Vancouver Sun
Published: Friday, April 26, 2002 Health reforms focus on costs, while ignoring big picture On Tuesday, the B.C. government unveiled its plans through the new health authorities to restructure health services delivery across the province. In fairness to the government, they understand – more so than the usual union leaders protecting their own turf and professional health care activists who lined up to lambaste the government – that the health care system, as presently structured and funded, is not fiscally sustainable. Health care costs now consume over 40% of provincial expenditures and even with a $1.1 billion increase in funding in the last year, health authorities are still projected to run deficits of $567 million. Predictably, the spend-more-money crowd says just a little bit more money will avert tough decisions. But these cost pressures are not unique to British Columbia: indeed this situation is the norm right across Canada. In the last five years provincial expenditures on health care have usually outstripped revenue growth by factors of three or four to one. Sadly, the new era for health care in British Columbia, on balance, is drawing on old-school supply-side, cost containment solutions more akin to Soviet-style central planning than thoughtful, long-term and inter-generationally sustainable public policy solutions. And if there is one area in health care where status-quo, big government socialist defenders of medicare and libertarian, free-market, competitive forces conservative thinkers agree, it is one this point: cost containment strategies in and of themselves merely shift resources, instead of freeing up or creating new resources. Of course, some of the macro solutions offered up by the government and various health authority officials do have merit. Committing to multi-year funding will facilitate better asset allocation and service delivery planning by health authorities. Similarly, adjusting funding levels to meet demographic profiles unique to various health authorities is entirely appropriate. Moving to performance-based contracts for senior health administrators is laudable. And the government is properly replacing some acute care beds now occupied by alternate level of care patients with more appropriate and less costly (in theory) assisted living, long-term care and/or home care spaces. These measures are similar in scope to those taken in NDP-led Saskatchewan almost a decade ago, in Alberta shortly after Ralph Klein took office, and those proposed by the Health Services Restructuring Commission in Ontario from 1996 to 1998. The common problem though is that all these provinces focussed primarily on cost containment to the exclusion of other equally important system wide issues, such as quality improvements, patient outcomes and resource – both human and physical – replenishment. As a result both Alberta and Ontario fired nurses and other allied health professionals, at some cost, and within five years, were forced to hire many of them back, again at tremendous cost. This week’s reforms will have some positive impact, but yet again reveal our Canadian bias for supply-side tinkering with budgets, health authority structures, staff levels, numbers of beds, etc. The demand side component of the health care equation (read: patient utilization and accountability) has been fundamentally ignored. Furthermore, as alluded to earlier, long-term and intergenerational issues from society’s aging demographic to the costs of new technologies to the geometric progression of pharmaceutical interventions to unquantifiable patient expectations were sidestepped. It is in these areas where cost escalation will be the most profound in the coming decades. Both the Clair Commission (2000) report in Quebec and the Mazankowski Report (2002) in Alberta recommend pre-funding strategies to meet future demand for services, and in the case of Quebec, new technology and capital needs. Health care constitutes one of our major lifetime expenditures along with retirement income and purchasing a home. Yet we continue to fund health care like a pyramid scheme where tomorrow’s surgeries at Vancouver General are funded from today’s tax collections. The question then becomes, why do we prefund our public (to a degree) and private retirement savings systems while not doing the same for health care? Another cost driver is the coming demographic shift which will be permanent and also increase costs per patient. More troubling still is the fact that demographic changes mean our health treatment professionals are also getting older. Are there plans or strategies afoot in B.C. or in concert with other provinces and Ottawa to address recruitment and retention issues for all types of health professionals? Turning to technology, what thought has been given to diagnostic equipment maintenance or new technology acquisition? Will the administrative savings to be generated as Tuesday’s reforms work their way through the system over the next few years be diverted to technology renewal? Again, fundamental questions remain unanswered, or worse … not even posed. Singapore has dealt with generational issues through their medical savings accounts regime of Medisave, Medishield, Medifund and Eldershield. The Chinese and an increasing number of American employers are adopting parts of the Singapore model. The Germans and the Dutch use employer sponsored or trade specific sickness funds to provide better coverage . The Brits have invested heavily in research and new equipment acquisition. And the Aussies have opted for a parallel system to alleviate pressure on their public resources. These countries have better addressed the supply, demand and future pressures components of health care in their reform efforts. So the question is self-evident: when will Canadian governments do the same? = = = = = (This article was co-authored with Mark Milke). |