Myths and demystificationMyths and demystification

• Canadian health care spending is out of controlCanadian health care spending is out of control– universal health care is unsustainableuniversal health care is unsustainable– health care crowding out other public spendinghealth care crowding out other public spending

• parallel privately funded care can shorten waiting parallel privately funded care can shorten waiting listslists

• the private sector always does it betterthe private sector always does it better– efficiency gains with private funding, for-profit deliveryefficiency gains with private funding, for-profit delivery

Health care system

Funding Delivery

Private Public PrivatePublic

For-profit Not-for-profit For-profit Not-for-profit

Myths and demystificationMyths and demystification• Canadian health care spending is out of Canadian health care spending is out of

controlcontrol– universal health care is unsustainableuniversal health care is unsustainable– health care is crowding out other public health care is crowding out other public

spendingspending

• parallel privately funded care can shorten parallel privately funded care can shorten waiting listswaiting lists

• the private sector always does it betterthe private sector always does it better– efficiency gains with private funding, for-profit efficiency gains with private funding, for-profit

deliverydelivery

Health Spending as % of GDP, Canada

5.0

6.0

7.0

8.0

9.0

10.0

11.0

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2006

Total Spending Public Spending

According to OECD

Source: OECD Health data, Organization for Economic Co-operation and Development (OECD) 2008

Total Expenditure on Health (% GDP) in 1992Total Expenditure on Health (% GDP) in 1992

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Czech RepublicJapan

UKPortugal

SpainNew Zealand

AustriaGreece

BelgiumAustraliaNorwayIcelandSweden

ItalyNetherlands

DenmarkFrance

SwitzerlandGermany

CanadaUnited States

Source: OECD 2004

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

LuxembourgHungary

SpainUK

NorwayAustralia

ItalyGreeceIcelandSweden

NetherlandsNew Zealand

DenmarkCanadaAustria

PortugalBelgium

GermanyFrance

SwitzerlandUnited States

Total Expenditure on Health (% GDP) in 2005Total Expenditure on Health (% GDP) in 2005

Source: OECD 2008

Isn’t health care eating up Isn’t health care eating up provincial budgets?provincial budgets?

• 19801980– health care 30% of Ontario budgethealth care 30% of Ontario budget

• 20042004– health care 45% of Ontario budgethealth care 45% of Ontario budget

• but public health care expenditure but public health care expenditure as % of GDP down, not up?as % of GDP down, not up?

General Gov't Outlays(From http://www.fin.gc.ca/frt/2008/frt08_e.pdf)

0

10

20

30

40

50

60

Per

cent

of G

DP

CanadaUS

What are we spending less What are we spending less on?on?

• educationeducation– universities from 0.5% GDP to < 0.18%universities from 0.5% GDP to < 0.18%

• employment insuranceemployment insurance– 80% eligible to 40% in Ontario80% eligible to 40% in Ontario

• social supportsocial support

• urban infrastructureurban infrastructure

• subsidized housingsubsidized housing

Ensuring sustainabilityEnsuring sustainability• wait time initiativeswait time initiatives

• centralization of listscentralization of lists• integration of care – specialized surgical facilitiesintegration of care – specialized surgical facilities

• interprofessional Careinterprofessional Care• right provider, right place, right timeright provider, right place, right time

• chronic disease managementchronic disease management• self-care pathwaysself-care pathways• home care and community-based carehome care and community-based care

• electronic Health Recordelectronic Health Record• duplication minimizationduplication minimization• safety and qualitysafety and quality

Examples of SuccessExamples of Success• Hamilton– 70% decrease in referrals to

psychiatrists

• Alberta • reduced wait times for hip and knee

replacements from 19 months to 11 weeks

• Sault Ste. Marie– 50% reduction in readmissions of heart

failure patients

• Nova Scotia South Shore• no ventilator associated pneumonias in

14 months

Is high quality universal Is high quality universal health care for all health care for all

sustainable?sustainable?• health care as % of GDPhealth care as % of GDP

– total stable over last 15 yearstotal stable over last 15 years- public even lesspublic even less

- Canada 2Canada 2ndnd 15 years ago, now middle of pack 15 years ago, now middle of pack

- tax cuts, not health spending, has compromised other tax cuts, not health spending, has compromised other social spendingsocial spending

- innovation can further increase efficiencyinnovation can further increase efficiency

- Romanow: Health care as sustainable as we choose it Romanow: Health care as sustainable as we choose it to beto be

Myths and demystificationMyths and demystification• Canadian health care spending is out of Canadian health care spending is out of

controlcontrol– universal health care is unsustainableuniversal health care is unsustainable– health care is crowding out other public health care is crowding out other public

spendingspending

• parallel privately funded care can shorten parallel privately funded care can shorten waiting listswaiting lists

• the private sector always does it betterthe private sector always does it better– efficiency gains with private funding, for-profit efficiency gains with private funding, for-profit

deliverydelivery

Logic and logical problemsLogic and logical problems• more money from private fundingmore money from private funding

– more resources, wait times shortermore resources, wait times shorter

• physician and nursing shortagephysician and nursing shortage– private funding won’t train moreprivate funding won’t train more– publicly funded facilities lose best trainedpublicly funded facilities lose best trained

• privately funded care can only exist if waiting lists for publicly privately funded care can only exist if waiting lists for publicly funded carefunded care

• affluent support for publicly funded care dependent on affluent support for publicly funded care dependent on participation participation

Access

Duckett. (2005). Australian Health Review 29. 87.

More private care More public care

Hurley et. al

Myths and demystificationMyths and demystification• Canadian health care spending is out of Canadian health care spending is out of

controlcontrol– universal health care is unsustainableuniversal health care is unsustainable– health care is crowding out other public health care is crowding out other public

spendingspending

• parallel privately funded care can shorten parallel privately funded care can shorten waiting listswaiting lists

• the private sector always does it betterthe private sector always does it better– efficiency gains with private funding, for-profit efficiency gains with private funding, for-profit

deliverydelivery

Private Funding is Inefficient

Total expenditure on health as a % of GDP

OECD Health Data (2007)

S Woolhandler Int J H Serv 2004;34:65-78.

Administration as % of Total HC Exp

0%

5%

10%

15%

20%

25%

30%

35%

US CAN

Administrative cost differenceAdministrative cost difference• developing insurance packagesdeveloping insurance packages

• selling insuranceselling insurance

• evaluating applicationsevaluating applications

• documenting use of servicesdocumenting use of services– hospital and physician officeshospital and physician offices

• assessing claimsassessing claims

• executive salariesexecutive salaries

• profitsprofits

Cost ControlCost Control•public paypublic pay

– physician services slight decreasephysician services slight decrease•15.4% 1991 to 13.4%15.4% 1991 to 13.4%

– hospital marked decreasehospital marked decrease•45% (1976) to 28%45% (1976) to 28%

•pharmaceutical increasepharmaceutical increase– 9% (1984) to 17.4%9% (1984) to 17.4%

Analysis of deaths considered “amenable to health care”in those under 75 years of age in 19 industrialized countries

Systematic review health Systematic review health outcomes in Canada and USoutcomes in Canada and US, ,

2007, 2007, Open MedicineOpen Medicine.. • 17 leading US/Canadian researchers17 leading US/Canadian researchers

• comprehensive search yielded 38 studiescomprehensive search yielded 38 studies• compared outcomes of conditions with identical diagnosiscompared outcomes of conditions with identical diagnosis

• cancer, cardiovascular disease, renal dialysis, cataracts...cancer, cardiovascular disease, renal dialysis, cataracts...

• 14 studies showed better outcomes in Canada14 studies showed better outcomes in Canada• 5/10 with broad populations, statistical adjustment5/10 with broad populations, statistical adjustment

• 5 studies favoured the U.S.5 studies favoured the U.S.• 2/10 high quality2/10 high quality

• 19 studies had equivalent or mixed results19 studies had equivalent or mixed results• 3/10 high quality3/10 high quality

SummarySummary

• single public pay more efficientsingle public pay more efficient– administrative efficienciesadministrative efficiencies– effective cost controleffective cost control

• single public payer cost-efficientsingle public payer cost-efficient– equal or better outcomes than much equal or better outcomes than much

more efficient U.S. systemmore efficient U.S. system

Health care system

Funding Delivery

Private Public PrivatePublic

For-profit Not-for-profit For-profit Not-for-profit

DebateDebate

• advocates of investor owned private advocates of investor owned private for-profit health care delivery arguefor-profit health care delivery argue– for-profit providers deliver care more for-profit providers deliver care more

efficientlyefficiently

• advocates of not-for-profit health advocates of not-for-profit health care delivery fearcare delivery fear– for-profit facilities compromise care to for-profit facilities compromise care to

maintain investors returnsmaintain investors returns

For-profit or not-for-profit?For-profit or not-for-profit?• for-profit initiativesfor-profit initiatives

– Ontario: home care, MRI/CT, P3 Ontario: home care, MRI/CT, P3 hospitalshospitals

– other provinces, surgical clinicsother provinces, surgical clinics

• systematic reviews systematic reviews – investor-owned for-profit vs nfp investor-owned for-profit vs nfp

• hospital death rateshospital death rates• dialysis death ratesdialysis death rates• hospital charges to payershospital charges to payers

Systematic review Systematic review and meta-analysisand meta-analysis

• systematic reviewsystematic review– focused questionfocused question– explicit eligibility criteriaexplicit eligibility criteria– comprehensive searchcomprehensive search– assessment of validity of primary studiesassessment of validity of primary studies– eligibility and quality assessments are eligibility and quality assessments are

reproduciblereproducible

• meta-analysis combines the results of meta-analysis combines the results of several studiesseveral studies

Screening processScreening process

• 8665 unique citations8665 unique citations

• teams of 2 individuals teams of 2 individuals – independently screened the titles and independently screened the titles and

abstractsabstracts

• 805 full text publications 805 full text publications – identified for full reviewidentified for full review

Assessment of study Assessment of study eligibilityeligibility

• masked results (i.e. blacked them out) masked results (i.e. blacked them out)

• teams of two individuals teams of two individuals – independently evaluated each masked independently evaluated each masked

article to determine eligibilityarticle to determine eligibility

• disagreements resolved by consensusdisagreements resolved by consensus

• agreement was excellent (Kappa 0.83)agreement was excellent (Kappa 0.83)

ResultsResults

• all studiesall studies– comprehensive search, top quality studiescomprehensive search, top quality studies– published in top peer-reviewjournalspublished in top peer-reviewjournals

• hospital mortalityhospital mortality– 38 million patients between 1982-199538 million patients between 1982-1995– 2% more deaths in for-profit2% more deaths in for-profit– 2,000 deaths in Canada (MVA, cancer, suicide)2,000 deaths in Canada (MVA, cancer, suicide)

• dialysis mortalitydialysis mortality– 500,000 patient years 1973 to 1997500,000 patient years 1973 to 1997– 8% more deaths in for-profit8% more deaths in for-profit

• charges 19 greater in for-profitcharges 19 greater in for-profit

Summary: overall

• pressures on health spending but:– Canada better than most other countries– problem is tax cuts, not health spending

• private pay won’t shorten waiting lists– will just make ability to pay, rather than

need, the criterion to get to the front

• single payer maximizes efficiency– not-for-profit more efficent than for-profit