Canada — the finest health-care chaos in the world

Posted on April 20, 2015 in Health Delivery System – Full Comment
April 20, 2015.   John Robson, National Post

Canadians often debate whether to keep our health-care system because it’s the best in the world or keep it though it’s not. Far too little attention is given to whether we have a system at all.

By that I don’t mean whether it’s truly portable or includes everything. I mean a system is meant to be an organic whole, with rational feedback mechanisms matching available inputs to desired outputs. We need to focus less on large goals like reducing wait times or controlling spending and get our minds and hands dirty with the mechanisms.<

Occasionally a news story peels back the curtain a small way and reveals the little man thrashing about in a panic. In 2011 The Globe and Mail reported that “quirks” of declining government funding “are pushing surgeons to delay costly hip and knee-replacement operations in favour of less expensive procedures, such as removing bunions.” See, the feds gave the provinces money to reduce wait times, so the provinces gave hospitals a quota of operations and a fixed budget, so hospitals did the cheap ones.

On the surface it looks like inept, miserly planning. But actually it’s just planning. If you won’t let prices control the flow of resources all you can do is set targets and watch people struggle to meet them. And if two targets prove incompatible, no mechanism exists for knowing why or how to fix it. What should the provinces have done?

Or take doctors’ pay … please. A typical 2010 story said the prevalent “fee-for-service” model seemed fairer to hard-working doctors but “growing evidence suggests it is emphasizing quantity of patients seen and services performed over quality of care.” One expert was quoted warning that it “incentivizes volumes.”

Of course it does. Targets always do. The only question facing planners is what volumes to incentivize.

For instance, P.E.I.’s government spent about a decade pushing doctors from fee-for-service onto salary to increase time spent with individual patients. Then in 2011 it sent a snooty letter telling them to see more patients because, newspapers reported, their “productivity” was “plummeting” with salaried physicians seeing “as few as half the patients as colleagues still on fee-for-service.”

Duh. You get what you pay for. Thus in fee-for-service Ontario the government just did the reverse, ordering doctors to see fewer patients or face penalties. But which is more “productive”?

You can’t tell. Counting patients per doctor, minutes per visit, or dollars per doctor looks like feedback. But it’s not, because you’re just dividing one target by another. Actual value, consumer satisfaction, has no way into the system because you can’t measure it.

Actually you can. As Leonard Read’s 1958 classic I, Pencil noted, nobody in the world knows how to make a pencil. It may seem a humble object. But it requires wood, glue, paint, “carbon black,” graphite, copper, etc., provided through a mind-bogglingly complex system in which wood is cut with chainsaws by loggers drinking coffee, shipped in trucks, painted in factories that themselves use paint and pencils and so on.

Nobody knows, or could know, how each component is made. Yet billions are made for pennies apiece because of the cybernetic miracle of prices. Nobody has to know why prices are what they are, only what they are, to make rational decisions all along the chain leading to a consumer with a limited budget deciding for herself what constitutes best value for money.

Now that’s a system. Planning isn’t. Like Soviet bureaucrats unsure whether to set numerical quotas for nails and get pins, or by weight and get spikes, our health ministries scurry from one quantitative extreme to the other because they need far more information than entrepreneurs but have far less.

Two months ago a C.D. Howe institute study said new specialists often struggle to find jobs while patients line up for their services

Last month Dr. Charles Shaver complained of Ontario cancelling its 50 per cent“chronic disease premium” (E078) to encourage follow-up visits for over 30 conditions from congestive heart failure to diabetes mellitus “for general internists, nephrologists, gastroenterologists, and cardiologists.” He asked “What unintended consequences might result…?” but no one can know, or what will result from Manitoba’s government doing pretty much the exact opposite on the same issue.

When we examine the details of health-care planning they seem irrational. Two months ago a C.D. Howe institute study said new specialists often struggle to find jobs while patients line up for their services, because the state pays physicians fees for service while giving hospitals global budgets, so an operation rewards a surgeon with income but punishes an administrator with costs.

Well, should planners reward both doctors and hospitals for maximizing surgeries and blow the budget? Punish both and strand patients? Or give conflicting incentives and hope the tug-of-war ends up in the middle?

What’s irrational is a system that leaves only such choices. Or rather, a non-system. Canada: The finest health chaos in the world.

John Robson is a journalist and documentary filmmaker in Ottawa. He teaches history at the University of Ottawa.

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