REVIEW and thoughts on: Chronic Condition, Jeffrey Simpson
Working from the hypothesis that “to appreciate where we are, it is worth revisiting how we got here,” this book includes a thorough review of the history of the Canadian Medicare system. This was very instructive to me, although some will be more familiar with these developments. Some of the important elements that stood out for me were:
1 – “Fee-for-service” for providers (specifically doctors) is well baked into the system
2 – Hospitals are a distinct and well-developed part of both the infrastructure and of the system
3 – Even though the Canada Health Act allows non-government service providers, the word “private” complicates any discussion because it conjures up “US-style,” “two tier,” and other terms that garner very emotional responses.
Simpson provides a thoughtful comparison of our system with those of England, Sweden and Australia. This illustrates how no one has a perfect system, but there are systems that perform much better than ours does. He suggests that low public awareness as to the mediocrity of results from the Canadian system (by OECD standards) is a big part of the problem. Maybe people are fine as long as we are not as bad as the US. Politicians certainly benefit from the misperception both in reducing panic of a looming crisis and in hiding any province-to-province comparison that could identify comparative laggards.
According to Simpson, continuing to throw money at the current system is a complete waste of resources and is an admission that funders do not understand the dire situation that we have created. The big thing at stake is what he calls “vertical equity” meaning that the status quo puts an unfair burden on future generations. (He uses “horizontal equity” to describe how the system treats people in terms of access and care at any given time.)
The big recommendations are threefold:
(1) Doctor and nurse unions have to stop being rigid in protecting compensation. Fee-for-service usually means that “how much” you get paid is a function of “how much” you work. Again, there is no clear answer but Simpson relays the challenge of how, for example, reducing wait times leads to rising costs because more patients are being served.
(2) Hospitals need to be allowed to do what they do well, and cease to provide ALC-type services that are both of insufficient quality and of exorbitant cost.
(3) Drug expenses have to come down. He suggests a national drug plan based on CPP.
Each of these avenues takes on a very specific and very powerful interest group: unions, hospital administration and pharmaceutical companies. All tough rows that need to be hoed.
I enjoyed the read, and it got me thinking about how much of the eventual solution will come from strong leadership in small areas that can start some momentum. Actions and results at lower levels can help to build the various beachheads that need to be established for more comprehensive systematic changes to bring sustainability and “vertical” equity.
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