Social Policy in Ontario

How medicare is morphing from ‘bare minimum’ to ‘best practices’

Posted on August 10, 2012 in Health Policy Context

Source: Toronto Star — Authors: Martin Regg Cohn

Torstar.com – news/Canada/politics
26 July 2012.    Martin Reg Cohn

HALIFAX—Here’s the dirty little secret of Canadian medicare: it’s mediocre by world standards, and only looks good when stacked up against America’s chaotic system.

Voters value medicare because it embodies the quintessentially Canadian value of equal access for all — even if it doesn’t always deliver value for money for taxpayers, or the best outcomes for patients. Most studies show our medicare is wasteful — not always healthful — compared with public systems across Europe.

The premiers, who deliver health care in this country, are painfully aware of this political paradox. That’s why they always talk up — and prop up — medicare at their annual meeting, this year in Halifax.

The premiers believe they have cracked the secret code to improving medicare — not just by doing their best, but sharing “best practices” across the country.

In the old days of federalism — before decentralization, conservatism and cost-cutting took root — Canadians aspired to “national standards” in health care. But Ottawa’s enforcement of the Canada Health Act is an anachronism, thanks to the erosion of the federal spending power that once bankrolled as much as 50 per cent of provincial health spending but now amounts to barely one-fifth.

In the eyes of the provinces, national standards merely ensured minimum benchmarks — that is, avoiding worst practices. Now, instead of bare minimum, the premiers aim to put their best face forward — at the best price.

Their latest report highlights case studies that cry out for action: Exhibit A is foot ulcers that plague diabetics when treated poorly, leading to needless amputations. Exhibit B is teamwork, using nurse practitioners to do more primary care.

All of the premiers’ proposed reforms — clinical guidelines, fairer fees, better teamwork, cheaper generics — are no-brainers. They are also old news, and ought to have been targeted by now.

Ontario, not to be too boastful, has been grappling with these questions for years. Health economists, not to be too pointy-headed, have been pointing out these savings for decades.

The truth is that the premiers, having set up their ambitious “Innovation Working Group” a few months ago, were in a desperate hurry to meet their deadline. So they dialled up the health providers at the Canadian Medical Association and the Canadian Nurses’ Association, who were only too willing to offer up the low-hanging fruit off the shelf, as it were — foot ulcers, unneeded X-rays, and so on.

The trouble with this quick and dirty approach: harvesting low-hanging fruit won’t get them to best practices, which requires rather more heavy lifting.

Premier Dalton McGuinty noted diplomatically that Ontario was already seized of these challenges: “In Ontario, we are going a bit further, perhaps a little more quickly,” he observed dryly.

Cost controls, for example, are vital if Ontario is to repurpose funding where it is needed most in home care and long-term care. Doctors take up one-quarter of all health expenditures in Ontario, about $48 billion, and roughly 42 per cent of all program spending in the province.

A few months ago, McGuinty sent out a letter to his fellow premiers ostensibly updating them on how Ontario was reining in doctors’ fees, but purposely seeking validation for his hard line. Other premiers responded privately by expressing strong support — and outright thanks — for paving the way.

McGuinty noted that Alberta, which is within a nose of Ontario’s spending on doctors, “is open to the experience that we are living through now.”

Alberta and the other provinces are also keen to replicate Ontario’s experience in pushing down the price of generic drugs, which are more expensive in Canada than almost anywhere else, by pooling their purchases.

For better or for worse, instead of the national standards dreaded by so many decentralizing provinces, they may be drifting unconsciously toward Ontario standards — rebranded as best practices at the lowest costs. But still not nearly good enough.

Tags: budget, Health, ideology, mental Health

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