Medicare made easy
The solution to our health-care funding problem is innovation, and it's already working brilliantly in some parts of Canada, says doctor and author MICHAEL RACHLIS

Globe and Mail
Monday, Apr. 26, 2004 - UPDATED AT 4:51 PM EDT

Last week, Alberta Health Minister Gary Mar suggested user fees to raise money for our health-care system, and federal Health Minister Pierre Pettigrew reiterated Ottawa's support for the Canada Health Act with promises of a new 10-year public funding plan. But examples from across Canada and around the world indicate that we don't have to spend a lot more money to solve medicare's problems.

Sometimes we hear simultaneously that "health costs are spiralling out of control" and that "our health-care system is dangerously underfunded." In fact, costs are not excessive, but neither is the system starved of funds. While costs have risen rapidly in the past five years, that followed five years of unprecedented restraint. Canada actually spends slightly less of its GDP on health care now than it did in 1992. On the other hand, looking back to 1975, government health-care costs have increased by nearly 3 per cent a year, per capita, in real terms. If more money were the remedy, we would have fixed medicare a long time ago.

The main problem with medicare is that it was designed for another time.

We started to debate medicare 100 years ago, when our main health problems were acute illnesses like diphtheria and tuberculosis. As we implemented medicare, Canada was transformed from a young country, with mainly acute illnesses, to an aging country, where the main health problems are chronic illnesses and frailty.

Canada provides world-class care for victims of heart attacks and car accidents, yet too many patients with diabetes and other chronic illnesses die from preventable complications. Former Saskatchewan premier Tommy Douglas always claimed that medicare would be implemented in two stages: the first involved public payment for the old, illness-treatment system; and the second, a new system based on prevention. He warned that if Canada did not refocus health services on prevention, the costs would rise and the enemies of medicare would call for its dismantling.

Although progress has been slow, there is now a plethora of models for fixing medicare with a preventive approach. Such inexpensive solutions to medicare's problems have been developed across this great country by the hundreds of thousands of Canadians who work in health care.

At least 10 per cent of hospital patients are waiting for a bed in a long-term-care institution, and another 10 to 20 per cent could leave hospital if there were appropriate home-care services for them. The Saskatoon Regional Health Authority seamlessly manages hospital care and has increased its home-care capacity, with the result that fewer than 1 per cent of the city's hospital patients are waiting for long-term care.

Edmonton's palliative-care program provides high-quality care. It also emptied hospital beds so quickly that if implemented across Canada, such a program would free up more than 1,500 hospital beds. An advance clinical directive pioneered in Ontario nursing homes offers residents more control over their care when they get sick; it too would free up more than 1,500 beds if implemented throughout the country.

As we have become more successful in treating heart attacks, the number of patients with congestive heart failure has soared. Because heart failure is complicated to manage, about 20 to 25 per cent of patients are readmitted to hospital within a month of discharge. A few years ago, the innovative Sault Ste Marie Group Health Centre assigned a home-care nurse to see every heart-failure patient; that reduced readmissions by 70 per cent.

The Northwest Territories' diabetic program ensures comprehensive follow-up and, at least partly as a result, no diabetic has suffered the loss of kidneys due to complications from the disease.

Many Canadians lack family doctors; others wait months for tests or appointments with specialists. Yet Canada actually has more physicians than ever. Better teamwork is the key to access. In southwestern Saskatchewan, one physician working in a team with three nurse practitioners looks after 3,200 patients, more than twice the Canadian average. In Hamilton, teams of counsellors, family doctors and psychiatrists have increased the numbers of patients treated for mental health problems by 900 per cent, while decreasing referrals to the regional psychiatry clinic by 70 per cent. In Sault Ste Marie, a taskforce reduced the time from mammogram to the definitive diagnosis of breast cancer by 83 per cent.

Canada's prescription-drug bill continues to escalate at a rate of more than 10 per cent a year. Far too many patients take drugs they shouldn't, and others take expensive new drugs when older, cheaper ones would work as well, or better. In North Vancouver, a program where a pharmacist provides education to doctors in their offices saves $1.50 for each dollar the program costs. B.C.'s reference-drug program substitutes older pharmaceuticals for new ones, and saves nearly $50-million a year.

Medicare is at a crossroads. The right shrieks privatization, while the left pleads for more money. Most Canadians oppose market solutions, but we understandably balk at continuing to pump public dollars into what sometimes seems like a bottomless pit. However, we can solve almost all of medicare's apparently intractable problems with innovation. And, we can implement these innovations without private finance or for-profit delivery.

In fact, for-profit care tends to increase costs while decreasing quality. Let's speed up medicare's renewal by spreading the best practices as quickly as possible. As the problems wane, so will the demand that we change the basic values upon which medicare was founded. It's not too late to save medicare and it's not too early to pitch in to help. Let's take our final direction from Tommy Douglas: "Courage my friends. 'Tis not too late to make a better world."

Dr. Michael Rachlis, an associate professor at the University of Toronto's department of health-care policy, is the author of Prescription for Excellence: How Innovation is Saving Canada's Health Care System.