A Vision of Healthcare in the 21st Century


(This is a condensed version of our Publication “Wanted: Leadership for Healthcare”, C.D. Howe Institute Verbatim, June 8, 2016)

Canada needs both ‘top-down’ and ‘bottom-up’ leadership to create a genuine system to meet our 21st century needs for health and healthcare services at a cost each province, territory and the country can afford. Governments need to step up to governing, of re-vamping the ‘delivery system’; doctors, nurses and other providers have to find better ways of working together.

Leaders would start afresh by envisioning a reinvented healthcare system. It would provide equitably the range of high-quality services needed to optimize the health of the population; its elements would be affordable, informed, and smoothly connected.

Their first step would be to create the new system’s apolitical governance, answerable ideally to the federal and provincial/territorial governments working together[1]. Second best, each Canadian province and territory would appoint separate bodies[2].

That governance would take step two, mandating adoption by all providers of a common information system capable of maintaining for every resident a health/medical record. It would include health status, records of every interaction with a healthcare provider, and measures of its outcome. The chosen EHR[3] should be the best then available as assessed by an expert sub-governance panel and capable of evolution over time. Many such EHRs exist internationally; strong leadership would be essential to avoid excellence being enemy of the good.A third step brings them to Medicare’s origins, a publicly governed and administered plan, universal, portable, accessible, and comprehensive, providing everybody the range of health and healthcare services needed to preserve and/or regain good health, independent of the ability to pay. Medicare does not meet those principles now. Drugs, home care, rehabilitation, and many other essential services are not accessible to many Canadians unable to pay $1750, the average out-of-pocket cost in 2015. Our “universal coverage” is far less comprehensive and equitable than it was over 50 years ago and is today in many other countries.

Originally there were co-payments by those who could afford them that made comprehensiveness more affordable to the public purse. In the new system, people unable to pay would also be exempt and a cap, also based on taxable income, would limit total annual private spending on healthcare services by any individual or family.

Adhering to the comprehensiveness principle, the range of insured healthcare services would include prescription drugs, mental health services, community care, rehabilitation, dentistry, and perhaps others. That breadth would be decided by the system’s governance and confirmed by governments. Expanding the range of insured services would be expensive but would cost the economy little more than is now spent in total[4]. There would be far more equitable distribution of benefits and, over time, reduced use of high-cost services as the effects of more comprehensive primary, home, and community care services were realized.

The next step would be to determine what proportion of each publicly insured service, categorized as primary (to include home and community care), secondary (to include ambulance and emergency care), or tertiary/quaternary, would be assumed by the public purse or paid by consumers as fees to the providing hospital, family health team, etc. The fees for primary care services would be low. The cost/price for each secondary and tertiary/quaternary service[5] would be determined against a resource-based relative value scale based on its complexity, the expertise, qualification, and experience necessary to provide it, and the cost of its provision elsewhere.

The next step would be to calculate the number of providers in their several fields required to provide efficiently the range of services needed by an area’s population. Primary care teams, hospitals, and other provider organizations in each area would be issued time-limited renewable billing numbers for the number and variety of providers recruited. Each organization would then claim from the insurance plan payment of the recompense of that organization’s providers at the average annual rate of pay (plus benefits) negotiated with the relevant professional associations, subject to a 10-20% ‘hold-back’ to fund bonus payments to organizations in proportion to the outcomes achieved and their registrants’ satisfaction ratings. They would also bill the insurance plan for foregone fee revenue from exempt people.

Given that home and community care would constitute a more significant component of primary care, particular attention would be paid to ensuring that primary care teams were staffed appropriately to deal with mental health and addiction services, long-term residential and home care, and related community services.

Among the final steps would be repeal of laws prohibiting providers from offering their services privately or to prohibit insurers from offering plans to cover fees paid to such providers. This would allow the development in Canada of a parallel “private” system. Such systems elsewhere do not impinge on the capacity of the public system to recruit and retain providers of the highest quality.

Canadians and their politicians are proud of Medicare, touting it as one of the best healthcare systems in the developed world. If it ever was, it is no longer even close to the best. It became both mediocre in terms of the quality of service it offers and overly costly primarily because of the failure of governments and providers to get on with what T.D. Douglas called in 1982 phase II, revamping the delivery system, “the big item we haven’t done yet”. It’s time to get on with it!

[1] Possibly the Council of the Federation with added representation from the Federal government.

[2] Although some might decide to join forces.

[3] Health Information System

[4] Estimated by CIHI to be 11.1% of GDP in 2016

[5] Including diagnostic services

Authored by members of the Queen’s Health Policy Council:

Don Drummond
Chris Simpson
Duncan G. Sinclair
David Walker
Ruth Wilson

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