Our Health Care System is a Competitive Advantage in a Global Economy
Toronto (Aug. 21, 2006) - Canadians worry about the sustainability of our health system and whether we will be able to readily access healthcare when we need it. We are concerned about increases in health costs and worried that these cost increases hinder governments' ability to improve other public services, such as education and transit. Indeed, Canadians are so worried about both health costs and access that some are willing to consider proposals for a parallel private system. Before turning away from a system that is widely admired outside of this country, it is necessary to consider specific advantages of Canadian healthcare delivery as well as the transformation of publicly funded healthcare currently underway in Ontario.
According to the Canadian Institute for Health Information, the Canadian health care system in 2005 cost about $4400/person. More than $3000 of this expense was covered by public insurance for hospital and physician care with the remainder covered by private insurance or out-of-pocket payments for drugs, dental care and other uninsured services.
Although healthcare costs have increased in Canada over the past ten years, these increases are comparable to other countries and largely driven by increasing drug charges and new technologies. We are generally paying more for better treatments: more effective drugs, better surgical procedures and improved diagnostic tests. Although the cost of new and better treatments has escalated, the proportion of health system resources consumed by hospitals and physicians has actually decreased over the past ten years. Ontario hospitals have responded to funding challenges by making remarkable gains in productivity, shortening hospital length of stay, and changing some procedures that once required patients to stay in hospitals to outpatient areas.
When we compare Canadian public health insurance to private health insurance costs borne by American industry, it is obvious that tight public control of healthcare budgets offers a competitive advantage for businesses locating in this country. Consider the staggering healthcare cost faced by General Motors (GM). In 2005, the auto giant's health insurance bill totalled more than $5.3 billion for its 1.1 million U.S. employees, retirees and their dependents.
This is at least 50 percent more than the cost of publicly funded care in Canada. The high cost of American health insurance means that GM spends more money on healthcare than steel in their automobiles. GM's $740-million announcement this week to manufacturer Camaros in Oshawa was welcome news and may in part reflect the advantage afforded by our public health care system in attracting investment.
Cost-effective health insurance is not worth having, however, if care is not available when and where we need it. Canadians' concerns about waiting times and access to care have been heightened by the much-publicized Supreme Court's Chaouilli decision, which has sparked discussions to develop a parallel, private health care system. These proposals are fundamentally flawed in that they imply that private care will help the public system by expanding services without public cost. There is no question that expanding access to provide care to a growing and aging population is necessary. But why would we create the inefficiencies and inequities associated with private funding, rather than simply expand and leverage the efficient public system to provide more access to treatment?
In Ontario, our health care system is undergoing rapid expansion of access for five well defined services: cardiac surgery and catheterization, cancer surgery, cataract surgery, hip and knee replacement, and MRI and CT imaging. The gains in access that have been achieved so far are impressive. However, the change in the system necessary to accomplish increased access to care is even more impressive. Theseimprovements in the process of care are generally overlooked by advocates of privately funded care and need to be clearly described and understood.
For example, hospitals receiving "Wait Times" funding for performing extra volumes in these areas are now accountable for providing information about the quality, as well as the quantity of care provided. For example, immediately following a cancer surgery, hospitals are required to submit electronic reports documenting the procedure to the province's cancer advisory agency, Cancer Care Ontario. These reports are reviewed to determine the quality of surgery (for example, the number of lymph nodes removed during colo-rectal cancer surgery). This philosophy of "Paying for Performance" - paying for the amount of care provided in our hospitals as long as the quality of the care meets monitored benchmarks - is long overdue and will increasingly serve to improve our publicly funded system. The transformation underway in Ontario healthcare also promotes innovative methods of delivery for services such as cataract surgery (the Kensington Eye Clinic is an excellent example) or total joint replacement (Total Joint Network).
Americans are struggling to introduce incentives to improve the quality of hospital care in their fragmented, multi-payer system. With only one payer in this province, monitoring the quality of care is potentially very straightforward. The Ministry of Health and Long Term Care needs to create an integrated information system to collect volume and quality data and then insist that any provider receiving funding must provide data to the system.
This Pay-for-Performance approach is already well advanced in some aspects of our system - cancer care and cardiac care are prime examples - and will ensure that Ontario citizens receive treatment that meets the highest international benchmarks. Why would we reject this pay for quality approach to introduce private care that is not accountable for mandated quality measurement? In the near future, integrated provincial information systems could also be used for wait list management allowing patients needing surgery to choose their hospital and surgeon based on publicly available information describing access as well as quality.
This is not to say that Ontario's healthcare system does not need further transformation.
Our Emergency Departments are over-burdened across this province and too many citizens lack access to primary care providers. However, the solutions to these problems can be implemented with a reasonable investment within our public system. We need cost-effective chronic disease management systems, more family health interprofessional teams, and enhanced coordination of care between hospital and community providers. These are achievable solutions that will improve our public system without resorting to parallel private care.
Some patients may want to access uninsured services that are not covered in our publicly-funded system. Examples include cosmetic surgery or access to expensive new drugs that are not sufficiently cost-effective to be publicly insured. Most of these uninsured services could be provided within our public hospitals at a lower cost to the patient since private clinic charges for bricks and mortar can be avoided.
Those of us who have worked in the Canadian and American health environments recognize the cost-effectiveness afforded by our single payer system. We need reform with greater accountability and especially application of the principle of Paying for Performance. We need expansion of the system as well as accountability - simply because our population is aging and growing. However, growth of the system and increasing accountability within the system can definitely occur within the context of public healthcare.
Ontario healthcare offers an economic advantage to our province in a competitive global economy and reflects our commitment to a coherent, inclusive society. The system needs to be improved and expanded, not supplemented by an inefficient and costly parallel private care alternative. Access to healthcare based on need rather that ability to pay is an important defining characteristic of this country's social policy that should be protected rather than deserted.
Dr. Robert Bell
President and CEO
University Health Network
