Canada's $192-billion health-care system under performing

TORONTO — Canadians are proud of our universal public health care system, but a recent report from the Conference Board of Canada underscores the danger of resting on our laurels. Of 17 countries reviewed, Canada has the fourth highest levels of health spending, and yet ranks only 10th in leading health indicators, such as life expectancy and infant mortality.

Such rankings necessarily involve simplification. Canada's performance is neither as good nor as bad as these rankings suggest, depending on what you count as performance measures.

Many Canadians would consider reduced wait times a desirable outcome in itself, independent of effects on life expectancy and infant mortality. And countless variables — other than inefficiency of the health system — may be to blame for our relatively poor health outcomes. Access to health care itself is estimated to affect just 20 per cent of health status.

Nonetheless, we must reflect on the Conference Board's findings as the federal and provincial governments limber up for the next round of negotiations over how much money or tax points to transfer for health care.

What is the evidence for more and more spending on health care? What do we really gain and what do we give up in spending more on health care? And how could we get better value for our health care spending?

There are three take-home lessons when we look at Canada's performance relative to other countries.

First, despite our shortcomings, we always outperform the U.S.. Out-performing the U.S. is a bit like shooting fish-in-a-barrel when it comes to health care and Canadians deserve far better than this as the only metric of success.

Nonetheless, this fact strongly cautions against greater reliance on private insurance and financing and magic market solutions. It is important to hang on to the fact that the "public" part of our health care system is where we seem to have the best cost-control, the "private" part that has seen unsustainable increases.

Second, we should not assume that by spending more, we necessarily get more — be it life expectancy or things like diagnostic tests, physician visits, etc. It may be that we are just paying higher prices.

The Conference Board notes the two outliers in their study are the U.S. and Japan. The U.S. spends the most and finishes last in terms of health outcomes; Japan spends the least and finishes first. One important difference, as the board notes, is that U.S. prices are approximately 25 per cent higher than the average; Japan's prices are 25 per cent lower. An important question for Canada is how we can pay less and get more.

Provincial health insurance plans, following international examples from Australia and New Zealand, should do more to negotiate prices with drug companies — paying more for breakthrough innovations and much less for those me-too drugs. And we must continually work at designing payment systems for health professionals that reward evidence-based, safe and effective care and dissuade them from providing anything other.

We need to recognize that more health care is not always better, and is frequently harmful — both to the patient and the sustainability of the system as a whole. We need to be more savvy as health consumers, saying no to high-priced "innovations" that provide very little benefit. Having the strength to say no will enhance our bargaining power with suppliers, turn us from price-takers to price-makers, and provide incentive for real innovation.

Third, our system needs to better serve those with complex chronic diseases, because those are the folks most likely to fall through the large cracks in our present system, resulting in suffering, poorer health outcomes and increased cost.

Countries that punch above their weight in terms of performance or have seen improvements in recent years have invested in primary-care reform. As many Canadians know from their day-to-day experience, we lag behind on primary-care measures such as wait times, access to after-hours care, the delivery of chronic care, the use of electronic health medical records, and the coordination of care between health professionals.

Instead of learning from path-breaking jurisdictions on this front and enacting real reforms, we as Canadians insist on revisiting sterile debates about public versus private. Because we can't seem to put to bed the zombie that nirvana exists out there if we only embraced more private financing or private delivery we never seem to get around to needed health-care reform.

By recent estimates, Canadians spend around $192-billion annually on health care — making this an industry equivalent to three Microsoft corporations. We shouldn't be surprised there are no simple fixes for something of this scale and the Conference Board rightly calls for us to grapple with the complexity of health-care issues.

There are no romantic, sweep-you-off-your-feet solutions from other places, but we need to get up off our comfy bed of laurels and engage in the hard, thoughtful work required to lift our game in health-care performance.

Colleen M. Flood is the Canada research chair in health law and policy, Faculty of Law, University of Toronto. She is also a an expert advisor with EvidenceNetwork. (www.evidencenetwork.ca), a comprehensive and non-partisan online resource designed to help journalists covering health policy issues in Canada.

-- Troy Media