This book is about making medicare better. But “better” in health care is a tricky word. Better in what way? Longer lives for Canadians? A better experience travelling through the system when we get sick? More affordable care? Health care systems don’t have just one goal. They aim to deliver health and a good experience to patients—at a cost we can all afford.
The notion that health care systems have to achieve all these things at once was a light-bulb moment for many when it was first articulated clearly. The term Triple Aim was coined in 2008 by Dr. Don Berwick and his colleagues at the Institute for Healthcare Improvement in the United States. They said that if we want to improve quality in health care, we need to do three things simultaneously: first, improve the health of the population; second, improve the patient experience of care; and third, lower (or hold constant) the per capita cost of care so that the health care system can be sustainable.
Whenever we implement a new way of delivering care, we should be measuring our success across all three aspects of the Triple Aim. Instead of seeking innovations that do just one of these things—like cool health apps that people enjoy but don’t actually improve health, or very expensive drugs that extend life minimally but reduce quality of life—we should aim for all three simultaneously.
Sound impossible? It isn’t. But it does require focus.
So, how are we doing in our quest to achieve the Triple Aim in Canadian medicare?
The first goal in the Triple Aim is to improve the health of the population. And at the population level, our health is generally quite good—with the noted exceptions of Indigenous peoples and some other marginalized groups. The proportion of Canadians who say they are in good or excellent health is high, which is great news. Our average life expectancy is just over eighty-one years, one year ahead of the average among developed countries, and our infant mortality rates inch just above average.
But those statistics aren’t the best measure of a health care system. Life expectancy is more related to social factors like poverty and education than it is to the performance of our doctors and hospitals. The test of how a system performs is how well we’re doing on outcomes for diseases that we know are treatable. For example, deaths from bacterial infections, diabetes, treatable cancers, cardiovascular disease, or even complications from surgical procedures are measures that better tell the story of a health system’s performance. By this measure, Canada comes in sixth place among nineteen high-income peer countries.
Taken disease by disease, we can see how we do in even more detail. When compared to thirty-four OECD countries, we ranked second last (very well) in deaths from stroke, nineteenth in deaths from heart disease, and thirteenth in deaths due to cancer. Overall, I would give our health care system a B for outcomes.
If your child comes home from school with a B grade, the first thing you’ll probably want to check is whether he’s improving compared to the last report card. A student who got a C last semester and earned a B this time deserves praise. An A-student who got a B needs a sit-down.
But what if you don’t know how he did last semester? What you may not realize is that the people delivering health care in Canada often have no idea about the quality of care they’re providing, or whether we’re doing any better this year than last year.
We collect lots of data in Canadian health care, but we do a very poor job of putting information about how we’re doing into the hands of providers and patients. Few surgeons know their complication rates or how those rates compare to those of their colleagues; few family doctors know how long their patients are waiting to get an appointment; and almost no one is getting paid based on the quality of care they’re providing. If there’s something to the old adage that you can’t manage what you don’t measure, we clearly aren’t doing enough to support improvement of health care quality in Canada. Which makes it really hard to know what grade we deserve and whether we’re on the right track for improvement.
Part of the reason for this gap is that our information technology systems aren’t up to snuff. Over the last ten years we’ve done much better in moving away from paper, but we continue to have problems with the integration of our digital systems. Just because the hospital and the family doctor’s office both use computers doesn’t mean that those computers talk to each other. Our information systems aren’t yet able to pull this week’s data so that providers can do better for patients next week, nor are patients able to routinely gain access to their own health data. In the absence of that kind of measurement and reporting, it’s hard to improve the outcomes of the care we deliver.
Of course, the big political controversy in Canada over whether medicare delivers the goods isn’t really about the outcomes once people get into the system. It’s about access. Timely access is especially important to people’s experience of care—the second part of the Triple Aim—though it can also influence both the health of the population and the cost of care if it’s seriously and consistently compromised.
Access to a wait list isn’t access to care. Many patients in my practice wait months for elective surgery or to see a specialist for a non-urgent problem. Our system does a terrific job of delivering care when people are seriously ill, and most of us are otherwise prepared to accept some amount of waiting. But we have a lot of work to do to reduce wait times in Canada for non-urgent but still necessary medical care.
Think back to the last time you were sick and needed to see your doctor. When you called for an appointment, could you be seen within forty-eight hours? Unfortunately, fewer than half of Canadians report that they could. Nearly one in five Canadians who needs elective (not urgent) surgery will wait longer than four months for it; that number is unacceptably high compared to other developed countries. The methods used to compare health care in different countries are always criticized, and there’s often a good basis for those criticisms. But for anyone who works in the Canadian health care system or has needed care of a non-urgent nature, the general findings ring true.
This is a problem that can be fixed. We can learn to do better, and we have. In some areas we’ve seen improvements on wait times. According to the annual Wait Time Alliance report cards, between 2012 and 2013, Canada went from an A to an A+ on waits for radiation oncology, which means that nearly everyone is treated within the four-week benchmark time frame. From 2013 to 2014, the B and C on hip and knee replacements improved to an A and B, respectively.
The good thing about our wait-times problem is that it isn’t a problem when needs are critical. In my experience as a Canadian family doctor, in both rural communities and big cities, if I pick up the phone to get something for a patient who really needs it, the system nearly always moves. If it’s an emergency or highly urgent, my patient is not going to wait. Sometimes she may need me to advocate and navigate the system for her, which is what family physicians are supposed to do. But in those critical moments, Canadians get the care they need, and the care they get is usually very good.
But what if my patient is a lawyer who experiences bothersome (but not life-threatening) headaches, isn’t responding to the usual treatments, and misses a day a week of work while waiting weeks or months for his neurology appointment? Or a grandmother who forfeits a whole golf season waiting for her hip surgery? Or a child showing early signs of a developmental disability who loses a semester waiting for an assessment? These people are not in “life or limb” danger, but the effects of waiting are real, and the waits need to be addressed.
The problem with the wait-times debate in Canada is this: some people want to introduce private financing into our physician and hospital systems in order to either support their free-market ideology or garner personal profit. They’ve seized on wait times as a justification, arguing that it’s single-payer, publicly funded medicare that engenders long wait lists. But those two things—wait times and private financing—have nothing to do with each other.
Some countries with single-tier systems have long waits, and some have short waits. Some countries with two-tier systems have long waits, and some have short waits. Our wait time problem isn’t caused by the fact that we pay for our health care collectively instead of individually. It’s mainly caused by poor organization of the resources we have.
Long waits affect real people, and they need to be addressed—not by massively increasing our health spending but by better organizing our resources. If we could do that, we would greatly improve Canadians’ experience of the health care system.
Reducing costs, or holding them constant, is the third aspect of the Triple Aim. We already spend a lot of money on health care in Canada, as do all developed nations. In 2013 (the latest year for which data are available at the time of writing), we spent nearly 11 percent of our GDP on health care services, putting us in the top quarter of OECD countries in terms of health care spending per person. The same percentage is expected to have been spent in 2015.
Some people say that this means we have an expensive health care system. That’s true if they’re talking about total expenditures, which include public spending on things like doctors and hospitals as well as private spending on things like dentists and prescription drugs. But among developed countries, the proportion of our health spending that’s public is near the bottom. For every dollar we spend on health care in Canada, seventy cents comes from government. Compare this to the U.K., where eighty-three cents of the average health care dollar is publicly financed. In Norway, it’s eighty-five cents. In France, it’s seventy-nine cents. It’s only because we so often compare ourselves to the United States, which has the highest private spending (48 percent) and the lowest public spending (52 percent) on health care in the developed world, that we tend to think of our public spending on health care as being high. By international standards, it is not.
Canadians spend a lot of money buying private insurance and paying out of pocket for services not covered by medicare. We have very low levels of public funding for essential services like prescription medications (about 40 percent) and dental services (about 5 percent), not to mention home care, physiotherapy, and long-term care. Since 1998, our average out-of-pocket health care expenses have been rising much faster than inflation. As a result, increasing numbers of Canadian families are spending substantial amounts of their incomes on services like dental care and prescription medicines. For too many, that means choosing between medical necessities and other necessities, like rent or food. A sustainable system is one that is affordable not just for governments, but also for citizens.
Indeed, if you follow the news on Canadian health care, you know that the word “sustainability” now makes its way into virtually every conversation, often in the context of doomsday predictions. Usually, the argument sounds something like this: “Twenty years ago health care took up only 26 percent of our provincial budget. Today it takes up 43 percent. If we continue along these lines, soon we won’t have any money available for schools, roads, or anything else—our entire government will just be one big Ministry of Health.” This has been called the Pac-Man argument—I always picture a big health care Pac-Man eating up all the other social services in the lanes it travels through.
There are many things wrong with the Pac-Man analysis. The first is what’s been called the “straight lines of death” fallacy—the belief that since health care costs have grown in the past, they’ll continue to grow at the same rate in the future. Yet this is untrue: the early 2000s saw a long-term upward trend in health care expenditures, but just as people started to panic, governments reined in spending growth following the 2008–2009 recession. Our total spending on health care is now falling as a proportion of GDP—hardly a “straight line of death.”
The second thing wrong with the Pac-Man analysis is its tricky math. While health care costs were rising in the past few decades, provincial budgets were shrinking. The best way to illustrate this point is through a story that Dr. Michael Rachlis, a public health specialist in Toronto, likes to tell.
Imagine there’s a family of four living together in a small house—two adults and their two kids. Every evening they have dinner together. One September the older child, now eighteen years old, goes off to university. For several weeks the remaining three family members continue their family meal each evening. But one evening the parents sit down with the younger child and say, “Son, we’re very sorry but we can’t afford to keep you around anymore. Last year you were eating only 25 percent of the food in this house. Now you’re eating 33 percent of it!”
This is what has happened in health care. Of course the younger son isn’t eating any more than he ate before his brother left. Rather, the denominator has gone from four people to three. As governments across the country cut taxes over the last two decades, the size of the communal pie—the total budget for public services—began to shrink. This made the fraction—health care spending as a portion of the total budget—appear to grow impressively.
No one likes to cut health care, so it’s been (mostly) shielded from cuts. Instead, cuts were made to social assistance, to colleges and universities, or to programs for new immigrants. This isn’t the fault of the health care system. We should value and protect the other important programs we choose to fund with our tax dollars. But we shouldn’t have to choose between health care and roads unless we’re prioritizing tax cuts over both health care and roads. In this scenario, the Pac-Man devouring things isn’t health care—it’s tax cuts. And these days, as citizens have pushed for better public services, governments are having to rethink tax cuts.
The third problem with the Pac-Man analysis (and another frequent cause of front-page hysteria about health system sustainability) is the myth that our aging population will drive health care costs through the roof. Let me emphasize: our aging population will not bankrupt the health care system. Well, at least not by simply aging. The proportion of Canadians over the age of sixty-five is increasing, but here’s the thing about aging: it happens only one year at a time.
It’s true that we use more health care services as we age, but as Canadian economist Bob Evans has so eloquently put it, we aren’t facing a grey tsunami but rather a very slowly moving grey glacier. If Canadian seniors continue to use health care at the same rates they currently do—which includes higher use as they age and especially in the final weeks of life—we can expect to see health care costs grow by about 1 percent per year (depending on the province) as seniors move through the system. Even modest economic growth should be able to absorb that kind of increase.
The real challenge of an aging population isn’t the increasing number of aging baby boomers, but the increasing number of tests and treatments we administer to them without improving their health.
If people in the future use about the same amount of health care as their equivalents do today, we need not fear the aging population. But if usage rates don’t remain constant, costs will increase faster than we think, regardless of how old people are. The biggest increase in health care costs over the last decade has come not from aging but from increased use of hospitals, drugs, and doctors.
Every Canadian adult, of every age group, is using more health care than his or her equivalent did twenty years ago. This includes heavier and more intense treatment even for healthy people over the age of sixty-five, not just those with chronic illnesses. Most of those costs are initiated by doctors like me. We’re the ones who tell Mrs. Jones to come back for a follow-up visit in a month or send her for an X-ray or prescribe a medication. Costs are going up not because Mrs. Jones is old, or even sick—we’re just providing more health care to her, and to her daughter and granddaughter too.
The problem with the aging population isn’t that it will bankrupt us, but that we won’t do it justice if we don’t change the way we deliver health care services. Canadian medicare has traditionally been at its best in the hospital and in acute moments of crisis. But as the population ages, more Canadians will be living longer with chronic health conditions such as diabetes, high blood pressure, heart failure, and lung disease. These afflictions can dramatically reduce people’s quality of life if they’re not well managed in the community, including at home. And if people bounce in and out of hospital and the emergency department for every exacerbation of a chronic illness, they won’t enjoy their old age. That really is unsustainable.
If, on the other hand, we can build a more robust and accessible system of home and community care, along with excellent primary care to support older people with chronic illness, we can welcome the demographic shift. The way we approach health care reform must, therefore, create new opportunities to treat patients with chronic disease, including seniors, outside the hospital.
The increases in health care spending we saw through the early 2000s have now slowed. If we can continue to be responsible about spending growth, we won’t end up with the One Giant Ministry of Health that some people fear. The real question is whether the amount we spend is worth it. If health care spending is increasing and health outcomes are also getting better, that may be a good investment. But if health care spending is increasing and health outcomes aren’t improving, then we have a problem.
On average, each year we spend about C$6000 per person on health care from public and private sources combined. (The United States averages nearly US$9000 annually per capita.) Of course, money spent on health care—whether public or private—is money that isn’t available to spend on other things. How much do we want to spend on health care versus education, housing, food, or even entertainment and recreation?
If I told you that I’d bought a car for $6000, it probably wouldn’t mean much unless I told you what kind of car. What make? What year? New or used? What we spend arguably matters less if we’re getting good value for money.
It’s hard to know whether our health care system is giving us good value for money because measuring the quality of a health care system is a complicated task. You can ask people how healthy they are. You can measure how long they live. You can look at how likely they are to die of diseases that we know medical science can cure. You can ask them how positive their last experience was with the system, or how long they had to wait for care. There is no single perfect measure, but if you look at a broad range of measures, including for vulnerable populations, and consider how much money you’re spending, you can start to get a sense of the value for money spent. This is why it’s so important to look at all three parts of the quality Triple Aim if you want to understand the performance of a health care system, and why so many international comparison studies don’t tell the whole story.
The bottom line is that we don’t have the worst health care outcomes in the world—but we don’t have the best outcomes, either. And as we’ve seen, it isn’t because we don’t spend enough—we’re one of the top ten spenders among forty-four peer countries.
What we spend in total, from both public and private sources, should be “enough.” But we spend less publicly than many comparator nations, and particularly less in areas like prescription drugs, home care, mental health care, and dental care. Our system is less “public” than many people think (remember, only 70 percent of health care is financed with public dollars). We concentrate our spending on doctors and hospitals in order to maximize the advantages of single-payer health care: equity and administrative simplicity. Those are powerful reasons, but we could maintain that structure while increasing public funding of other services.
Rising costs are real, but what matters more than what we spend is what we get for it. Based on outcomes, our performance is solid—but too often, it’s not excellent. We need to improve our performance in areas relating more to chronic, long-term problems as opposed to acute ones. And the Achilles heel of our system is access, especially with regard to long wait times for non-urgent, or planned, medical and surgical care.
If Canadians are as committed to medicare as we say we are, we must uphold the core values of our system. But we also want a set of improvements that will speed access to non-urgent care when we need it, control costs, and deliver better health for every dollar we spend. This means we must be prepared to make big and exciting changes.
What should those changes be? We could begin by discarding a bunch of bad ideas before we get to the good ones.