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Text File | 1991-05-09 | 13.8 KB | 299 lines

                              HEALTHY CHOICES

                              By JOAN RAMSAY
                               Southam News

     OTTAWA It's been easy for most Canadians - get sick, get help.

     For almost 25 years, equal access to quality health care has been a
     right of citizenship: Individuals can't buy their way through the
     system; cancer doesn't equal bankruptcy; hospitals can't demand
     proof of solvency; people don't die because they can't afford
     treatment; doctors don't get tiffed on bills.

     The problem is, you can't have virtually unlimited advanced care on
     a limited budget.

     And if Canadians want to keep quality universal health care,
     they're going to have to start making some pretty hard choices,
     governments and health care experts say.

     Expensive ``miracle cures'' that don't quite work will have to be
     passed over.

     Treatments will have to be proven before attempted - ``do whatever
     it takes'' is just too costly, given that it usually doesn't work.

        See also <08health -medicaid>  about treatment trade-offs

     And some funding that would go to short-term care will have to be
     diverted to long-range prevention.

     Canadians must make these decisions knowing they will cost some
     people longer lives, experts say.

     Because unless something is done, Canada's universal health care
     system will deteriorate into one system for the rich, another for
     the rest.

     Medicare has become a black hole, sucking tax dollars
     indiscriminately and, too often, inefficiently. Canada spends about
     $60 billion a year on health care - that's $164 million a day; $7
     million an hour; $114,000 a minute.

     Now, with Ottawa clamping shut its funding funnel, the provinces
     are  scrambling to control medical costs and services. Hospital
     beds have been closed, staff has been cut and waiting lists for
     care have grown.

        See also <03health> - The Mechanism of Medicine

     Health care experts say that's Band-Aid action, that more basic
     changes are needed in a system barely changed since medicare began
     a quarter century ago in Saskatchewan.

     And some say it's time for consumers to start getting involved in
     deciding who gets what treatment, and when.

         See also <08health -Oregon> for trial of patient choices

     In 1989-90, health care commissions in Alberta, Quebec, Ontario,
     Saskatchewan, New Brunswick and Nova Scotia called for increased
     consumer control and responsibility for health resources, and a
     shift to home-based and community services from hospitals and
     institutions, according to a synopsis by Terry Sullivan, executive
     director of research and policy for the Ontario premier's council
     on health, well-being and social justice.

     In April, that council made similar recommendations to move to more
     community services, saying the health-care system is too big and
     inefficient and there's not enough emphasis on sickness prevention.

     Generally, the problem seems to be that providers are penalized for
     being careful and there are no controls on use:

      - Under the fee-for-service system, doctors who see a patient
     every five minutes earn three times as much as colleagues who give
     each patient 15 minutes of his time.

          See also <06health -opposed> about fee-for-service
           and <06health> for general discussion of doctor's salaries

      - Hospitals that come in under budget lose the extra money
     instead of being allowed to keep it to use later.

      - Patients can get expensive treatments that don't improve
     either quality or quantity of life.

        See also <08health -coronary> about coronary bypass surgery

     ``I think we need to take a much more realistic view about what it
     is we expect our health care system to do for us,'' says Prof. Bob
     Evans, a health economist at the University of British Columbia and
     member of the province's royal commission on health care, which is
     to report in September.

     ``I think we should expect it to provide for us services that are
     demonstrably effective. . . . You don't provide things just on spec
     and on the thought that somebody said to somebody else once that it
     might do you some good.''

     Health economist Jane Fulton of the University of Ottawa agrees,
     saying billions could be saved immediately by taking more care in
     what surgical procedures are done.

     ``What's happening is that people who are not in real need of
     surgical procedures are getting them because the system is driven
     by physicians and not by consumers,'' she says.

        See also <06health -driving> about doctor's driving the system

     For example, ``we know that a third of the coronary artery bypass
     surgery done in this country is not necessary. Well if you stop
     doing that, that frees billions of dollars of resources for other
     things.''

     As well, Evans says the numbers of new doctors annually is
     outpacing population growth and should be controlled.

        See <06health -over> for number of doctors

     ``Now we can have a big argument about how many doctors are enough
     and how much is too much . . . '' says Evans. ``But the thing that
     you can't argue about is that we continue to turn them out at about
     two to three per cent a year per capita.''

     The only answer, he says, is to either reduce doctors' incomes,
     ``at which they're going to get very excited,'' or restrict growth
     in some other part of the system.

     The problem is not new, Evans adds. ``It's been 15 years since
     people started pointing out that this was going to be a problem.''
     It's just that no one wanted to face the flak that cutting or
     closing medical schools would cause.

     A Health Department report in March shows Canada had 49,706 doctors
     in 1988, or one for every 525 Canadians. In 1985, there were 44,230
     doctors, or one per 571 people. And in 1978, there were 35,433
     doctors, one per 667 people.

     As of Sept. 30, 1990, there were 1,242 hospitals in Canada, with
     178,067 approved beds, or 6.82 beds per 1,000 population, according
     to Statistics Canada. (Approved beds doesn't mean available beds,
     as hospitals restrict access to save money.) At the same time, the
     average operating cost per patient-day was $489.53.

     In 1988-89, there were 3.7 million admissions to hospital
     accounting for 43.7 million days of care, up slightly from 3.6
     million admissions and 40.7 million days of care in 1979-80,
     according to Statistics Canada. The number of admissions for
     surgeries dropped slightly in the last decade, to 6,994 in 1988-89
     from 7,263 in 1979-80.

     In a bid to control costs, Quebec has proposed a $5 user fee on
     emergency visits, to deter people from using emergency wards as if
     they were after-hours doctors' offices. In September 1990,
     emergency wards across Canada handled an average 76 people per day.

     The Canada Health Act of 1986 banned extra billing, but that isn't
     expected to last if the federal government eventually turns full
     responsibility for health care over to the provinces, as some
     provinces want.

     Indeed, within a few days of assuming the federal health portfolio
     last month, Benoit Bouchard suggested the time had come to transfer
     more health-care responsibility to the provinces.

     The Canadian Hospital Association fears federal funding cuts are
     putting medicare at serious risk.

     ``Across the provinces there's relative inability to step in and
     pick up the space that appears to be being vacated by the federal
     level,'' says CHA president Carol Clemenhagen.

     As a result, she says, hospitals are being expected to provide the
     same amount of service with less and less funds. ``It's a pressure
     cooker environment.

     ``It strikes me that we're on very dangerous ground and we're at
     the point that we're saying to health care facilities, get out
     there and fund raise;  we're hearing from the provincial level
     interest in `disentanglement' from federal conditions and
     principles; we're in a point of development where people are
     starting to think about `Can we afford universal access.'''

     What is needed is some form of national health objectives, covering
     everything from what procedures to fund to rules on resuscitation.

     ``You need to have a framework that says these are the health
     problems that we in this country need to address.''

     And for Fulton that means admitting that some procedures are just
     too expensive, considering the outcome.

     ``If we reorganize medicare and it becomes a cost-effective
     service, you could get a kidney transplant but, in this century, we
     will stop doing liver transplants and we will not do heart
     transplants because they're not cost effective.''

     She says liver transplants, given high rejection rates, have very
     limited ability to either prolong life or improve quality of life
     because ``the drugs you take to manage rejection are so powerful
     that you're pretty well half-dead from that, too.''

     Kidney transplants, on the other hand, are very cost effective,
     because  rejection is low, they enormously improve quality of life
     and they save the health system the cost of renal dialysis.

     Instead of performing liver transplants, she says, ``what we need
     to do is put in place psychiatric and psychological and emotional
     support for families to cope with the death'' of their loved one.

     ``That's why we need more health science research which says `here
     are the criteria by which we are justified in spending $500,000 on
     somebody's transplant and here are the criteria by which we are
     pretty well assured that the person will die anyway,' and they will
     then not be eligible for the transplant.''

     Then there are the procedures to prolong a life without quality -
     the kind of procedure more and more people say they would refuse -
     resuscitation, machines.

     ``Why are we in this tremendous crisis to find ever more resources
     to do things that none of us would want if it was us?'' Evans asks.

     The obvious answer is that ``nobody wants to say `Let people die'
     and nobody wants to be directly involved in making those kinds of
     decisions, playing God as the phrase has it.

     ``And yet, our failure to address those issues openly and publicly
     translates into an ever more costly system.''

     There's a growing belief among governments and health care groups
     that the emphasis must start moving toward sickness prevention, and
     that ranges from adequate food and housing for the poor to
     controlling pollution.

     ``What we need is a paradigm shift, a new model, a new way of
     thinking,'' says geneticist Dr. Patricia Baird of the University of
     British Columbia.

     ``I think that if our goal is producing health, then the citizens
     have to realize that funding a sickness-care system is not the most
     important way to produce it,'' adds Baird, a member of the National
     Advisory Board on Science and Technology and chairman of a federal
     commission on new reproductive technologies. ``Part of living is
     dying . . . we should accept that.''

     But in order to get the money needed to attack the causes of
     illness, Fulton adds, ``we have to make tradeoffs'' in the medical
     system.

     ``Some of those tradeoffs involve not providing a medical
     intervention to somebody who's probably going to die anyway.''

     Adds Evans, people must realize now ``that there are limits to what
     medicine can ever be expected to do. You're not going to get out of
     life alive. You're not going to be able to cure all the ills that
     flesh is heir to.''

     Because if the pressures on the system don't ease, and if the
     federal government hands the problem to the provinces, Canadians
     will step back in time.

     If that happens, Evans says, it will be done in small steps:

     Ottawa will cut its responsibilities, the provinces will find
     themselves coping with still larger deficits and will decide that
     the simple solution is a combination of user charges, letting
     physicians extra-bill again and allowing reintroduction of private
     insurance.

     ``Just for people who can afford to pay, you understand, not the
     people who really need it - it's just those who can afford to pay,
     should.''

     Year by year from then on, he says, ``it becomes easier and easier
     to say:  `Well you know we're under such fiscal pressure that we
     can't afford to increase physicians' fees this year. But they can
     always get the difference from the patients and maybe we can
     provide some tax assistance for private insurance again to cover
     that. You know, of course, we will always look after the people who
     really need it.' ''

     And then they slowly chip away until we're back where we were
     before medicare and where ``the Americans have been all the way
     through.''

     Twenty years later, Evans says, ``you'll look back . . . and say
     `My goodness, the system has totally changed.'

     ``But there won't be a single point in time where you can say, `Ah
     yes, this was the crisis.'

     ``There's no High Noon scenario here where we can meet the bad guys
     in the street.''

     (With research by Cathy Campbell, Southam News.)