Speech. Fulfilling Medicare s Promise. Canadian Club of Ottawa. Dr. Anne Doig President Canadian Medical Association Ottawa, ON May 11, 2010

Transcription

1 Speech Fulfilling Medicare s Promise Canadian Club of Ottawa Dr. Anne Doig President Canadian Medical Association Ottawa, ON May 11, 2010 Check against delivery

2 Introduction Thank you Grant for that kind introduction and thank you ladies and gentlemen for your warm welcome. This afternoon, I am going to talk to you about fulfilling the promise of Canada s Medicare system. Beginning with the passage in 1961 of the first provincial legislation to create universal health insurance in my home province, and continuing through the enactment of the Canada Health Act in 1984, Medicare has become for all Canadians a symbol of our national identity. We defend Medicare with the same fervor that we protect all of our other national symbols in fact, even more than some. However, like many icons, what was once a shining symbol has become a little battered and tarnished. Over the intervening years the world has changed. Canada has changed. Medicine has changed. Medicare must also change not just to catch up with changes that have already occurred, but to anticipate and prepare for changes we cannot yet see. We must transform Medicare so that it is sustainable and will meet the future needs of all Canadians. Medicare has provided an extraordinary Canadian advantage over the years; but protecting it from attack must not mean protecting it from reform. If we want to save Medicare, we have to change it. Setting the stage We know that just as with building Medicare in the first place, there are tough issues to debate. Tough issues make for tough debates. But that is no reason to avoid the debate. Just ask President Obama. Over the past year, we have watched the US health care debate with interest, and perhaps, a little national smugness. Canadians went through those difficult discussions 50 years ago. As a nation we worked through the issues and did the heavy lifting to put a universal health insurance system in place. Because of this, there is a tendency in Canada to think of health care as a problem solved or a victory long since won. This complacency must end. While Canadians like to think that we have the best health care system in the world, the facts say otherwise. The Conference Board of Canada, the Organization for Economic Co-operation and Development (OECD), the World Health Organization, the Commonwealth Fund, and 2

3 the Frontier Centre for Public Policy all now rate Canada s health care system poorly in terms of value for money and efficiency. At 91% overall, Canada has the highest hospital occupancy rate in the OECD. While it would seem that having a hospital operating at or near capacity would be a marker of efficiency, in fact just the opposite is true. Research has shown that the higher the occupancy rate of a hospital, the higher the mortality rate. Moreover, running acute care hospitals at or above full capacity means that we do not have surge capacity to meet the natural fluctuations of illness rates. Needless to say, running hospitals in which hallway nursing is the norm is unacceptable. Today, roughly 25-30% of hospital acute care beds are occupied by patients who do not require hospital or medical care but rather need 24-hour supervised care. Scarce long-term care facilities and home-care services dictate that patients remain in hospital, delaying hospitals from performing elective surgeries and restricting the movement of other patients from the emergency room to acute care wards. Further, should a patient be able to leave hospital, research shows that much of the burden of continuing care falls on informal unpaid caregivers who need to be better supported. Statistics Canada reported that in 2007 about 2.7 million Canadians aged 45 and over, roughly 20% of all Canadians in this age group, provided some form of unpaid care to someone with long-term health problems aged 65 years of age or older. The trouble is that the incentives contained in the existing Canada Health Act no longer work. They were developed at a time when hospitals were at the centre of our health care system. That is no longer the case. In addition to the problems in acute and long-term care, prescription drug spending is rising rapidly as new pharmaceutical innovations help people live better and longer. In 2009, drugs accounted for the second-largest share of total health care after hospitals over 16% of Canada s total $183-billion health-care bill, or about $30 billion. Prescription drugs and care outside of hospitals represent two of the larger challenges faced by governments seeking to rein in health care spending. We can turn these challenges into advantages if we have the courage to act now. But the Canadian health care system deserves more than just ad hoc change. We deserve an approach that learns from what works here and from what works around the world. 3

4 The Promise Canadians value their system of Medicare and the 5 principles listed in Canada Health Act. As demonstrated by the challenges I discussed a few moments ago, our system is not meeting the needs of Canadians as it once did. It is also clearly inadequate when it comes to addressing the challenges that we will face in the future. We need to manage our system better. We need to focus on quality. And we need to adopt and adapt to new technologies. Canada s health care system can and must do better. Clearly, we must take a smarter approach to the funding, delivery and use of the system to make it more effective. Now is the time for all of us citizens and patients; doctors, nurses and pharmacists; political leaders and public servants to draft a new blueprint. But as we seek to remodel our medicare house, we can still use the solid foundation of the five principles of the Canada Health Act as our base. I ll explain how, by discussing each principle. First, Universality: All Canadians should have access to publicly insured services on uniform terms and conditions. Canadians take pride that the greatest strength and advantage of our publicly-funded health care system is that all eligible Canadian residents are covered. Yet, there are several population groups in Canada that have inadequate coverage or are unable to access care. Socially and economically disadvantaged individuals and areas have fewer services to support good health. This is not just true of Canada s North or of our Aboriginal communities where the situation is truly desperate. This is a problem in cities like Saskatoon and Ottawa. Make no mistake, barriers hindering access to services or just a plain lack of services in many parts of the country makes the principle of universality ring hollow for some Canadians. Right now, we have first-dollar coverage for a narrow range of insured services essentially only for hospital and physician services. While I m not suggesting that we necessarily abandon the idea of first-dollar coverage, what we need going forward is a more flexible arrangement for a broader basket of services based on the principle of universality. 4

5 We have to look for new funding models that are not only affordable, but that include incentives to encourage both quality and efficiency. However, all Canadians must have access to medically necessary health services, irrespective of their ability to pay. Which brings me to the second principle; Comprehensiveness: Provincial health insurance plans must insure all medically necessary hospital and physician services. Canadians health care needs are quite different now than they were in the 1960s when Medicare was established, and even than they were in 1984, when the Canada Health Act was passed. Moreover, there is a lack of clarity and consistency in the definition of medically necessary services as contemplated within the Canada Health Act. In 1984, physician and hospital services represented fifty-seven percent of total health spending; this has declined to forty-one percent in Yet programs such as seniors drug coverage and home care that are not subject to the Canada Health Act criteria now consume over 25% of total public spending. These programs are critical to the health of Canadians, yet their exclusion from the provisions of the Canada Health Act exposes them to the risks of provincial budgetary constraints. Most Canadians of working age and their families are covered by private health insurance for extended health benefits, that is, those expenses not covered under provincial medicare plans. There is inconsistency and variability in the coverage under employmentbased EHB plans just as there is interprovincial variability in medicare coverage. Moreover, part-time workers and those with lower incomes are less likely to have such benefits. For them, paying the full cost for extended benefits too often means overextending the family budget. Even worse, tying EHB insurance to employment means no job, no coverage. Or at least significant gaps in coverage during employment transition. All Canadians must have access to the full continuum of needed services, such as drug coverage and home care, using a variety of funding options as necessary to ensure universal coverage. Canadians should be able to examine debate and decide upon a defined set of nationally comparable, publicly funded core services in an evidence-informed and transparent manner. We must have mechanisms that help citizens understand what is covered and that encourage jurisdictions to share information and best practices. 5

6 The next principle Accessibility, dictates that provincial health insurance plans must provide services under uniform terms and conditions without impeding or precluding reasonable access. The principle of accessibility in the Canada Health Act does not specifically refer to providing timely access to necessary care. Yet does waiting months on end for necessary investigations or treatment really constitute accessibility? For many types of treatments, Canadians wait longer than citizens in most other industrialized countries that have universal Medicare systems like ours. Physicians know accessibility is a key element of both quality and safety. Delayed care is by definition care of lesser quality. All Canadians must have timely access to necessary services. This begins with access to family physicians for primary care; includes diagnostic testing and imaging and continues across the spectrum of patient need. Patients must also have a publicly-funded recourse for instances when timely care is not available. Another valued principle of our health care system is that of Portability, or the ability to travel to another province and still be fully covered under Medicare. All Canadians should receive coverage while traveling outside of their home province. Contrary to what most people believe, portability under the Canada Health Act does not cover citizens seeking non-urgent and non-emergency care outside their home province. Canadians who seek such care in another province may not be covered by their health insurance program unless they receive prior approval. Further, the rules governing portability of coverage and reciprocity of payment are not consistent across all provinces. Canada is opening its internal boundaries under the provisions of the Agreement on Internal Trade. We are entering an age of increased internal mobility for Canadians seeking work in other regions. The expectations for our health insurance coverage should mirror the expectations for personal and professional mobility articulated in the AIT. Last but not least, the principle of public administration. Of all the principles in the Canada Health Act, this is the one that is misinterpreted the most. Public administration simply means that the health insurance plan must: be operated on a not-for-profit basis; be accountable to the provincial government for decisions on benefit coverage; and that accounts must be audited. However, public administration has often been misinterpreted to mean that health care must be publicly delivered. That is not the case. Furthermore there has been confusion between private delivery and private funding. Across the country there are numerous 6

7 examples of publicly funded private delivery the most obvious being self-employed physicians of whom, for over 30 years, I have been one. These misunderstandings about the meaning of public administration have undermined our ability to assess the value-for-money provided by our health care system. Canada is among the highest health care spenders compared to other industrialized countries with universal care, but we do not systematically assess the value that we get in return. All Canadians have a right to know how their system is performing. All Canadians have a right to know how their tax dollars are being spent. All Canadians have a duty to hold governments accountable for their administrative decisions. Fulfilling the Promise We need to get better at managing the system with funding that will only grow slowly in the decades to come. We need to find the path to this new system in the face of an aging population and spiraling costs of new medical technologies. We all must take responsibility and we must all be accountable. Every participant in the health care system has a role to play in its transformation. The good news is that efforts are being made. Even in the face of challenges, both economic and demographic, provincial and local initiatives and actions are being developed across the country and they are making a difference. To cite just a few: British Columbia has recently announced that based on successful pilot projects aimed at alleviating emergency room congestion, patient-focused funding will be rolled out province-wide for its hospitals; Saskatchewan has launched its Saskatchewan Surgical Initiative with the goal of reducing surgical wait times to no more than three months within four years; The Manitoba Bridging General and Specialist Care project has developed pathways to expedite referrals between family physicians and specialists; Ontario s Princess Margaret Hospital has introduced same-day diagnosis for potential breast-cancer patients; Quebec plans to introduce an annual health account that will promote accountability and transparency for the use of health funds; and, Jurisdictions across the country are getting behind the quality agenda. To date, six provinces, the most recent being New Brunswick, have established councils to monitor and report on quality of care. What we need now is a sustained effort to support these local good ideas and translate them into broader, national improvements. 7

8 That means stepping up and acting. Physicians know where changes are needed urgently in the allocations of all resources in health care. We have always advocated for what is needed for direct care for patients. We are the content experts; we must speak out and we must act. Doctors can make some changes ourselves, but we need to be involved intimately in the broader transformative change to medicare. We were marginalized from government decision-making during the budget cuts of the 1990s and our system is still recovering. If Canadians want to fix our system and make it more effective and efficient, physicians must be involved in the process. Similarly, patients must speak out clearly about what they want in their health care system and what role they want to play in it. This is an important point, because the system exists to care for patients. It is not mine. It is not governments. It is the patients health care system. The CMA believes our system can become more effective and sustainable while still preserving core values such as universality and accessibility. Above all, our goal is to ensure patient-focused, high-quality care for all Canadians. The CMA is pushing for the creation of a high-quality, patient-focused health care system through its Health Care Transformation project. This project includes many ideas for strengthening the foundation of the Canada Health Act, but there is another important element a Charter for Patient-Centred Care. I m talking about a charter in the very best sense of the word. This charter will be an aspirational document describing the health care system that Canadians deserve. One that defines the expectations we all share for a high-functioning system. The Charter for Patient-Centred Care is meant to be a rallying cry that unifies providers, patients, administrators and funders in the achievement of common goals. Conclusion The first statement in the CMA Code of Ethics can be summarized as consider first the well being of the patient. This commitment is at the heart of every physician s practice. It also drives our advocacy efforts to transform the system. Doctors are ready, willing and able to do our part. What we need now is the public to demand that politicians step up to the plate and do theirs. That won t be easy. What is clear though is that the status quo is not an option. All governments must focus on health care because their current funding agreement expires in The political temptation will be to put off the debate but the longer we wait, the greater the possibility that all we ll get is another band-aid solution. 8

9 Political parties of all stripes and on both sides of the House need to show some political courage and tackle the issue of health care head-on. They need to debate health care honestly and openly without resorting to meaningless rhetoric. As I hope I ve been able to show this afternoon, innovation is already happening across the country. Provinces, providers and administrators are coming up with better, more efficient ways to deliver health care not by sacrificing the principles of the Canada Health Act, but by building on them. We need to capture the momentum for change growing across the country and marshal that energy into a new, national vision for health care. After all, Medicare was born through strong local initiatives and vision that grew into a national consensus. That spirit still exists in Canada today and we must recapture it. All of us can and must come together if we are to have any hope of improving our ailing health care system and fulfilling Medicare s promise. Thank you. 9