Improving Medicare

Christian van der Pol (medical student, University of Toronto)

2009 My Better Medicare Essay Contest Winner

“A nation’s greatness lies not in the quantities of its goods but in the quality of its life.”¹

So stated Tommy Douglas the man known as The Father of Medicare and voted the Greatest Canadian of all Time in a 2004 contest sponsored by the CBC. Mr. Douglas introduced a health care system that is now a source of pride for Canadians and is regarded by many as a defining characteristic of Canada. A 2009 Harris poll on Canadian healthcare revealed that while 82% of Canadians feel their system is superior to the US system, over 28% feel that the Canadian system is performing either not that well or not well at all.² Dr. Anne Doig, the incoming president of the CMA, has said that the Canadian health care system is “imploding” and “precarious” and that it needs an overhaul.³ Clearly there is room for improvement.

In the 1950s American efforts to reduce motor vehicle injuries were focused on the driver as data showed that most injuries were a result of driver error. Initial attempts focused on manipulating driver behaviour, but it was soon realized that changing the transportation system itself was a more cost effective method for increasing overall safety. Emphasis was places on the use of seatbelts, third break lights and divided highways. Consequently the number of motor vehicle fatalities per mile was reduced by more than 75%.⁴ Improving our health care system requires a similar approach, efforts should be focused on changing the health care system itself.

Implement and integrate electronic health records

With the advent of PCs, personal digital assistants and ubiquitous access to the internet it is a huge lost opportunity that a standardized Electronic Health Records (EHR) database does not exist. Currently, only 37% of Canadian physicians use some form of electronic medical records.⁵ Continuity of patient care can be improved by providing health care providers with access to past medical records. A centralized database would provide useful information for research and aid in the establishment of public health policy. Data meeting requirements for surveys could be tracked and fed into registries. Patients matching study criteria could be automatically identified with consent and evaluation forms made instantly available. According to Canada Health Infoway, the setup cost would be $10 billion, however savings would be from $6 - 7 billion annually.⁶ Current financial and political barriers to implementing standardized EHRs must be overcome as this will lead to more integrated and better care for patients.

Improve patient safety

Like EHRs, barcoded medication administration is another underutilized technology for improving healthcare. This requires a barcode on a patient’s wristband to correspond to a barcode on prescribed medications at the bedside. A mobile scanner displays a “go” or “stop” directive along with pertinent instructions, and each dose is automatically logged in the patients electronic medication record.⁷ This system could be integrated with the patient’s EHR to identify drug contraindications. Many hospitals already use barcodes for tracking inventory. The barcoded system is not only more efficient at managing the records of prescribed medications but also provides a high level of protection against erroneous administration of medications.

Patient safety can also be improved by providing more single patient rooms. These can reduce airborne and contact-related nosocomial infections.⁸ Single patient rooms also reduce the need to move patients because of infection control, end-of-life care, or administrative transfers, all of which can be associated with harm due to reduced monitoring, missed treatments, and psychological stress.⁹ Transfers also consume considerable hospital staff resources. An initiative in Calgary known as the Ward of the 21^st Century is a multidisciplinary research program that has successfully incorporated single patient rooms into its design.¹⁰

Address shortages in access to the health care system

As of 2008 more than 5 million Canadians did not have a regular medical doctor.¹¹ This, in part, can be attributed to the improper implementation of suggestions made in the 1991 Barer-Stoddart report.¹² This report stated that physician supply was exceeding population growth and influenced politicians across Canada to cap the number of medical school seats. This recommendation came with a warning that over 50 additional recommendations should also be implemented.¹³ Unfortunately capping medical student seats was one of the few suggestions actually acted upon. This, in combination with federal budget cutbacks and increased physician retirement has contributed to a major doctor shortage in Canada. Now there are about 2.2 physicians per 1000 people, much lower than the OECD average of 3.1.¹⁴ Recently the CMA initiated a “Help Wanted” campaign urging  politicians to take action to alleviate the current doctor shortage, everything from allowing medical students to delay paying back their student loans to repatriating Canadian Doctors who have relocated to the US.¹⁵ Politicians must now take the initiative.

Another solution is to expand the role of nursing and allied health in patient care. A recent example was the creation of two new health care positions in Ontario called “anaesthesia assistant” and “nurse practitioner-anaesthesia.” While each operating room requires the constant presence of an anaesthesia assistant, one anaesthesiologist can oversee several operations at once.

Reduce excessive and unnecessary use of medical care

Physicians need to be aware of and educate patients about health services outside of GP’s offices, walk-in clinics and emergency departments. According to the 2008 Commonwealth Fund survey only 25% of Canadians used a telephone help line for medical or health advice in the last two years, yet 87% found it helpful.¹⁶ Patients are underutilizing such services which can substantially alleviate stress on the system.

Patients sometimes request unnecessary medical interventions that have risks associated with them. For example, some imaging procedures are a source of exposure to ionizing radiation and can result in high cumulative effective doses of radiation.¹⁷ Similarly, being hospitalized puts a patient at increased risk of numerous iatrogenic events. Doctors must ensure that such interventions are only prescribed where indicated.

Practice preventive medicine

The value in preventive medicine has been recognized since the hygienic codes in the book of Leviticus. Yet, for a number of reasons, there is a discord between the ideal of preventing disease and the practice of curing disease. For one it is difficult to track true rates of preventive measures as they are often found outside physicians’ offices and don’t show up as billing claims.^18,19 When preventive measures are tracked it appears they are underutilized as indicated by a recent study conducted in Ontario.¹⁹ Medical students should be taught how to change unhealthy behaviours in patients, physicians should be remunerated for promoting preventive medicine and public policies should be put in place that facilitate conditions for healthy living.²⁰

Another way of reducing disease is to make health deteriorating behaviours socially unacceptable. In Canada, it is now more difficult than ever to smoke. Smoking has been banned from almost all indoor work and public places and, in some provinces, even while driving a car with children aboard. This has been accompanied with a societal shift in the image of a smoker e.g. moving from Joe Camel to Joe Chemo.²¹ The fact that people of lower socioeconomic status have higher rates of smoking emphasizes the need to further focus efforts on this socioeconomic group.²² Making excessive alcohol consumption and unhealthy diets less socially acceptable as was done with tobacco would further help reduce disease.

Finally, studies have shown that increased cigarette taxation also reduces smoking. Every 10% increase in the price of cigarettes results in a 3-5% decrease in cigarette consumption. ^23,24 Applying a similar taxation on non-nutritious foods would surely be effective in reducing their consumption as well.

Conclusion

In spite of the view that our healthcare system is broken, in many ways Medicare works well. A profound example of its efficiency is provided by David Cutler in Your Money or Your Life.²⁵ In Ontario the government allows fewer than ten open-heart surgery units to be in operation. In California, which has three times the population of Ontario, there are ten times as many bypass surgery facilities. Such limited availability in Canada means there is no way we can treat our patients as intensively as in the USA. Instead we have to triage and treat only the sickest. Yet survival after a heart attack is practically identical on both sides of the border. The difference is that we do the same job with fewer resources. Also, even though we have less choice in insurance coverage, we arguably have more choice of hospitals, physicians, diagnostic testing and treatments compared with the United States.²⁶ Plus our insurance coverage is guaranteed.

Canadians are ageing and will undoubtedly place tremendous stress on the health care system in the years to come. With the recent economic downturn and subsequent requirement to stimulate the economy through increased government spending, an opportunity exists to improve funding for healthcare. Lets take advantage of this opportunity and make the changes necessary to ensure that subsequent generations will continue to benefit from Tommy Douglas’ dream and legacy.

Reference:

1              Tommy Douglas Research Institute. Available at: http://www.tommydouglas.ca/?page_id=28. Accessed Dec 10, 2009.

2              The Harris Poll. Is the U.S. Health Care System the “Envy of the World”? Not in Canada. Available at: http://harrisinteractive.com/harris_poll/pubs/Harris_Poll_2009_08_12.pdf. Accessed Dec 10, 2009.

3              Louise. What Canadians Think Of Their Health Care. Colorado Health Insurance Insider. Available at: http://www.healthinsurancecolorado.net/blog1/2009/08/19/what-canadians-think-of-their-health-care/. Accessed Dec 10, 2009.

4              Hemenway D. Regulation of Firearms. NEJM 1998;339(12):843-5.

5             Schoen C, Osborn R. The Commonwealth Fund 2009 International Health Policy Survey of Primary Care Physicians in Eleven Countries. The Commonwealth Fund 2009. Available at:

http://www.commonwealthfund.org/~/media/Files/Publications/In%20the%20Literature/2009/Nov/PDF_Schoen_2009_Commonwealth_Fund_11country_intl_survey_chartpack_white_bkgd_PF.pdf. Accessed Nov 14, 2009.

6              Steinberg HA. Alvarez RC. Canada Health Infoway Annual Report 2007-2008. Available at: http://www2.infoway-inforoute.ca/Documents/Infoway_Annual_Report_2007-2008_Eng.pdf. Accessed Nov 14, 2009.

7             Cescon DW, Etchells E. Barcoded Medication Administration: A Last Line of Defense. JAMA 2008;299(18):2200-2.

8             Ulrich R, Quan X, Zimring C, Joseph A, Choudhary R. The role of the physical environment in the 21st century: a once in a lifetime opportunity. Report to the Center for Health Design for the Designing the 21st-Century Hospital Project. 2004: 10-11. Available at: http://www.healthdesign.org/research/reports/physical_environ.php. Accessed Nov 21, 2009.

9             Detsky ME, Etchells E. Single-Patient Rooms for Safe Patient-Centered Hospitals. JAMA 2008;300(8):954-6.

10           Ward of the 21st century. Available at: http://www.w21c.org. Accessed Nov 21, 2009.

11           Canadian Community Health Survey (CCHS) 2008. Available at: http://www40.statcan.ca/l01/ind01/l3_2966_2967-eng.htm?hili_none. Accessed Nov 14, 2009.

12           Barer ML, Stoddart GL. Toward Integrated Medical Resource Policies for Canada. Report prepared for Federal/Provincial/Territorial Conference of Deputy Ministers of Health, 1991.

13           Stoddart GL, Barer ML. Will increasing medical school enrolment solve Canada’s physician supply problems? CMAJ 1999;161(8):983-4.

14           OECD Health Data 2009 - comparing health statistics across OECD countries. Available at: http://www.olis.oecd.org/olis/2009doc.nsf/ENGDATCORPLOOK/NT0000490A/$FILE/JT03267652.PDF. Accessed Nov 14, 2009.

15           The Ottawa Citizen. CMA hopes ad blitz will heal doctor shortage. Avialable at: http://www.canada.com/ottawacitizen/news/story.html?id=02bfd235-e330-4e81-8187-3f86999d8098. Accessed Dec 10, 2009.

16           The 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults. The Commonwealth Fund 2008. Available at: http://www.commonwealthfund.org/~/media/Files/Surveys/2008/The%202008%20Commonwealth%20Fund%20International%20Health%20Policy%20Survey%20of%20Sicker%20Adults/IHP2008_CMWF__DSQ_for_web%20pdf.pdf. Accessed Nov 14, 2009.

17           Fazel R. et al. Exposure to Low-Dose Ionizing Radiation from Medical Imaging Procedures. NEJM 2009;361:849-57.

18           Kwong JC, Manuel DG. Using OHIP physician billing claims to ascertain individual influenza vaccination status. Vaccine 2007;25(7):1270-4.

19           Wang L, Nie JX, Upshur REG. Determining use of preventive health care in Ontario. Can Fam Physician 2009;55:178-9.e1-5.

20           Genuis SJ. An ounce of prevention: a pound of cure for an ailing health care system. Can Fam Physician 2007;53(4):597-9

21           Available at: http://www.joechemo.org. Accessed Nov 22, 2009

22           James PD. et al. Avoidable mortality by neighbourhood income in Canada 25 years after the establishment of universal health insurance. J Epidemiol Community Health 2007;000:1-12.

23           Gallet CA, List JA. Cigarette demand: a meta-analysis of elasticities. Health Econ 2003;12:821-35.

24           The World Bank. Curbing the epidemic: governments and the economics of tobacco control. Tob Control 1999;8:196-201.

25           Cutler DM. Your Money or Your Life. Oxford University Press. New York, New York. 2004:58.

26           Ross JS, Detsky AS. Health Care Choices and Decisions in the United States and Canada. JAMA 2009;302(16):1803-4.