Michael Rachlis MD

Canada needs to beat more countries than the US at health care

9 July 2010, 7:28 PM

Canadians tend to mock Americans’ ignorance of our country and the rest of the world. We do know more about their country than they know about ours. But we also tend to be unsophisticated when it comes to the rest of the world.

The U.S.-based Commonwealth Fund released their latest comparison of seven health systems on June 25^th. Predictably, the U.S. system rated last overall and that was the focus of the fund’s report and the U.S. and international coverage. But Canada was second last. We were last for overall quality, effective care and timeliness of access. We scored second last on efficiency. The report compared Canada with other countries 18 times in the text. These included two favourable comparisons and 16 unfavourable ones.

Read my op ed in the July 4^th Toronto Star on how Canada is playing in the wrong league when we only compare ourselves to the US. Download it here.

See more on the Commonwealth Fund Study “Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally, 2010 Update” at: http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2010/Jun/Mirror-Mirror-Update.aspx

Apocalypse Not Now

30 June 2010, 12:00 AM

We have been hearing a lot this year that Medicare is unsustainable. The usual claim is that health care used to be 35% of provincial program spending but now is 40%+ and will be 80% by 2030 according to the TD Bank’s economics department. There are so many problems with these projections the mind spins. And, while the mind spins one becomes intensely nauseated at the use of this misanalysis - which is usually used to support a dismantling (quickly or incrementally) of the principles of public finance and non profit delivery.

But there are serious problems with all of these apocalyptic scenarios. For example, the Ontario budget paper page 55

http://www.fin.gov.on.ca/en/budget/ontariobudgets/2010/papers_all.pdf

warns that health care consumes 46% of program expenditures now and will be 70% by 2022. However, a footnote on the same page notes that health care will be 45% of program expenditures for 2010/2011!

How can health’s budget share go down next year but then grow like topsy over the next 12 years?

And, the TD report on Ontario health care

http://www.td.com/economics/special/db0510_health_care.pdf

is just as bad on the economics. Their graph on page 14 of their report shows health care’s share of program spending flat for the last several years and then they spin it upward out of control into the future.

Here’s what my graph of health spending as a share of the Ontario government’s program expenditures. By the way, I am using Statistics Canada data and defining program costs as overall spending minus debt payments. The government also excludes so-called “one time only” budget expenditures like auto industry bailouts. But, the trouble is that recently 5-10% of the budget has been devoted to a particular year’s one-time only spending. It seems cleaner to me to define program spending as only excluding debt payments but the shape of the line is the same.

You can read my April 4^th Toronto Star op ed on Canadian health care sustainability here and an op ed on the Ontario situation which unfortunately I couldn’t get anyone to publish in the wake of the TD’s report on the upcoming Medicare cost catastrophe.

The TD report wasn’t nearly all bad. They did highlight the need to change the way doctors are paid and increase their accountability. Tom Closson, CEO of the Ontario Hospital Association and others in the health administrator community have been banging this drum for a awhile

http://www.thestar.com/comment/article/705859

and its campaign culminated in the Excellent Care for All Act, which was passed this spring by the Ontario Legislature.

http://www.ontla.on.ca/web/bills/bills_detail.do?locale=en&BillID=2326&detailPage=bills_detail_the_bill&Intranet

I’ll try to be more current in my blogging. Let me know if you find the new material useful. It’s always good to hear from readers.

Sault Ste Marie leads the way!

3 November 2009, 9:32 AM

Yesterday’s blog post has been edited and today is an op ed in the Toronto Star — How one Ontario community avoided chaos at H1N1 clinics. It is always a delight for me to highlight best practices in Canada’s health system and Sault Ste. Marie is full of them. See more about the Group Health Association health centre on pages 101-105 of Prescription for Excellence.

Canadian H1N1 vaccine rollout hits a pothole

2 November 2009, 11:52 AM

I did interviews with nine CBC morning shows today on the troubled roll out of the H1N1 vaccine. Canadians are rightfully enraged at the chaos of last week’s H1N1 vaccine clinics. There must be a better way to run a vaccine program. There are two main reasons why the vaccine roll out looks like rush hour at a Mexican bus terminal.

Late last week, vaccine manufacturer GlaxoSmithKline notified the federal government that it would not meet its production quotas and would temporarily have to reduce the amount of vaccine delivered.  As a result, BC had no vaccine over the weekend and Alberta has no vaccine today.

However, there is a worldwide problem producing the vaccine. The horror stories in Canada are matched by those in the US. And the federal government has shipped 6 million doses of H1N1 vaccine which should be enough to vaccinate those at high risk — pregnant women, children 6 months to less than 5 years of age, people under 65 with chronic conditions, people who live with or care for infants under 6 months old and immuno-compromised people, and health care workers. The real problem is delivering the vaccine to those who need it.

There are some places in Canada which are delivering vaccine expeditiously to those who need it and we can learn something from these communities. For example, in Sault Ste. Marie, the Group Health Association Clinic is using its computerized appointment system to book patients for H1N1 vaccinations from throughout the Algoma Health Unit. Eighty percent of “the Soo’s”  residents get their health care from Group Health. The appointments schedulers have access to Group Health’s electronic medical record so they can ensure that the patients they book are indeed high risk. Patients arrive at the clinic and get their needle within 10 minutes. No waiting

Group Health has over 60 doctors and 300 other staff and is cooperatively run by a community board and the Algoma District Medical Group. It has been a national leader in health care innovation since it first opened in 1963. The Centre has had a computerized appointment system for 20 years and a comprehensive medical record since 1997. Roy Romanow referred to it as a “the jewel in the crown of Medicare.”

In other parts of Ontario, public health is now delivering the vaccine to selected family doctors offices. Some might ask why public health didn’t simply give the vaccine to family doctors in the beginning. In fact, Ontario Medical Association president and family physician Dr. Susan Strasberg and other family doctors have been asking this question. In fact, Ontario and some other provinces have been quietly distributing the vaccine to clinics and shelters dealing with very high risk populations such the homeless, AIDS patients, and drug addicts.

What held public health authorities back initially was the concern that much of the vaccine could be wasted in family doctors’ offices. Most Canadian family doctors still work in small offices with one or two doctors, a non-professionally trained receptionist and no electronic records. Many family doctors don’t even have adequate refrigerators to store the vaccine and with the vaccine packaged in multiple dose vials, public health authorities were understandably concerned that much of the precious vaccine would go to waste in doctors’ offices. On Friday Ontario announced that like some other provinces and distribute vaccine to certain family doctors who met criteria and requested it. As the Globe notes this morning, Ontario and BC have both (perhaps inadvertently) sent vaccine to for profit, exclusive family practices which charge their patients extortionate and likely illegal annual “club fees”.

Some family practices have the vaccine and are distributing it to their high risk patients. In the midst of Toronto’s complete chaos and confusion one of the province’s new family health teams is advertizing this week’s vaccination clinics for its high risk patients. No fuss no muss no waiting. That’s how Canada should have rolled out the vaccine if we had a decent system of primary health care. Family doctors offices and community health centres would have vaccinated the patients they knew to be at high risk from their electronic health records. Public health then could have focussed on groups like the homeless who otherwise wouldn’t have been vaccinated.

If there were a Group Health Centre in every Canadian community, our H1N1 vaccination campaign wouldn’t make us look like a third world country. We need more effective primary health care in Canada and we need to effectively link primary health care to public health. Let’s not wait 50 years for the next pandemic to make this a reality.

I coordinated a workshop for the Public Health Agency of Canada four years ago on how to improve collaboration between public health and primary health care. I’m sorry to say the previous Liberal government was lukewarm to follow up my work and the current Conservative government sees little role for the federal government in health care. No national leadership and little provincial leadership. Fortunately, there are still enough local examples of excellence to provide us with prototypes for a better future.