Tuesday, April 12, 2016

(Think) Tanks for coming out!

Another day, another alleged crisis plaguing Canadian health care.

Canada's Health-Care System Is Failing To Deliver Timely Care To Patients.

It's weird to see a piece on the Huffington Post written by someone from the Fraser Institute. For those unfamiliar with Canadian think tanks (and why in the world would you want to be familiar with them?), Fraser is the most prominent font of right-wing ideas north of the 49th parallel. Not what I would normally associate with HuffPo.


I've never understood the point of think tanks with an ideological bent. We're taught early in medical school that you should diagnose a problem before offering a prescription. Starting with the solution (more privatization, more unions, higher taxes, whatever) then working backwards to describe a problem seems awful lawyer-ish, rather than a "thinking" way to run things. And we all know what they say about lawyers...


But let's get down to brass tacks. The first claim is that, though wait times for priority procedures appear largely unchanged in the past five years, Canada's health care is failing. Huh?

The study cited in the HuffPo piece comes from the Canadian Institute for Health Information, or CIHI, measuring how quickly patients receive a procedure within the medically-accepted benchmarks, from the time they first see the consultant. Believe it or not, Canadian health care is doing pretty good by that yardstick. The number of people waiting too long is up slightly (2%) for hip replacements and moderately (6%) for cataract surgery, but down for knee replacements, hip fractures, and radiation therapy. Moreover, there's been a major increase in the number of those procedures performed, upwards of 20% for the major joint replacements. That's a substantial surge in volumes without a concomitant jump in patients' prolonged misery.

(As a side note, it's strange to see hip fractures measured here. Fixing a broken hip doesn't have a "wait time" in the way we would think about it...it's an urgent surgery done within 48 hours of the fracture.)

Of course, the major drawback to the CIHI paper is that it doesn't report on the first component of a patient's wait, namely the length of time that passes from the family doctor/GP making the referral to the appointment with the consultant. As luck would have it, the Fraser Institute conducts research on that very question! In truth, things aren't all that different when you compare 2015 to 2014, but My God have waits been worse since 1993.

I wonder why Fraser would only report comparisons to the prior year and (the rather arbitrary time frame of) 22 years? Did something important happen in Canada in 1993?


Well sure, and I suppose that explains the comparison to 2015, but...


Nah, the Leafs did pretty well that year, too. That can't be it...


Yeah, I have trouble figuring out what about 1993 might perturb conservatives as well.

But what about the lost productivity of these long waits? If we add up the equivalent in lost wages from all this waiting, it's costing Canadians $1.2 billion in national wealth. Factoring in all the waking hours of suffering, that number balloons to $3.5 billion!

Not to diminish the suffering of anybody with chronic pain or disability--I've been there, and it's an agonizing hell on Earth--but the overwhelming majority of people waiting for hip replacements and cataract surgery don't earn a wage. It's not because they're disabled, but because they're retired. Yes, seniors still work and volunteer and travel and spend money, but to assert that the people on those wait lists would be full-time wage earners is "Smilin' Emoji"-level BS.


The proffered solutions to wait times? Private hospitals or quasi-hospital facilities and user fees. I'm not going to address the pros and cons of these ideas here, and they certainly merit consideration in the endless debate around health costs.

However, it's worth noting that Canada has both private hospitals and private outpatient procedure facilities. We have all sorts of private insurance plans for physiotherapy, chiropractic, and medications, some through employers and others on the open market. Seniors have a co-pay and a deductible on their prescriptions, even if they're impoverished. And there's already a co-pay every time you visit a hospital for anything, a co-pay that can grow to a small fortune for people in the big cities with chronic illness, namely parking.


Again, the point isn't to dismiss the ideas completely, but a case needs to made for policies that can stand up to serious scrutiny. Health care affects hundreds of thousands of workers, a giant chunk of the economy, and millions of Canadians, many of whom are poor, sick, and disabled. Any shift in policy needs careful deliberation, honest and open debate.That means--dare I say it--a willingness to think outside the tank.


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