Politicians and bureaucrats are always attracted to simple ways to control health-care spending. In the early 1990s, they decided the best way to control spending was to cut down on doctors. This brilliant idea resulted in a doctor shortage that has taken the past decade to fix.

The reach for the quick fix has made fundamental change in health care all but impossible. It has given us the worst of all possible worlds – a system in which everyone behaves as if the competition for resources is a zero-sum game and no one is rewarded for acting in the collective interest. The system virtually guarantees turf wars. As a result, the medical professions resemble medieval guilds – fiercely protectionist, rigidly conservative and jealous of their status and perks.

This explains why all the sweeping top-down master plans to fix our health-care system will never work. As one insider puts it, “At each step, you find the structural impediments to change are extraordinary.”

There are lots of cheaper, more effective ways to do health care. But the system is rigged to squash innovation. Take a simple thing like colonoscopies. This procedure – the single most effective screening test for cancer – is conducted in Canada by gastroenterologists. In other countries, it’s done by nurse-clinicians. Why can’t we do that too? Because the barriers erected by the various professional silos are almost insurmountable. Who would pay? Who would be ultimately accountable for the procedure? And so on.

Or take prescriptions. Do you really need to see a doctor to renew your Lipitor? Why don’t we give prescribing powers to pharmacists? In fact, much of the work that family doctors do – ordering tests, taking your blood pressure, lecturing you to lose weight, even treating your bladder infection – is routine. Nurse practitioners and physicians’ assistants could do it just as well. Don’t try to persuade the doctors, though. (The last time I tried, they told me I might have bladder cancer and could die.) Besides, they need the fee income they get from seeing you.

But doctors are defeated by the system too. One group of doctors came up with a way to improve care for breast-cancer patients. Instead of sending a woman on an endless round of specialist appointments to the radiologist, the plastic surgeon and so on, they arranged for all the specialists involved in her care to meet with her all at the same time in order to lay out a treatment plan. When they told the hospital CEO about this breakthrough, he begged them not to spread the word. He feared the hospital would be flooded with patients it had neither the space nor the operating-room time to treat.

What kind of room is there to do things more effectively and efficiently? Here’s one suggestive statistic. We spend around 12 per cent of our GDP on health care. Singapore spends around 2.4 per cent. By almost any measure, Singapore has better health-care outcomes than we have.

Everybody knows that health-care costs cannot continue to rise at the current rate. Everybody in the system can point out lots of ways to do things better. We have a highly trained work force full of talented, hard-working and dedicated professionals. But until we can figure out ways to get them to work collaboratively together, and to reward innovation – not punish it – genuine reform will be impossible. Doctor-bashing is not the place to start.

< http://www.theglobeandmail.com/news/opinions/margaret-wente/doctor-bashings-not-the-cure-for-health-care-costs/article2434938/ >

Remember that warm and fuzzy ad campaign depicting doctors in white coats, sporting stethoscopes and smiles?

Doctors aren’t smiling any more.

That feel-good branding exercise, part of a year-long charm offensive by the Ontario Medical Association just ahead of fee negotiations, has faded from bus shelters. Now, doctors find themselves sheltering from a perfect storm that is branding them as the fall guys.

It’s not just the governing Liberals taking a hard line, but the opposition Tories demanding a blanket freeze and New Democrats wanting to make the rich pay. With public servants taking a hit, the healing profession is feeling everyone’s fiscal pain.

This time, the writing was on the wall before both sides even sat down at the table. Cabinet approved its final negotiating “mandate” in February for doctors — and teachers: No spending increases.

Doctors are paid about $11 billion; factor in teachers and other public servants with contracts up for renewal, and about $25 billion is at stake in negotiations this year — nearly one-quarter of total government spending. That’s why retreat is unlikely, lest the government’s deficit-reducing fiscal plan crumble.

Read more:How Ontario’s doctors get paid

Outgunned, the OMA deployed a secret weapon of its own: It hired the government’s guy.

As deputy minister of health in the last negotiations, Ron Sapsford helped craft the government line. After leaving in the wake of the eHealth scandal, he joined the OMA, rising to CEO last year.

Sapsford has changed chairs, but times have also changed.

Last time, the government was flush with cash and keen to win OMA support in a highly politicized drive to reduce surgical wait times and increase the supply of family physicians.

This time, doctors can’t complain of falling behind: payments have increased by 75 per cent since the Liberals took power in 2003. They remain the best-paid in the country (despite quibbling from the OMA and others, the data suggest our docs are tops when all payments are included for 2011).

This time, threats of another brain drain are contradicted by the quiet return of émigré doctors from the once-promised land of America, describing how private insurers won’t authorize treatments, patients don’t pay their bills, and malpractice premiums are punishing. Also, medical school slots have recently doubled with a clutch of new schools across Ontario, plus a surge in foreign-trained doctors.

This time, technological advances have bolstered the government’s case for fee reductions. Exhibit A is cataract surgery, which takes 15 minutes today compared to two hours in the past.

This time, expert opinion — and a strong all-party political consensus — is pushing to reallocate spending to long-term care and home care, freeing up acute care beds.

And this time, the government is being goaded by outside experts to hang tough. In his high-profile reported last February on public spending, economist Don Drummond warned, “Aggressively negotiate with the Ontario Medical Association for the next agreement.” In his annual report, Auditor General Jim McCarter complained that Ontario may not be getting value for money from special incentives for doctors.

Against that backdrop, Sapsford hasn’t been able to deliver any medical miracles for the doctors he once bargained against, but now bargains on behalf of. In frustration, the OMA walked away from the table last month.

Sapsford also faces a formidable opponent in Deb Matthews, the health minister whom he served for a few months before taking his leave. Matthews is not above demonizing doctors in public. She has artfully sugar-coated the freeze, which in reality amounts to cuts for some (since more than 550 new doctors every year will compete for that fixed pie).

Last week, Matthews went ahead with nearly 40 unilateral fee changes that achieved most of the government’s targets for this year. Now, she is inviting them back to the table to address the unfinished business for the next three years.

As for Sapsford, his OMA sought a private meeting with Premier Dalton McGuinty. But it was seen as an end-run around Matthews, his former boss. In the end game, the meeting never materialized.

And doctors aren’t smiling any more.

< http://www.thestar.com/news/canada/politics/article/1177718–cohn-why-ontario-s-doctors-won-t-win-fight-on-fees >

Ontario physicians are angered by the provincial government’s high-handed approach to fee negotiations. Perhaps it’s time for both sides to do the obvious: End fee-for-service medicine; put doctors on salary.

Originally, the pioneers of Canadian medicare assumed that doctors would become salaried employees of government. That’s what happened in Britain when its National Health Service was established after World War II.

In Saskatchewan, the storied birthplace of Canadian medicare, an established system of salaried rural doctors already existed when Tommy Douglas’s Co-operative Commonwealth Federation (the forerunner of the New Democrats) took power in 1944.

But Douglas’ CCF didn’t follow the British example. The reason was fierce physician opposition.

Self-employed doctors — and even many salaried physicians — preferred the piecework system known as fee-for-service, one in which practitioners are paid set amounts for each procedure or consultation.

In part, this was because doctors preferred to see themselves as independent entrepreneurs.

But in part, it was because fee-for-service gives doctors great leeway in determining their own incomes. To get more money, a physician need only see or treat more patients.

Eventually, Saskatchewan’s CCF government adopted the fee-for-service variant of medicare. That in turn became the model for the entire country when medicare went national in 1968.

In spite of doctors’ initial misgivings, fee-for-service medicare turned out to be a bonanza. They could still charge piece-work rates. But their payments were guaranteed by government.

Today, however, governments don’t want to pay as much. Over the years, they have gradually eroded physicians’ fee-setting autonomy

Ontario’s government, for instance, began by negotiating overall financial settlements with the Ontario Medical Association,leaving physicians to divvy up the pot.

But that proved unsatisfactory since it allowed the most politically powerful factions within the OMA to reap the bulk of the rewards. This in turn left some areas — particularly general practice medicine — woefully underfunded.

Then governments began to involve themselves in the nitty-gritty. Premier Dalton McGuinty’s Liberals initially used carrots, giving doctors extra bonuses on top of fee-for-service in those areas of medicine where the government wanted more done.

Now, the Liberals are using sticks, threatening to unilaterally remove some of the goodies they introduced in the first place.

In short, the government is doing its best — in a rather clumsy way — to treat doctors as employees, calling upon them to do more for less.

It’s the same message Queen’s Park is giving all of its salaried workers, from teachers to prison guards.

So maybe it’s time for both sides to face what is going on. So-called alternative payment schemes (such as paying doctors on the basis of their patient rosters) have already moved the system away from pure fee-for-service. Why not go the whole way?

Incidentally, salaried docs don’t do that badly. In Britain, a general practitioner can earn up to $131,000 for a 40 hour work week. And that’s just base pay. There’s overtime and merit pay on top.

There’s also a handsome, fully inflation-indexed pension plan and up to six weeks paid holiday annually — perks that Ontario’s self-employed doctors don’t enjoy.

Best of all, the entire pay packet goes to the physician. Overhead and office costs are covered by government.

The advantage for government is that it can manage the system it funds. The advantage for doctors is they can focus on medicine.

And patients? The evidence from Britain suggests they do just fine with salaried doctors.

< http://www.thestar.com/news/canada/politics/article/1177014–walkom-why-not-put-all-ontario-doctors-on-salary >

Ontario’s doctors complain of being “deceived” by the Liberal government after several hundred fees paid for services were slashed to save $338.3 million this year.

Health Minister Deb Matthews announced Monday there would be 37 changes to the OHIP fee schedule, targeting hundreds of services provided by cardiologists, radiologists and ophthalmologists.

The doctors claim this will mean longer waits in emergency wards and for test results — and warn that patients could expect a harder time finding a family doctor or a specialist because of fewer physicians.

“Our doctors are the best paid in Canada,” said Matthews, whose gambit comes as the province’s bitter negotiations with the Ontario Medical Association, which represents 25,000 doctors, have stalled.

“Instead of another raise for doctors, we need a real wage freeze so we can invest in more home care,” she told a press conference at Toronto Rehab, a continuing-care hospital. “I was left with no choice.”

Dr. Doug Weir, the new president of the OMA, accused Matthews of not negotiating fairly because she has not moved from her initial bargaining stance yet now wants to slash $1 billion in fees and programs.

“Where I come from, holding your breath until you get what you want is not negotiating,” said Weir, who was on his first day on the job. “This is not a wage freeze, it is a cut.”

Matthews argues the OMA is looking for a $700 million boost and what is the equivalent of a 5 per cent raise for physicians, which works out to about $20,000 per doctor.

The OMA says this is false; they will take a two-year fee freeze and help find another $250 million in savings.

Weir, a Toronto child psychiatrist, said it is clear the government never had any intention of really negotiating with Ontario’s doctors.

“We have been deceived. In doing so, they have chosen confrontation over collaboration.”

The OMA has launched a $1.5 million print, radio, TV and online advertisement campaign in an attempt to arouse public sympathy.

While the doctors have promised not to stage a job action, such as a strike or working to rule, Weir predicted patients would feel the pain of the changes.

“Patients in Ontario, particularly seniors, will suffer from reduced access to medical care for blinding conditions like macular degeneration, glaucoma and diabetes,” he said, adding ultrasound and mammography waits could return to levels not seen for decades.

The changes, which affect several hundred of the 4,500 OHIP services, were filed Monday and are retroactive to April 1, said Matthews.

Insisting that she is choosing “seniors over specialists,” the minister stressed she still wants to work with doctors to hammer out an agreement.

“Our budget was explicit; we were looking for a real wage freeze. This comes as no surprise to doctors. I am hoping they will now come back to the table so we can continue to work.”

Weir’s predecessor, Dr. Stewart Kennedy, angrily denied on Friday that all the doctors want is a raise. They say this is a fight about the future of the health system as the boomer population rapidly greys and demands more services.

With 407 specialists billing OHIP more than $1 million each a year, the Liberals believe vast savings can, and must, be found as the province faces a $15-billion deficit.

Conciliation, first refused by the government but pushed for by the doctors, was agreed to late Friday. However, the Health Ministry placed a 48-hour time limit on talks, saying the OMA had until only Sunday night.

The doctors would not accept this, saying they would talk to Matthews about conciliation Monday.

She responded by regulating fees.

Payments for cataract surgeries will be cut to $397.75 from $441 — surgeries that took two hours in the 1980s now take 15 minutes, thanks to technological improvements. Fees for eye injections for retinal diseases will be cut to $90 from $189 over four years.

“Specialties have seen tremendous windfall profits because of enhanced technology. We need to share in some of those productivity changes. It is only appropriate we update fees to reflect reality,” said Matthews.

In some specialties, new technologies have boosted doctors’ pay to $700,000 a year on average, she said.

Payments for 250 different diagnostic radiology tests, such as X-rays, CT/MRI scans and ultrasound will be reduced by 11 per cent over four years.

Self-referrals — the practice of doctors referring patients back to themselves for additional procedures — will be curbed. Currently $88 million is spent on that, but the government wants that reduced to $44 million.

Matthews noted doctors’ pay has risen an average of 75 per cent since the Liberals were elected in 2003 — from $220,000 to $385,000.

Progressive Conservative Leader Tim Hudak supported her move to impose the fee cuts and to freeze the total compensation package for doctors because “something has to happen.”

But Hudak said he’d go further by introducing a bill soon to impose a mandatory wage freeze on all public-sector workers with “no exceptions, no special deals” instead of waiting for wage freezes to be negotiated.

Premier Dalton McGuinty told Hudak that wage freeze legislation is too provocative, saying “we’re not going out there looking for a fight.”

NDP Leader Andrea Horwath chastised the government for taking the “my way or the highway” approach and not engaging the doctors in a more meaningful dialogue.

“The patients have become the ping pong ball in this high-stakes game.”

With files from Rob Ferguson

• Fee per service for any combination of retinal disease or glaucoma will be reduced to $25 from $63, and service will be limited to four times a year.

• Fees for anesthesia for conscious sedation (colonoscopies, cataracts, etc.) will be reduced to a combined fee of about $60 from $120.

• Electrocardiogram fees are being reduced to $4.95 from $9.90.

• Complete colonoscopy fee is being reduced to $197 from $218.90.

• Payments for cataract surgeries will be cut to $397.75 from $441.

• Fees for eye injections for retinal diseases will be cut to $90 from $189, over four years.

< http://www.thestar.com/news/canada/politics/article/1174205–deb-matthews-slashes-fees-for-ohip-services-to-save-338-million >

Canadians with cancer, heart disease, diabetes and just about every other physical illness don’t think twice about going to their doctor for help. But, when it comes to mental illness just one in three affected adults and as few as one in four children seek and receive treatment.

For some, stigma and fear keep them from getting the medical care they need. Others desperately want treatment but can’t find the appropriate services in their community or face long waitlists. This is why Prime Minister Stephen Harper has called mental illness “a major national public health problem” and, in 2007, created a national agency to tackle it.

This week, the Mental Health Commission of Canada released its blueprint for a national strategy to properly treat and support Canadians with mental illness. The comprehensive document covers every aspect of what needs to change – from how employers and schools handle mental illness to the need for more affordable housing and a reformed justice system that doesn’t criminalize illness.

The danger now, though, is that rather than embracing the challenge, Harper may throw up his hands at the enormity of it all – and the seemingly high price-tag that comes with it. That can’t be allowed to happen. The status quo is not an option when one Canadian in five suffers some form of mental illness every year and it costs our economy more than $50 billion, according to the commission.

If Ottawa needs a manageable place to begin improving the lives of Canadians, why not start with our kids? In many communities, children and youth face the greatest shortage of mental health services. Resources spent on children have enormous impact. Early identification and treatment can save young people from a lifetime of challenges that come with untreated mental illness.

Without proper health services and community support, childhood mental illness can stress families to the breaking point. Children drop out of school, wind up in homeless shelters or, worse still, the prison system. Crown wards and First Nations youth are particularly vulnerable to this downward spiral.

Focusing on children will also teach everyone involved about the extraordinary level of cooperation and coordination that is required. This is not just a health problem. The solutions cross federal-provincial boundaries and run across multiple ministries, including health, education, social services, housing and corrections.

Breaking down those silos will require strong federal leadership. That, unfortunately, is not something this Conservative government has shown much interest in, especially in the health care.

When Prime Minister Harper launched this commission he promised “their work will improve quality of life for Canadians and their families dealing with mental illness.”

Whether that happens depends on what his government does now. So far, it isn’t looking promising. Health Minister Leona Aglukkaq welcomed the report and committed the government – not to action, but to yet more research.

The 6.7 million Canadians suffering with a mental health problem or illness deserve better than that.

< http://www.thestar.com/opinion/editorials/article/1175149–focus-on-children-first-in-tackling-mental-heealth >

Settling in by the window of a French bistro along the strip of Harbord Street that caters to Toronto’s academic gentry, the psychiatrist David Goldbloom refuses a glass of wine without a second thought. Frankly, he looks appalled at the suggestion, as he will soon be seeing patients at the Centre for Addiction and Mental Health, where the lingering odour of even the most delicate grape could cause untold problems.

And yet, given the daunting task before him as the new chair of the Mental Health Commission of Canada, whose national strategy launches on Tuesday, one imagines the man could use a drink.

For the casual observer, the parade of news stories about mental illness at the extremes can inspire despair. In Halifax, a gay activist is killed by a man on a one-hour leave from a secure forensic psychiatric unit. In Toronto, a schizophrenic man kills his father at home, and then himself in jail. An Ontario appeals court rules that a man who killed his wife may collect on her life insurance, over their son’s objection, because he was insane when he did it.

And the Ontario legislature vows to review police procedure to reduce the number of mentally ill people hurt or killed in confrontation with police.

With headlines like these, it is tempting to see serious mental illness as the incorrigible problem child of Canadian health, social and justice policy, epitomized by Ashley Smith, the mentally ill New Brunswick teenager whose cross-country tour of Canada’s penal system illustrated its myriad failings and ended with her suicide being videotaped by guards.

But as he prepares to launch Canada’s long-awaited national strategy on mental health, complete with a budget-style media lock-up on in Ottawa, Dr. Goldbloom is much more optimistic, and his perspective is wider than the terrible extremes.

“We do have a problem with perceptions of dangerousness among people with mental illnesses,” he said. But it is only that — a perception problem — and things are changing.

“We know that prisons, jails, are the last great asylums of North America for people with mental illness,” he said over a lunch of steak frites and tap water. “The biggest asylum in the United States is the Los Angeles County Jail. There’s about 20,000 inmates and about 2000 of them are severely mentally ill. We know that people with mental illness are really vulnerable to being victimized in a prison system, and that care in a prison system for people with mental illness is nowhere near where it needs to be.”

At the same time, he said a shift in public attitudes to mental health has opened vast new possibilities for progress all across the spectrum of mental health — from problems that are not illnesses, through the various forms of depression, anxiety and behavioural symptoms, to serious and persistent illnesses like schizophrenia and bipolar disorder. Big philanthropy has followed suit, such as the $10-million donation last week by Margaret McCain, widow of food magnate Wallace, for youth programs at Toronto’s Centre for Addiction and Mental Health, where Dr. Goldbloom is senior medical advisor.

Once an aspiring actor, he also chairs the Stratford Shakespeare Festival, and comes from a family of prominent doctors. Energetic and funny, he joked that he recently emailed some Jewish friends about the Stratford Festival’s recent Broadway smash hit production of Jesus Christ Superstar, and included a “spoiler alert” in case they did not know the lead character dies in the end.

“I’ve never seen anything quite like it,” Dr. Goldbloom said about the spike in public and government interest in mental health programs, and the newfound ease with which these topics come up in public discourse — even in death notices that explicitly mention suicide, where once it was taboo. By taking lessons from grassroots advocacy for breast cancer and HIV, Dr. Goldbloom said he hopes to harness and promote this trend, but problems keep coming fast and furious, and he has taken over the commission at a decisive moment in its history

Formed in 2007 with $130-million in arms-length funding from Health Canada, and set to close in 2017, the Commission has always had a dual purpose, first articulated by inaugural chair and retired senator Michael Kirby, whose family experience with mental illness inspired his 2006 report Out of the Shadows At Last.

On the one hand, the MHCC combats stigma, a goal it has pursued, for example, by commissioning research on media archives to show journalism students how frequently news stories that mention “schizophrenia” are negative in tone, and how infrequently they are positive.

On the other hand, the MHCC was also mandated to prepare a national strategy on mental health from its uniquely independent position outside the federally-funded provincially-administered health system.

It is that duality in the commission’s purpose — between its optimistic orientation against stigma toward empowerment and recovery, and the worryingly frequent system failures on serious mental illness that call out for a comprehensive strategy — that has caused it the greatest grief and put it on the defensive, never more than last year, after the leak of a draft strategy that was long on platitudes, but short on substance.

One psychiatrist observed that the draft version did not even mention “psychiatry,” nor “schizophrenia” or “bipolar,” but “recovery” was mentioned 67 times and “support” 127 times. Advocates for schizophrenia treatment have similarly warned of the influence of anti-psychiatric academics, even anti-medicine conspiracy theorists, on the commission’s many advisory boards.

The draft was so widely criticized that the Commission’s CEO, Louise Bradley, vowed in a letter to Canadians to “correct” its failures of emphasis, because it “does not sufficiently reflect the essential role neuroscience, treatment and psychiatry have to play.”

This is one of the many problems Dr. Goldbloom, a long-time MHCC board member, was promoted to solve. As a front-line expert on the nastiest of mental disorders, he is ideally qualified to quell suspicions of anti-psychiatry from without, while also confronting expressions of it from within. But he is touchy about what went wrong.

“What got released was a draft. The draft was nowhere near a level of reaching board approval. It was a work in progress,” he said. “It’s a better document now. The language has been refined over the course of the last year to try to better communicate the beliefs of the commission and the beliefs of the people who serve on it.”

He said the next few years will be devoted to the critical “translational aspect” of the strategy, in which a national vision is adapted for local application, from provinces, most of which already have strategies, down to the level of municipalities.

Dr. Goldbloom said the board focused closely on the strategy’s terminology, deciding on the term “severe and persistent mental illness” to capture the worst, while also taking the position that not all mental health problems are illnesses. He said “presenteeism,” for example, or being incapable of working while at work, is of major social and economic concern, though not an illness in itself.

“That is not talking about mental health ‘issues,’” he cautions. “I hate ‘issues.’ Nobody with cancer says ‘I have neoplastic issues,’ ‘I have cell proliferation issues.’ They say they have cancer.”

It is a refreshing bluntness. More than any other health problem, mental illness is vulnerable to fuzzy, clichéd thinking. Psychiatry itself has a mixed history in this regard, Dr. Goldbloom said, of being misled by its own metaphors, and forgetting what is proven and what is fanciful theory. Freudian psychoanalysis is the big example, but the same can be seen in theories, false but once widely held, about the origins of mental illness in faulty parenting.

With the rise in understanding of genetics, Dr. Goldbloom said we have shifted to “a much more profoundly biological paradigm” in how we understand mental disorders, but full insight remains elusive.

“We don’t know what causes schizophrenia, but it’s not bad parenting,” Dr. Goldbloom said, pointing out that if you have an identical twin with schizophrenia, your odds of getting it are 50%.

“The point is it’s not 100%. If it was cystic fibrosis, you would get cystic fibrosis,” he said. So there is more going on than just genes, some of which you might be able to control, such as exposure to stress, for example, or marijuana, which in susceptible young people can trigger psychoses. Similarly, if everyone in your family had a heart attack at 40, you would probably take measures to prevent your own,” Dr. Goldbloom said.

“This is about managing risk. You can’t control genes, you can’t pick your parents. But genes are not absolute destiny,” he said. “The extent to which stigma, illiteracy or shame stops people from checking things out is a tragedy.”

At the extremes, the contrasts between normal and pathological are stunning and clear, but Dr. Goldbloom doubts he will ever be able to pin mental illness to the wall, in the way that viruses explain the common cold, or tobacco smoking explains lung cancer.

“What people don’t appreciate is that we draw arbitrary lines in medicine, between health and disease, all the time. There’s been intense focus on this line drawing in psychiatry, in the context of all of the controversy around DSM-V [psychiatry’s diagnostic manual],” he said. “We are inexorably attracted to certainty. We love dichotomous variables. We love lines that we can draw. Unfortunately, the simple conclusions are often the most alluring and the most incorrect.”

He cited the panic over suicide and drug abuse among NHL enforcers as an example of jumping to glib conclusions, but he acknowledges that the impulse to grasp at even a wisp of understanding is unavoidably human.

“How do the parents of any child who has any kind of disorder not wonder about their own genetic contributions to their kid’s illness?” he said. “Every caring parent scrutinizes themselves, their behaviour, their biology, when they see a child of theirs suffer. I think it’s inevitable. We don’t have evidence they could have done something difference when it comes to schizophrenia or autism, so I think one of the comforts we can provide to families is alleviating that sense of blame, castigation, but also not simply blame, but sometimes shame. Those are not the same. And one of the things that magnifies shame is stigma. Because if your child has liver failure or diabetes, the response of the community around you is support. They’re all over you like a dirty shirt… But [in the case of mental illness], for some families the response is social distance. People back away.”

< http://news.nationalpost.com/2012/05/06/a-character-study-of-mental-illness-and-change/ >

The Ontario government has reached its first test in its efforts to curb compensation costs — negotiations with the Ontario Medical Association over physician pay.

The OMA claims that a fee cut will increase wait times. The province’s position is that not raising fees given the budget situation is both necessary and reasonable. A few decades ago, policy-makers were worried that physician compensation in Ontario was out of step with our competition and that we would lose doctors to the U.S. or other jurisdictions that might court our highly trained medical workforce. Policy-makers continue to be concerned about physician compensation being out of step, but this time, in the other direction. Have times changed in Canada relative to the rest of the world? How does physician compensation pay in Canada compare to doctors in other countries?

Comparing doctor salaries across countries can be misleading as the cost of living often differs a lot between countries. Two ways to think about comparing compensation are: 1) converting currencies so that a dollar basically buys the same amount of goods in each (this method is called purchasing power parity or PPP) and 2) compare doctors’ salaries to the average wage earned in that country. Policy analysts use both of these.

A recent paper put out by the OECD suggests that in 2004 Canadian GPs were paid about the same in PPP dollars as doctors in Switzerland and Austria, but less than those in the U.S., U.K. and Germany. Using the comparison to average wages, however, Canadian GPs are among the highest paid in the OECD, just below the United States (3.2 times the average wage versus 3.4 in the U.S.).

Among specialists, Canadian specialists were again among the highest paid in 2004, at almost five times the average salary, although far behind those of the United States, which was 50 per cent higher. There has been substantial growth since these comparisons were recorded in 2004. Over the last 10 years, according to the Canadian Institute for Health Information, physician compensation in Canada has basically doubled.

Canada, as well as every other country in the OECD, has costs that are much lower than those in the United States. So saying that our costs are much lower than theirs doesn’t mean much in the global context. Comparisons with the U.K., however, are potentially more interesting. According to a recent study, while overall health-care spending is much higher in Canada per capita than in the U.K. ($4,079 U.S. versus $3,129 U.S. in 2008), GP physician salaries are considerably lower after expenses ($125,101 U.S. versus $159,000 U.S.). The gap for orthopedic surgeons between Canada and the U.K. is even greater. So the U.K. manages to pay its doctors more while spending less overall. On the other hand, Canada has far fewer physicians per capita than most OECD countries. We’re on par with the U.K. and the U.S. (around 2.4 per thousand in both countries) but below Germany, France, Italy and Spain (3.5 per thousand on average).

How should we think about the relationship between spending on physicians and wait times? It’s difficult to draw absolute conclusions from these spending and price comparisons, but here is what the research reports: countries that spend more tend to report lower wait times. This is perhaps not surprising. Beyond spending more, targeting funds at reducing wait times through activity-based funding is correlated with reduced wait times. Included in this is increased compensation for what physicians do (fee for service) when what they do is aligned with the goals of reducing wait times in specific areas. Simply increasing funding does not. There is little evidence on the relationship between doctors’ salaries and wait times.

Comparing Canada’s doctors with those in other OECD countries suggests that our doctors are paid relatively well compared to most, but less than those in both the U.S. and the U.K. That said, the U.K. manages to spend much less overall than Canada does and, recently at least, fares better in international wait time comparisons. Simply spending more doesn’t seem to solve the wait time problem, but targeted spending on agreed upon targets that increases productivity appears to deliver better results than across-the-board increases to any part of the health-care system.

Mark Stabile is director of the School of Public Policy and Governance and a professor at the Rotman School of Management, U of T.

< http://www.thestar.com/opinion/editorialopinion/article/1172109–paying-doctors-and-wait-times-how-does-canada-compare >

Having won the Alberta election, Premier Alison Redford is now setting her sights on providing leadership in establishing the national agenda on health-care reform. In doing so, she won’t be able to ignore the issue of patient wait times. Wildrose may have lost the election, but it did propose some ideas in this regard that are likely to remain front and centre on the political agenda.

An important one that will have life in Alberta and beyond is a Patient Wait Time Guarantee, which would have allowed Albertans on lengthy waiting lists to seek care from independent health providers in or out of province with provincial public insurance coverage. Allowing such coverage is not merely Wildrose election rhetoric – basic elements of a plan to allow greater flexibility in provincial insurance coverage of services received out of province were contained in a leaked confidential Alberta Health and Wellness planning document in 2010.

Would such practices be consistent with the Canada Health Act or would they trigger financial penalties for the province? On this hot-button issue in health-care reform, Ottawa needs to clarify its position.

To comply with the Canada Health Act – to which Wildrose stated a clear commitment – independent health providers in Alberta wouldn’t have been permitted to extra-bill patients. But reimbursement for services provided elsewhere would have been at the rate provided for in the provincial schedule; if provided out of country, the patient would pay the difference between the Alberta rate and the fee actually charged – otherwise known as extra-billing.

Though detractors will claim that this violates the “spirit” of the act, the CHA allows this practice on out-of-country treatments. At the same time, it grants discretion to, but does not require, the federal minister to levy penalties for such practices should the minister determine they impede reasonable access to services.

The case is less clear for services provided by independent facilities in another province. The Wildrose proposal didn’t extend its restriction on extra-billing to independent providers in other provinces. While the CHA says there must be deductions from federal cash transfers for extra-billing “by medical practitioners or dentists in the province,” it’s unclear as to whether extra-billing by providers in another province automatically requires federal penalties.

This lack of clarity creates another grey zone, subject to the discretion of the federal minister. The minister also has discretion to levy penalties for such practices where the minister determines that reasonable access is impeded.

Wildrose said it didn’t “advocate” extra-billing; but its Patient Wait Time Guarantee certainly would have allowed it in these specific instances. But, then again, so does the CHA – unless, of course, the federal minister exercises the discretion granted in the act to say it doesn’t.

Should provinces wish to pursue reforms, they shouldn’t be hampered politically by a lack of clarity regarding consistency with CHA criteria. Rather, they should be able to make such decisions – and be forced to defend them on their merits – with relative certainty regarding consistency (or lack thereof) with CHA criteria. To help provide such certainty and clarity, the federal government should stop avoiding these public debates and, instead, clearly and publicly state its position on issues such as the proposed Quebec health deductibles or terms for out-of-province care as they arise.

Paradoxically, this might well place the CHA on a firmer political footing. The bias against reform generated by a lack of clarity has contributed to the sense that the CHA places a straitjacket on reform, which has resulted in calls for its suspension or repeal. Greater clarity and expanded political latitude for reform might well dull such calls.

Moreover, to the degree that providing such clarity is a key step toward meaningful public dialogue on health care in Canada, the federal government should do so. Clarity is one thing that’s clearly missing from current debates.

Gerard Boychuk is a professor of political science at the University of Waterloo and Balsillie School of International Affairs. His C.D. Howe Institute Commentary, Grey Zones: Emerging Issues at the Boundaries of the Canada Health Act, can be found at www.cdhowe.org.

< http://www.theglobeandmail.com/news/opinions/opinion/health-reform-ottawa-must-provide-clarity/article2414166/ >

Six organizations studying how government policies on everything from toxic chemicals to the legacy of residential schools impact women’s health will lose their funding as part of widespread cuts to the federal budget.

Health Canada expects to save $2.85 million a year by eliminating the Women’s Health Contribution Program, which supports the work of four research centres and two communications networks across the country, by next March.

The organizations now facing an uncertain future have conducted publicly available research looking at on-reserve aboriginal programming for maternal and infant health, barriers to treatment for pregnant women and mothers addicted to drugs or alcohol, and casting a critical eye on funding for the HPV vaccine.

Anne Rochon Ford, the Toronto-based executive director of theCanadian Women’s Health Network, one of the groups set to lose its federal funding, said the biggest loss will be how the groups went beyond clinical research to focus on how particular government policies and regulations affect the health of women.

“That analysis, I think, is unique to the program and that will be gone,” Rochon Ford said Wednesday.

The National Network on Environments and Women’s Healthbased at York University, for example, has taken a look at how the federal regulation of toxic chemicals affects the female population in a particular way.

“Women are exposed to more chemicals, because we use more personal-care products and . . . women are often making these decisions about what chemicals they are exposing themselves and their families to,” said Jyoti Phartiyal, projects manager at the network.

Steve Outhouse, a spokesman for federal Health Minister Leona Aglukkaq, noted the program began in 1996 when there were fewer resources available for research into women’s health.

Outhouse said Health Canada now plans to focus its research funding through the Canadian Institutes for Health Research (CIHR), which includes an Institute of Gender and Health with an annual budget of about $54 million.

“We’re not diminishing the work that anyone has done, (but) when we’re in a process of deficit reduction we’re always looking at how do we achieve that mandate as efficiently and effectively as possible?” said Outhouse.

Outhouse added the annual budget for gender health research includes about $33 million for “open” research, which is one way the groups losing their federal funding can still apply for grants to conduct research on a project-by-project basis.

Rochon Ford noted that in contrast to the scientists conducting clinical research funded by the CIHR, the groups had a mandate to advise the federal government on policy.

Still, Rochon Ford said that role had diminished long before Health Canada announced the funding cut.

“That has eroded considerably with this latest government. It’s been made very clear to us that they don’t want our policy advice,” said Rochon Ford.

Outhouse pointed out that health care is a provincial and territorial responsibility and that the research funded by the CIHR will be available to hospitals to incorporate into their practices.

Health Canada has also come under fire for plans to wind down the National Aboriginal Health Organization (NAHO) by the end of June, but Outhouse explained that was largely due to internal problems with the non-profit group.

Three of the five national aboriginal organizations that made up NAHO recommended in a letter to Aglukkaq last fall that it disband and be replaced with three separate agencies for First Nations, Inuit and Métis, which Health Canada rejected.

“That made the decision fairly straightforward at that time, since the organization doesn’t technically exist without the national aboriginal organizations,” said Outhouse.

Health advocates are also upset with a decision to cut $15 million from the Federal Tobacco Control Strategy, arguing that it will scale back regulatory and enforcement activity at Health Canada and eliminate a grants and contribution program that went to anti-smoking initiatives.

Aglukkaq said Health Canada is turning its anti-smoking efforts toward Canadians with above-average smoking rates, such as aboriginal populations, where smoking rates are as high as 50 per cent.

< http://www.thestar.com/news/canada/politics/article/1167987–federal-budget-2012-health-canada-cuts-funding-to-women-s-health-research-groups >

Fast food is packed with sodium — a fact that’s no surprise to most people. But why here in Canada is our fast food even more sodium-laden than in other countries? According to a study published in the Canadian Medical Association Journal, McDonald’s Chicken McNuggets in Canada contain more than twice the amount of salt as they do in Great Britain. It wasn’t that long ago that Canada topped a world-wide list of the amount of sodium in products like breakfast cereals.

Meanwhile, Health Canada has indeed recognized that our sodium-rich foods are putting our health at risk. So what does this government agency do to help Canadians reach recommended targets?

Not much.

True, they did strike an expert committee to deal with our excessive sodium intakes and when the Sodium Working Group came up with hard hitting recommendations, Health Canada disbanded the committee. According to the group’s report, slashing our intake by 1,800 milligrams a day would prevent a staggering 23,500 cardiovascular disease events such as heart attacks and stroke per year. Many of the abandoned recommendations dealt with cutting sodium from processed food, which is where most of the sodium in Canadian diets comes from.

Consider that reducing our intakes would also lead to a whopping savings of $1.38 billion per year in direct health care.

The government’s latest blow for making smart food choices was the news from the recent federal budget that the Canadian Food Inspection Agency (CFIA) will no longer police food labels. It’s just the latest in a number of moves that appear to be putting corporate health before the health of Canadians.

As science shows the importance of healthy eating in both the prevention and treatment of disease, the government has taken away an important weapon in the battle against a variety of diseases. This at a time when the statistics link diet-related stroke, heart disease, cancers, diabetes and obesity to approximately 48,000 deaths annually in Canada.

With the government relinquishing its watchdog status, there is nothing to motivate companies to correct inaccurate and potentially misleading information that may make their products appear healthier.

Take, for example, what happened with a package of jumbo hot dogs brought to me by a client. It was a product with a label listing an incredibly low sodium content. She thought she had made a spectacular nutritional find. But to my expert eye, it made no sense that a hot dog (with added sodium in the ingredient list) could contain less sodium than a comparable amount of raw unseasoned beef. I contacted the company, which flat out denied that its label could be inaccurate. I then filed a complaint with the CFIA. The updated label that resulted from their investigation revealed that the sodium content listed was about 10 times the previous one.

Now there’s no longer anyone to hold companies accountable for providing Canadians with accurate information about the foods they eat.

The government says that it’s a cost-cutting measure but what about the fact that diet-related diseases cost more than $6 billion per year, a number that’s expected to keep rising.

This action is just the tip of the iceberg.

In February, Health Canada shuttered plans to regulate trans fats saying it would be a regulatory burden to food companies. This after their own expert committee recommended legislation, not voluntary action, to rid Canadian foods of this toxic ingredient. Consumption of trans fats is linked to heart disease, stroke, diabetes and more.

Health Canada also recently allowed caffeine to be added to non-cola soft drinks — an initiative that might yield more caffeine per can than the maximum recommended daily intake for some children.

Their inaction over the past five years in dealing with helping consumers select disease-fighting whole grains is another example. Because of outdated regulations that allow for whole wheat to be refined, yielding a product that is not whole grain, consumers are very confused. They logically think the word whole denotes whole grain, yet a bread that is 100 per cent whole wheat may not be a whole grain.

It’s time for Health Canada to get back to the business of safeguarding our food and health and protecting the money we spend on good nutrition instead of ensuring the food companies a healthy profit.

Rosie Schwartz is a Toronto-based consulting dietitian in private practice and is author of The Enlightened Eater’s Whole Foods Guide (Viking Canada).

< http://www.thestar.com/opinion/editorialopinion/article/1164814–health-canada-isn-t-helping-canadians-cut-salt-intake >