New delivery models, not talk, are key to health-care reform

Posted on August 15, 2012 in Health Delivery System

Source: — Authors: – commentary
1 August 2012.   Adam Radwanski

Meetings with more than three or four people around the table, and nobody firmly in charge, tend not to accomplish a whole lot.

So even before they got sidetracked by a dispute between two provinces over a pipeline that’s unlikely to get built any time soon, it required a leap of faith to expect 13 premiers to walk into a room in Halifax last week and emerge with a serious plan to tackle the country’s biggest and most confounding public-policy challenge.

Still, the feebleness of what they did come up with on health-care reform – and the derisive snorts it elicited from those who have long toiled in that field – is difficult to get past. The most useful function of the report attributed to Saskatchewan’s Brad Wall and Prince Edward Island’s Robert Ghiz, and signed off on by all their counterparts, is to help put to rest the notion that health care will be made sustainable through some showy form of national consensus.

That’s not an easy goal to let go of, because universal care is one of the few tangible ties that bind us. But unanimity on how to preserve it was easier when a “fix for a generation” (as Paul Martin probably regrets calling it) was mostly just about throwing more money into the system. Now that the imperative is to flatten health-spending increases, while funding expensive new technologies and treatments for an aging population, it’s a recipe for stagnation – especially because the federal government is disinclined to use either carrots or sticks to get anything controversial through.

On occasion, the premiers will collectively stumble onto low-hanging fruit. The one substantive money-saving measure agreed upon last week, which will see the provinces bulk purchasing generic drugs, fits the bill. In a worst-case scenario, corners of the pharmaceutical industry won’t be thrilled.

Where matters get much trickier is in reforms that the general public will notice, which is to say most of them.

To modernize health-care spending necessarily involves a discussion about rationing care to ensure prescriptions and referrals and treatments are only offered when they’re really needed. It likely involves shifting away from the idea of the general hospital toward more specialized models. It may mean patients interacting less with doctors and more with other medical professionals, travelling greater distances for certain services or even receiving some of them remotely rather than in person.

These are not the sorts of politically risky measures that 13 governments will simultaneously plunge into at once. So reports such as the one last week – of which there will be more, since Mr. Wall and Mr. Ghiz continue to head a health-care working group – skirt around the edges. In this case, that meant nodding toward the need for physicians to adopt more standardized practices, without explaining how a notoriously territorial profession would be made to do so, and calling only for changes (such as new guidelines for treating diabetes) that would be unlikely to make patients nervous.

The good news is that, however much we may like the idea of our leaders collectively coming up with neat and tidy solutions, that’s not how it has to work or even necessarily how it works best. The most productive contribution that premiers can make, rather, is to lead by example.

At this point, whoever’s running Ontario – be it Dalton McGuinty or someone who succeeds him – seems likeliest to play that role, if only because the province’s fiscal predicament is the most dire. Although per-capita health costs are already relatively low compared with other provinces, a structural deficit is forcing Ontario to try to drive them lower still. That means, for instance, that the province is in the midst of a protracted fight with doctors over how specialists are paid, and more structural changes should be on the table before long.

Many other provinces don’t need to move quite as quickly, so they can afford to sit back and watch. Among the advantages of a federation in which our challenges are similar, but not exactly the same, is that we can learn from each other. When one province experiments with new delivery models, others can be counted on to take notes, if not to outright cheer them on.

In other words, if the odd province is willing to lead the way, we may yet wind up with a meaningful consensus on health-care reform after all. It just won’t be one that’s forged around the conference table.

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