Ask any group of Canadians what they hate about our health-care system and chances are they’ll give you a one-word answer: waits. Waits to find a doctor. Waits at ER. Long waits for non-urgent tests. Endless waits to see a specialist and to have procedures. Waits, sometimes, even when your chances of recovery depend on timely treatment.
Charlie Fischer knows all about waiting on Canada’s government-throttled health-care system. When he was diagnosed with Stage 4 throat cancer in April 2014, one of the first things he was told was how urgent it was to start treatment within two weeks. Stage 4 is the most advanced form of cancer, in which cancer cells have spread to other organs in the body, and is considered gravely life-threatening. It didn’t happen. Instead, Fischer had to wait. Through a shocking series of avoidable missteps, it was six weeks before he started the urgent treatment he needed to save his life. The experience turned Fischer, now 69, from happily retired oil patch executive into an outspoken advocate for health-care reform. Charlie’s “retirement” was unlike those of many for, as a Calgary-based community icon, he remained active as a volunteer and member of numerous boards.
Before his treatment could begin, Fischer travelled a long road of diagnosis, referral, assessment and more tests in Calgary. It was a “linear” path, he says – in which one step had to be completed before the next could begin. It seemed to lack the urgency he felt. After his diagnosis, he was referred to an ear, nose and throat specialist in Calgary, but again had to wait because the doctor was only doing intake one day per week. That doctor referred Fischer to a medical oncologist and radiation oncologist. “But guess what?” says Fischer. “They only have intake one day a week, and they’re busy.” Doctors ordered a positron emission tomography (PET) scan, but that was also delayed because Fischer’s oncologist determined a broken tooth crown needed to be repaired before the scan could be done. Why, Fischer wondered, had no one mentioned this weeks earlier? It might have avoided still more delays.
It was all quite bizarre to one of Canada’s senior oil patch veterans. As head of Nexen Inc. from 2001 until 2008 Fischer, who holds an MBA from the University of Calgary, had applied principles of business efficiency to transform a once-stodgy subsidiary of a U.S. oil company into a highly profitable Canadian independent producer. (Since his departure, Nexen has once again become a subsidiary, this time of a giant Chinese oil company.) Fischer notes that, in business, it’s a given that a business unit or project team will perform multiple tasks concurrently to avoid delays. This simple lesson appears lost on otherwise talented and dedicated health-care professionals in Canada’s public system.
Fischer reasons that if the health system had conducted several tests and procedures at the same time, he could have cut the six- or seven-week wait “in half.” When Fischer raised his concerns about the delays with doctors, they told him a week wouldn’t matter. “I said, ‘What about a month?’ And they said, ‘A month would make a huge difference,’” Fischer recalls. “I said, “You jerks. Every one of you thinks you have a week and you all take it. The week turns into three, four, five . . . whatever.’” The process was, needless to say, also extremely hard on Fischer’s wife, Joanne Cuthbertson.
Many Canadians experience similar frustrations with health-care services: delays, lack of communication, information gaps, inconsistent care delivery, and lack of coordination among doctors and specialists. Although Canada’s health practitioners are often touted as world-class, the system as a whole does not seem to function efficiently. Instead, it comes across to dissatisfied patients as less than the sum of its parts. No wonder that, when their lives or well-being depend on it, many Canadians who have the financial resources head south of the border. Fischer, however, stuck it out at home.
A study published in 2018 by the Fraser Institute estimated that long waiting times affected more than 1 million Canadian patients that year. The cost in lost wages alone was estimated at $1.9 billion. That study did not account for the avoidable costs added by the system’s operating inefficiency, nor attempt to estimate the actuarial costs of lost long-term productivity as a result of shortened lives, let alone the intangible costs of stress, fear, pain and suffering (all of which would be calculated in the case of a person or group suing a private party for negligence or other harms). The report found that after receiving a referral from a general practitioner, the typical patient waited more than 21 weeks to initiate treatment from a specialist.
One of the key problems is the system’s siloed approach to treatment, says Fischer. Doctors in one specialty are out of touch with what other doctors are doing or planning. “You don’t get the sense that treatments are coordinated,” he says. “Everybody’s sort of doing their own thing.” Hospitals, primary care physicians, specialists, primary care, social care and other disciplines function as entities unto themselves. As a result, there is poor information sharing and a general failure to coordinate treatment.
Curiously, many Canadians remain smug about their publicly funded health-care system, seeing it as superior to the U.S., where per-capita spending on health care is double that of Canada’s. In Canada, that level was $6,839 per capita in 2018, while in the U.S., it was equivalent to Cdn$13,722 in 2017. Critics of the U.S. system contend that while insured Americans can receive outstanding health care, others receive little or none at all. Some U.S. hospitals, however, routinely provide emergency care free of charge, and hospitals owned by religious or charitable organizations have various programs to provide primary care for the indigent. In addition, the U.S.’s massive federal Medicare and Medicaid programs cover the old and the poor, respectively. The key characteristic that has many Canadians voting with their feet and wallets and going abroad for health care, however, is sheer speed. To patients who can pay, the customer truly is king in the U.S. and the lethargic pace and delays that threatened Fischer’s life are essentially absent.
In any case, when Canada’s health-care system is put up against other OECD countries, there is no reason to be smug. Of 44 countries assessed and compared by the OECD in 2018, Canada’s per-capita spending was in the top third, yet its health outcomes were just average. In Alberta, where per-capita spending is the highest in the country at $7,552, outcomes are below average, according to the 2015 Report of the Advisory Panel on Healthcare Innovation. Worse, of 11 countries’ health-care systems, Canada’s was ranked ninth – just two above the U.S.
“We have a relatively high-cost system, but we’re getting such mediocre health care,” Jack Mintz, a member of the Healthcare Innovation advisory panel and President’s Fellow of the School of Public Policy at the University of Calgary, said in an interview. Mintz, who has been described as “the premier public policy economist in Canada,” was founding director of the school from 2008 to 2015, and built it into a prominent academic think-tank for public policy research and education. Currently, Mintz, a member of the Order of Canada, conducts research, builds capacity and provides leadership on tax, financial regulatory and urban policy programs.
Canada’s $238-billion health-care system is not one entity, but rather 13 distinct provincial and territorial authorities which, in turn, negotiate with the federal government for annual transfer payments. As a consequence, there is ongoing tension between provinces and territories, which cherish their right to shape their health-care systems, and the federal government, which attempts to lever its funding power to influence provincial health-care policy.
The Healthcare Innovation panel was chaired by Dr. David Naylor, a Canadian physician, medical researcher and former president of the University of Toronto. What became known as the Naylor report found that, “Canada’s approach to the finance and organization of health services is very poorly integrated.” Doctors and hospitals are funded through separate budgets, it notes, a practice that makes “little sense for the majority of specialists, given the substantial influence they have over hospital expenditures.”
To illustrate the problem, the report cited the example of a Canadian badly injured in a motor vehicle accident. “Care for this citizen would involve tapping into a dozen separate private and public programs, with varying degrees of coverage and incomplete sharing of clinical information across programs, institutions, and providers,” the report stated. “Such a patchwork can hardly operate in the best interests of the patient and his or her family.”
Indeed, the interests of patients can often get lost in the discussion. Fischer recalls attending a health-care quality summit where the facilitator asked a group of health-care providers and administrators to identify “the customer”. “A dozen ‘customers’ were defined before anybody thought to say, ‘the patient,’ which for me was shocking,” says Fischer. “So the system largely sees itself as its own customer, which tells you that the patient is not the priority.”
Fischer and Cuthbertson had already experienced the system’s callousness years earlier, when they witnessed unsatisfactory end-of-life care and decision-making for both of their mothers, the year before Fischer’s illness struck. They complained in writing to Alberta Health Services (AHS), and then-provincial Minister of Health, Fred Horne.
“Our general view is that the hospital was much more concerned with getting their bed back than providing care to a needy old woman,” the couple wrote. “The system…has lost its humanity.” The couple did at least manage to trigger a response, although perhaps not the one they were hoping for. Fischer was invited to participate in health-care reform discussions.
Despite all this, many Canadians maintain an almost fanatical attachment not only to public health-care funding, but delivery. Fischer, however, thinks it’s past time that Canadians broaden their horizons, figuratively and literally. New approaches need to be tried. They don’t need to be invented from scratch, for there are numerous working examples to consider from countries around the world. With other countries having done much of the heavy lifting of trying out new policies and approaches, discarding the failures and keeping the successes, the risks of health-care innovation have been lowered significantly – if Canada’s health-care establishment is willing to look and learn. In nearly all instances, the private sector plays important if not dominant roles in delivery, even as government tends to remain the primary funder. Such partnerships can work; some of the world’s most highly rated health-care systems comprise varying blends of public and private funding and delivery.
Switzerland’s health-care environment is heavily regulated but privately operated, and it has achieved what are widely believed to be the world’s best health-care outcomes. The country’s universal system requires everyone to buy insurance from private companies. To accommodate disparate incomes, almost 30 per cent of Swiss receive subsidies offsetting the cost of insurance premiums, on a sliding scale pegged to income. Most doctors work on a national fee-for-service scale, and most patients have a broad choice of doctors and hospitals. The result is a system in which providers compete for patients rather than attempting to hold them at bay. Some hospitals even advertise on roadside billboards.
Australia has developed a mixed system in which in-patient care in public hospitals, most medical services and prescription drugs are all free. Voluntary private health insurance gives access to private hospitals and to some services the public system does not cover. The government pays for at least 85 per cent of outpatient services, and for 75 per cent of the medical fee schedule for private patients who use public hospitals. Patients must pay out-of-pocket for whatever isn’t covered. Most doctors are self-employed, work in groups and are paid on a fee-for-service basis. More than half of hospitals are public.
In France, everyone must buy health insurance from one of several non-profit funds, which are largely financed through taxes. Public insurance covers 70-80 per cent of costs and voluntary health insurance the rest. France’s Ministry of Health sets budgets and regulates the number of hospital beds, what equipment is bought and how many medical students are trained. It also sets prices for procedures and drugs. Paired with this heavy reliance on centralized, top-down decision-making, France also uses market principles to foster competition across public and private hospitals, and doing so incentivizes quality and innovation.
The city-state of Singapore offers basic care in government-run hospital wards that is inexpensive, sometimes free, with upgraded care in private rooms available for those paying extra. Singapore’s workers and their employers contribute more than one-third of the average employee’s wages to mandated savings accounts that may be spent on health care, housing, insurance, investment or education.
Clearly, then, countries around the world have demonstrated an array of innovations in health-care funding, structure, operation and delivery, creating a rich field of ideas Canada could draw upon. Set against that impressive context, however, the reforms proposed in Canada’s Naylor report feel much like putting a finger in the dike. The report called for more information tools, creating incentives for greater patient engagement, and supporting digital health tools with standards across all health jurisdictions. It also proposed a refundable tax credit for medical services not covered by public health insurance.
Its mindset, in other words, was largely technocratic and process-oriented. The Naylor report also fell into the trap of throwing money at the problem. It proposed a multi-year Healthcare Innovation Fund, which would ramp up to $1 billion per year. Mintz admits that then-prime minister Stephen Harper was “not happy” on receiving the report. “That extra spending certainly wasn’t popular,” Mintz said. “The government didn’t want more pressure to spend more money.”
Harper, a trained economist, had a basis for his disappointment and suspicion. It was almost as if no one involved with the Naylor commission recalled or bothered to consider former Liberal Prime Minister Paul Martin and his 2004 Health Care Accord. It vaingloriously promised a “fix for a generation” and in the ensuing years the feds paid an additional $41.3 billion to the provinces and territories. Far from fixing the problem, a 2010 international survey found Canada the worst of 11 countries on waiting times to see a doctor or nurse when sick, while nearly half of waits to see specialists were more than two months long.
Long waiting times are probably the most visible and damaging manifestation of how socialized medical systems cope with scarcity. Budgets are fixed, while patients’ needs are open-ended. The system itself has no built-in mechanisms or incentives to promote efficiency, so the solution is to delay, limit or withhold care. And because a third party – government – rather than the individual customer pays the bills, patients themselves are virtually powerless. Fischer’s assessment is that within the system, “The focus is on the money and not on the outcomes.”
The need to restrict spending is partly the consequence of a system in which consumers pay nothing for the services they get. When health care is seen as “free,” people put unrestrained demand on medical services, and there is no incentive to limit visits to doctors or to choose cost-efficient providers. In response, governments control costs by setting strict budget caps that limit the number of staff, the amount of equipment hospitals can buy, or the operating times for critical equipment and facilities such as surgical suites. That guarantees rationing of services.
Because the customer’s money is essentially worthless in Canada’s socialized system – it’s illegal to use one’s own resources to pay for services covered under the Canada Health Act – personal connections and influence matter more than ever. Fighting for his life, Fischer frankly notes that he and Joanne constantly demanded information and attention, and it helped to have “friends in high places.” Through his experience on the Dean’s Advisory Council for the University of Calgary’s (U of C) Faculty of Medicine, for example, Fischer had access to senior academics and health professionals. The private health clinic to which he belongs also helped move the process along, he says.
Nevertheless, even with such advantages, Fischer still “found the system to be very linear and slow.” During his fearful, initial waiting period, Fischer took his concerns directly to Jon Meddings, Dean of the U of C’s Cumming School of Medicine. Those conversations led Fischer to Judy Birdsell, a one-time nurse who went on to earn a PhD in organizational analysis. Fischer and Birdsell teamed up to lead a conference called IMAGINE: Alberta with a Patient-Centred Healthcare System. Held in Calgary in January 2015, that event led to the formation of a group called IMAGINE: Citizens Collaborating for Health.
IMAGINE strives to build bridges between individuals and other stakeholders in the province’s $22-billion health-care system. A core theme is making patients – or what IMAGINE refers to as “citizens” – equal partners in their health care. That means patients have immediate access to their own health records and test results, and medical staff are trained to listen and respond to patients’ expressed wishes.
Fischer believes the health-care system has become structurally resistant to change out of sheer inertia caused, in turn, by too many people working too hard to maintain a status quo that suits their way of working. “Any one person within that system has little ability to effect change,” echoes Birdsell. In fact, she regards it as less of a system than “an eco-system” with a lot of moving parts. “It’s just too big,” says Birdsell. “People don’t feel they have any power. And they don’t.” Indeed, at least some of those who are clear-headed enough to recognize problems are fearful of speaking out. One sympathetic nurse, for example, shared Fischer’s dissatisfaction with the way his mother was treated in her final days. Yet she couldn’t bring herself to point out the problems to her superiors for fear of repercussions.
In Canada’s current system’s five decades of existence, health-care hierarchies have become deeply entrenched into dozens of fiefdoms. Many members of the health-care establishment, including administrators, specialists, and nurses, fear system disruption could affect their roles or even their jobs. “Everything has become so political,” says Mintz. “Everybody is protecting their own turf.”
It is unclear how far Alberta’s newly elected UCP government is willing to go to reform health care. One might think the province’s more conservative nature and entrepreneurial business culture would make it a veritable health-care Petrie dish, but the province has only occasionally touched upon the subject and has been far less aggressive in pushing private-sector delivery than B.C. or Quebec. While a couple of Alberta premiers have blustered about challenging the Canada Health Act, they always backed down. The rest have avoided the subject or sought to buy time by expanding budgets.
During Alberta’s election campaign in the spring, even UCP leader Jason Kenney guaranteed that a UCP government would do no worse than freeze health spending. He also promised to reduce waiting times for surgery to no more than four months by the end of the UCP’s first term. Kenney, now premier, said his government would invite third-party clinics to bid on the publicly insured system, a strategy he says would both cut costs and increase delivery speed.
In May, newly appointed Minister of Health Tyler Shandro announced that the government would carry through on its promise to review Alberta Health Services. According to a government news release, the review “will identify ways to deliver better results for Albertans and find efficiencies across the health system.” The promises remain vague, and so far there’s no indication the UCP is prepared to take the political hits – both in popularity at home and in triggering yet another conflict with Ottawa – that might result from making fundamental changes to health care in the province. But there’s a long list of urgent issues. At the top are doctors’ compensation, the highest in the country, Alberta’s ongoing support for costly rural hospitals – and of course those waiting times.
To Fischer, the lack of market discipline is at the core of what ails the health system. “I’m an oil-and-gas guy,” he states. “When crude oil prices fell to $30 per barrel, companies had to decide what was important. You set your budget targets and figured out what you’re going to do and what you’re not going to do.” Faced with the choice of cutting back or shutting down, private sector companies somehow managed to do more with less, innovating under duress and coming out the other end more efficient, more effective and better prepared. “We don’t have a health-care problem, because we have providers who know what they’re doing, and they can provide world-class diagnoses and treatments,” says Fischer. “What we have is a change management problem.”
In the end, Fischer was treated and, remarkably, his Stage 4 cancer was not only slowed, but fell into remission. That marvellous period lasted for some time, but eventually Fischer’s regular follow-up visits indicated the cancer had returned. By spring 2019, Fischer’s health had worsened considerably.
In Canada’s health-care system, the only change everyone gets behind is getting more money from governments. Mintz agrees the powerful monopolies in Canada’s health care-system are highly resistant. One way to break the deadlock, he says, could be through the introduction of more competition, following the lead of some European dual-pay systems. Moreover, he remains hopeful that some of the Naylor report’s findings will be adopted over time. “I happen to be very patient with public policy,” Mintz says. “I feel the Innovation Report…” Mintz pauses to consider his answer: “We’ll see how much will get adopted over time. We’ll see.”
It could take time. It had better not take forever. Many Canadians may be used to waiting for their health care, and others may be resigned to it, but Fischer’s experience proves that being forced to wait for treatment can be a very near-run thing.
Doug Firby is a Calgary-based journalist with four decades of experience, and is President and Publisher of Troy Media Digital Solutions.