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March 2002

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Canadian Health Care Fails Five Ways

Good health care rests on five pillars ... and they're not the
"five principles" government officials espouse

by Dr. David Gratzer

Canadians demand certain basic characteristics in a health care system. They speak of the "five principles" of the Canada Health Act: public administration, accessibility, portability, comprehensiveness, and universality. But obsession with those principles largely misses the point.

Provincial portability may be nice, but it isn't as essential as timeliness of care. Portability between provinces is a regulatory agreement worth pursuing, but no one will die if portability is not enshrined in federal law and is instead left to the provinces to negotiate among themselves.

The defining characteristics of a health care system should speak rather to the basic pillars upon which good health care rests. The following are the five pillars of health care:

Quality. Canadians need a health care system that provides quality medical care. The latest technology should be used to diagnose and treat citizens; medical facilities should be modern and well-equipped; physicians, nurses, and other providers should be highly trained and skilled.
Timeliness. Illness should be diagnosed and treated quickly. Doing so makes economic sense, as long waits mean people are less productive. And timeliness is morally necessary, for forcing patients to wait in pain and anxiety for treatment is both cruel and wrong.
Cost effectiveness. The system needs to produce acceptable results for the funds put into it. Precious resources must not be wasted on unnecessary procedures and unproductive administrators.
Patient orientation. The health care system must exist to serve patients, not providers. Additionally, patients, not bureaucrats, must be the ultimate decision makers about their individual care. The choice of physician and course of treatment must ultimately rest with the patient.
Accessibility. Regardless of financial circumstances, no Canadian should be deprived of the opportunity to get necessary medical care.

These five pillars are hardly controversial. But it's alarming to realize the extent to which the present system fails. On nearly each defining characteristic, Canadian health care--termed "medicare"--falls short.


Quality

With limited funds available for investment in such capital expenditures as technologically advanced equipment and building maintenance and renovations, the quality of care has suffered in Canada.

Consider, for example, a straightforward arthroscopic surgery on the shoulder described in a 1997 article in the Canadian Medical Association Journal. The older equipment currently in use in the medicare system requires an incision of 15cm (6 inches). An incision of that length affects recovery time: The patient will miss four months of work.

With state-of-the-art equipment, the same surgery would require only a tiny incision and a six-week recovery. In both cases, the shoulder heals ... but there's a clear difference in the quality of care.


Timeliness

Timeliness doesn't simply mean emergency care is readily available. It also refers to the ability of the health care system to diagnose and treat illnesses promptly. Of course, no health care system is without delay, but there's a profound difference between heart bypass surgery being scheduled within a week and within a year.

Waiting lists plague Canada's system of health care delivery. A reasonable estimate is that tens of thousands of Canadians are waiting for some form of health care. Many of them are in pain, and some will die. In an annual international study by the Harvard School of Public Health, Canada distinguished itself by having the longest wait times for breast biopsies of five modern, industrialized nations surveyed.


Patient Orientation

With the state as payer, the patient orientation of the health care system diminishes. For one thing, the doctor-state relationship replaces the doctor-patient relationship. To bill successfully, physicians must meet not their patients' needs, but the government's regulations.

In fact, the influence of the state extends to nearly every aspect of health care delivery. In the interests of "cost savings," medical developments--such as new treatments for the previously incurable tremor of Parkinson's or ultra-effective cancer agents--are not available.

And the state as payer means an artificial system of funding is created. Block funding to institutional providers (hospitals, for instance) means they have little incentive to concern themselves with the real needs of the communities they serve.


Cost Effectiveness

Is Canada getting good value for the billions of taxpayers' dollars invested in medicare? With limited accounting practices and tracking of patient outcomes, it's impossible to determine medicare's cost effectiveness. Nevertheless, it seems evident medicare isn't well organized.

Corruption of the doctor-patient relationship invites misuse of the system. Patients over-consume health services, and doctors over-provide those services. The bills add up. And the funding of institutional providers, allowing hospitals to function essentially as health care-providing cartels, is certainly ineffective.


Accessibility

For financial accessibility, medicare seems to deserve a passing grade. Generally, Canadians are able to access the health care system without concern for cost.

The de-insurance of certain services and the introduction of limited user fees worry some because of their potential to threaten accessibility. For the most part, however, those concerns seem unfounded.

But to say our health care system is "accessible" is an equivocation of sorts. Financial circumstances, after all, won't keep an individual from getting the MRI scan he or she needs, but waiting lists and government guidelines can and do.


Access to What?

Yes, Canadians can marvel at the accessibility of medicare, but the question remains: "What do we have access to?"

One family doctor answers that question with examples from his own practice:

a patient with liver failure who never had an "elective" admission, and whose spouse had to stay home from work to provide care;
an elderly patient with acute renal failure who was never offered dialysis; and
two patients needing spine operations who waited months for MRI scans.

Dr. David Gratzer is a physician and writer. He is the author of Code Blue: Reviving Canada's Health Care System (ECW Press, 1999).

For more information ... David Gratzer's Code Blue--awarded the 1999-2000 $25,000 Donner Prize for best Canadian public policy book--is now in its fifth printing. The book can be ordered from Gratzer's Web site at http://www.healthpolicyreform.org.