OPINION: Fourteen health care systems versus COVID-19

Are these the best systems for future health care decisions and needs?

 

https://doi.org/ 10.37964/cr24725

 

COVID-19 has revealed “cracks” in Canada’s health care system. Our 14 health care systems have no evidence-based process for prioritizing health care needs or services with a politically directed component. There is no real collaboration, administrative functions are duplicated, provincial borders create patient access restrictions and barriers to collaboration around academic institutions and centres of excellence, and hospital/provincial human resource budgeting is becoming more difficult to support. Has the time come for recognition, discussion, debate, and decision about health care delivery and how it could be provided in a more cost effective, cost benefit process, for both patient and provider enhancement, for all regions of Canada?

 

CITATION: Wilson RD.  Fourteen health care systems versus COVID-19: are these the best systems for future health care decisions and needs? Can J Physician Leadersh 2020;7(1):27-30.

 

This commentary is not about the dedicated heath care professionals at all levels of care and how they provide the best care possible. It is about the bigger national health care picture: its organization, infrastructure, decision and policy processes, human resources, and implementation of evidence-based protocols. Is there a need to have a fresh look at the delivery of health care in Canada?

 

COVID-19 revealed “cracks” in the present organization of the health care system. The facts that support a consideration of reorganization include:

 

• Provincial governments could not manage COVID-19 needs without federal support
• The federal government could not manage COVID-19 needs without provincial support
• Every day, there were multiple reports from provincial and federal politicians
• Every day, there were multiple reports from provincial and federal medical leaders
• Every day, provincial and hospital groups were doing provincial and hospital planning, in most cases, in isolation
• Every day, independent provincial health care decisions were made, on many levels
• Every day, mixed messages were received, decisions implemented, decisions withdrawn, creating large-scale confusion for the public and medical support personnel
• Some provinces appeared to have made the right decisions, while others appeared to struggle, with no real national oversight
• Large-scale national planning and triage opportunities were not available, while other important and needed health care services were delayed or cancelled

 

All of this activity created massive daily redundancy, with large financial, time, and human costs. There will be a next time and, yes, the approaches to COVID-19 of the 14 health care systems will be analyzed and discussed, possibly allowing us to be better prepared, but do we need health care system processes to be done 14 different ways? Top

 

 

Is it time to consider a real national health care system? Has the time come for recognition, discussion, debate, and decisions about health care delivery and how to provide it in a more cost effective and cost benefit way, for both patient and provider enhancement, for all regions of Canada?

 

How is it going?

 

In 2017, the Fraser Institute1 reported on the sustainability of health care spending in Canada and identified significant concerns:

 

The pressing question today, however, is what can we reasonably expect to occur in the near future in the absence of any significant shift in government policy?

 

After years of increasing health care spending at an unsustainable pace, it seems as though provincial governments have started to reach their limits over the past 5 years — understanding that a continuation of such increases would result in either reductions in other spending, or higher taxation, higher deficits and debt, or some combination of these three. Top

 

The Canada Health Act indicates that the roles and responsibilities for health care services are shared between provincial or territorial governments and the federal government. The provincial and territorial governments are responsible for the management, organization, and delivery of health care services for their residents.2 The federal government is responsible for:

 

• Setting and administering national standards for the health care system through the Canada Health Act
• Providing funding support for provincial and territorial health care services
• Supporting the delivery of health care services to specific groups
• Providing other health-related functions

 

The federal government has minimal impact on the national standard of care provided, as each province or region has determined or creates its own standard of care. Health care service equity, access, quality, and safety vary significantly across the country. Federal administrative involvement and oversight is present mainly in hospital and educational accreditation processes and focused federal health care responsibilities and programs. Top

 

Shared funding support, as reported by CIHI,2,3 has health care spending as 70% public (provincial–territorial 65.1% and other public sector 5.3%) and 30% private (out of pocket 14.1%, private insurance 12.3%, other 2.9%). Federal transfer payments are a collection of payments made by the Government of Canada to  provinces and territories under the Federal-Provincial Arrangements Act; they include the Canada Social Transfer, the Canada Health Transfer ($40.4 billion) and equalization payments (for 2019–20, the provinces and territories will receive $78.7 billion through major transfers). Considering a Canadian regional health transfer approach, the transfer payments are for Atlantic Canada ($2.6 billion), Quebec ($9.1 billion), Ontario ($15.6 billion), Western Canada ($12.9 billion), and Northern Canada ($134 million).

 

Canada is among the highest spenders on health care in the Organisation for Economic

Co-operation and Development (OECD), at $7068 per person. Tables 1 and 2 compare OECD and provincial health care spending.3

 

Where is the budget being spent?

 

The exact additional cost of COVID-19 for the federal and provincial health care systems cannot be determined as yet. Reviewing pre-COVID-19 spending patterns gives us a better understanding of future budget implications.

 

In 2019, total health expenditures in Canada were expected to reach $264 billion or $7068 per person and, overall, health spending would represent 11.6% of Canada’s gross domestic product (GDP).3 Hospitals (26.6%), drugs (15.3%), and physician services (15.1%) were expected to continue to use the largest share of health care dollars in 2019.3  Top

 

The growth of physician spending has outpaced that for hospitals and drugs. Here is the forecast for each category in 2019:3

 

• Hospital spending: 26.6% of total health care expenditure, $1880 per person, 2.0% annual growth per person
• Drug spending: 15.3% of total health care expenditure, $1078 per person, 1.8% annual growth per person
• Physician spending: 15.1% of total health care spending, $1064 per person, 3.5% annual growth per person; for 2018, there were 89 911 physicians in Canada, representing 241 physicians per 100 000 population3-5

 

Concerns over the sustainability of Canada’s health care systems frequently involve discussion about physician compensation, drug prices, and wait times.6 Teja et al. highlight that capital funding to support infrastructure is largely neglected in these discussions. One of their key points supports the need for a national health care process, as Canada’s health system is particularly vulnerable to fluctuations in capital spending because the cycles for capital investment are longer than political cycles.

 

A recent series of articles titled “America’s health care system is broken” has highlighted American issues, but many are systemic in Canada as well.7 Top

 

Conclusion

 

For consideration and discussion of a national health care system, we need:

• Innovative new national care models and collaborative organization for optimized human resources training, enhanced national mobilization of service expertise, and provision of care with no provincial geographic exclusions.
• New national evidence-based prioritization of primary/core and innovative complex care services and more predictable human resources funding models (blended models: salary, alternative payment plan, fee for service). Although federal and provincial/territorial funding sources can provide appropriate focused evidence-based care,4,5 the provincial/territorial health care budgets are more than 40% of total provincial budgets and may not be sustainable.
• A greater national consideration in the directed regional planning process to create and enhance the concentration of excellence with reduced health care service duplication and cost. The concept of “closer to home” may not always be affordable for all desired services.
• A national, provincial, and local research opportunity for basic science, clinical health, and social research, but through an innovative health research policy with funded protocol implementation components. Health research prioritization should be linked to the clinical care prioritization process allowing optimization for the innovation and translational knowledge outcomes.
• A discussion regarding the possibility of a national health care process, because Canada can no longer afford the present 14 regional health care system model.   Top

 

References

1. Barua B, Palacios M, Emes J. The sustainability of health care spending in Canada 2017. Vancouver: Fraser Institute; 2017. https://www.fraserinstitute.org/studies/sustainability-of-health-care-spending-in-canada-2017 (accessed 1 Dec. 2019).

2. Understanding the Canada Health Act. Ottawa: Council of Canadians; n.d.

3. Health spending. Ottawa: Canadian Institute for Health Information; n.d. https://www.cihi.ca/en/health-spending (accessed 1 Dec. 2019).

4. Strickland M, Datta I. Idle hands? What we know about surgeon unemployment in Canada. Can J Surg 2018;61(2):82-4. https://doi.org/10.1503/cjs.014317

5. Why the future of health care is salaried. CMAJ 2019;191:E1390-1. https://doi.org/10.1503/cmaj.1095819

6. Teja B, Daniel I, Pink GH, Brown A, Klein DJ. Ensuring adequate capital investment in Canadian health care. CMAJ 2020;192(25):E677-83. https://doi.org/10.1503/cmaj.191126

7. Hoffer EP. America’s health care system is broken: what went wrong and how we can fix it. Introduction to the series. Am J Med 2019;132(6):675-7. https://doi.org/10.1016/j.amjmed.2019.01.040

 

Author

R. Douglas Wilson, MD, MSc, FRCSC, is professor emeritus, obstetrics and gynecology, Cumming School of Medicine, University of Calgary.

 

The author has no competing interests related to this article.

 

Correspondence to:

doug.wilson@ahs.ca

 

This article has been peer reviewed.

 

Top