An insider's view of the Canadian system.
The Canadian health care system is going through a period of destabilization and radical change. Right across Canada, every province is once again conducting an in-depth analysis of its health care systems and civil servants. Administrators and providers are scurrying to come to grips with all the rhetoric.
In Ontario, the deputy health minister is promoting "total quality management." Is it possible that the Canadian health care system, often touted by government officials as the best in the world, has been operating for more than 25 years without total quality management? The awful truth is yes. The system introduced in 1964 has been inherently flawed from its inception. It has evolved to the point that it consumes one third of every province's tax base and is potentially capable of destroying the ultimate health and well being of Canadian citizens.
Canada is a country under great stress. Its cherished social support programs, especially health, are all under the gun. Canada is #1 in per capita health care costs among OECD (Organization for Economic Cooperation and Development) countries that provide universal coverage to their citizens. (More is spent in the United States, but 37,000,000 or so U.S. citizens have no coverage and millions more have inadequate insurance.) Provincial governments are beginning to realize that:
* Spending more on health care doesn't guarantee population health.
* There are more factors involved in maintaining the health of populations than hospitals, doctors, or high tech interventions.
* New health care technology may increase life expectancy, but it does not guarantee high quality of life.
* There is a strong possibility that norms of patient care may have been established on the basis of physicians' income and life-style expectations rather than outcome.
* Many health care interventions are not supported by scientifically controlled trials and may be inappropriate in their applications. Despite claims that medicine is an exact science, there is mounting evidence of wide variations in practice patterns and treatment across both Canada and the United States.
Maintaining the status quo and spending more money on health care is not an answer for a healthy Canada, and it is one that Canadian governments have discounted. Is there any solution to our problems? Do you have anything that you are working on that we might use in Canada or vice versa? I think you do. It's another American idea that will probably not work in the United States, but I think it stands a good chance of working in Canada, if our monopsonistic governments see the value of the concept, provide some financial incentives and leadership, and let providers and consumers get on with doing it.
The idea is called outcomes management. If you stand back from the Canadian or the U.S. health care system and observe it for a period, it reminds one of a fibrillating heart. Every player in the system is working full out, but rarely in rhythm with anyone else. Just as with a fibrillating heart, where every cell is quivering away, you get less than effective output.
Ellwood, writing about the mess of the U.S. system, noted the same pattern of uncoordinated activity.(*) He said that, in order to sort out the mess and gain effectiveness, the system needed a central nervous system to link all the players together. He calls this central nervous system "outcomes management". The deputy in this province calls it total quality management. I'm an academic from McMaster, where we call it, in epidemiology, the iterative loop.
Outcomes management means that we should measure the impact of a health care intervention on the patient's quality of life. We shouldn't do something to a person unless there is a corresponding worthwhile improvement in his or her health status. Doctors and patients need to know the results of interventions so that they can make appropriate decisions. The World Health Organizations says that one of the prime determinants of a health population is the ability to have self-determination. I would suggest that informed self-determination is required and, without outcomes management, this is impossible.
The awful truth in the current systems in both countries is that, in most cases, we have little information or data on outcomes. As a result, we have confused, litigious consumers with unrealistic expectations and ever-increasing demands. We have skeptical funders and a media that is basically becoming more and more aware and critical of the situation. We have doctors on both sides of the border who are angry and confused and, finally, administrators of both of our systems who are under great stress. Generally, the result is increasing chaos.
To make outcomes management work, four essential ingredients or activities are needed:
* Analysis and dissemination
There is great activity on both sides of the border regarding the setting of guidelines for practice. The United States, as usual, is leading the way. The Physician Payment Review Commission has reported to Congress, and its recommendations on guidelines make good sense. Funding has also been forthcoming from the U.S. government to encourage outcomes research.
The big issue in Ontario and in Canada is who should set the guidelines. Should it be medical associations? Should it be the licensing bodies? Should it be the government? I would hope that it's the people working in the system, because if they fail to rise to the occasion and do it voluntarily because they see the inherent worth and value in the concept, it will fail when it is forced down their throats from other agencies.
The big stumbling block will probably be collection of the data required in such a system. It has taken over a year to ascertain the burden of illness in the southwestern part of Ontario regarding cardiovascular disease. Thus, a committee that I am currently chairing, which is looking at a problem of delivery of cardiovascular surgery in that region, is still perplexed as to the need for a heart bypass facility in the community.
In Canada, because governments have controlled health care costs by blunt instruments, such as global budgets, negotiations, and limiting of high technology, we often don't have any databases that are conducive to precise analysis and management of our health care delivery system. We just haven't needed them. But now we're being asked to manage. To do utilization review, quality assurance, outcomes review, total quality management. Everyone is scurrying around computerizing. Some hospitals have been successful in their efforts. Others are into their third systems and are still not operational.
Ideally, it's not too late. Maybe we should pause and think about what we are doing. If we really want to create guidelines, analyze the results of our interventions against these guidelines, and disseminate results back to the patient/provider interface, we are going to have to learn to work together. We are going to require massive interrelational data sets that are compatible, appropriate, fully funded, massive, and long term.
If I see any major role for the Canadian government in this leap into effectiveness, they should have enough vision to encourage standardization of the information needs of the Canadian health care system and to facilitate outcomes management. The days of controlling the Canadian health care system through negotiations, legislation, or regulations or of controlling high technology by blind feat are limited. If I'm to act as a gatekeeper of the system, I'm going to need help. It's getting very complex in health care. It's almost impossible to keep up, let alone critically appraise every piece of new information. When a physician is uncertain, he or she will do more. This is why physicians need expert guidelines to prevent waste.
All the parts and technology are there; it's just a matter of putting them together. We have increasingly more powerful computers; voice dictation of health care records is just over the horizon; smart cards, practice guidelines--all of these things are evolving at a rapid pace. I'm all for smart cards--not only for the obvious benefits an electronic health passport would bring, but also because I know that, for the smart card to work, there has to be a massive, interrelational database in place.
We are entering an era of assessment and accountability. There will be much debate surrounding the introduction of this era. Repeated attempts will be made to block the formation of practice guidelines. In Canada, the leaders of our provincial associations may be promoting such activities, but the front line troops are still not convinced and, in fact, have little if any capability of carrying out the activities.
The electronification of health care data will not come easy. Cries of confidentiality, cook book medicine, possible litigation will come from the old priests in the temple of healing who have a vested interest in keeping the smoke surrounding their activities and worth thick. But we must press on. On both sides of the border, the health care empire as we have known it is in need of an overhaul. We can no longer pay for every intervention that exists. We must define what is appropriate and efficacious.
Canadians are slow to change, but there is no denying that the winds of change are blowing throughout the country. In one province, a report was recently issued stating that basic coverage should be redefined, and only interventions that are efficacious should be part of comprehensive coverage and thus declared universal to the citizens of the province.
We are on the verge of a renaissance in health care in both countries. Perhaps if we link together across this continent and share our experiencs, data, guidelines, analysis, and outcomes, we can provide the best health care to the populations of both countries.
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|Title Annotation:||International Health Care|
|Author:||Psutka, Dennis A.|
|Date:||Nov 1, 1992|
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