Not all health-care metrics are good health-care metrics

Hey there, time traveller!
This article was published 12/09/2024 (435 days ago), so information in it may no longer be current.

Tom Brodbeck’s opinion piece on health care spending (Real concern is how governments spend health-care dollars, Sept. 4) raises some very interesting points. However, a number of issues from the article must be addressed, particularly in regard to performance metrics.

There is much time and effort spent in our health-care system reviewing performance metrics. Several performance metrics used today are clear cut and are linked to measuring clinical outcomes.

For example, the time it takes for a patient with a suspected heart attack to have an electrocardiogram (ECG) directly influences how quickly they receive definitive care, which in turn influences their likelihood of survival. The metric of ‘door to ECG time’ is easy to measure can be readily modified, which will improve patient outcomes. In fact, Winnipeg’s emergency departments have developed processes that measurably improve this metric (and patient outcomes).

Other metrics are easy to measure, yet far more difficult to address. It is known that increased wait times in emergency lead to poorer outcomes, and it stands to reason that any initiative that decreases wait times should improve patient outcomes. However, the reality is far more complicated. Physicians (in emergency and on the hospital wards) are under increasing pressure to discharge patients in order to free up beds and decrease wait times. If patients are prematurely discharged, they are more likely to have poor outcomes. Therefore, although you may see improvements in one metric, you see adverse results in another.

Comparing metrics between systems in different countries is even more notoriously difficult.

Whereas Mr. Brodbeck compares Europe with Canada (and not all European nations are the same), metrics regarding cost and outcome need to be interpreted with the consideration of variables that are beyond the health-care system, but which have outsized effects on how the health-care system functions.

Several European nations invest in robust social services programs that are effective at reducing issues like poverty, homelessness, and drug addiction, and these programs in turn lead to a significantly reduced burden (and cost) on the health-care system as a whole. Unless Canada significantly increases its funding of social programs to the level of these European nations, a hybrid system will not have the same result as in the European nations to which Mr. Brodbeck alludes.

Australia, which has very similar geography and demographics to Canada, had a single-payer system and then in 1997 went to a hybrid (“two-tier”) system with a mix of public and private systems.

The assumption was that patients going into the private system would create more space and thus provide better service and improved outcomes in the public system. (Advocates of a hybrid system in Canada make the same claim.)

In fact, what happened in Australia is that while those patients in the private system have improved access, shorter waits and improved outcomes (like mortality and long-term recovery), those in the public system now experience longer wait times and worse outcomes compared to the time where there was only one public system. (In fact, patients in Australia’s public system experience much longer wait times for surgery and diagnostic procedures than in Canada.) Additionally, recent analysis by the National Institutes of Health in the U.S. indicates that Australia’s hybrid system costs more than if there was only a public (single payer) system.

Advocates of a developing a hybrid system in Canada need to take a very close look at whether that practice would be applicable in Canada, and whether it would be of benefit to Canadians.

At the conclusion of the article, Mr. Brodbeck states, “Whether the federal government contributes 20 per cent or 25 per cent to Canada’s health-care system is, in the long run, of little consequence.” This statement fails to take into account the very nature of how a public health-care system relies on adequate funding. Hospitals, equipment, supplies and staff wages all require money, and the Canada Health Act exists to ensure that there is adequate funding required for all the vital elements in a health-care system.

The Canada Health Act agreement is predicated on the understanding that money transferred to provinces for health care is actually used for health care.

Unfortunately, we have a problem with accountability, where there is little recourse available to the federal government when money earmarked for health care is not spent on health care. Perhaps the Canada Health Act needs to be reviewed in order to explore how greater accountability for the expenditure of health care money may occur.

This point has been made by the Canadian Medical Association in a report that was just released (The Canadian Press, Sept. 9) calling for a better tracking of health-care spending and a greater commitment to tracking improvements in delivery and patient outcomes.

Canadians are rightly proud of our universal public health-care system. We know that there are problems and deficiencies in this system, and solutions need to be found to address these.

However, before there is any major change in our health-care system we need to take a careful and thorough look at all available data to ensure that any changes actually benefit all Canadians.

Dr. Doug Eyolfson is an emergency physician in Winnipeg and was member of Parliament, Charleswood­–St James–Assiniboia–Headingley, during 2015-19.