDDES

A few years ago a revolution seemed to be brewing in Canadian health care. Patient frustration over interminable waits for procedures like hip replacements and cataract surgery was boiling over, prompting politicians to pump money into the system. In 2004, Paul Martin’s short-lived Liberal government cut a deal with the provinces to funnel $5-5 billion over 10 years into cutting waiting lists. When the Supreme Court of Canada ruled, the very next year, that Quebec’s waits were too long to be tolerated, and struck down the province’s ban on private insurance for treatments covered by the provincial plan, it looked like the bid by Martin and the premiers to save medicare from its own sluggishness might have come too late. With the election of the Tories the following year, the shift away from pure universal health insurance appeared sure to accelerate.

But the revolution has at least been postponed, maybe forestalled entirely. Instead of court-driven, ideologically fraught upheaval, Canadian health care is undergoing something closer to a burst of evolutionary adaptation. Over the past three years, most provinces have significantly shrunk waits for treatment. The Wait Times Alliance, a doctors’ group set up to push for faster care, produces an annual colour-coded report card on provinces’ progress: red for slower, yellow for no change, green for faster. “Green just dominates the page,” Dr. Lome Bellan, a Winnipeg ophthalmologist and the alliance’s co-chair, says of this year’s report. “And it’s all been done within the public system.”

The result: the clamour for radical change has subsided into low-level background anxiety. For federal and provincial politicians, health waits have dropped below issues like the environment and law enforcement among agenda-dominating items. A glance at a few snapshots of what’s happening in hospitals and specialists’ offices shows why. Back in

2004, nearly half of cataract patients in Regina waited more than a year for their operations; by the first half of 2007, only about five per cent languished so long. An innovative Alberta project has compressed the average wait, from consultation to surgery, for knee and hip replacements to just 37 days from 290 days at clinics in Calgary, Edmonton and Red Deer. In Ontario, 96 per cent of heart patients are getting their elective bypass surgery within the recommended time, up from 86 per cent in 2004Nobody, though, is declaring final victory quite yet. Although the strides being made are undeniable, progress is uneven and making precise comparisons among provinces is still impossible. They all use different methods for measuring waits, and most report on only some, not all, of the five priority areas set out for special attention in 2004—cancer, heart, diagnostic imaging, joint replacement, and sight restoration. Whether or not provinces can keep up the momentum is uncertain. A key sign will come at the end of this

month, when, under their 2004 funding agreement with Ottawa, they are all supposed to set multi-year targets for actually achieving mutually accepted benchmarks for delivering care in the so-called Big Five.

Even if progress on the five priorities continues, skeptics doubt the success can be broadened. The alliance wants a second set of five more specialties to benefit from focused attention and more funding: emergency care, psychiatry, reconstructive plastic surgery, gastro-

enterology, and anesthesiology. And some influential voices question the emphasis on drawing up lists of treatments to tackle. “It’s just a start,” says Brian Day, president of the Canadian Medical Association, “and there are thousands of areas that need to be done.” Day, a Vancouver orthopaedic surgeon, argues for overhauling how hospitals are funded, not just picking a few selected procedures for faster delivery. He says the typical Canadian system of block funding, which gives a hospital a certain amount of money no matter how many patients it serves, fails to reward excellence—or penalize poor performance. If hospitals got more money by attracting more patients, he says, they would have an incentive to improve service. Day

DAY NOTES THE BALLOON EFFECT: WHEN RESOURCES GO INTO ONE CORNER, OTHERS GET SQUEEZED

likes to quote a recent Organization for Economic Co-operation and Development (OECD) report that said, “Market-orientated mechanisms reduce costs of hospital services, even when primarily government-operated.”

Day is famous—notorious in some circles— as an advocate of privately owned, for-profit clinics, even when their services are paid for under public insurance. His market-driven approach, however, might have gotten more traction if his one-year term heading the CMA had come a few years ago, when wait times looked intractable. Assuming leadership of the country’s major lobbying group for doctors for 2007-08, at a point when the mostwatched lists are actually getting shorter, has probably blunted his impact.

Instead of looking for root-and-branch solutions like Day’s idea for changing hospital funding, experts tend to be concentrating on management measures. Tom McIntosh,

a University of Regina political science professor who specializes in health policy, says key lessons are already spreading from provinces where experiments worked. He points to two big innovations: creating centralized lists of patients, which allow provinces to move them where they can be helped fastest, and obliging doctors to follow standardized assessment guidelines, which lets the system sort out which patients most need treatment soonest.

Both ideas take some getting used to for doctors. McIntosh says they often resist being told they need to follow a common procedure for rating their patients’ needs. As for centralized waiting lists, even though the idea is not new—Ontario’s Cardiac Care Network has been doing it for 17 years— many specialists were still used to maintaining their own private lists and informal networks. Along with these sorts of basic steps to manage lists more efficiently, change has sometimes come through a simple cash injection. McIntosh points to diagnostic imaging, mostly MRI and CT scans, as one area where investment in new machines had fallen far behind demand. Ottawa earmarked hundreds of millions for new scanners starting in 2003. As the new equipment was delivered, in many cases backlogs eased. “There are fewer reports,” he says, “of people getting on a plane to go and get their MRI.”

Still, skepticism remains about the targeted approach that has emerged as the Canadian norm when it comes to tackling wait times. Day points to what he calls the “balloon effect”: when resources are pushed into one corner of the health system, another part of the system must be squeezed. In his own practice, he says, the drive to shorten wait times for hip and knee replacements means a patient who needs, say, shoulder surgery might have to wait longer. Bellan has heard about similar anecdotes about unintended outcomes related to his eye specialty. “Referring doctors have patients with eye problems that are not cataracts,” he said, “and the response from the [ophthalmologist’s] office is, ‘We’re booked up solid doing cataracts.’ ”

The drawbacks in the drive to cut wait times, however, don’t seem to be fuelling much appetite for more fundamental reforms. Even in Quebec, the Supreme Court’s 2005 decision in what is called the Chaoulli case hasn’t

ushered in the sweeping change many predicted. Last year, Premier Jean Charest’s government satisfied the court’s requirements by promising to provide joint replacements and cataract surgery within six months of a doctor determining a patient needs the surgery. If government-funded hospitals can’t do the job, the government will pay to have it done at a private clinic. As well, the Charest government moved to let Quebecers pay privately for a limited range of services, but predicted few would, since the public system was about to get considerably faster.

The widely predicted flood of Chaoulliinspired challenges to bans on private health insurance elsewhere in Canada has been slow materializing. A similar case launched in Ontario might get to court in late 2008 and a related class-action suit in Alberta even later. Rulings in those cases might yet reignite the debate over whether Canada needs to allow privately insured care to run parallel to the publicly insured system. For now, though, the primacy of universal insurance seems to be holding up. Only a few years ago, critics of the Canadian model commonly pointed overseas, arguing that short wait times in Europe must result from the existence of privately insured care running alongside generous public plans. But closer study of European systems hasn’t borne that out. A 2004 OECD report found no clear evidence that allowing a privately insured option eases wait times in a mainly public system. And Paul Dutton, author of the new book Differential Diagnoses: A Comparative History of Health Care Problems and Solutions in the United States and France, says France’s short waits result partly from integrating many privately owned clinics into the government-funded plan, but not from a privately insured system operating in tandem with the public one.

Dutton, a history professor at Northern Arizona University, points to other factors that make the French system attractive. “They have more doctors,” he says, “and they make less than half of what U.S. doctors make.” Indeed, France boasts about 3.4 physicians for every 1,000 people, whereas in Canada there were 2.2 and in the U.S. 2.4 for every 1,000 in 2005.

More doctors working for less money: it’s an enviable edge. For all the attention lavished lately on managing wait lists, doctors like Day and Bellan are starting to put more emphasis on managing human resources. As baby boomers age into their peak demand years, training or recruiting enough GPs and specialists, and finding the money to pay them, could turn into the bigger challenge. The debate over timely delivery of care may have eased, but the real crunch might be yet to come. M