Healthcare - Right versus Privilege

Is it your right? Do you deserve this? Is it a must? At what costs? Economic theory states that resources are scarce and demand is high. This is true of healthcare as well. So what does this mean in terms of access? Not enough resources to go around, so do we give everyone a little piece of the pie, do we give those that need more, or do we allow those who can afford to purchase more?

I am going to get a bit controversial here...

Healthcare is a privilege. My reasoning is this. There are many decisions you make that affect outcome. You smoke? Higher healthcare costs (on average). You ride a motorcycle? Organ donar. You eat unhealthy? Heart attack. The list goes on.

The challenge is that it is not that simple. What about genetics? Family history? Co-morbities. For these, it should be a right.

Prediction. Healthcare funding of the future will have per patient funding tied to genetics. Anything outside of this range will have to be paid for out of pocket, or by insurers (though they won't insure you because of genetics).

Let the debate begin. Curious about what you all have to say.

US Election, Canadian Election = Healthcare Change?

Big day. The election of the next president. And much has been discussed about healthcare, the need for healthcare reform, a move to more socialized care, change, change, change. This is now.



3 weeks ago, Canada re-elected a minority Conservative Government. The shocker? Healthcare barely made any news. In fact, little can be said of the last few years, other than a mandated provincial waitlist strategy in order to recieve federal funding, regarding healthcare reform in Canada. Canadians love their healthcare system, the idea of equal access to quality care, and the notion of coverage, regardless of means. At the same time, anyone who has used healthcare, often complains about their experience, like a badge of honour. To discuss the idea of privatization, while more than 50% of the country is interested in the discussion, is akin to giving away your first born. The notion of private delivery makes people cringe about the second coming of everything wrong with the US system (even though there are other models of private delivery). All of this, right or wrong. None of this discussed, debated, lauded, during the election. That was then.



So which is the case? Debate or not? Clearly both sides of the border have much to learn, and fear from each other. More importantly than system is health HR. Where are nurses, physicians and other healthcare professionals going to come from? More are retiring than entering the profession. Complexity and diminished resources have lead to burnout at faster rates. Why is no one talking about this? To simply say “We will hire more MDs and RNs.” How? We do not grow on trees.



I am hopeful that the election will re-spark the debate. It has to. Our lives depend on it.

Error in Healthcare

Recently in the Reader’s Digest there was a post outlining “18 ideas to reform healthcare”. #2 struck me once again because part of what I do day in and day out is prevent and over ride medical error. There are a few studies done out there, all with different methodologies and different results (some say 1 out of 4 cases have an error, others are higher than 50%) the exact number is not as important as perspective. Let me explain. Lets assume that all the numbers in the studies are grossly miscalculated and that the error rate in healthcare or adverse outcome rate, or rate of preventable death or the rate of preventable mishap, whatever you want to call it, averages about 10% —I know, I know, you say WOW! that is a 90% success rate, good enough for an A plus (in fact a passing grade in most masters programs is 70%). But lets assume this is correct. 10%. 1 in 10. Now lets compare this to the airline industry like the article did. Statistics from 2007 for Toronto’s international airport showed 370,198 flights originating from the terminal (lets assume that the private jets perform way better). The same period showed 31,452,748 passengers (yes that would be millions). This works out to roughly 85 passengers per flight. Now for true meaning, lets assign a 10% crash rate (this doesn’t mean deaths, just injuring, maiming and death - those requiring some form of additional medical treatment). 37,000 crashes. 3,146,683 people injured, killed etc. Cut this in half to 5%. Still 1.5 million. How about 1%? 315,000 injured. We could argue 1% is reasonable - but it is obviously not. And this is just one airport.

So what does this have to do with healthcare? Well, let me explain. We don’t accept 50% for a plane ride. Nor do we accept 20%, 10% or even 1%. No one would travel. Certainly not at today’s prices and with fuel surcharges. Not with a big chance of injury. So why do we accept this for healthcare? Blindly in fact. These are published studies, yet we go about “consuming” healthcare without batting an eye, without challenging. You wouldn’t except this error rate for a vacation, yet you are willing to accept it for you life, or a family member’s?

What can be done? Well I wish I had the silver bullet, though its probably more of a buckshot approach (some one else coined this, but apologies for not referencing it here, can’t remember!). A simple start is to ask questions. Question your PHP, your treating team. Take notes. Take a family member to listen when you are not. Ask why they are doing things, have they thought of something else etc. Ask tons and tons of questions - you do when you are fixing a car, why do you stop when you are with a physician. It is your right. Your body. You are not the expert, therefore you need to ask questions. You don’t need to be rude about it, be polite, but persistent. Question and Question.

Simple Ideas to Improve Healthcare Quality and Costs Part 2

Lets talk about funding. Over the past few years, hospitals in Ontario have generally been funded by block methods (meaning global budget for hospital, hospital spends as it likes). There are of course some variations with patient weighting etc, though the case costing, discharge analyisis etc… albeit this largely occurs on a macro level. There is very limited funding based on performance, or at least considers performance in some fashion. What I mean is this: If hospitals are provided a certain percentage of their funding based on the number and types of cases they complete (meaning types of surgeries and admits) as well as a percentage based on some measurable outcomes we could create some incentive for hospitals to outperform themselves (rather than the threat of government intervention (as an example)). This does a few things. 1) It forces hospitals to focus on quality improvement that results in meaningful outcomes for the patients (yay!) 2)makes hospitals “compete” for the business of the patient (meaning by publishing results, patients become consumers based on quality) which therefore increases funding for the hospital because of more surgeries/admits etc. This has a significant impact on ensuring resources are utilized to their capacity - nurses, physicians, surgeons, imaging equipment, in areas that it is not because of black out times or lack of funding (like most surgeons, even though they have wait lists, may only be granted 1-2 days of OR time a week or less!).

This is not as groundbreaking as it sounds. This is done in other areas (NHS in Britain has a significant pay for performance/outcome component to it with some good successes). It seems to me that the most difficult aspect of this solution is that it must make hospitals, administrators and government take proper responsibility for the delivery of healthcare instead of just throwing money at it. Incentives work in many other aspects of life (you should see how quickly my toddler cleans her room with the promise of a sticker for good work!), why couldn’t it work here?

Simple Ideas to Improve Healthcare Quality and Healthcare Costs

In Ontario, much like the rest of Canada, the province runs a healthcare monopoly. They control the costs, resources, and funds that are allocated to care for patients. They also make the rules, rules that in some cases, like the Commitment to the Future of Medicare Act that actually make it illegal to seek out or provide alternatives to the monopolized healthcare. Among many challenges this presents, one significant one affects hospitals. Hospitals become virtual extensions of the government, while operating as independent public organizations, the significant portion of their budgets are determined by the government. This includes capital budgets whereby only the government can agree to fund those programs or improvements where it makes strategic sense. This can limit an organization that may need an MRI machine, a major capital expenditure like an expansion, or building more beds. These organizations, by virute of their reporting structures and accountabilities cannot take on debt (yes a bad word these days), all important in the business world, of which the healthcare sector should consider itself (even against its will). By changing a simple rule that will allow these organizations to assume some debt (yes, create rules, like maximum ratios etc to keep some controls) the hospitals can be allowed to make the appropriate stategic investments in their facilities and capital equipment. This can improve healthcare quality, attract and retain qualified staff, and improve patient outcomes. Allow the hospital to function more as a business and the successes will follow. This will be the first post in a series of simple but elegant ideas to improve healthcare quality and healthcare costs.

Healthcare North and South of the Border

The Canadian election is wrapping up today. Short of “hiring more doctors, and more nurses” (apparently they grow on trees), there has been no major healthcare initiative announced on any platform. No reform. No spending. No new ideas. How did this happen? Canadians are fixated on their healthcare, yet it goes completely unnoticed for 6 weeks. Even the US is on board. In the midst of a financial crisis and both leaders are looking at wholesale changes to the system, albeit differently.



What about private sector involvment? Improved quality? Increased spending (disagree)? Decreased waste (agree)? Insurance? Wait lists? Access to drugs? Access to MDs? Where are you Canadian healthcare, that which we love and hate?????

Healthcare Economics

There is a concept in Health Economics called the welfare loss of insurance or the “moral hazard.” This is a direct distorting effect that insured patients demand more services than they would in the absence of insurance. By lowering the marginal cost (the cost of the next unit) of healthcare to the insured, health insurance encourages the use of health services. If consumers face no charges, or no direct costs for healthcare they have no restraint against the use of health care services. This obviously produces excessive demand and resulting wasted resources which has the effect that the cost of producing those services ACTUALLY exceeds what the consumer would be willing to pay for the same service if they had to pay out of pocket.

The opposite of this is where there is an absence of health insurance, which has the undesireable effect of causing the consumer to delay seeking care because they lack the means or ability to pay. This can result in more cost in the longterm as well a harmful effects.

The moral hazard phenomenon is described in a graph which basically shows that the value of the last unit of health care purchased would be far less than its actual cost (over consumption and underpayment resulting in inefficient waste which increases cost). The welfare loss or moral hazard is the area in the graph that is equal to the value of the excess resources consumed (the excess waste is only half of the total excess cost because the resources consumed still have some value to the consumer).

So what can be done? A famous experiment was conducted over several years called the RAND Health Insurance Experiment (see below for more info) The studies basically showed that introducing a cost sharing plan (co-pay, co-insurance) reduces both necessary and unessesary care however it also had NO effect on most measures of health outcomes. When individuals have access to free care, there is an 86.7% chance they will use the heath care system. When the indivuduals had to pay 95% to a capped maximum of $1000 after which the care became free, that chance of useage dropped to 68%. The medical expenses per person were $700 in the 95% group as compared to $1,019 per person in the “free” group.

There are obvious considerations, such as a means to ensure the sick and poor still have affordable access, say a means excemption for those in a specific earnings bracket.

There is a tremendous opportunity to explore this further and put the smartest minds to work to develop the “right” number for the co-pay as well as the income based opt-out. This kind of open dialogue is critical to reform.