Soaring costs force Canada to reassess health model
Wait, Canada has universal coverage, long queues, and much better primary care penetration than the US. Why do they have soaring costs? Clearly we in the US suffer from higher overhead, less primary care and too many imaging machines, but trying to understand Canada's problems might eventually help us.
I do not really know, but here are my thoughts:
- We have transformed many diseases with short life span into chronic diseases. The best example is end stage kidney disease. We offer dialysis to almost everyone, and the costs while on dialysis are significant. CHF used to have a short life expectancy, but now we markedly extend life span. HIV/AIDS has become a chronic disease for those who take antiretrovirals and prophylaxis. The costs associated with these and other chronic diseases are truly new costs to our respective health care systems, and those costs increase consistently.
- We have new devices and imaging machines that provide better outcomes and information. AICD saves lives, but it is not cheap. MRI machines make diagnoses at a very high cost. You can think of other important examples.
- We have markedly increased life expectancy. As life expectancy increases, costs mount. Older patients more often have multiple diseases that we control at high cost.
I invite the readers to suggest other reasons for soaring costs in Canada. But I will speculate on what my thoughts mean. We may not be able to "bend the cost curve" if we try to provide everything for everyone. We must consider true rationing.
The US public will never be happy with the concept of rationing, and I suspect Canadians are no different. We can control some health care costs through better use of resources, but my reasoning above suggests that successes of medical care induce costs.
So either we develop a rationing strategy, or we spend a higher percentage of the GDP on health care each year. Which direction should we go?
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TD Economics has prepared a report with ten recommendations on the issue of health care inflation in Ontario. In short:
Some of the ideas seem more likely to generate savings than others; it would be useful to hear reactions or other suggestions.
All countries are suffering from soaring health costs, not just the US, for reasons 1-3 that you describe. The difference is that we’re much farther ahead on the problem because our system is poorly designed (as also mentioned in your post) and we have twice as many sedentary/obese/diabetic people as the other OECD countries.
We can already do more than we can afford for people. The 2 solutions are either more rationing (we already have some rationing) or better prevention through lifestyle changes (more walking, eat more vegetables, drink less pop, eat less meat).
The only way to do true and honest rationing is by having the patient in charge of paying for the care. The insurance / state can reimburse the patient later, a certain percentage. That would drive the cost down and generate true competition among physicians.
My practice has 20 % cash patients, 50 % private insurance and 30 % Medicare. The biggest spenders are the Medicare/Medicaid bunch. Their outcomes are the same (even worse if you account for complications of useless tests). My God, they push for every possible test, even when I tell them it is not needed. But if it’s free, why should they care ? For example, there are tons of type 2 diabetics who get complete blood work every 3 months. Why ? Well, there are several explanations and the doctors are not all angels… and then the patient expects. So, if you don’t poke them with a needle every 90 days, you are a careless doctor…
I vote for that dirty word in medicine that we call rationing. Fact is we already have rationing. We ration by ones ability to pay. The real question is will we ration in a more socialistic manner (another dirty word in this country) that provides access to quality medical care for both the well to do and the not so fortunate, or do we take the Darwinian approach of letting only the strong survive.
FREE = MORE
As a Canadian emerg doc I have a few thoughts about the ballooning health care costs in my country.
1) We have no strategy for caring for elderly debilitated patients in Canada. They end up occupying hospital beds for months at very high cost, before suitable disposition can be arranged. The overcrowding in the hospital resulting from this has a number of significant hidden costs that are never accounted for.
2) We do not really ration anything in Canada. Sure we use wait times as a proxy for rationing, but if your willing to wait it out you can get whatever therapy or test you’d like. Doctors in Canada have GIVEN UP trying to ration within our system in the face of increasing patient demands.
3) Drug costs are astronomical. Our elderly populations medications are covered by the government (ie. the population). However, there is not an evidence based strategy to prescribing. I routinely see patients with advanced dementia on expensive medications for which there is no evidence, likewise with palliative cancer patients on hopeless and expensive chemo regimes.
4) Medication creep. It is not uncommon to see an elderly person on 20 to 30 different medications. The meds start as a trial and then become a permanent fixture in the regime, they are rarely reviewed and rarely stopped. The most frequent offenders are PPIs, sleepers, antihypertensives, and statins. Often the debilitated old patient will magically wake up a bit once a couple of hundred dollars are trimmed from their monthly pills.
In Canada we are at a crossroads. We have an aging and increasingly demanding population. The group that is now staring down old age (yes baby-boomers, that’s you) have a policy of denial about their own health and mortality. Clearly Canada cannot afford the projected increase in health costs we are facing, but the will to address any of these problems is almost entirely lacking.
Economists seem fond of pointing out that the demand curve is downward sloping.The more something costs the less is demanded and , of course, the cheaper the good or service the more demanded.This is why insurance companies insist on a co pay.The greater life expectancy and the more medical services available both amplify this basic economic principle.
May be we should cut cost elsewhere. Hope the USA administration reads your blog. Agree with Oskie MORE=FREE. One way to cut cost is paying the doctors less. It is going to happen or happening in USA.
Hah. Looks like FREE=MORE in Canada has finally been recognized for what it is. Unsustainable.
That Yahoo article seemed like a bit of an exaggeration. It’s not “fundamentally changing the principles of the system” to either cut and/or restrain the prices that the provincial plans are paying for drugs and treatment. Heck, they did that before back in the 1990s, when costs started being a problem.
That’s a problem in pretty much all of the 1st World countries – the elderly part of the population is rapidly growing in absolute numbers, and often in terms of a percentage of the population as well.
I’m not sure how we’ll deal with it in the long-term, either, aside from phasing out the whole idea of “guaranteed retirement” upon a certain age (complete with state pensions and special state-funded health insurance). That would at least ameliorate some of the tax drain that the retired elderly will be imposing.
I thought the Japanese had a cheaper version of the MRI machines in their system? It was in that T.R. Reid book.
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