ONTARIO SOCIETY (COALITION) OF SENIOR CITIZENS' ORGANIZATIONS
ROMOANOW COMMISSION SUBMISSION
OCSCO'S POSITION PAPER ON HEALTH CARE
To the Commission on the Future of Health Care in Canada
October 17, 2001
The mission of the Ontario Society (Coalition) of Senior Citizens' Organisations is to improve the quality of life for Ontario's seniors. Our membership is composed of over 130 seniors' organisations, representing more than 500,000 senior citizens from across the province. We are glad of the opportunity to present to you our views on the future of health care in Canada.
We note that your letter of invitation speaks of a "high quality, universally accessible, publicly administered health care system." We hope that this wording does not reflect a pre-judgement that the future must eliminate "publicly funded" as a description of our system or that we must accept, with all its potential dangers under NAFTA, the failure of the present Ministry of Health to over-rule Alberta's Bill 11.
OCSCO supports a completely public system, which allows no room for the profit motive to drive any decisions concerning our health care. Surely the American experience is definitive in showing us the disastrous and expensive folly of profit-driven health care. The corollary is that our present fee-for-service compensation for physicians, particularly primary care physicians, should be eliminated as far and as fast as possible.
We believe that a truly public system is sustainable, despite the ageing of our population and the alarms being raised by those who would prefer a two-tier system. But it may not be compatible with a continued priority being accorded to tax cutting, at both the provincial and federal levels.
Our views on sustainability, change management and co-operative relations will be elaborated under the following headings:
- Primary Health Care
- Pharmaceuticals
- Home Care
- The role of the private sector
- Primary Health Care
- Sustainability
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Primary care is the foundation on which our health care system rests. Its present fee-for-service funding mechanism resulted from the historic compromise which Saskatchewan was forced to make in the face of the intransigence of their physicians in 1962. That Saskatchewan doctors found their incomes rising substantially, after that province's pioneering introduction of a publicly funded health care system, may be equally significant.
Canadian doctors have responded, perhaps predictably, to the perverse incentive presented by a fee-for-service system where payment of their fees is guaranteed. Many have come to think of themselves as entrepreneurs, small businessmen, who have fixed expenses but, naturally, strive to increase their revenue by any means the law allows. (In Ontario, for example, the Ontario Medical Association has demanded and been granted the right for their members to incorporate their practices.)
Individual exceptions abound, of course: doctors who see themselves as dedicated healers, expecting a comfortable income, but not motivated primarily by the "bottom line." But all too often doctors may yield to the temptation to
- see as many patients as possible in the course of a day;
- give the patient a prescription, necessary or not, to terminate the visit quickly;
- suggest that patients come back whether another office visit is warranted or not;
- order laboratory tests, useful or not, that require another office visit (and, sometimes, to hold profitable shares in the laboratory where patients are sent);
- tell patients who require medical attention after hours to go to the nearest hospital emergency room
The costs of our system are driven by physicians' decisions, which may represent their best clinical judgement, but can represent, consciously or unconsciously, the easiest way to maximise their fees. Eliminating the fee-for-service payment method, especially for family physicians, can only enhance the sustainability of our public system.
- The perverse incentive of fee for service is by no means the only reason that the reform of primary health care is essential to the future of our health care system. Outside of large cities, and sometimes even within them, we face a shortage of physicians, a shortage which can only increase, as more of them reach retirement age while fewer are in training to replace them. Newcomers to an area are frequently finding that no local family physician is accepting new patients, or, in some cases, new patients over the age of 65. Their only recourse is to use walk-in clinics or hospital emergency rooms when they need care.
The coming bulge in retirements will, of course, affect every profession and occupation. But it will be felt most keenly in areas, such as health care, which are already facing a deficit in human resources. To sustain our public health system we have to make the most effective use of all our health professionals.
Primary health care must be re-organised into teams of health professionals, including nurse practitioners, nurses, midwives, dieticians, podiatrists, social workers and other therapists, as well as family physicians. Many procedures performed by solo practice doctors could, for example, be performed competently by nurse practitioners. One doctor can take responsibility for many more patients if he or she is relieved of these routines. Ontario's community health centres provide an excellent working example of primary health care thus organised.
- The experience of patients in community health centres has been very positive. One-stop shopping is, of course, an important convenience. Equally important is the fact that the salaried doctors who work there have ample time to talk with their patients. Senior patients in particular, who are often managing several chronic conditions, appreciate seeing a doctor who has time to consider the problem that provoked today's visit in the context of all their health problems.
There are many times, too, when talking with a nurse practitioner may offer just the kind of advice, reassurance and routine checks that a patient needs. And the importance of dieticians in supplementing the lifestyle counselling of doctors and nurse practitioners is self-evident. Moreover, now that the social determinants of health are widely recognised, the services of social workers on primary health care teams add an important dimension to patient care.
- Unquestionably, health promotion receives much greater attention from all the health professionals in community health centres. This ounce of prevention, too, is resource-effective and enhances the sustainability of our health care system.
Finally, primary health care centres can organise extended hours, home visits and on-call systems to guarantee that medical help is available around the clock, not just during banking hours. Senior patients particularly, who may find any unfamiliar symptom alarming need after-hours access to care and advice immediately. If it is not otherwise available, they frequently resort to hospital emergency rooms, already overburdened by bed and nursing shortages.
- Change management
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By making the most effective use of all our health care professionals, re-organisation of primary health care, on the community health centre model, can make our health care system more sustainable. To do so will involve substantial changes in attitude among both patients and health care professionals, particularly physicians.
Patients may worry about whether this re-organisation will lead to the American "managed care" model, in ill repute because it has been seen to prohibit, rather than enhance, access to care. They may also worry about whether they will lose the privilege of choosing their family physician; no one lightly terminates such an important relationship, which may be of many years' standing.
Public education of patients and the exhibiting of successful models can, in due course, allay these fears. But change must be managed so that these fears really are groundless. Re-organised primary care must be, as well as seen to be, universally accessible, with no possibility of any centre refusing or discouraging older patients or those with pre-existing conditions. The principles of our Health Act must apply unconditionally.
Moreover, while some form of enrolment is necessary for any capitation-based system, there must be no greater obstacle to leaving one centre and joining another than now exists in leaving one doctor and attaching one's self to another doctor. And, of course, the use of another centre in any emergency away from home must be completely acceptable.
- Can doctors' attitudes be changed? We know that many doctors have voluntarily sought employment in community health centres and that approximately half the members of the College of Family Physicians in Ontario have expressed willingness to leave fee-for-service for some alternate method of compensation. Geriatricians, whose numbers in relation to population need are below even those of family physicians, are largely in favour of alternate methods of payment. If salaries are high enough, and if malpractice insurance, overhead costs and normal employment benefits (holidays, pensions, maternity leave, etc.) are paid, doctor's positions in primary health centres can be attractive to many family physicians.
The Ontario Medical Association's pilot models of reformed primary care, now operating in several areas in Ontario, are, however, completely unacceptable. They are merely joint practices of physicians, experimenting with a variety of modifications to fee-for-service compensation. The physicians need not even share the same office space, though they may choose to do so to save on overhead. They can be joined electronically, i.e. have electronic access to one another's files in order for an on-call physician to be able to deal with another physician's patient. But with several hundred doctors involved in these pilots, there were, at last count, less than ten nurse practitioners, hired by a few doctors, and no other health professionals at all -- a far cry from the teams of health professionals working together in community health centres. Meanwhile several hundred nurse practitioners in the province are unemployed or underemployed.
The Ontario provincial government is financing, as a supplement to the OMA models, a program of "telehealth", which allows anyone to speak with a triage nurse on the telephone, though the nurse has no access to the patient's medical history. There are some situations where this is helpful, but it is far less satisfactory than being able to reach a member of your community health centre team, who has access to your medical files. Moreover, these phone lines are being operated on a contract basis by private corporations and, we understand, are attracting nurses away from short-staffed northern hospitals to a less stressful work environment (leaving the hospitals even more short-staffed and the remaining nurses even more stressed).
C. Co-operation
- Properly reformed primary care can go a long way in co-ordinating health care for each patient. Family physicians, who now receive no fee for the service of tracking their patients in acute care or arranging for their home care, often do not know when one of their patients enters or leaves a hospital until the patient reports the event. If they were on salary or some form of capitation-based payment, they could perform these essential roles as a matter of routine, to the benefit of the patient and of a smoothly integrated health care system.
- Federal-provincial co-operation is clearly essential to make any design for greater sustainability effective. The federal government could establish the principles for primary care reform and fund whatever incentives are needed to persuade family physicians to leave fee-for-service behind. But such funding would need to have strings attached, unless provincial governments' attitudes are changed in the negotiating process.
We have no magic answer to the longstanding problems of federal-provincial relations. It is unfortunate, from our viewpoint, that the federal government reduced its ability to influence provincial health care decisions by reducing its financial contribution and going to block funding. We don't underestimate the difficulties in this area, but we believe that if your Commission exerts leadership in showing the way to preserve our public system, you will have the overwhelming support of Canadians everywhere.
II. Pharmaceuticals
A. Sustainability
- Canada once led the world in making drugs available at moderate prices, when it allowed the licensed manufacture of generic copies of patented drugs five years after the patent was granted. It was a sad day for Canadian health care when patent protection was extended to twenty years, in return for a promise by multinational pharmaceutical companies that they would locate more research in Canada. While some research jobs were generated, very little of the research located in Canada has led to break-through drugs; much of it has been merely finding a way to modify another company's product enough to give it a new name and a new patent.
The price controls that were supposed to protect Canadians from extortionate prices for patented drugs were never intended to examine whether the price of a new drug was justified by the research invested in it. The Pharmaceutical Prices Review Board merely verifies that a new drug is not being sold in Canada at a price higher than the price at which it is being sold in other industrialised countries. This is one of the causes of the substantial increase in the portion of health care dollars spent on drugs, which has now outstripped the portion devoted to physicians' services.
- Drug benefit programs vary among the provinces. In Ontario the Drug Benefit Plan covers only seniors and those on social assistance. Single seniors with incomes over $16,100 per year are required to pay a deductible of $100 each year and to pay all dispensing fees. Those whose incomes are under $16,100 or who are on social assistance pay $2 for each prescription. Even this restricted drug benefit plan has been called into question by the present Ontario Minister of Health, who has floated, as a trial balloon, the idea of setting a ceiling for income, above which no benefits would be available. From our viewpoint, diminishment of universality is the beginning of diminishment of public support for any program, with erosion of the program virtually inevitable.
Even without any diminishment, the present Ontario Drug Benefit Plan affords less than complete insurance against pharmaceutical costs, which can be devastatingly high. The formulary of drugs covered is amended too slowly, leaving patients with prescriptions for new and more effective drugs to bear their full cost. There are a number of very expensive drugs, such as those used for HIV/AIDS, which, in Ontario, are included in a special means-tested drug benefit program. But for the elderly, Visudyne, which costs up to $17,000 for the required course of treatment, is not covered at all. Visudyne is the only effective treatment for macular degeneration (a common cause of vision loss in the elderly). Such costs are prohibitive for most seniors; but blindness, which results from leaving macular degeneration untreated, means earlier loss of independence for sufferers and, in the long run, greater costs to the health care system for both home and facility long term care. This is not the road to sustainability.
While by no means defending the high prices charged by pharmaceutical conglomerates for new drugs, we believe it is less than cost-effective for our health care system to leave families to pay these high prices if they can. Too many seniors and low-income families are forced to leave their prescriptions unfilled, with resultant health deterioration that eventuates in more costly interventions (acute care, home care and long term facility care).
- The incorporation of Pharmacare into our public health care system would, to some degree, prevent the need for more costly kinds of care, making the whole system more cost-effective. Further savings are also available in a public plan by allowing the single payer to negotiate lower prices for the bulk purchase of the most frequently prescribed medications. By broadening the scope of our publicly funded system we can, therefore, make it more sustainable.
B. Change management
- Since most provinces have some form of drug benefit plan, it should not be too difficult to set national standards and put them into effect, given the political will and the federal government's willingness to lead the way.
- An important change is required in the workings of the patent system. While we never supported and still oppose Bill C91, which extended pharmaceutical patents to twenty years, we realise how difficult it would be to reverse that decision now. But it is not impossible to enforce the right of generic drug manufacturers to produce generic versions in advance of the final patent date to be ready to distribute immediately after that date. Generic production is now being delayed for months and sometimes several years by injunctions and other legal manoeuvres by patent-holders. The cost of every day's delay is very high for Canadian consumers and should be considered intolerable in a publicly funded Pharmacare system, which would, of course, insist on the use of generics as available.
- Co-operation
No problem would arise in gaining the co-operation of consumers and we believe that pharmacists would co-operate willingly with any changes made. A public education campaign to persuade consumers to fill all prescriptions at one pharmacy would be a health promotion effort worth making. If primary care is reformed on the community health centre model, these centres could incorporate pharmacies and/or contribute to the needed public education effort.
We do not anticipate any eagerness from the multinational pharmaceutical companies to lower the total cost of their products to our health care system, but they would have to respond with lower prices for drugs purchased in large quantities by a publicly funded system of Pharmacare. Canadian manufacturers of generic drugs would naturally be "on side" in this matter.
As with Primary Care reform, federal funding incentives may be needed to establish national standards and ensure provincial co-operation.
III. Home Care
- Sustainability
We appreciate the federally funded National Evaluation of the Cost Effectiveness of Home Care and the important work they are engaged in. The recently released study by Dr. Marcus Hollander has at last provided empirical evidence of the importance of the maintenance and preventive function of home care for the elderly. His study makes clear that it is cost-effective to provide homemaking and personal support services for persons with age-related disabilities. Over a three-year period, those receiving such services had less illness requiring a physician's care, made less use of Emergency Rooms and acute care hospitals and were less likely to enter facility care than those who had been cut off from low-level home care services. Researchers studying the value of home visiting in Britain came to similar conclusions as reported in The British Medical Journal, September 29,2001
Hollander's findings take on special significance in Ontario, where inadequate and frozen budgets, combined with Ministry-mandated priorities, are forcing the Community Care Access Centres to use more and more of their resources for the care of the very sick patients being discharged from our hospitals. The policy directive of the Ministry, to take care of the sickest first, means that the maintenance and preventive function of home care takes second place to the acute care substitution function. Acute care substitution has, of course, become increasingly urgent, because inadequate hospital funding has created bed shortages and drastically shortened lengths of stay. It is not yet clear, however, whether sub-acute beds within hospitals might not be more cost-effective than home care, particularly for very sick patients, those who have undergone day surgery and those who have just given birth.
It is a vicious circle, which we sincerely hope your Commission will be able to break through. A national perspective must be brought to bear on home care as an increasingly important segment of our health care system. The shifting of care from institutions to communities is clearly a well-established trend, not only in Canada, and its aim everywhere is cost-effectiveness. But we must be sure that the adequate shifting of resources to keep up with this trend is equally well established. This is not the current Canadian reality.
- Change management
An effective balance between institutional and home care is essential to making our health care system sustainable. In the absence of national standards, with home care falling legally outside our publicly funded system, our progress towards an effective balance is greatly hindered. The change needed is for home care to become recognised as a medically necessary service governed by the principles of the Canada Health Act.
Changing the attitudes of provincial governments in this area could be made easier by federal leadership and targeted funding. Whatever the predilections of current provincial governments, the citizens of all provinces will give wholehearted support to bold federal initiatives aimed at integrating home care into our publicly funded system.
IV. The role of the private sector
We are aware of some, but probably not all, of the ways that the private sector has become involved in our health care system. Where their participation is publicly known, the arguments in its defence are most often based on several myths. One is that the profit motive guarantees efficiency. Another is that economy of scale adds to efficiency.
These are, at best, only partial truths.
Bureaucracy and red tape are the most frequently used tags to suggest that what is done by governments is always less efficient than what is done by corporations. Anyone who has tried to deal with a large corporation, such as a bank, knows that bureaucracy and red tape are endemic in the private sector. Large scale, we have all learned from experience, makes organisations less efficient, from the consumers point of view, even when and, perhaps, even because everything is rosy from the shareholder's point of view.
Enlisting the private sector in the delivery of our health care is often ideologically driven, with efficiency having little or nothing to do with it. We have a glaring example of this in Toronto, where for some time a shortage of radiation technologists had meant danger- ously long waiting lists for the radiation treatments prescribed after breast or prostate cancer operations.
The first response to this problem was to finance Toronto patients to travel to northern Ontario or American border cities, where they could receive treatment promptly. This was, of course, a very expensive solution, involving travel, hotel and meal costs reimbursed to the patients. After many months of this expensive procedure, our Health Ministry decided to let the private sector solve the problem.
The private sector in this case consisted of a new private company, headed by the former head of Cancer Care Ontario, who resigned his position to start the enterprise. The company was set up explicitly for the purpose of eliminating high travel costs and providing timely treatment for Toronto patients. Where did they find the radiation technologists, whose inadequate numbers had led to this crisis? They found them by paying high overtime rates to those already working in the system. Where did they find the new equipment for them to use? They found it by using the equipment of a public hospital, Sunnybrook, after regular hours.
Nothing was added to the system, neither equipment nor personnel, by this new private company. What they did could readily have been done by the publicly funded hospital, if it had been given the funding now being directed into private hands.
The hospital could have offered the same premium overtime pay to technologists and used their own equipment after hours.
This arrangement can only be described as blatant, ideologically driven privatisation. Its irregularity was so clear to those involved in setting it up, that they made no announcement until it was a fait accompli, admitting, when they finally announced the move, that they were afraid public protests might delay the start of operations.
We must also point out that the contracting out system, which our Community Care Access Centres are forced to use, has been the direct cause of a visible deterioration in the quality of care provided to people in their own homes. For-profit agencies bidding for Access Centre contracts, worked, from the start, with a casual homemaking and personal support work force, an obvious economy in labour costs. Some agencies put even registered nurses on casual status, resulting, in at least one instance, in strike action by nurses. Many also hired untrained homemakers, provided brief in-house training to give them conditional status, and then paid them less than the prescribed minimum wage for their positions. Their formal training, to achieve regular status and regular minimum wages, has often been on their own time.
More even than inadequate training, casual employment has been the direct cause of quality decline, because it has virtually destroyed continuity of care givers for those being cared for. When care recipients are asked to choose the most important aspect of quality care, continuity -- having the same care giver coming all or most of the time -- always heads the list. Sadly, the managed competition system has often impelled even the non-profit agencies to place their workers on casual status.
Managed competition, the contracting-out system, has resulted in a substantial increase in the share of contracts going to private, for-profit agencies, who, unlike the non-profit agencies, are exempt from any pay equity requirements and can afford to offer "loss-leader" contract prices. Non-profit agencies that have served our communities for decades, and whose workers have been on staff for many years, have been forced to close offices and programs when they lost Access Centre contracts. At the same time, brand new private agencies have won contracts and then had to seek the aid of the defeated non-profit agency to train their workers.
Like the radiation centre at Sunnybrook, the establishment of a contracting-out system in home care is a form of ideologically driven privatisation. It has resulted in lower quality of care and it has driven from the work force many dedicated workers with years of experience behind them.
Conclusion
In conclusion, we want to emphasise that we see the barrage of doom saying about our public health care system as politically and ideologically motivated. Those who are loudly predicting that the health care costs of an ageing population will overwhelm provincial and federal budgets, are those who would prefer a two-tier system.
Ample evidence now exists to show that the ageing of our population has very little to do with rising health care costs. Today's seniors, who are living longer than previous generations, are also more healthy than seniors were in the past. And, with the continuing advances in medical knowledge, this trend will continue and accelerate as the "Boomer" generation reaches their senior years.
It is also evident from experience in other parts of the world that the two-tier system works only to favour those whose incomes range from ample to luxurious. For the majority of citizens, whose incomes range from moderate to low, the deteriorating public tier provides less than adequate care.
Our highly valued public health care system is sustainable and we, along with a large majority of Canadians, hope that the work of your Commission will serve to protect it. We appreciate that you may have more difficulty in focussing the attention of governments on the needs of our health care system at a time when they are preoccupied with Military and Intelligence concerns. At the same time we trust you share our belief that public health care is one of the defining values of the society we all want to defend.
Respectfully submitted,
ONTARIO SOCIETY (COALITION) OF SENIOR CITIZENS' ORGANISATIONS
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