Doctors,nurses, perfusionists, and other personnel in short supply

By Randall F. White, MD, FRCPC
29 June 2008

At St. Paul’s Hospital in Vancouver, where I practice, 50 heart surgery cases have been cancelled since April 2008. The spokesperson quoted in The Province on June 26 said that the hospital sometimes lacks enough perfusionists to keep the cardiac operating rooms open. The opposition health critic in the legislature blames the government for its 2006 decision not to fund a perfusionist training program at Thompson Rivers University in Kamloops.

A few days before, The Province newspaper reported that BC Children’s Hospital in Vancouver has cancelled 50 surgeries since April because of a shortfall of at least 10 intensive-care nurses. The same week, The Globe and Mail reported that a small town in BC is so desperate for doctors that it is raising money to build a new health clinic for physicians who have yet to be hired. The public is painfully aware of the physician shortage. The 2008 Health Care in Canada survey found that 19% of people named it second only to wait times as the leading problem in our system.

In January 2008, the Canadian Medical Association launched a campaign to raise political capital for increased domestic training of physicians, an appropriate advocacy issue for Canadian physicians. But at the same time, the CMA leadership, including president Dr. Brian Day, advocates for a second tier of health care. They haven’t explained how this second tier would be staffed given the immediate need for 26,000 physicians to bring Canada up from a ratio of 2.1 doctors per 1000 population to 3 per 1000, the mean among OECD nations.

Doctors aside, private hospitals and clinics require nurses, perfusionists, and other personnel who are in short supply and who require expensive, lengthy training. These facilities would take such personnel from existing institutions, including St. Paul’s Hospital, BC Children’s, and the others that serve most Canadians. Wealthy people who can afford to pay a premium could avoid wait lists and cancellations while the rest of Canada would endure even more such failures of the public system.

This pattern occurred in Australia after the introduction of a privately funded, privately owned tier of hospitals. According to the Australian Medical Association, wait times and crowding in the public hospitals have reached a crisis. The same would happen in Canada; in fact, we have a crisis despite having no official second tier. So let’s forget tier two, train more health professionals, and make our existing system work better.

Sceptical Reflections on the BC Pharmaceutical Task Force

By Randall F. White, MD, FRCPC

9 June 2008

The BC minister of health, George Abbott, assembled a task force in 2007 to review policy on pharmaceutical coverage under the province’s PharmaCare program. According to the Web site http://www.health.gov.bc.ca/pharme/, the program “subsidizes eligible prescription drugs and designated medical supplies, protecting British Columbians from high drug costs.” Abbott’s appointments to the panel surprised even cynics.

Adrian Dix, the opposition health critic, called the composition of the nine-member task force “highly debatable” because five of the members had ties to the pharmaceutical industry. It included Russell Williams, the president of Canada's Research-Based Pharmaceutical Companies, a leading industry lobbying group. The conflict of interest was glaring, yet aspects of the province’s decision-making that displease industry were open for review.

Most provinces turn to the Common Drug Review that for decisions about covering medications. For therapies that fall outside the Common Drug Review, BC has an independent review process called the Therapeutics Initiative (TI), which also provides education for clinicians on its Web site Therapeutics Initiative The TI review process has been praised for outcomes such as preventing widespread use of COX-2 inhibitors in BC, medications which turned out to have a poor risk/benefit ratio.

The task force released its report in April 2008, and just as critics expected, the recommendations lean hard on efforts to protect tax payers and public health at the expense of Big Pharma’s profits. The report concluded, without substantiation, that the TI is “widely regarded as being in need of either substantial revitalization or replacement.” The panel even recommended that the TI cease educational activities, suggesting that they have not been “unbiased and evidence based.”

In barely concealed contempt for the TI, which is housed at UBC and is explicitly designed to keep the evaluation process shielded from industry influence, the panel suggested a new process that includes “disease-specific experts.” Although experts have a lot to offer, the fact is that many are involved in research and education funded by Big Pharma: more conflict of interest. In an egregious example, Dr. Joseph Biederman, a renowned child psychiatrist and researcher at Harvard, was recently found to have concealed a large sum of pharma income New York Times

What about a government’s conflict of interest in inviting industry to craft public policy? Big Pharma spreads its money around, including to Abbott’s party, the BC Liberals. The Pharmaceutical Task Force illustrates how commercial interests influence health policy, and why Canadians should hesitate to allow commercialization of other aspects of the health care system. Once corporate interests are let in, their lobbyists want a say in whatever government does.

CDM calls on BC government to reject two-tier health care disguised as "sustainability"

The BC government should remove “sustainability” from the proposed Medicare Protection Amendment Act, Bill 21, unless it unequivocally rejects private for-profit care for medically necessary services and commits to keeping the universal single-payer system, says Dr. Randall White, BC Chair of Canadian Doctors for Medicare.

“We all believe in a sustainable health care system,” says Dr. White. “We all believe in innovation, transparency and accountability – words the government wants to enshrine in the legislation. We all believe patients should have choice in the kind of care they get, that there should be personal responsibility. But we believe in these principles within the context of the public system because the evidence is that single-payer systems provide better value for money than private systems, with health outcomes that are as good or better.”

When governments enshrine these principles in legislation, they provide fodder for the supporters of for-profit care to argue that choice, personal responsibility, and the needs of other public programs require private for-profit health care, says Dr. White. This creates the impression that health care is siphoning funds from other programs, like education. “The reality is the health care budget has grown so much compared with other program budgets because the BC Liberals have reduced social spending and cut taxes.”

Alarmist rhetoric from promoters of commercialized medical care suggests Canada has a crisis that demands privatization, says Dr. White. For example, for-profit supporters use statistics stating Canada ranks 30th in the world in health care. This is from a discredited World Health Organization report that ranked Colombia as No. 1 in "fairness in financing" and the United Arab Emirates as No. 1 in "responsiveness". Meanwhile, favourable studies, such as a 2008 report showing that Canada ranks sixth in preventing deaths from medically treatable disease, are ignored.

Private for-profit care requires commercial insurance, which most Canadians will not be able to afford; or will not quality for. Studies elsewhere show the major beneficiaries of private insurance are investors in insurance companies, private hospitals, and specialist doctors who command high fees. Private clinics will take less complicated cases, leaving the more difficult cases to the public system – along with even longer waiting lists because the specialists will be busy in private clinics.

“We don’t need private for-profit care to have a sustainable system,” says CDM Policy Advisor Karen Palmer. “What we need are innovation and reform within the public system (see Successful Medicare Innovations). This means more surgical capacity in our public hospitals, queue management to reduce wait times, the most efficient use of operating space and staff; and systematic collaboration between generalists and specialists. We also need widespread efforts to prevent chronic diseases such as obesity, diabetes, and addiction.

“The path to sustainability is through a universal, single payer system, not through efforts to cap spending, outsource care to for-profit clinics, and shift costs to patients.”

For More Information:

Randall F. White, M.D. - BC Chair, Canadian Doctors for Medicare
Email: info@canadiandoctorsformedicare.ca
Phone: 604 221 2313 or 604 682-2344 x63966

Two Visions of Sustainability

Randall F. White, MD
19 April 2008

Professor Marie-Claude Premont said that the BC government is attempting to undermine the foundation of publicly funded, not-for-profit health care in British Columbia. She spoke to the delegates of the The Health Sciences Association of BC at their annual convention on April 18 about Bill 21 www.leg.bc.ca , which was introduced by health minster George Abbot and has had first reading.

Premont, on the faculty of L’Ecole Nationale de l’Administration Publique de l’Universite du Quebec, said that the preamble of the Medicare Protection Amendment Act contains important words that belie its intent. It calls for “individual choice, personal responsibility, innovation, transparency and accountability,” each of which may be used as means to introduce privatization and profit motives into health care. Accountability, she said, is a business term and not a traditional term in public administration. Despite this, the bill would insert it into the “public administration” paragraph of the Medicare Protection Act. Premont believes this may facilitate activity-based or, as Brian Day prefers, “patient-centred” funding.

The bill’s rhetoric also aims for an “integrated” health care system, which many Medicare supporters would endorse. But Premont said this could mean an integration of public and private elements.

The heart of the bill is its call for sustainability, defined as “annual health expenditures that are within taxpayers' ability to pay” without taking too much of the provincial budget. This leaves the door open for spending caps. Premont pointed out that the denominator of the equation is tax revenues, not provincial GDP or some other measure of total wealth. If the BC Liberals continue to prioritize tax cuts over social spending, the inflation-adjusted budget for health care will shrink in coming years. This will pave the way for shifting costs to patients, a wider market for commercial insurance, and accelerating privatization.

Canadian Doctors for Medicare has a different, broader vision of a sustainable health care system, one that considers patients’ and providers’ needs, not just the minister of finance’s needs. Increasing the capacity for publicly funded and delivered health care, including innovative surgical programs, better primary care access, collaborative care, and universal pharmacare could help achieve sustainability. The BC government, however, is enacting a narrow vision and is setting the stage for health-care profiteering. BC residents should immediately let their MLAs know what they think of that.

Patients should be at the centre of the health care system

Re: Healing the system, Vancouver Province, Wed 02 Apr 2008, Page: A4

Dr. Day has it right; patients should be at the centre of the health care system. Unfortunately his prescription for getting them there - forcing competition between hospitals and private clinics - will put profit at the centre, resulting in unhealthy outcomes for most Canadians.

Patient-centred care requires collaboration, not competition. The British Medical Association has expressed serious concerns about the effect of competitive practices, as have doctors south of the border, a majority of whom now want a collaborative style national health insurance program[Annals of Internal Medicine]. The major side effect of competition in countries that allow private for profit care is that the benefits generally go to private hospitals, insurance companies, specialists and wealthy patients. Even Dr. Day's own organization the Canadian Medical Association has said private insurance for medically necessary physician and hospital services does not improve access to publicly insured services, does not lower costs or improve quality of care, can increase wait times for those who are not privately insured, and could exacerbate human resource shortages in the public system.

No doctor wants to see their patient languish on a waiting list. But reducing wait lists does not require the profit motive. It's being done across the country through queue management, improved primary care access and collaborative care models, resulting in dramatic drops in waits in such key areas as hip and knee replacements, cataracts and cancer care. We need a lot more of this.

However, it's also important to remember, that far from being at the bottom of the pack in providing health care – as Dr. Day often suggests - a recent study in Health Affairs by researchers at the London School of Hygiene and Tropical Medicine rated Canada sixth in the world in preventing death from treatable conditions, an excellent value for money.

Danielle Martin and Randall White
Canadian Doctors for Medicare

Majority U.S. Physicians support single payer national health insurance

A new survey [Annals of Internal Medicine] of US physicians has found that 59% support legislation to establish a single-payer national health insurance. A previous survey completed in 2002 found that 49% supported a single-payer program. The 10% increase in support during 5 years parallels the increase in uninsured Americans from 43.6 million in 2002 to 47 million in 2006, the last year for which a US Census Bureau estimate is available.

The survey, done by two Indiana University researchers, found that a majority of physicians in every specialty support single-payer universal coverage except surgical subspecialists, anaesthesiologists and radiologists.

The American Medical Association, which represents an estimated 19% of US physicians, has steadfastly opposed a single-payer model. The organization is perceived to represent all US physicians, but its diminutive membership and lack of leadership in addressing the crisis of the uninsured would seem to make it irrelevant. Because no countervailing organization has emerged to represent the other 81% of US physicians, the AMA could make a large difference in the debate by acknowledging these new survey findings endorsing a national health program. I think it would then reverse its membership decline, but I also think it highly unlikely the AMA will change its position.

The leadership of the Canadian Medical Association wants to move away from a single-payer system, and the procedural specialists are leading the way. The current president, an orthopaedist, and the president-elect, a radiologist, both advocate for privatization. This reflects the US survey findings, suggesting that highly paid specialists feel constrained by a publicly funded system.

In Canada, physicians face a dilemma. How can we prevent the discontented procedural specialists from taking us down a path that will be destructive to our single-payer, equitable system? Some of their grievances and frustrations are legitimate. Yet their ability to obtain operating room time, new equipment, and high remuneration should not undermine access to care for our patients, the majority of whom would find premiums for private care a serious financial burden or even unaffordable. Furthermore, we know from experience in Australia and the UK that private clinics flourish at the expense of the public system. We need to establish dialogue within the profession, but we also shouldn’t play nice indefinitely lest we find ourselves with a CMA that no longer reflects the values of most Canadian physicians.

Randall White, M.D.

Re: Quebec opens door to more private health care

The Castonguay Commission’s report on health care in Quebec recommends a number of pro-privatization solutions, including the sale of duplicate private insurance for medically necessary care.

In most provinces, such private duplicate insurance is illegal under the Canada Health Act. These findings were predictable from the outset given that Claude Castonguay was trained as an insurance actuary and was once President of the Canadian Institute of Actuaries. He is a longtime proponent of private health insurance coverage, increased private delivery of care, “double dipping” into both the public and private purses, and user fees.

In research analysis, we are trained to look for the inherent biases in a study before we accept the findings. When a study finds, for example, that “butter is good for you”, but it’s sponsored by the Dairy Association, we have to ask ourselves whether there is some self-interest in the conclusion. When a report of drug industry-sponsored research says that a drug shows a favourable outcome, we must question the safety and efficacy of the drug. Similarly, the perception of bias in Castonguay'’s support of private insurance makes all of the Commission’s pro-privatization and pro-market recommendations highly suspect.

Karen Palmer, Alan Katz, Nan Okun and Bob Woollard; Members of the Board of CDM-MCRP.