By Desmond Colohan
There are many impediments to improving our delivery of health services on Prince Edward Island and one of the most egregious is our complete and utter dependence on physicians.
When Tommy Douglas introduced the Saskatchewan Hospitalization Act in 1946 he couldn't have had the foggiest notion that Canadian medicare, for which he is given well-deserved credit as founder, would end up with the mess we have created. Collectively, we Canadians are spending nearly $200 billion a year on health care. That's about $5,700 a year for each man, woman and child, and health services are rapidly consuming nearly 50 per cent of all public expenditures. This is unsustainable.
Medicare was conceived as an insurance scheme intended to save middle and lower income Canadians from financial ruin when they became sick enough to require hospitalization. Early efforts to promote universal medicare included strategies to get initially-skeptical physicians to support medicare by paying for physician services in hospitals. Eventually remuneration was expanded to include most physician services, no matter where they were delivered. No longer would physicians have to worry about whether they would get paid for their efforts, a real concern in the pre-medicare free enterprise marketplace. This was a great deal for doctors and for financially-strapped citizens, but there were strings attached.
In exchange for a guaranteed income, physicians had to give something in return, and that something was to become a thorn in their side. Physicians were asked to become the gatekeepers of the health-care system. Medicare was designed to channel demands for health-care services through the physicians who ran our hospitals, recommended hospital admission, ordered increasingly expensive tests and medications, performed more and more complex surgeries, and kept critically ill babies, children, adults and frail elderly alive. Doctors-in-training are taught from the get-go to put the best interest of their individual patient first and to preserve life at any cost. Expense be damned! You can see how this might create a significant conflict of interest when the financially-strapped health-care system asks [nay, tells] them to do fewer tests, get people out of hospital faster, not admit them to hospital in the first place, not recommend dialysis to keep them alive when they reach a certain age or prescribe a cheaper drug.
We spend nearly 30 per cent of our Canadian health-care dollars on hospitals, 16 per cent on pharmaceuticals and 14 per cent on physician services ($120 billion in 2009). Acute care hospitals are designed to deal with only 10 per cent of our health issues but are responsible for a hugely disproportionate percentage of our expenditures. It would be naive to suggest that simply shifting a chunk of this money to the community in an effort to prevent the development of chronic illnesses, the biggest cause of our current and future health-care woes, would solve all our service issues, but a serious rethink on our priorities is long overdue. If we were to develop more successful strategies for preventing chronic diseases such as diabetes, heart disease, cancer, chronic pain, arthritis and chronic lung disease, all of which are the result of bad genetics, poor lifestyle choices and bad karma, we would have way less need for our very expensive acute care hospitals.
If we were more realistic about the future role of our smaller community hospitals it would be a major step in the right direction. If we were prepared to accept and support a major shift in our thinking about the appropriate role of the physician in the health-care system, we would be well on the way toward developing a kinder, gentler, more patient-oriented health system. Is there anyone who really believes that the current system is designed to meet the needs of the patient and not the provider?
If I were to ask you what you really want and need out of the health-care system, what would your priorities be? I would bet that most of you would say something like "I want someone competent and caring to be there when I or someone I care about gets really sick or seriously hurts themselves. I don't want to worry about whether I can afford the care or the drugs in my time of crisis. I want the health-care system to look after me and mine in our time of need."
If you think about it, this was the reason Canadian medicare was developed. All the other stuff has been added on over time as we have become less able or less willing to look after ourselves and more and more dependent on the state. As I've said before, we have to take back personal responsibility for our own health and wellness. At the same time, we must give physicians the time they need to do the things that they are best able to do, like sorting out complex medical problems, minimizing unnecessary death and disability, and reassuming their rightful role as essential members of the health-care team. Physicians are harassed to the point of burnout with requests to complete insurance forms, Worker's Comp forms, back-to-school notes, camp and pre-employment physicals, routine prescription renewals, well baby exams, consoling the worried well and catering to third party payers. We've got to get rid of this gatekeeper role. It's not what doctors were really trained to do, at significant cost to the public purse, I might add.
Does it really matter to most people whether the health professional they consult on a non-complex, non-urgent issue is a physician or a nurse, a psychologist, a nurse practitioner, a pharmacist or any other well-trained, competent professional? Do you really need to consult a health professional at all for the minor health problems of everyday life? I don't think so, and I hope you will agree.
Desmond Colohan is a P.E.I. physician with a keen interest in responsible public health policy.