Tag Archives: Canada

Monopolists and Healthcare

In Canada, healthcare in British Columbia is slowly coming apart because of the existence of a private health clinic.

Canada

Afraid, very afraid.

This link is to a legal foundation that takes on legal cases such as this and provides a reasonable overview of the situation: LINK

In Canada there is continuing debate whether the Canada Health Act‘s language that healthcare be publicly administered, means that it must be government-run. A Senate report (LINK here to the final report) of some years ago drew the view that this one of the great myths of Canadian healthcare, but the more publicly acceptable Romanov report caved in to political correctness and said that people preferred a government monopoly.

There is, however, an interesting problem that state monopolies can cause: namely that they may be manifestly unable to provide the services that they monopolise. That is to say, the government controls the whole healthcare system in some form (what in Canada is referred to in part as a single payer system, but in the case of providers, excludes providers that are emantions of the state — i.e. publicly mandated in some form) and in so doing does not provide the range of services or access provisions to meet those obligations. Now, at a simple level, would a rational person accept to buy a service from an organisation acting as a monopoly that could not meet their needs? Unlikely and we’d most likely find somewhere else to get what we needed; but what if you have no choice? This is the essence of the problem in Canada.

The European Court of Justice rulings have caused so much change in access to healthcare across Europe but the really important, in my view, relevant to healthcare actually aren’t about healthcare.  In some work I did a few years ago, some ECJ cases are instructive and may serve to help Canadian authorities identify key factors for their own decision making; the last one of the list is the one that is most interesting:

  • CBEM v CLT and IBP Case C 311/84 [1985] ECR 3261: statutory monopolies have a dominant position in the market
  • Bobson v Pompes Funebres des regions liberyees Case 30/87 [1988] ECR 2479: states may not use a dominant economic position to fix prices and restrict market entry of competitors
  • RTT v GB-INNO Case C 18/88: public undertakings operating public infrastructures abuse their dominant position by excluding third-party service and content competitors
  • Merci Convenzionali Porto di Genova SpA v Siderurgica Gabrielle Case C 179/90: dominant positions are not in illegal, but undertakings may not be created which cannot help but abuse that dominant position in what they are tasked to do by the state
  • Hofner and Elser v Macrotron GmbH Case C 41/90 [1993] 4 CMLR 306: states may not create economic entities with dominant positions that are unable to meet the demand for services, or distort the competitive structure of economic markets.

Now, the ECJ rulings may or may not interest folks in Canada as this would not necessarily present a ‘made in Canada’ solution. It is a sine qua non of Canadian healthcare that the state edifice, constructed by the Canada Health Act, protects Canadians from healthcare costs and trades off greater choice and service access (i.e. waiting times) for that benefit.

Of course, one might argue that healthcare isn’t an economic market, but in fact it is hard not to think of it as such for a number of reasons. It accounts for about 10% of most economies, perhaps 5% of the workforce is employed in healthcare, it comprises provider and payer bodies that interact with each other through contractual arrangements of one sort or another, and there are user fees/copayments, or reimbursements to patients which clearly suggest some sort of economic transaction. Keeping things simple helps, and avoiding the usual arguments that patients are unable to make informed choices or generally do not as such ‘choose’ healthcare as a consumable good, but are forced into a transaction by their liver or heart or an accident. How we get their seems irrelevant: it would be like arguing that the housing market wasn’t a market because people are ‘forced’ into needing housing, or even food….

In my view it is time for the Canada Health Act to be interpreted in the form that Kirby and others in their Senate report urged and enable greater contestability of the provision of healthcare, as long as the basic underlying principles of community risk sharing on the payment side isn’t compromised. It is this latter point that was the essence of the ruling of the US Supreme Court (the bit about mandates and whether payment was a tax or a penalty).

No country today sensibly tries to restrict provision so long as they have control of the payment levers. However, and here austerity raises an ugly presence, healthcare is the biggest item in the provincial budgets and unless the provincial governments figurer out how to bend the cost curve down, this cost area will continue to consume a larger and larger chunk of provincial expenditure. Solutions lie, in part, in creating conditions for consumer (patient) driven reforms; there are no incentives for health professionals to do things differently (i.e. less expensively) when the state decides the structure and capacity of the healthcare system, which might actually under specify what is needed, but overpay for that capacity. Across Europe, healthcare costs are included in the national debt restructuring but we don’t see enough reform efforts as the bulk of the research has focused on state-mandated health reform so little is know about how to take apart a health system. The same holds true in countries like Canada. Sclerotic administrative practices and controls that manifestly restrict freedom of consumers to choose and those choices to lead to system reform need rooting out.

Regretfully, it appears, like in all things that really matter, the courts will force the health reform debate.

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Health IT Industry Canada/UK

Mike recently chaired an event for UK companies to explore the opportunities for health information technology companies in Canada. Sponsored by UK Trade and Investment, GLE London, and the Canadian High Commission, the event attracted a group of firms with expertise in this sector, to hear presentations from EMIS and RIM and also learn about R&D tax credits, FP7 opportunities and partnering opportunities that are often not exploited.

Opportunities abound in Canada as it seeks to enhance the uptake of information technology in healthcare. Canadian physicians have a low adoption rate of office-based clinical systems, while connectivity between hospitals and primary care is not well developed. The focus in Canada has seen public investment, mainly linked to InfoWay, being poured into hospitals systems, with very little actually where the bulk of clinical encounters occur, namely in primary care. Slow adoption of electronic prescribing systems, coupled with often weak and poorly defined provincial electronic health record implementation strategies suggest that market entry opportunities lie in bringing order out of chaos and demonstrating clear benefits for clinician adoption.  The companies attending this event had that experience and could bring this level of structure to the market.

The partitioning of health markets into provincial systems means market entry strategies must pay particular attention to provincial characteristics and objectives, and incentives, such as tax credits, but also links to provincial infrastructure and innovation opportunities. There are pros and cons to each provincial system from a market entry strategy where the Alberta system has clearly centralised to Ontario with a purchaser/provider split and major reform underway in Quebec. There are also opportunities in specific market segments such as military health, prison health, workplace health and aboriginal health, which are frequently ignored as firms tend to focus on the publicly funded system as a whole and ignore these specific areas of opportunity and which offer market entry. Working with smaller Maritime provinces for instance offers scalable opportunities.

In addition, Canada’s position next to the US offers firms access through NAFTA, to take advantage of the huge stimulus in healthcare technology that is linked to health reform in the US; providers are early adopters and invest in technologies, including clinical systems so there are market-based opportunities around, for instance, clinical decision-support systems.

My own presentation focused on the opportunities working with Canadian academic health science centres [AHSC], which anchor provincial specialist service delivery, research and professional training. Since they combine research, teaching and service delivery, they offer partnering opportunities across a wide range of areas, and have sufficient commercial freedom to engage in alpha or beta partnering as well co-investment with start-ups. While many are still tied to the traditional technology transfer or licensing model, other ways of structuring deals are available.  They are valuable sources of new technologies for early stage investment, and with a relatively small early stage health investment community, the AHSCs are always looking for new people to have commercial discussions with. There is considerable interest by the federal government to ensure that early stage firms do stay in Canada so jobs and opportunities stay domestic, rather than being exported mainly to the US. But risk aversion and apparent shortage of second round financing sees many firms find their future with US investors. The removal, though, of disincentives in the income tax act which made life overly complicated for investors (similar to disincentives used in Australia) by the current government may encourage investors to feel more relaxed about the income tax regime.

Agricultural Innovation

Mike recently discussed commercialisation of agricultural innovation in Canada. There are real problems in this sector, not just how to feed the future and changing dietary patterns. Agricultural innovation tends to focus on new seed varieties as these can be commercialised, but we also need to look at a whole range of other issues, but research funding for soil science for instance, is small compared to other areas.

What’s an EHR for, anyway?

Sample patient record view from VistA Imaging
Example of EHR (VISTA)

There is trouble in e-health land, at least in Ontario’s funny notion of what they might mean.  EHealth Ontario has been subject to an emergency audit of its procurement or not of an electronic health record [EHR] by the Auditor General of the province.  Apparently, somewhere approaching C$1 billion has been spent with virtually nothing to show for it.  The problems lie in a bad ehealth strategy, and inappropriate use of consultants.

There are lessons here for other jurisdictions, as they seek to embrace the benefits of EHRs, and ehealth more widely, in particular. Of course, what is an EHR for, is the core question.

One of my alma maters, McMaster University, has sprung into the fray saying it has an EHR called OSCAR that could be implemented for perhaps 2% of the estimated cost of a provincial EHR.  Their argument being that a lot of doctors are using it.

EHRs are not a tool for doctors, though.

EHRs are an integrated information repository to facilitate better healthcare.  Doctors are not the only oranges, and nurses, physios, social workers, pharmacists, OTs, oh, yes patients and parents, informal carers, too, need access to health records. In my view, patients should own and hold their own health record, to ensure high audit standards (would you let an error remain on your health record if you knew about it?).

Servicing the specific needs of doctors alone is not an EHR strategy worth having, and doctors themselves should be the first to say this. It is time they showed leadership within the wider healthcare system, and rejected self-serving models, such as McMaster’s, which automate obsolete information models. McMaster, too, should have known better.

The Ontario Ministry of Health has wisely rejected OSCAR’s offer, but for the wrong reasons.  Citing the need for doctors to choose their own systems, just shows their continuing logic of catering to the needs of a particular health profession, rather than addressing the systematic provision of patient information within an integrated decision-support system.

All this is being driven by beleagured officials who really need to think again about their priorities and why they really need an EHR.  Perhaps they are afraid to admit to having made a mistake.  Such hubris.

Clearly more work is needed to define the purpose of the EHR and the goals for an ehealth strategy in Ontario (and other jurisdictions of course), before more taxpayers’ money is spent on ehealth.

Oh yes, apparently Ontario are going for a tender on a diabetes registry. NYC has one. I fear the worst.

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E-health and Ontario

The wordmark of the Government of Ontario, fea...
Waiting for the e-health revolution

From across the Atlantic comes news of apparent financial maladministration at E-Health Ontario, the body charged with implementing the province’s e-health strategy.  It seems to be the usual nonsense of untendered contracts, friends in high places, and chums helping chums.  It is also an example where no one seems to have asked the simple question, “why would you do that?”  — the strategy is a nonsense, and I am surprised that no-one challenged this before the policy had gone this far in implementation.

I would, naturally be more inclined to be concerned if the province’s e-health strategy were actually about e-health, or likely to deliver results worth having, but the $700 million or so per year will be spent on things like a diabetes registry, wait times, electronic prescribing/electronic health records.  Only the last have anything really to do with e-health.  The last can also be procured, so there really isn’t a need to make a supplier meal out of putting something in place.  I will concede though that an EHR is a critical component of e-health, but it isn’t quite the same as e-health — it is a bit like confusing the foundation of a house with the home it will become.  But having worked on eRx,  the province’s failure to prioritise some sort of a patient-held smart card is a mistake as without this it is difficult to deal effectively with identity.

Without system redesign in the province, the e-health strategy is really just throwing good money away and given the current economic (and political) climate, this is no longer an option, if it ever really was.

Two things are of critical importance.  First the province needs to have a thorough-going governance review of e-health Ontario, mainly to determine how to make sure it is fit for purpose in actually providing the leadership for development of an e-health infrastructure service delivery platform.  Secondly, and this is the challenge, it is necessary to make sure that the e-health services are ones that the public will use and value.  The province has failed on both counts.  The next challenge though will be to find people to review e-health Ontario who haven’t been tainted by this scandal and benefited from the feeding frenzy e-health Ontario created. It may require looking further afield, to interested, but uncontaminated parties.  They may even not live in Ontario — golly gosh, so much for made-in-Ontario mediocrity.

So, having vented on that last point,what would an outline e-health strategy look like for Ontario, assuming that some governance arrangements are put in place,.  These are really just illustrations as certainly I would want to get a good understanding of priorities from interested patient groups:

  • There are about 90 rural and small hospitals in the province.  A good plank in an e-health strategy would be to enable them to become a single, integrated, but distributed healthcare provider, perhaps with some sort of local and shared corporate governance.  A distributed healthcare provider, using e-health infrastructure technology would deliver specific outcomes to rural people, such as access to networked diagnostic imaging technologies, electronic prescribing and remote access to health records.  I would certainly save people in Thunder Bay a lot of trouble getting down to Toronto for a scan.  With a little bit of imagination and thought, this could work.
  • About 60% of diagnostic facilities are located in Toronto, but which has only about 25% of the population; these are licensed clinics which often only offer a single procedure.  Using networked imaging technologies, remote diagnostic telecare booths (you can buy one from Cisco) many of these suboptimal centres could be relocated either to the rural network, in the previous plank, or provide a more accessible urban service across the provinces main urban centres.
  • Smart card technologies (whether a smart card or an electronic secure passport) would give a better reason for constructing electronic health records than ones focused on improving data access for health professionals alone.  Patients, when given access to their health information, will have a vested interest in ensuring that the information is correct (my Ontario health record when I lived there had an error showing I had a condition affecting women, but I am a man — I still don’t know if the error was corrected; in an electronic system, that error would have been a problem, but I would have made certain that it was corrected, too).  As an ‘auditor of one’ patients can make sure information is correct, and drive substantial service quality improvements.  This is not to say that health professionals can’t do that, just that the evidence shows it comes slowly and is complicated by cartel-like professional practice barriers.  Start by putting the e-health card in the hands of the heavier users of the health system, to better manage their healthcare, access to information, and gradually as people see their family doctor, or get born, migrate the whole population over.  Of course, this will mean that family doctors, clinics, pharmacies will have to adopt some sort of information system.
  • Don’t do what the English NHS is doing with Connecting for Health, by creating a large-scale government-led initiative.  E-health Ontario’s predecessor took a look at Denmark, but failed to learn the lessons despite what they wrote in their sham of a consultation document — they missed the point partly because they appeared to have another agenda heading toward a particular solution.  Denmark has shown how disparate stakeholder groups can work together to create an information system that works, and does things people value.   Better that than spend vast amounts of money on a grand plan to nowhere.

The general plan is to build an infrastructure that starts with the patient/family as user.  My experience in developing an interactive health television channel showed me the importance of starting there, and defining the benefits from that perspective.  Change will drive from that end too.  Finally, engage all the stakeholders (like the Danes did), find commercial partners with interesting technologies that do things that people value (rather than whizzy technologies), look for alternative systems to pay for healthcare services, as failure to develop a suitable and workable reimbursement system for e-health services is a barrier ( just ask Norway).  Oh yes, don’t forget political will.

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Ontari-ario: innovator and leader, or just left behind?

Suck (film)
!

A recent two week work schedule in Toronto had me reflecting not only on how much snow there can be in my homeland, but also the need for a real electric charge to the province’s policy making.  The province is facing near meltdown, after an ill-conceived pursuit of manufacturing jobs in the automotive sector, with some 150,000 manufacturing jobs lost over recent years, never to be seen again.  Trying to jump-start this industry with taxpayers’ money seems a bit like investing in buggy whips while watching Henry Ford’s Model T drive you to town for a nice lunch!

Investing in universities and research has been coupled with a punitive tax regime, that drives new businesses into the arms of other provinces, or to the US.  Early-stage venture capital is scarce, and the mandarins on Bay Street that do profess to know what to do are more focused on generating returns to their funds (or these days just keeping the rent going on their plush offices), than on understanding the driving force that is the commercialisation of research.

Brains not brawn should be the cornerstone of provincial policy.  This will become especially important as the US, largest trading partner with a 10:1 ratio of US scientists to Ontario/Canadian scientists ramps up scientific investment after a near-decade of scientific politics under the last elected regime.  That sucking sound you will hear (apologies to Perot) will be American scientists returning home to the US.

Ontario, time to get the boots on, review taxation policy, look to rethinking what the best use for bail-out money really is.  Some industries will go and that is sad, but what will replace it will establish the future credentials for the province for at least this half of the 21st century.

Unless, of course, you like buggy whips.

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Strategic Healthcare Purchasing: UK/Ontario

The Classic Guide to Strategy album cover
Play on!

The most advanced development of the purchasing function is with the English NHS. Other countries, such as the Netherlands are leaders in using competition to improve purchaser performance.

The priority for the English NHS has been to ensure the effectiveness of purchasing (or commissioning as it is called), as poor purchasing is seen as the weak link for ensuring good service delivery. For Ontario, this means that LHINs will need to be robust organisations with the necessary capabilities to undertake the necessary work to deliver integrated health services.

Strategic commission involves the following for LHINs:

  • Planning healthcare

  • Determining local health priorities within the provincial health strategy

  • Assessing and identifying local needs based on patterns of service that respond to the population’s needs

  • Establishing local capacity plans that extend into the future (and achieve the integration objectives)

  • Purchasing healthcare

  • Deciding which services are provided by which providers, taking into account current balance of service delivery (and risks in areas of strategic low priority) and future capacity requirements

  • Developing the right SAA arrangements that achieve integration (taking account of service utilisation, risk, quality)

  • Appropriately overseeing the resulting arrangements within a collaborative governance arrangement

  • Monitoring and performance managing healthcare services

  • Are the agreed services being provided to the volume that has been identified for the population’s needs?

  • Assessing provider clinical performance using quality assurance through external auditing and accrediting bodies that a service meets external standards, and SAA-specific quality standards that the LHIN may seek.

  • Is a high-quality, integrated patient experience being provided?

Effective purchasing focuses on delivering health outcomes to national targets, with the ability to establish novel provider arrangements as they see fit, and which provide at least equivalent clinical benefit (that ensures that changes are not just for change sake but are value-adding). This addresses an element of strategic purchasing about how to encourage novel forms of provision, and move beyond legacy providers.

Various challenges for strategic purchasing by LHINs include:

  • The ability of a LHIN to measure health needs and inequalities and model appropriate service provision, in the present and for the future.

  • The ability of a LHIN to collaborate with other LHINs and multiple providers particularly around specialist service areas.

  • The ability to achieve integration strategies with non-LHIN-funded providers.

  • Determining the appropriateness of cross-LHIN-boundary patient flows that may not be compatible with LHIN-based integration strategies.

  • How can LHINs achieve integration solutions that reduce inappropriate use of secondary care, by

  • shifting resources toward primary care,

  • enabling service redesign by providers

  • working with non-secondary-care/community providers.

This presents a developmental challenge for LHINs for a number of reasons:

  • There is a very small number of people on LHIN boards who have direct experience of the purchasing function, and who have not developed their perspective on health system performance from other than a provider experience. This means that considerable efforts will be needed to ensure that LHIN board members learn the appropriate strategic approaches to service redesign, transformation and integration from a non-provider perspective.

  • Proposal: a board-level development plan is needed to ensure that LHIN board members are able to embrace the appropriate health system reform models compatible with a purchasing function.

  • Differences between LHINs and providers are real in terms of them having different roles within the Ontario system; explicit recognition of this is necessary.

  • Proposal: individual chairs and chief executives of LHINs may find it useful to engage in a learning-set development process with chief executives and chairs of providers to explore their different roles.

  • LHINs need to engage with like-minded organisations with purchasing experience

  • Proposal: a series of workshops for LHINs with people with direct and practical experience of the problems and challenges of purchasing.

References

Commissioning in the NHS: challenges and opportunities, NERA Economic Consulting, London, June 2005.

NHS Alliance, The Future Shape of Primary Care and General Practice – who will be the providers of the future, and how will they be organised? November 2004). Dr Mike Tremblay led the development of this paper for the NHS Alliance.

Mike Tremblay, Tremblay Consulting

Role Description
Planning
Short term demand forecasting

Use of actuarial techniques to forecast demand, even in short term

Modelling techniques

Long term demand forecasting and capacity planning Strategic perspective on future activity levels taking account of epidemiological models and service design assumptions
Market management Taking account of longer-term capacity requirements, relationship between purchasing decisions affecting one provider may impact on others
Financial, risk management Risk pooling of high-cost low demand care where population is small or insuring against unavoidable overspending in high priority (necessary) areas of service delivery
Purchasing
Procurement Contract negotiation, based on agreed activity from planning process with providers
Supply chain management Pro-active approach to ensuring the best pattern of service delivery, rather than functioning as a ‘flow-through’ funding body
Patient relationship management Ensuring the administrative control of the patient’s journey through the healthcare system, to achieve service integration from the patient’s perspective
Monitoring
Contract management Reviewing service quality and service provision; payment
Information Standardised and timely information to monitor financial performance of the local system
Benchmarking Using comparative information on providers to permit service improvement through peer-learning

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Canada’s dairy supply management system is a public health menace

Espace Opéra Milk
Hard to believe, but this is a symbol of politics in Canada: free-traders beware!

The supply management system inflates the cost of diary products to Canadian consumers. Canada also applies substantial duties on imported dairy products. Both of these practices are of dubious benefit to consumers, and cost them substantial sums of money each year. It also has public health consequences that have been ignored.

In other countries, and particularly within the European Union, prices for milk, cheese, probiotics, yoghurt, etc. are about 30-40% of Canadian prices. By comparison, in a typical Canadian grocery store, a litre of low fat milk ranges between C$2.14 and C$2.40, three times the price in Europe.

There is some evidence that high prices may discourage parents from buying milk for their children. This may correlate with family income relative to poverty thresholds. Research has quantified how children substitute sugary carbonated drinks for milk. Reduced dairy consumption may be contributing to rising obesity in children and perhaps rising incidence of Type II diabetes, something we thought only showed up much later in life.

Milk consumption is also lower for girls, which may predispose them to osteoporosis later in life. Recent Canadian research has shown that reduced milk consumption during pregnancy leads to low birth-weight babies. We are also seeing the return of rickets.

At present, the parties to the supply management system itself are the main sources of information for consumers on dairy products. This makes it virtually impossible for consumers to access independent information. This is a tight circle that may not be acting in the public interest when looked at in terms of implications to human health.

The logic of the dairy supply management system is weak when tested against public health outcomes.  It is time to abandon this policy, which favours the few, has public health consequences for the many, and adds costs to provincial healthcare systems already under significant stress.

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More on Courts and Health Reform

European Court of Justice
Health Reformers?

The Canadian Supreme Court ruling on private health insurance has alerted us that individual rights do matter and now they matter in health care, more than people had thought. Perhaps the greater impact of this ruling may be the emergence of legal or rights-based challenges to health policy, something the European Court of Justice has shown global leadership on.

Traditionally, health care decisions revolve around money, how much who gets and how; Canadian health politics is littered with the wrangles between the federal government and the provinces, and where has it got us?  Years of polemic perhaps about fiscal priorities, but perhaps little mileage on how to ensure Canadians get the health service they are paying for.  Other countries have been rudely awakened from this complacent slumber and found themselves faced with a steep challenge; in the UK, government spending on their National Health Service is being virtually doubled, to bring average UK spending in line with average spending in the other European countries.  Indeed, it used to be a hallmark of the venerable NHS that is was parsimonious in delivering health care, but the social costs in waiting times and waiting lists became politically unacceptable when compared with the rest of Europe.  Canadians of course compare Medicare to that the US system, and thank heaven that we don’t do that here!  But reality is of course much different, and we are learning daily now that there are things our mother never told us about Canadian Medicare, and finally perhaps the public is asking, “so, remind me again, what is we have been paying for all along?”

How do we know if we are getting a decent health system for our money?  The answer is not easy, but there are some clues.  Unfortunately, waiting lists and waiting times are indicators of resource shortages, not necessarily whether the health system is working well.  It’s a bit like heading into Home Depot to buy some paint, they may have lots of paint, great variety in the catalogues, but you need to line up to discuss the colour with one person, line up to get the cans from someone else, and third person to mix them for you, and you still haven’t paid for the paint!  Canadian health care is fascinated with hospitals, the most expensive, inefficient and labour intensive institutions known to modern society.  Not noted for being particularly safe, people get sick there while they’re recuperating from being sick.

One way to make sense of how well as health system works is to look at how well it treats new entrants, i.e. babies.  Infant mortality is a measure of the deaths of newborns, up to 1 year of age, and measured as a death rate per 1000 live births, so a number of 5 means 5 infants died in year for every 1000 babies born alive (i.e. not still births). High death rates pick up on problems associated with access to health care facilities, medicines, as well as maternal knowledge of child-rearing, diet and hygiene.  Low rates suggest the opposite.

In 1996, Newfoundland had a rate of 6.6, compared to the Canadian average of 5.8.  Nova Scotia had a rate of 4.9, while Nunavik Region in Quebec had a rate of 22.9.  In Ontario, Quinte area, rated by some as one of the best places in Ontario to live, had a rate of 6.8, Northwestern Ontario at 8.6 with the lowest being Halton/Brant at 3.9.  As we head west, Manitoba sits at 7.3, Saskatchewan, the birth place of socialized medicine at 8.7, Alberta, the new driver of health system reform at 6.1 and BC at 5.3.  Nunavuk is 17.9 and the Yukon 8.7.  Quite a spread.  To put it into a different perspective, the infant mortality rate in 2003 in Austria is 4, Finland 3, Romania and Argentina 17 and Colombia at 21.

So, once we survive that first year, how long will we live?  In Canada it is about 78.3 years of disability free life (1996 data).  But the best place to live if you’re a woman is BC with 81.8 years, and the worst place is Nunavut for men at 69.8.  Does the health system have any impact on how long we live?  Probably not, as most people’s encounters with the health system are around accidents and child birth, and the regrettable tenure we endure in our final days when the system’s heroic efforts to keep us alive gradually fail.  Most health system expenditure is incurred within the last 6 months of life, we just know when those last 6 months are.

Does money matter?  Well, you’d think it did, but there isn’t really any accepted correlation with how much a country spends on health care and the results it gets for its spending.  Canada spends a lot of money percapita (per person).  Newfoundland is the biggest spender, at $2151 per person along with BC at $2157, and PEI the smallest at $1718 and Quebec at $1760.  This money is being used to buy the same sorts of things in all these provinces, with varying degrees of success in meeting public expectations and service standards.  But it is how we organize those resources, well or badly, that determines whether we get good value for our spending.  The case may be building that the problems with Medicare are problems with design, the choices we’re made on how to organize it.  The main problem in my view being this fascination with hospitals and the bottlenecks created through them in accessing diagnostic tests for example.  Most countries trying to reform their health system, believing it will improve the statistics mentioned above, are trying to reduce expenditure and use of hospitals, and move resources into the community where the focus is on greater real-time engagement with people to help them maintain their health, rather than respond with a ‘sickness service’.

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