What makes Canadians sick?

By Ken MacQueen - Saturday, March 23, 2013 at 8:00 PM - 0 Comments

Andy Clark/Reuters

On March 28, Maclean’s hosts “Health Care in Canada: What Makes Us Sick?,” a town-hall discussion at the Mack Theatre, Confederation Centre of the Arts, Charlottetown. The free event—focusing on the social conditions that influence the health and longevity of Canadians—is held in conjunction with the Canadian Medical Association (CMA). It will be broadcast by CPAC. The conversation on the health impact of disparities in income, education, housing and employment continues in April in the magazine, at a town hall in Calgary, and online at healthcaretransformation.ca.

As Canadians, we love our health care system to death. But in fact health care systems around the world—be they publicly or privately funded and all the variations in between—are but one part of the complex web of social supports and personal and governmental decisions that determine our life course. Health care may be a misnomer, and we have an effective—if expensive—“illness care system” to mend us when we break, as many participants noted during the town hall meetings staged this winter by Maclean’s and the CMA in Winnipeg and Hamilton. But set Canada against its peers—the world’s wealthiest democracies—and we are at best a middling performer when it comes to health outcomes. Many blame a waning concern for creating the living and working conditions that maintain healthy lives.

The Conference Board of Canada, an independent body researching economic and social policy issues, publishes one of the most comprehensive comparisons of international health outcomes. Its most recent survey, “How Canada performs,” puts Canada a mediocre 10th place among 17 industrialized nations. It is well behind the leading nations on such key indicators as infant mortality and deaths due to cancer, diabetes and such musculoskeletal diseases as arthritis, osteoporosis and muscular dystrophy—though Canada’s relative rate of health spending exceeds the top six countries that outperform it: Japan, Switzerland, Italy, Norway, Finland and Sweden. It’s true that Canadians are living longer and with better outcomes for many diseases, but other wealthy countries are improving at faster rates, said Dr. Gabriela Prada, director of health innovation, policy and evaluation for the conference board.

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When it comes to waiting for health care, Canada is last in line

By macleans.ca - Tuesday, February 19, 2013 at 7:00 PM - 0 Comments

Wait for the next available customer service agent. Wait for your boarding call. Wait for the ads to end so the movie finally begins. Waiting is a major component of modern life. And while most of that time spent waiting is simply an inconvenience, sometimes it can be life-threatening.

For decades, wait times have been a consistent and much-lamented component of the Canadian health care system. Within the strictures of medicare, we endure lengthy waits for family doctors, specialists, tests, therapy, beds and on and on. Canadians, in fact, wait longer and more often for health care than citizens in all other developed countries. Why do we consider this acceptable?

Earlier this month, the Organisation for Economic Co-operation and Development (OECD) released a major survey on international health care waiting lists and policies. Canada is at the bottom of the pack in almost every category. One example among many: 25 per cent of Canadian patients waited more than four months for non-emergency, elective surgery, the highest proportion of any country reported. The figure is 18 per cent in Australia and seven per cent in France, Switzerland and the United States.

The OECD also reveals Canada to be one of five countries (out of a survey of 22) that report major wait-time problems in all six possible health care categories—from emergency rooms to long-term care.

Finally, and perhaps most depressing, we’re included in an unhappy group of counties that spend above the OECD per capita average on health care but nonetheless report significant wait times. We pay more but still underperform.

To be fair, Canada has made substantial progress on wait times over the past decade. But this just reflects the depth of our problems. A major federal-provincial agreement in 2004 allocated more money and attention to waiting lists, designating five priority areas for wait-time reductions—cardiac, cancer and cataract care, hip and knee replacements and diagnostic imaging—and setting benchmark times for treatment. It also committed to greater transparency about how long Canadians wait.

Since then, all provinces have put wait-time data online for everyone to see. And measured by the benchmarks, waiting has generally improved across the five priority items. Ninety-nine percent of all cardiac patients, for example, now receive bypass surgery within the specified time frame. (Although anyone with a heart problem might argue that six months is a rather generous benchmark.)

Without question, all this scrutiny has improved health care provision in this country. And with the 10-year 2004 agreement set to expire next year, Canadians are being told a story of great progress. But we still wait much longer than our peers in other countries. We can do better.

Certainly, a broader array of services needs to be included in any new deal, one that covers the more routine aspects of health care, such as emergency-room, rehab and long-term care. According to a survey of 11 developed countries, Canadians make the most use of emergency departments and are most likely to wait longer than four hours to see a doctor.

Canada should apply successful strategies from other countries, regardless of ideology. “High expenditure is not a guarantee of [short] waiting times,” reminds the OECD report; evidence-based innovation is more important than money. That countries with public health insurance and no patient cost-sharing tend to have the longest waiting lists suggests Canada’s sacred medicare system may be one of the biggest obstacles to improving service. Finland, for example, found that a voucher system for certain procedures led to a reduction in wait times. It also established wait-time guarantees (as opposed to benchmarks) enforced by fines.

We need to take note of innovations occurring within our own borders, as well, such as successful pay-for-performance experiments in British Columbia and dedicated nursing-home paramedics in Nova Scotia whose goal is to reduce the number of ambulance trips taken by seniors. St. Mary’s General Hospital in Kitchener, Ont., even posts up-to-the-minute emergency-room wait times on its website (6.5 hours to see a doctor, as of noon on Monday), allowing potential patients to make informed decisions on their best treatment options. From this perspective, the recent news that, for political reasons, Quebec has dropped out of a pan-Canadian committee on health care innovation seems entirely retrograde.

However much progress Canada has made to date on health care wait times, the fact remains that we’re still worst among our peers. A real and permanent solution will require focus, imagination and an end to misplaced ideology. There’s no time to waste.

Pediatric pain

By Elizabeth MacCallum - Wednesday, January 30, 2013 at 12:00 PM - 0 Comments

Michelle Del Guercio/Science Source

Pippa is a big girl now, almost 4, so she’s very good on the swing. “Higher! Higher!” she squealed and James McKee, her father, obliged with delight. Then it happened. The nightmare. Pippa sailed through the air like a bird and crash-landed with her right leg underneath her. To avoid hours in the notoriously slow waiting room at the Hospital for Sick Children’s emergency ward in Toronto, McGee and his wife, Amy Nugent, took Pippa to a general hospital nearby. Waiting there more than five hours for an ambulance—because children with serious broken bones in Toronto go to Sick Kids—Pippa would doze off briefly, only to wake screaming. No one was around at the ER desk who could respond to McKee’s pleas for more appropriate medication for his daughter. When the family arrived at Sick Kids, Pippa was immediately made comfortable with the completely necessary pharmacological brew, as she waited until orthopaedic surgeons pinned the fracture in her femur later that day in the operating room. Continue…

Conflicting flu shot rules confuse B.C. heath-care workers

By Rosemary Westwood - Monday, December 17, 2012 at 10:35 AM - 0 Comments

British Columbia’s front-line health professionals must either get the flu shot this year or wear a surgical mask in patient areas. Except it’s okay if they don’t. Such is the confusion in B.C. hospitals and clinics after the ministry of health watered down its controversial policy of mandatory flu shots for health workers who deal with patients.

The province originally announced the policy in August to combat low vaccine coverage among health workers. At the time, B.C.’s chief medical officer, Dr. Perry Kendall, said it would protect patients from contracting influenza, which causes more deaths than any other vaccine-preventable disease. An editorial in the Canadian Medical Association Journal praised the move, but B.C.’s major health unions fought it, arguing it infringed on worker’s rights and liberties.

On Dec. 4, the health ministry suspended the enforcement of the new policy for one year. That’s left “considerable confusion,” says Bonnie Pearson of the Hospital Employees Union, which helped negotiate the temporary compromise. Some employers are still telling workers to wear a special badge if they don’t get the shot, even though that part of the policy has been suspended, she says. Pearson argues a mandatory policy can have the opposite effect: “It’s that kind of a perverse ‘I’m not going to do it because you tell me I have to’ argument,” she says.

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Uncut replies from the Science-ish questionnaire

By Julia Belluz - Friday, November 30, 2012 at 10:50 AM - 0 Comments

Replies from the office of the Hon. Leona Aglukkaq, Federal Minister of Health

1. In your opinion, what is the role of the federal government in health care?

Our Government has a clear and strong commitment to health care.  We actively support a publicly funded, universally accessible system that respects the principles of the Canada Health Act. Federal funding for health care has reached historic levels.  With Budget 2012, we have put the Canada Health Transfer on a sustainable long-term growth track, reaching at least $40 billion by 2020 21. This will provide provinces and territories with the certainty and flexibility they need to address current priorities and to plan for the future. We also work with our partners to support health care innovation, with annual investments of over $1 billion in research and system improvement.  And we play a direct role in promoting healthy lifestyles and regulating health and consumer products to reduce health risks. These federal actions and investments in health care are helping to keep Canada’s health care system strong so that Canadians can get the care they need, when they need it.

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A facial scrub with that MRI?

By Martin Patriquin - Monday, November 19, 2012 at 8:40 AM - 0 Comments

Photo illustration by Andrew Tolson

The term “medical tourism” may conjure images of clinics in far-flung countries that offer a tempting proposition: world travel and cut-rate surgery. Yet a Quebec clinic hopes that Canadians will instead think of a warm bed, perhaps an invigorating facial scrub at a renowned Quebec City spa and the chance to skip the clogged lines that are the reality in much of the Canadian public medical system.

“Mix prevention with pleasure” reads the brochure for Fairmont Le Château Frontenac’s medical tourism package, which charges $1,000 for a two-night stay in a suite, including a massage and a complimentary bottle of wine. Medical examination costs are the client’s responsibility. The service, “a first in Canada,” according to the luxury hotel chain, is available to Canadian residents, and promises “VIP treatment” with “wait-free access to your medical professional.” Medical tourists visiting Quebec can avail themselves of six various tests, including mammograms, CT and PET scans, as well as a virtual colonoscopy. These are provided by Radiologie et Imagerie Médicale de la Capitale (RIMC), a Quebec City-based private clinic.

“We cater mostly to a business clientele who don’t have much free time,” says Jacques Lévesque, a radiologist and medical director at RIMC. “We had patients coming here from outside Quebec City, even from outside the province, and we were forever hindered with the fact that they had to leave the same day, so we partnered with Fairmont.” Continue…

The medical lottery: treatment rates vary wildly from one city to another

By Julia Belluz - Tuesday, November 13, 2012 at 12:42 PM - 0 Comments

Ghislain & Marie David de Lossy/cultura/Corbis

Ewan Affleck, medical director of Yellowknife’s health and social services, describes it as “a huge issue that is largely unaddressed” in Canadian health care, in many ways “a hidden secret.” He’s seen it in the places he’s worked as a family doctor, from urban clinics in Montreal to hospitals and nursing stations in the Inuit villages of northern Quebec, and now in the primary-care centres of the sprawling Northwest Territories.

The secret is “unwarranted variation”: the stark and sometimes alarming regional differences in the health care patients receive, determined by things like the capacity of the local system on a given day or the preference of the doctor instead of actual need or even medical evidence. Canadians participate in a lottery every time they have a brush with the health care system; it can mean the difference between getting screened for prostate cancer or not, or whether or not you have your uterus removed. Though medicine is now supposed to be evidence-based, the simple fact of where you get care, and from whom, can influence your treatment as much as the latest science.

This arbitrariness disturbed Affleck, who has the lean frame and single-minded focus of the ultra-marathon runner that he is. “This is a national issue,” he says. “Who drives the Canadian health system? The day-to-day drivers are mostly doctors and other health professionals.” Continue…

What the Danny Williams' case says about Canadian health care

By John Geddes with Cathy Gulli and Tom Henheffer - Tuesday, February 9, 2010 at 2:03 PM - 63 Comments

No sooner did news break that Danny Williams had flown south to the United States for treatment of an undisclosed heart condition than the chronic debate about the state of Canadian health care went critical. Opponents of universal insurance—both in Canada and the U.S.—pounced on his trip as a told-you-so moment. The populist Newfoundland premier has, after all, been an ardent defender of the public system. Campaigning during the 2008 federal election to keep Stephen Harper from winning seats in his province, he warned Newfoundland voters that a majority Harper government would threaten Canada Health Act tenets like universality, public administration and accessibility. “Nothing would be safe, quite frankly,” Williams said, “when it comes to going after sacrosanct principles.”

Those principles don’t say anything—at least, not exactly—that conflicts with the right of a 60-year-old Canadian millionaire-politician to check himself into an expensive American clinic for cardiac care. And Newfoundlanders, by and large, saw it that way, leaping to Williams’ defence through talk radio, Facebook get-well messages, and letters to the editor. Some went so far as to say that what’s good for Danny’s heart is good for Newfoundland and Labrador. “I think he’s looking after his health and his best interests,” said Dean MacDonald, a St. John’s venture capitalist and old friend of the premier. “And clearly his best interests are the province’s best interests.”

Off the island, however, such stalwart declarations of support gave way to conflicting claims. Critics of public health insurance seized on this latest case of high-profile medical tourism as proof the Canadian way must be second rate—and no model for America. “This should be a wake-up call to Congress and the administration,” said a Fox News medical commentator. “It is a fact beyond dispute that the United States remains the global destination for patients from all over the world.” Canadian conservatives pounced, too. “It’s symbolic,” said Brett Skinner, president of Vancouver’s Fraser Institute. “These services are not available at all or not available on a timely basis here in Canada.”

That seemed like a reasonable conclusion to draw. Why else would Williams wing off to the U.S.? However, a chorus of Canadian physicians said they were at a loss to think of any heart surgeries, beyond rare and exotic procedures, done in the U.S. that aren’t readily available at Canadian institutes, although often not in Newfoundland. Dr. Bryce Taylor, surgeon-in-chief at Toronto’s prestigious University Health Network, said Ontario’s heart centres offer the latest techniques with virtually no waiting lists, unless a patient insists on a particular famous surgeon. Taylor was annoyed by pundits who assumed Williams went south to get some better procedure faster. “They were impugning our ability to give patients good access,” he said.

There are, of course, differences between what’s on offer on either side of the border. For example, Taylor said some wealthy patients are enticed to U.S. medical “boutiques” that advertise surgery with very small incisions and sometimes robotic equipment. But those innovations are not proven, he added, to be better for the patient. Doctors in both Canada and the U.S. are divided on them. Another difference is the deluxe service offered, for a price, by some famous U.S. hospitals, such as the highly ranked Cleveland Clinic. “It is true that the Cleveland Clinic has so-called concierge treatment,” Taylor said. “They will meet visitors at the airport in limos. I suppose that might be very seductive.”

Canadian hospitals can’t match expensive U.S. clinics when it comes to upscale amenities. Keeping pace on cutting-edge procedures is another matter. When it comes to repairing heart valves, for instance, specialists in Ontario, like virtuoso surgeon Dr. Tirone David, Toronto General Hospital’s head of cardiovascular surgery, are internationally renowned. Why don’t sick American millionaires come north for such surgeries then? Actually, they often ask to, but are usually turned down. The reason: since 2004 Canadian physicians and hospitals have generally not been insured if malpractice suits are brought against them following elective surgeries in U.S. courts, where judgements can be huge.

No matter how many eminent physicians leapt to the defence of Canadian heart specialists, news of Williams’ decision left a lot of Canadians with the impression cardiac care must be better in the U.S. Dr. Jack Tu, senior scientist at Toronto’s Institute for Clinical Evaluative Sciences, has researched outcomes for heart patients in the two countries. Despite famously contrasting health insurance systems, Tu said there’s little difference. But in a recent, unpublished comparison, he found Canada seems to do somewhat better when it comes to patients having to be readmitted to hospital after being discharged following treatment for heart failure. In the U.S., about a quarter end up back in hospital within a month; in Canada, it’s about one-fifth.

Tu suspects pressure to keep hospital bills down means U.S. patients are more likely to be discharged a bit too soon. “In Canada, hospitals are on a global budget,” he observed. “We don’t have insurance companies bugging doctors to send people home quickly.” In fact, the issue of readmissions has prompted the American College of Cardiology and the U.S. Institute for Healthcare Improvement to launch a program called Hospital to Home, in a bid to find ways to lower that troubling readmission rate. Even the elite U.S. hospitals are seized by the issue. Last year, the Cleveland Clinic appointed a task force to study the problem. Broadly speaking, Tu said American hospitals tend to have the edge in technology and intensive care facilities, but Canada’s health system is better at caring for patients over longer periods, including after they leave hospital, and in making sure they get the prescription drugs they need.

Such distinctions in strong and weak points between the two countries didn’t figure in the Williams uproar. It came down to one rich guy’s ability to exit the system he had insistently championed. “If he wants to buy 20-year-old Scotch, I don’t have an issue with it. If he wants to spend his money on his health, I have no issue with it,” said Dr. David Gratzer, a Toronto physician and critic of the Canadian health system. “My issue is with his hypocrisy. My issue is that he says, ‘This is good enough for you, but if I run into trouble I’m taking my jet to Boston or Cleveland.’ ”

Nobody keeps track of how many well-off Canadians pay out of their own pockets for American care. Occasionally provincial health plans pay for U.S. care for ordinary people when services aren’t readily available at home. Provinces spent $1.14 million on U.S. care in 2007-08—less than 0.001 per cent of total health spending. But that’s no more precise an indicator of shortcomings in the Canadian system than Williams’ trip is. Dr. Lorne Bellan, chair of the Wait Times Alliance, an organization of Canadian doctors aimed at speeding up access to treatment, said those problems are serious, complex, and likely to get worse as the population ages.

According to Bellan, provinces made quick progress after Paul Martin’s short-lived Liberal government cut a deal with them in 2004 to funnel $5.5 billion over 10 years into cutting wait times. Queues for cataract surgery, joint replacements and other high-demand procedures shrank fast. Then the Conservatives won election in 2006 on a promise of bringing in wait time “guarantees.” In 2007, each province signed on to deliver one health service, from radiation therapy to bypass surgery, within a guaranteed period. But Bellan said these were token gestures in areas where the waits were already reasonably short. Real progress stalled as politicians shifted to focusing on issues like climate change and the economy.

At least, until the Danny Williams story. “It’s brought to light again this question of what our system is able to provide in Canada,” Bellan said. “It allows us to point out again that there is unfinished business.” Among the persistent problems, he said: shortages of MRI machines and nerve-wracking waits for surgery for serious but non-life-threatening conditions.

Officials in Williams’ office said his surgery was done on Feb. 4 and he was released from intensive care the next day. He is expected to say more about where he went and why when he comes home within a couple of weeks. Whatever his personal story turns out to be, if those details spark only another round of crude claims about complicated issues, the episode won’t have done nothing to move the Canadian health care debate forward.