We can address the supply of surgical procedures, the demand for surgery and improve co-ordination within the system
By David Urbach
Expert Advisor EvidenceNetwork.ca
Canadians
treasure our single-payer, publicly-funded program of physician and
hospital care, virtually as a defining part of our national identity.
And yet, increasing legal and political pressure over quick access to
elective surgeries - cataract extraction and joint replacement, for
example - threaten to undermine that support.
And a case before the British Columbia Supreme Court
aims to topple provincial regulations that limit private payment for
medically necessary services, claiming that surgical wait times for
elective procedures such as arthroscopic knee surgery violate the
Canadian Charter of Rights and Freedoms.
The truth is that few people anywhere in the world are in love with their health-care system. Canada is no exception. Why?
Modern health care is expensive - so expensive, at C$5,900 per person per year in Canada, US$9,900 in the U.S. and £2,900 in the U.K., that it costs more than many people are happy to pay, whether through taxation, insurance premiums or out-of-pocket.
Many
Americans still lack health insurance and even insured Americans may
not be approved for every treatment they desire. Among developed
countries, Germany has the highest public support
for their health system but even there, 40 per cent believe the system
requires fundamental changes or a complete rebuild. Sound familiar?
But
this doesn't mean Canadians are doomed to long waits for elective
surgery forever. There's actually much that can be done fairly easily
without resorting to private payment. We can address the supply of
surgical procedures, the demand for surgery and improve co-ordination
within the system to gain significant improvements.
Increasing the supply of surgery can be achieved by paying hospitals using "activity-based funding"
payments for each procedure they do for surgeries like joint
replacements, rather than receiving an annual global budget in the hope
that they will meet the demand. Reimagining the way we use hospitals,
incorporating new anesthesia techniques and virtual care to transform common procedures like joint replacement to day surgery can reduce costs and free hospital beds to further increase the supply of surgical procedures.
The
demand for surgery is also elastic. Removing people who aren't in dire
need of surgery from waiting lists improves access for those in greater
need of services. It also prevents the overtreatment of healthy people,
which is rampant in many areas of medicine - 32 per cent of patients waiting for cataract surgery in B.C. had near-perfect vision, in just one example.
Ironically,
the case before the B.C. court - the most pressing legal challenge to
the constitutionality of Canadian medicare - is in part about access to
arthroscopic knee surgery, a procedure that might actually cause more harm than benefit in some patient groups.
Wait times in Canada may be long on average, but they're not long everywhere. Take the example of knee replacement surgery in Ontario.
At first glance, the waits certainly seem long: in 2017, only 78 per
cent of people had their knee replacement within the recommended six
months and 10 per cent waited longer than nine months. In spite of this,
half of all people actually had their surgery within three months.
Why is it that some people have surgery quickly and others wait?
Mostly
because there's little co-ordination of surgical practices. Long ago,
other industries adopted effective queue-management strategies that
prevent situations where some people wait much longer than others. Single-entry models
- where all people enter one queue and take the next available slot
once they get to the front of the line - smooth out the waits and
increase efficiency in banks, fast-food restaurants and at Disneyland.
Centralized
intake, triage and referral of patients to appropriate heath-care
providers - taking advantage of inter-disciplinary teams including
nurses and physiotherapists - would go a long way to reducing variation
in wait times and improving access to surgery.
Medicare
is not perfect, but it's still very good at providing excellent quality
care to all Canadians who become ill and require hospital and physician
services. Decisive action to improve wait times is necessary to
maintain the public confidence required to preserve our unique
health-care system for future generations.
The
good news is that this can be done by fixing medicare's problems with
surgical precision, without killing the patient in the process.
David R. Urbach, MD is an expert adviser with EvidenceNetwork.ca,
surgeon-in-chief at Women's College Hospital, Toronto and professor of
Surgery and Health Policy at the University of Toronto. He is also
senior innovation fellow, Women's College Hospital Institute for Health
System Solutions and Virtual Care (WIHV). |
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Monday, June 4, 2018
How to shorten hospital wait times in Canada
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