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    "When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov

    ''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.''
    -Robert Ehrlich, drug advertising executive.

    "Opinions are like sphincters, everyone has one." - Chris Rangel

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    Friday, September 24, 2004

    Canadians Respond: Evidently, Canadians aren't exactly in agreement about the state of their healthcare:

    Might I take a moment to "fisk" the comments from my fellow citizen. I'm not certain where this individual has been living lately but it certainly hasn't been inside the Canadian health care system.

    I think I can speak from a position of some knowledge. I am a nurse currently working on a PhD in a health related field. My husband is an overworked GP. Between us we have 40+ years of toiling in this system in two different provinces and have a number of family and friends working in various aspects of health care throughout the country. Anyway here goes...

    Canada has an enviable record of providing universal, quality health
    care at a reasonable price for the last half a century. But, as in
    every other country, our health care system is facing several strains:
    While we have a history of providing excellent care, currently we are not living up to expectations.

    The system is not just strained it is about to implode. There are not enough physicians (one town in northern Ontario has put paving its streets on the back burner in order to have money to recruit doctors - 80% of its citizens are without a primary care physician). We anticipate a severe nursing shortage in the next few years and presently do not have enough lab or x-ray techs to fill vacant positions. Why? In short, no one wants the jobs. How come if its such a great system no one wants to work in it?

    Soaring health care costs, driven by astronomical salaries paid to senior medical practitioners by competing private health-care providers in the US.

    Huh?? I simply just don't understand this comment. What private health care providers pay physicians in the US has no bearing on what provincial governments (the only real employer of physicians in Canada) are willing to pay. Government budgets have been under considerable constraint in the last few years and physicians have received only a few meagre increases in renumeration. In fact, their renumeration levels have not kept pace with other health care sector employees. Compared to their counterparts in the US, Canadian physicians are significantly underpaid.

    Disproportionally high usage of the health care system by Canada's
    exploding immigrant population.

    Might have a point here but its anecdotal only. I am unaware of any study that has quantified this. Ageing population needing more health services is a problem everywhere in the western world but particularly salient in Canada as compared to Europe - we had a larger baby boom.

    The answer of US-worshipping Canadian neocons is two-tier health care. Why, cries John Tory, the new leader of the hapless Ontario Conservative party, shouldn't Canadians have "choice" in their health care services? This is classic conservative re-framing of public debate. "Choice" in health care means choice for those who can afford it, which means doctors who want to make obscene amounts of money (including many of the best ones) would work for the higher-paying private-tier system and the rest of us would be stuck with long waits and second-class service, just like we face in every other private sector of the economy.

    Good lord, where do I begin. Let's start with the epithet "neocon". Then again let's not. I'm tired of trying to have a rational discussion with my fellow citizens about how the whole system is just crumbling only to confront the "neocon" argument. Oh, and by the way, reforming the system is not about physicians being able to make "obscene amounts of money". Somehow the argument always seems to return to this as well. Bottom line, Canada is the only country in the world that does not allow its citizens to spend their own money on health care. England, Australia, Germany, France (just to name a few) all have complimentary private systems and yet manage to have public systems that are (in many cases) superior to Canada's.

    Fortunately, and to the chagrin of the Canadian neocons, the vast majority of Canadians aren't buying this Orwellian deceit. Recent polls say support for a public, single-class health care system is as high as ever.

    Really? What polls? Last I saw people were actually warming up to the idea of a complimentary private system.

    So what's a civilized country to do to deal with the three great challenges of 21st century health care bulleted above? I recently listened to a talk show featuring the federal Minister of Health, discussing how these problems should be solved. Caller after caller said the same two things:

    Much of the work done by doctors should be transferred to paraprofessionals and to self-diagnosis and self-treatment. Much more
    information, expert systems and self-service equipment needs to be
    provided to enable this. [I spoke to two doctors who said they would
    love to do this, since the majority of the work they do does not
    require a licensed professional to do it competently -- but that the
    lawyers wouldn't let them do it.]

    Which paraprofessionals? I'd really like to know what he/she means by this. For instance, I would consider a nurse practitioner to be a professional not a paraprofessional and while they are a good idea there are a number of limitations. Remember that nursing shortage I mentioned previously? Well, if we turn more nurses into nurse practitioners who's going to take their place? Robbing Peter to pay Paul. Besides, it takes 5-6 years to create a nurse practitioner (4 years for a BScN then 1 to 2 years post grad training) so, we're not exactly going to have a glut of them anytime soon. Oh, and then there is the little problem of their scope of practise. Currently, most NP's do well baby care, prenatal care, uncomplicated diabetes management, uncomplicated HT management, colds, flu, etc. But, as we have already noted, the population is ageing. When was the last time you saw a someone over the age of 65 who needed well baby care or for that matter had uncomplicated diabetes? What the ageing population is going to need are more physicians with good internal medicine knowledge not more people who are limited to diagnosing otitis media.

    There needs to be a massive shift in the health care system from
    treatment to preventative care.

    Snort! And this pays off when exactly?? What do we do with all the boomers who have already smoked and eaten their way into chronci illness? Furthermore, the last time I looked there wasn't any preventive measure for growing old. In other words, if we sink a lot of money into prevention we might (just might mind you because after all we have to die of something) affect the health care budget in 2060.

    When the moderator asked the Minister whether he had learned anything from these recurring messages, he 'summarized' the discussion by saying that better measurement systems were needed to ensure hospitals were operating as efficiently as possible, and that the government was looking into ways to do public-private partnerships without allowing competition or giving up control over pricing and access. The interviewer was incredulous: Had the Minister not heard the two messages that the public had been bombarding him with for the past hour? Of course these things would be considered, he replied, but the first priority was to find ways to increase access without increasing cost. His deafness to these two obvious solutions to the malaise of the system was astonishing.

    See above.

    What one listener of this talk show said about neoncons' true motivation for wanting two-tier health care was also telling: "The reason rich politicians want a two class system is that they're embarrassed to have to wait in line for health services the same as 'ordinary' Canadians, when their US business colleagues can jump the queue so easily and have their company write off the extra cost as a business expense. They're also embarrassed that, to jump the queue,they have to fly to the US and pay out of their own pocket". So in fact there is a choice for the very rich to jump the queue: Pay for treatment in the private US system.

    Sigh. It's the neocons again (bad neocons, bad). Hate to tell him but, I don't think there is much of a queue to jump in the US. Also, I don't think embarrassment is the motivation here. Stark, cold fear maybe, but not embarrassment. Hell, median wait time to see an oncologist post cancer dx in Canada is 6 weeks. If I had the money, a dx of cancer, and was looking at at least a 6 week wait for treatment...Mayo clinic here I come.

    Is Canada's health care system the best in the world? Far from it. Health care in Canada's cities is much better than in rural areas. The bureaucracy in much of the system (notably the blood collection system and the 'walk-in' clinics) is suffocating, and needlessly so. And because of its zeal to protect jobs in the system, Canada, which ranks first in the world in per-capita patents of medical technology, ranks forty-first in the world in the use of modern medical technology in its hospitals (MRI equipment is as scarce as gold, for example).

    Again, I don't get what he means about bureaucracy and the blood collection system or "walk in clinics". I suspect walk -in-clinics run just the same up here as they do in the US. Child's got an ear ache and you don't want to wait 8 hours in emerg (or three weeks for an appointment with your overworked family physician) go to the walk-in.

    Canada is in thelower 1/3 in OECD countries when it comes to providing medical technology and sinking fast. But it's still an excellent system, and one that a two-class health care system won't improve, at least for 95% of the population. If only the politicians and bureaucrats only had the intelligence and vision to listen to the Wisdom of Crowds and make the two changes (more paraprofessional/self-care, and more prevention instead of treatment) that the public is already starting to make themselves, our system would be the best in the world.

    Excellent system? No access to technology, unacceptable wait times for treatment, professional bailing with no one to replace them, can't find a doctor - yep, that's my definition of an "excellent" system.

    Oh -- a word about prescription drug costs: You may have heard that
    many Americans come up to Canada to buy prescription drugs much cheaper than they can buy them in the US. Now, US municipal and state governments are fighting for the right to buy their drugs from Canada, too (and Kerry wants them to have this right). The funny thing is, the companies selling them are essentially all the same companies, since the Canadian pharmaceutical industry is dominated by the same handful of global corporations as the US industry. Why do these companies charge more in the US than the rest of the world for the same drugs? Not, as the neocons and the pharma industry are telling Americans, because Canadian drugs are inferior (perhaps, it is implied, dangerously so) -- they are the identical drugs. They sell them for higher prices in the US because they can. Drug companies charge as much as the market will bear, and in the bloated US health care system where if you have enough money you can buy anything, the market will bear a lot. In the rest of the world money available for drugs is much less, so to sell their products pharma companies lower prices by 30, 50, even 70%, and still make a good margin. This is a case where globalization threatens to backfire on some of the corporations that most benefit from it. Couldn't happen to a nice bunch of guys.

    You're correct on this issue. It's because provincial drug plans (they cover a significant amount of the cost of drugs for seniors, welfare recipients etc) determine what goes on their formularies (the drugs they will cover) they are able to bludgeon the drug companies into supplying the meds at a lower cost. In essence US drug consumers are subsidizing all the R&D that we eventually benefit from. I'm going to say thanks but somehow I doubt your grateful.

    And no, antibiotics aren't available without a prescription up here. My husband was flabergasted when we walked into a pharmacy in Mexico only to see just about every antibiotic he prescribes for sale over the counter. Ticked him off as well. Physicians here get a lot of grief about "over prescribing" antibiotics (implicitly blamed for increasing antibiotic resistence) when in many countries (Mexico obviously and according to his patients, much of Eastern Europe) they are OTCs. To the best of my knowledge about the only difference in prescription vs. non prescription meds between Canada & the US are some of the antihistamines (Loratadine and dimenhydrinate are OTC for instance).

    Anyway, sorry for the screed but I'm soo sick of my unenlightened fellow citizens who feel the need to flaunt their apparent health system superiority. Hate to tell them, but the emperor has no clothes.

    And about that "two-tiered" system, another reader notes:

    A comment from your Canadian correspondent caught my eye:

    Health care in Canada's cities is much better than in rural areas.

    Hmmm, and is that somehow NOT a "two tier system"? Looks like one to me.

    Well, then, what is to be done? Here'a a modest proposal. Let there be a government appropriation of the labor of physicians in the name of the people, and let physicians work for a compensation that the people deem fair. And let physicians, or other health professionals, be prohibited from working for any health care company that pays "astronomical" salaries. And let the government determine where each physician and health care professional will work - urban or rural, in the name of the people. And while we are at it, let laws be enacted to prevent those "high utilizing immigrants" from entering the country, and let us arrange to deport those immigrants who are guilty of high utilization. And finally let us ration the care for our seniors. This solves our cost problems, so we can then proceed building the world's finest health care system with the finest docs and hospitals.

    This reminds me of "The Doctor's Dilemma" - well, not Shaw's play actually, but his lengthy introduction, in which he argued for physicians to become public employees.

    Was Shaw so much ahead of his time, or is the set of proposals above so 100 years ago?

    Maybe the latter, considering Shaw believed vaccinations were dangerous. Oh, wait, that's a modern bugaboo, too. The more things change, the more they stay the same....


    posted by Sydney on 9/24/2004 08:11:00 PM 0 comments


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