The Mark 2010

Two-tier care won't curb rising health costs, but a massive overhaul of the existing public system will.

We continually hear journalists and commentators say that public health care in Canada is unsustainable, often assuming the problem will be solved by moving costs from public budgets to household budgets.

But over the past two decades, spending on private health care has grown far more rapidly than the cost of Canadian Medicare – those insured services protected under the five principles of the Canada Health Act. Furthermore, our provincial single-payer reimbursement systems have proven far more effective and less costly than any mixed or private insurance mechanism, as the ongoing health care crisis south of the border illustrates.

Far from being the source of the problem, the way we fund Canadian Medicare is our ace in the hole in achieving both fairness and efficiency.

While I agree that we have a sustainability problem, it has far more to do with the way we organize and deliver health services than with the way we fund these services.

We can solve part of the problem by doing the things we already do better – what economists call technical efficiency. This includes implementing electronic health records, which bring down the cost of transmitting information and improve the quality of care by ensuring providers and patients have relevant medical histories and charts at their fingertips.

However, technical efficiency will only get us so far. To truly wrestle down cost in the long run, we have to change quite fundamentally the way we do things. In particular, there are three areas of health care that are in desperate need of a major overhaul: pharmaceuticals, primary care, and long-term care.

Over the last two decades, public and private spending on prescription drugs has increased faster than costs in every other health care sector, growing at almost double the rate of our total spending on hospitals and physician care.

Fragmentation in funding, regulation, and delivery is one reason. Another is that, despite the good press that generic drug manufacturers get relative to brand name drug companies, Canada has among the highest generic drug prices in the world due to a lack of regulation.

The answer is obvious but difficult: establish a national drug plan that uses the existing regulatory powers of the federal government and the market power of a single plan to force drug prices down or, at least, constrain the long-term growth in cost.

We also have a serious problem with the quality of primary or first-contact health care in Canada. In most of the country, this care is still largely provided by family physicians working in solo or small medical practices. The majority are paid on a fee-for-service basis rather than for the time they spend with each patient.

As a result, doctor visits are extremely short and often end with a doctor rapidly scribbling out a prescription or making a referral to a specialist. In addition, family doctors are not adequately trained to spot or manage mental health problems. And because of fee-for-service remuneration, they prefer not to deal with complex patients, including the elderly and those suffering chronic conditions.

The solution? Move from solo and small family physician practices to group practices involving psychologists, mental health nurses, nurse practitioners, physiotherapists, and others. Provincial health ministries can do this by moving funding for family doctors to regional health authorities or local health integration networks and let them introduce new forms of primary health care.

The demographics of the baby boom, including a rising incidence of dementia, means that we will need more and better long-term care than what we have now. Without this major adjustment, we are likely to pay even more for hospital care for mentally (and physically) frail seniors.

We should look to the Dutch model, in which elders suffering from mental disabilities are placed in separate homes and wards dedicated to their needs, both in terms of physical layout and specialized physicians and other care providers.

These are long-term, difficult solutions that require courage, intelligence, and focus. They require political vision and leadership. They require the kind of constructive engagement between Ottawa and the provinces we have not seen in some time.

Given the current minority government and policy vacuum in Ottawa, as well as the Harper government’s ominous silence on this important file, the ability to engage constructively with the provinces now depends on the opposition leader who can best articulate what needs to be done. Doing this will both capture the imagination of Canadians and help win the next election.