MEDICAL REFORM Newsletter of the Medical Reform Group Issue 125 Volume 22, Number 4 Spring, 2003 NEXT STEPS ON ROMANOW Rosana Pellizzari
t has been just over 4 months since marked to address urgent needs like reminded Ottawa of his Commissioner Romanow submitted waiting lists, could easily be squandered, recommendation that the federal Ihis final report to the House of and that the bulk of the promised funds government pay for 25 per cent of health Commons, and 2 months since the First will not be accessible until late in 2003, care funding by 2005-6. Ministers signed the 2003 Health Accord. jeopardizing the possibility to move The 2003 Health Accord commits “The Health Accord is a major first step forward and creating delays in governments to establish a Health Council in fixing Medicare”, Mr Romanow told implementation. by May 5, 2003. Mr. Romanow warned the Standing Committee on Health at its Mr. Romanow went on the warn the that the Council should not be an April 3rd meeting in Ottawa. He outlined Committee that the Health Accord could additional layer of bureaucracy. Given its his reasons for his support. be rendered ineffective if there wasn’t important role, he warned that the First, he believed the Accord affirmed urgent attention given to building health mandate, membership, resources and the five principles of the Canada Health infrastructure and the expansion and agenda should be very thoughtfully Act. They recognized the need for greater “alignment” of health human resources. determined. accountability and transparency by He urged the federal government not to In the question and answer period which replacing the current federal transfers with lose sight for the need to address chronic followed, Judy Wasylycia, MPP for a dedicated Canada Health Transfer. illness by investing in strategies to prevent Winnipeg North and former NDP health According to Mr. Romanow, the obesity, diabetes and sedentary lifestyles. critic, expressed disappointment that the agreement not only heralded new federal He recommended a national and federal government did not officially investments, but also outlined consensus coordinated strategy. adopt the recommendations of the on targets and objectives, and led to a As he had in his report, Commissioner Commission as a blueprint. She asked Mr. commitment on the First Ministers part Romanow reminded the Standing Romanow to comment on the private/ to monitor population health and direct Committee for the need to “modernize” public funding of health care. To this, Mr. Health Ministers to address disparities in the Canada Health Act to include Romanow responded that there was no health status. homecare and prescription drugs. He evidence to support private funding, and But the outcome that proved most that he hoped that provinces would set significant to the Commissioner, was the INSIDE ideology aside in order to do the right agreement to form a Health Council to thing. facilitate and direct the many Doing the right thing, though, seems far recommendations made in his report. from the practice here in Ontario, where However, Mr. Romanow warned the the Tories seem committed to proceeding Committee that the money in the Accord, PJ's Adventure...... 3 with their private-public hospital purported to be between $30 and $35 Ontario Election...... 4-9 partnerships and the privatization of billion over the next several years, is less US Study Tour...... 10 MRI testing. Beyond ideology, according th than he recommended, and less than A Member Returns...... 17 to an NDP media release on January 28 , recommended in the Senate’s report, Guyatt Columns ...... 11-12, 18 it’s probably political donations that fuel chaired by Senator Kirby. He warned that the privatization in Ontario. Three Principles & Policy...... 13-16 the details for the $16 billion health companies bidding on the Royal Ottawa reform fund were sketchy at best. That Hospital all donated to the Tories: Health the $2.5 billion immediate “top-up, ear- (continued on page 2) Medical Reform Group, Box 40074, RPO Marlee Toronto, Ontario M6B 4K4 NEXT STEPS ON ROMANOW (continued) MedicalReform Medical Reform is the newsletter of the Medical Reform Group of Ontario. Sub- Minister Tony Clement received $10,000 But it is a small one. If our politicians scriptions are included with member- from Aecon, $2,500 from Borealis are to keep on track, and the Health ship, or may be purchased separately at Infrastructure and $2,500 from Ellis Don. Accord does not even keep on the $50 per year. Arrangements to purchase Borealis also donated almost $5000 to the track of 25% federal health care multiple copies of individual newslet- Conservative Party. funding by 2005-6, it will require the ters or of annual subscriptions at re- duced rates can be made. NDP research has uncovered that Aecon, vigilance of citizens and activists Articles and letters on health-related Borealis, Ellis Don, and two other Tory across the country. Clearly, the next issues are welcomed. Submissions Party funders, SNC and PCL, are all step is the formation of the Health should be typed, or sent by e-mail to involved in the bidding for the private Council in early May. The way in
2 Medical Reform Volume 22, Number 4 - Spring, 2003 PJ’S VERY EXCELLENT ADVENTURE Janet Maher
teering Committee member PJ PJ: Sure. And I want to note that this is As it turned out, this research was being Devereaux reflected recently on his part of on-going work which has had the completed just as health commissioner Sexperience as the lead researcher on participation of many other MRG Roy Romanow was completing the the series of investigations on investor members (Gordon Guyatt, Ted Haines, investigative part of his inquiry and we owned private for-profit health care at Ahmed Bayoumi, Deborah Cook, David presented him with the findings. He was McMaster University that have kept him Haslam, and Maureen Meade) besides impressed and stated publicly that he at the centre of one of the most myself. thought the findings were compelling and contentious health care debates in many The point of our first two systematic directly relevant to Canada years. He spoke recently with Janet Maher, reviews was to look precisely at the issue The second systematic review focused on on the lessons of that work. of health outcomes in investor owned investor owned private for-profit versus private for-profit versus private not-for- private not-for-profit death rates in the JM: Can you explain to me what led to profit health care facilities. As stated above outpatient setting. In this study we used the systematic review? a systematic review provides the clearest the example of dialysis care and the results answer to any research question by bringing were published in November by the PJ: I was reading the book “Clear Answers” together all of the high quality studies that Journal of the American Medical by Kevin Taft and Gillian Steward and I have addressed our research question. Association.The findings were consistent was struck by a passage in the book that Because we did not want to introduce any with our first systematic review (that is the described part of the debate in the Alberta bias into the selection process of studies investor owned private for-profit facilities legislature over bill 11 (the private for- addressing our research question we had higher risk adjusted death rates profit health care delivery bill). In the trained personnel to remove the results compared to the private not-for-profit debate an opposition member stated there from the studies with a black marker. facilities). were studies suggesting investor owned Our eligibility criteria were based on the private for-profit health care was more design and methodology of the studies not JM: Can you describe the reaction on the expensive and resulted in poorer health their conclusions. Therefore, after this second round? outcomes. Ralph Klein remarked you ‘masking’ process we then evaluated the have your studies, we have our studies. studies in duplicate to determine if they PJ: Given that this was the second time The implication of his comment is that fulfilled our eligibility criteria. As a result around for us with essentially the same one can learn little from empirical studies. of this process we could not select studies message—death rates are demonstrably Upon reading this I realized that health based on their findings/conclusions worse in the investor owned private for- policy had failed to learn the lesson that because we were unaware of them. profit settings—and that both Romanow medical research had learned 20 years The first systematic review focused on and Senator Michael Kirby were hotly earlier. The lesson being that the clearest hospital death rates and we began by debating this very issue as they prepared answer to any research question comes reviewing over 8,000 citations of studies their reports for public release, meant that from bringing together all of the high Through our masking procedure described I was given a lot of opportunities to quality studies that have addressed the we identified 13 publications of 15 studies discuss our results with many varied types question of interest. This process of that fulfilled our eligibility criteria and were of people across the country. In addition undertaking a ‘systematic review’ enhances included in our hospital mortality study. to speaking to and debating with health the statistical power available to correctly This systematic review demonstrated researchers at universities and hospitals answer the research question and enhances higher death rates in the investor owned across the country, I was also invited to our ability to avoid assuming chance private for-profit hospitals and was share my findings with grassroots activists, findings are real. published by the Canadian Medical advocates and the public at large at several Because there were no true ‘systematic Association Journal in May of 2002. forms in a number of provinces, and in reviews’ to inform this important health Because our findings challenged the Quebec, in a special conference on health policy issue, and the unsupported but prevailing accepted wisdom at the time it care at the National Assembly, attended nonetheless prevailing accepted wisdom in caused quite a stir. This stir was intensified by leading provincial bureaucrats. the media was that everything that was because our results suggested a change to private in health care was better we investor owned for-profit hospitals in JM: I seem to remember hearing of a decided to undertake a systematic review Canada would result in an extra 2200 challenge with Alberta premier Ralph to inform the issue. deaths annually and this is in the range of Klein—what happened there? how many Canadians die each year from JM: Can you explain the design of your colon cancer, motor vehicle accidents, or research? suicide. (continued on page 4) Volume 22, Number 4 - Spring, 2003 Medical Reform 3 PJ’S VERY EXCELLENT ADVENTURE MRG STUDIES (continued) PROVINCIAL PJ: Well, shortly after the second study member of the board of directors of a results were released, I was invited to giant investor owned private for-profit ELECTION Alberta by the Friends of Medicare for a nursing home company may have had series of public meetings and university something to do with his decisions. . CHOICES IN lectures in Calgary, Lethbridge and ONTARIO Edmonton. The Alberta media asked if I JM: You speak powerfully of the role of had any message for their premier, long the media in this affair. I wonder if you reputed as an advocate for opening health can speculate a little on why you think they The coming provincial election gives Ontarians care to investor owned private for-profit initially paid little attention, and then turned some important choices—particularly in regard health care. I indicated I was keen to speak out to be so helpful in spreading the word? to the future of health care. We present here a to him, either publicly or privately, to summary of the issues and approaches members summarize the results of our research and PJ: Well, I think there has been a systematic can expect to see debated as the election process its implications for his plans. undermining of everything in the not-for- moves into high gear. This was personalized by the media in the profit sector, be it public or private, following days as a challenge to Premier throughout the last few decades. It is to Klein, carried by the media there directly the point that the majority of people (and to the Premier. He eventually declined, definitely the media) think everything in CRITIQUE OF THE pleading the pressure of his preparations the not-for-profit sector is slow and NDP HEALTH for the first ministers meeting on health. inefficient and everything in the for-profit sector is lean mean and efficient. I believe PLATFORM JM: I know you had a direct meeting with this characterization is inaccurate and Gordon Guyatt Romanow, and presented to his hearings. essentially the result of the fact that the How did you get through to Kirby? not-for-profit sector is under a completely different level of scrutiny than things in he NDP presents its program PJ: Well, directly, not much at all [MRG the for-profit sector. The media and public in the form of 10 “practical member Joel Lexchin appeared on our have enormous access to information on solutions” to Ontario’s health behalf at the Toronto hearings held by the running and management of our not- T care problems. I’ll use their structure and Kirby in the fall of 2001 prior to our for-profit institutions whereas it is systematic reviews coming out]. completely the opposite case with the for- comment on the first seven, adding As with Romanow, we were eager to profit institutions. In fact the for-profit some comments on what is missing and communicate our results, and sought sector has no obligation and no desire to a bottom line conclusion. meetings with Kirby, but he declined, share any information, other than their though that did not stop him commenting successes, with the public/media. It is not Make sure feds pay their fair share on the results. Kirby felt our research was until things have gone so awry (e.g. This recommendation is one with which important enough that he commissioned ENRON, Worldcom) that we final hear every provincial party, whatever its a review by an economist associated with that a for-profit institution has squandered political stripes, will agree. There is the Atlantic Institute for Market Studies. the savings of hundreds of thousands of nothing to lose in criticizing the federal Basically this economist tried to use people. Because of the differential access government, and no cost to the promise anecdotal evidence to dismiss our findings to information it is not surprising, but to fight for more money. Beyond that, which is what our research is all about nonetheless disappointing, that the media any provincial government that doesn’t avoiding (that is he failed to understand initially was if anything supportive of proceed with further tax cuts is on very that it is only through a systematic bringing investor owned private for-profit health strong ground demanding more federal together of all of the high quality research care. money. evidence that we can understand the true Why I think the media publicized our The NDP is correct in its analysis that effect). research so much was the media loves the federal-provincial accord came up It would seem somewhat surprising that controversy and our research flew in the short in terms of the new federal if Senator Kirby was sincere in his desire face of the accepted logic and it was a funding that Roy Romanow recom- to understand this issue that he would not national hot issue of debate. What is mended. While their enthusiasm for have asked us about our research or more extremely heartening is that our work has further tax cuts compromises any high importantly asked us to respond to his gone a huge way toward reversing the moral ground the Conservatives might commissioned report on our study. misperceptions that investor owned health claim while making this demand (after Senator Kirby’s conflict of interest as a care is superior.♦ (continued on page 5) 4 Medical Reform Volume 22, Number 4 - Spring, 2003 CRITIQUE OF THE NDP HEALTH PLATFORM (continued) all, if you are cutting taxes, where is the cheating government programs and That is what has happened in Britain, desperate need for federal money for agreed to pay a total of $1.7 billion in which has conducted the largest health care?) the NDP’s disinclination to fines and penalties, the largest fraud experiment with P3 hospitals to date. tax-cut makes their argument stronger. settlement in U.S. history. Another large Ultimately, resources that should go to investor-owned for-profit chain, patient care end up in the pockets of Cancel private MRI and CTs National Medical Enterprises (NME), private financiers. While their terminology leaves something suffered a fraud conviction with a total While the NDP is on strong ground in to be desired (we would prefer clearer settlement of $379 million. opposing the P3 plan, whether they distinctions between funding and These examples, while among the largest, would be able to make good on their delivery, private for-profit and private are not unusual. The U.S. Justice promise to cancel the proposed deals not-for-profit, and between investor- Department estimates that $100 billion, depends on what the government has owned and small business models of for- or 10 per cent of the $1 trillion Americans signed by the time they lose office (if, profit health care provision) the NDP’s spend on health care each year, may be indeed, that is the outcome of the strident opposition to for-profit lost in fraud. When health care delivery election). provision is on strong evidentiary is a business, fraud is often too easy, and ground. A systematic review of all high- too tempting. Ontario puts itself at risk End home care privatisation and “ensure quality studies comparing private for- of such fraud, and the cost of adequate support” for the elderly profit and private not-for-profit hospitals prosecuting and policing it, when it moves The Tories have engineered a dramatic done by a team of researchers led by to investor-owned for-profit health care change in the home care sector, which McMaster cardiologist and MRG steering provision. has moved from largely not-for-profit committee member PJ Devereaux, The NDP’s proposal to eliminate provision to largely investor-owned for- showed higher death rates in for-profit investor-owned for-profit diagnostic profit provision. The same arguments I hospitals. Devereaux’s second systematic facilities is well justified. outlined above with respect to diagnostic review demonstrated similar higher death services support the NDP plan to move rates in largely outpatient for-profit Cancel P3 hospitals back to not-for-profit providers. dialysis facilities in comparison to not- Public-private partnerships reflect a The NDP platform implicitly promises for-profit facilities. growing movement in hospital financing. more resources for home care, without The consistency of these findings, the fact The Ontario Tories are currently planning being at all specific about how much is the plausible biases in the original studies two new hospitals, one at the Brampton needed, or how much it will cost. The were against the not-for-profit providers, campus of the William Osler Health proposals are in line with Roy Romanow’s and the easily identifiable mechanism (15 Centre and another at the Royal Ottawa recommendations and, if implemented, per cent or so of total income that not- Hospital, that would be designed, built, might not only provide much-needed for-profit providers can spend on patient financed, owned and operated by the support for family members providing care must go, in for-profit firms, to private sector. The hospital board will use care, but ease the burden on ensuring that investors get their anticipated public money to lease the hospital from overcrowded hospitals by facilitating return on income, necessitating corner- its owners. out-patient management. cutting in delivery of care) all suggest a The idea of these public-private valid and generalizable finding. partnerships (P3s as they are called) is to Establish 100 new community health centres The likelihood that investor-owned for- help governments raise money to pay for (CHCs) profit providers will, to ensure profits, public services, such as hospitals, which While the evidence supporting compromise on quality of care, require massive start-up investments. We’ll multidisciplinary integrated health care is ultimately yielding adverse patient be able to build more hospitals, not strong, the logic is sound, and over outcomes, is not the only reason to shun advocates argue, if private dollars are two dozen reports in the last two decades for-profit provision. For-profit hospitals available for initial funding. (including both Romanow and Kirby) in the U.S. have an unenviable record of The argument doesn’t hold up, in theory have recommended the transition. The health care fraud. The biggest American or in practice. The problem in theory is number 100 chosen by the NDP is no fraud bust involved the nation’s largest that public borrowing is always more coincidence–that is the number of for-profit hospital chain, then known as expensive than private borrowing, and communities that have let the Columbia/HCA Healthcare. At the end so the government will end up paying government know they would provide of 2000, the company pleaded guilty to the additional costs of private financing. (continued on page 6) Volume 22, Number 4 - Spring, 2003 Medical Reform 5 CRITIQUE OF THE NDP HEALTH PLATFORM (continued) local support for community health this one is more challenging. We have little The NDP has read the Romanow report centres. The NDP action would evidence to tell us what minimal staffing well. Their proposals are completely constitute a welcome change from the standards would be appropriate, and consistent with the report. Of particular effective freeze on CHCs which has evidence that quality monitoring note is the absence of any mention of characterized the Tory period in power. improves outcomes is, at best, limited. increased support for hospitals. This is Implementing this proposal intelligently consistent with Romanow’s virtual Cut medical school tuition, more full-time nursing would likely prove challenging. omission of hospitals from his report, and nurse practitioner positions and with evidence that suggests that Medical student tuition has risen to Streamline training and accreditation of foreign increases in hospital spending can absorb outrageous levels of well over $10,000 trained health professionals huge amounts of health care dollars per year in most Ontario univerersical In private conversations, NDP while producing little benefit. schools, compromising access to young representatives acknowledge the At the same time, hospitals need a people from low-income backgrounds. problem that facilitating jobs in Ontario government that will provide a plan for The NDP proposals regarding nursing for foreign-trained physicians risks, in realistic and stable hospital funding. care go hand-in-hand with their proposal many instances, the rich robbing the Perhaps the NDP’s mention of better for CHCs which one would expect poor. On the other hand, having large working conditions for nurses implies a would be the largest employer of an numbers of foreign-trained physicians in promise for expanded hospital funding. increased volume of graduating nurse Ontario unable to qualify while many Certainly, to deal with increases in nursing practitioners. Ontarians can’t find a family doctor is incomes and job situation that would problematic. Facilitating system entry make hospitals more attractive to nurses Roll back long-term care fee increase and remains questionable until we can be will require substantial increases in introduce tough standards for long-term care assured that the policy will not encourage hospital allocation. institutions, hospitals, and community care a flight of trained health professionals Paying for long-term care by direct from less prosperous nations to Canada. The Bottom Line charges to recipients and their families is, Roy Romanow’s recommendations were in effect, a special tax on the dependent What is Missing from the NDP proposals? well thought-out and largely evidence- and their support systems. Paying for The NDP platform fails to get specific based. The NDP proposals are long-term care through taxes is a more about the costs of their proposals. While completely consistent with the report, and equitable way to provide the needed disappointing, one can understand that provide initiatives in the right areas of resources. to do so would be challenging, and may health care delivery. A government that As with other aspects of their platform, not make sense politically at this stage of implemented these proposals would lead the NDP provides little detail about the incipient campaign. Given Ontario’s to a better-functioning health care system exactly what their proposal to implement economic situation and the NDP’s lack in Ontario.♦ ¨tough standards¨ would actually mean. of interest in tax cuts, funding the While it isn’t difficult to read between proposed expansion in health care should the lines in other aspects of the platform, not be problematic. THE LIBERALS: STYLE OR SUBSTANCE Ted Haines
he introductory photo has leader Romanow Commission. Here they set up believes in more private health care. They Dalton McGuinty grinning at a a contrast with the Tories. allowed private MRI and CT clinics, Tpatient’s bedside. For citizens who ‘Privatization takes us backward, to an era opened the door to private hospitals, cut are weary and wary of political messaging, when we received only the care we could homecare services and raised fees for the meaning of the image may be pay for out of our pockets. Romanow seniors living in nursing homes.’ ambiguous. And a close look at the called on us to strengthen our public health They characterize the Harris-Eves agenda Ontario Liberals’ proposals suggests that care system, not give up on it. To as one of ‘creeping privatization’ and cite while they are impressively crafted, they modernize, not privatize, Medicare. We Romanow (and indirectly the work of are lacking in cohesion and substance at couldn’t agree more.’ Devereaux and others) that there is no key points. Their touchstone is the And…‘The Harris-Eves government (continued on page 7)
6 Medical Reform Volume 22, Number 4 - Spring, 2003 THE LIBERALS: STYLE OR SUBSTANCE (continued) evidence that this ‘will deliver better or and to fund more positions for nurse practices; cheaper care, or improve access (except, practitioners. ‘Our goal is to have 70 · Replacing Ontario’s coal-burning perhaps, for those who can afford to pay per cent of registered nurses working plants, the biggest single sources of out of their own pockets).’ full-time, up from only 50 per cent air pollution, with cleaner energy Indeed, they promise to ‘cancel the Harris- today’; sources. Eves private clinics’. Instead they will · Working ‘with medical schools, It all sounds admirable, but on a bit of support the expansion of diagnostic universities and colleges to prepare scrutiny, gaps appear: imaging services in hospitals, noting that new professionals to practice in family · Recognizable obfuscation around ‘many communities have already raised health teams’. They recognize that ‘privatization’. You won’t find the money for a new MRI or CT for their students who live or train in under- terms ‘investor’ or ‘profit’ in their local hospital, but have been denied serviced areas are more likely to platform, whereas the evidence is that operating funds by the Harris-Eves practice there and so promise to profit-taking is the key to the adverse government.’ ‘accelerate the development of the effects on health outcomes in for- Other measures proposed ‘to strengthen Northern Ontario Medical School and profit facilities, rather than private our public health care system’ include: the Windsor medical school satellite versus public ownership status as such; · Providing adequate multi-year funding campus.’ There is talk in generalities · Lack of clarity on P3 (‘Public-private for hospitals and health sciences of making ‘medical tuition more partnership’) hospitals. They say that centres; affordable’. They intend to increase Harris-Eves ‘opened the door to · Intention to ‘invest in home care’. ‘We medical school enrollment by 15 per private hospitals’ but don’t indicate will remove the arbitrary Harris-Eves cent and also increase the number of what their approach will be; limits on homecare. If you require family medicine residency positions. · Lack of mention of funding sources care and want it in your home, and A creative notion is to provide loan for hospital support and the various that care costs less than sending you forgiveness to students who choose ‘investments’ promised. No reference to a hospital or nursing home, we will to train in family medicine. There is is made to advocating for an make sure you get it’. They further general talk of removing barriers to appropriate level of federal state: ‘Our long-term vision is to make practice for qualified foreign-trained contribution; homecare a medically necessary physicians. · Lack of intention to deal with the service’; The Liberals further demonstrate some destructiveness and inefficiencies of · Improving standards for nursing forward-looking, provocative thinking and competitive bidding through homes. The Tories had removed understanding of the significance of health Community Care Access Centres, for provisions that nursing home residents determinants with proposals such as: example, for home care services, or receive at least 2.25 hours of nursing · Creating a ‘Family Medical Leave Act with the massive expansion of care daily and 3 baths per week; these to provide up to six weeks of job- investor-owned for-profit provision in will be revisited. In addition, the protected unpaid leave to help you this sector; Liberals propose better regulation of care for a member of your family’; · Intention to pass a ‘Commitment to nursing homes. Licensing and · Intention to ‘invest in community Medicare Act that will make inspections systems are currently in mental health agencies to improve universal, public Medicare the law in disarray. Further, they will ‘cancel the services, including family self-help, Ontario’ but what for? Where does Harris-Eves 15 per cent increase in crisis intervention and community that leave the Canada Health Act? And nursing home fees’; treatment’ as well as supportive in general, apart from respectful · Establishing 150 ‘family health teams’ housing for those suffering from mention of Romanow, the Liberals across Ontario. The Liberals will work mental illness. Here they refer to the offer no specifics of how his with communities to create such links between inadequate mental recommendations will be implemented ‘teams’ that meet local requirements. health services and homelessness; in Ontario or of cooperation with the While there is no specific reference · Restoring the nutritional allowance for federal government and provinces. to Community Health Centres, they expectant mothers on social These deficiencies raise doubts about mention as a ‘Success Story’ the assistance, cut by Harris-Eves; where the Liberals really stand on genuinely Group Health Centre of Sault Ste. · Banning the sale of junk food in acting on publicly funded, not-for-profit Marie. They talk of improving elementary schools; health care. In the photo, the patient is incentives to attract and retain doctors · Mandatory daily physical activity in grinning back at McGuinty: the patient may for under-serviced communities; schools; have more insight into his policies and · Intention to ‘hire 8,000 new nurses’ · Promoting healthy workplace postures than McGuinty realizes.♦
Volume 22, Number 4 - Spring, 2003 Medical Reform 7 LET ONTARIANS DO THE MATH Janet Maher
s our current government in average of $475 for nearly a million case of health; and despite the power, the Ontario Tories have senior households; recommendations of Rozanski in the Athe advantage in timing the next the remaining tax cuts are focused on the case of schools; all of which indicated provincial election to their best advantage. corporate tax payer. pressure points for funding which had In the absence at press time of a formal These include been neglected in the previous 5 years, campaign platform, we can get a few • the further 10 per cent reduction in the regime of stable core funding is slated ideas of the direction they can be capital tax, and by the finance minister to grow over the expected to take from the 2003 budget. • a range of more specific tax next three years only at roughly the rate One of the recurrent themes of the incentives to support industry-based of inflation. March 27th budget was accountability— innovation and skills training, and new In her speech, Ecker indicates that this of the federal government, of hospitals, energy generation. commitment is for continuing core schools and universities and As well, the chair of management board services based on current service volumes municipalities, but remarkably little has been instructed to find and eliminate and other funding decisions. She further regarding the provincial government an additional $500 million in waste in notes that “any additional funding will itself—perhaps not a surprise given the government waste. be subject to three key factors: economic cynical relocation of the presentation of Specifically in the area of health, the growth, the level of federal government the budget from the legislature to a Tories expect the additional $2 billion they support and results to be achieved corporate shop floor deep in the heart will spend on health over last year will through greater accountability,” a process of the 905 region. include spending of of setting targets and benchmarks she The sale of hydro assets gets hardly a • Approximately $275 million for will work with hospitals, school boards, mention. Still the budget presented by physicians and other health care colleges and universities to achieve. Finance Minister Janet Ecker manages to providers in the implementation of The government has reserved for its next touch some of the hottest buttons on primary care reform budget a “dialogue” with municipalities, the minds of Ontarians this spring. Will • Almost $200 million to cover higher the fourth agency traditionally supported there be health care for me and my family utilization of Ontario drug programs by provincial transfer payments, with the when I need it? Will my child get an objective of completing a multi-year • A further $193 million for diagnostic education at primary, secondary, post- funding agreement with them for the and medical equipment upgrades secondary level and be competitive in the cost sharing of municipal services. In the • $250 million for a 5 year 21st century? How much will it cost? interim, they have found some funds to comprehensive mental health reform As the Finance Minister reminded several enhance municipal infrastructure in the • times during her budget speech, the initiation of a $1 billion Cancer area of clean water and waste government sees itself as continuing the Research Institute of Ontario management, primarily in small towns Harris legacy in that “tax cuts are the key • enhancements and expansion of and rural districts. to [our] prosperity.” In addition to long-term care facilities to address In spite of passionate pleas from friends • the personal income tax cut of 20 persistent bottlenecks in hospitals and of the government on the need to invest per cent promised and then existing long term care. in programming for the early years, the withdrawn last year reannounced for Perhaps what is claimed as the most only new spending announced for the 2004; interesting innovation is the children’s services sector is an increase of implementation of stable multi year • the readjustment of the floor for some $200 million targeted to the funding for continuing core services in the provincial surtax to $75,000 protection of children at risk of neglect colleges and universities, schools and taxable income; and abuse and support for the families hospitals. This has been a bone of • additional support of an average of of children with autism. contention for years with the so-called $300 for 165,000 caregivers of seniors On the day after the budget and writing transfer agencies, and will certainly be and persons with disabilities; and on behalf of the Ontario Alternative welcome. • rearrangement of tax credits for Budget Group, labour economist Hugh What is notable about this funding is that Mackenzie charac-terized the provincial seniors to reduce the education despite the anticipated pressures of the portion of property taxes by an government proposals in the following double cohort at colleges and universities; terms: despite the findings of Romanow in the
8 Medical Reform Volume 22, Number 4 - Spring, 2003 LET ONTARIANS DO THE MATH (continued)
Tax cuts are front-and-centre — cuts with $300 million, or 3per cent for 2004- be implementing Rozanski. In fact, it a full-year cost of over $1 billion…. The 5…basically only inflationary cost is doing the opposite. The projected tax cut projections don’t include the increases since 2002-3…[with funding for school boards over the ultimate costs of reductions promised little…to address the financial crisis next three years will deliver roughly in this budget, but not fully implemented that hospitals are in today…. 55% of what Rozanski yet. It doesn’t count the corporate What the government didn’t say is that recommended. And by 2005-6, when income tax cuts that have been put back it took $967 million of the new Rozanski will supposedly have been on line, effective January 1, 2004. That Federal money announced in February, fully phased-in, the school system will schedule will result in a reduction in 2002 in advance and used it to offset be more than $1.6 billion behind corporate tax revenue of $2.6 billion by the revenue loss from the fact that they what Rozanski recommended. That the time it is fully phased in… didn’t sell Hydro One. compares with the catch-up funding [According to Mackenzie, the March In post-secondary education, that Rozanski recommended of $1.4 27th budget..] doesn’t count the cost operating grants are projected to billion (a total of $2.1 billion, $700 of eliminating Ontario’s personal increase by $200 million in 2003-4; million of which was new income surtaxes — what used to be another $200 million in 2004-5 and investments). called the Fair Share Health Levy. $100 million in 2005-6. This increased Elementary and secondary education When the surtaxes have been funding, however, falls far short of funding will be $200 million further eliminated completely, they will cost what is needed to enable these behind it was when Rozanski was Ontario $3.1 billion — 94% of which institutions to meet the challenges of appointed, using Rozanski’s logic and will go to the 5% of taxpayers with the double-cohort and avoid further method. incomes over $100,000 a year. cuts to other programs. Based on Eves is counting on the good will of On the expenditure side, the current projections for increased Ontarians when they see commitments Government makes a lot of noise enrolment in 2003-4 and beyond, to the pressure points like primary care about new investments in health care; $200 million in additional funding will reform and water safety. The coming elementary and secondary education; not even accommodate the increased election will be the testing ground for and colleges and universities. enrolment, leaving nothing to deal with his estimation that Ontarians will pay Announced multi-year funding for the impact of increased costs. more attention to what he says than what hospitals provides increases of $500 In elementary and secondary he does.♦ million, or 5 per cent, for 2003-4 and education, the Government claims to AMERICANS STUDY CANADA: THE AMSA COMPARATIVE HEALTH POLICY TOUR
Gary Bloch “[The tour] gave me a firsthand look at the Canadian health care system. Now when I talk to people about single-payer, I can say ‘I’ve been there, I know it can work, because I’ve seen it working.” — American medical student
n January, the Medical Reform exciting validation for our efforts to students from the University of Toronto. Group hosted a group of medical preserve a single-payer, equitable The following day was spent in Toronto, Istudents from across the United approach to providing health care for with presentations by experienced health States, representing the American Canadians. care providers on medical and surgical Medical Student Association, on a study The group began their tour in Hamilton, specialty services, hospital administration, tour of the Canadian health care system. with an introduction to the Canadian emergency services provision, and Over three days, the fourteen students health care system. This was followed residency training. explored, in-depth, the realities of by talks on occupational health services, They discussed how well the system planning, working within, and being and medical education in Canada. That responds to health care recipients with a served by, our system of care. Their evening they socialized and compared patient with years of experience in the enthusiasm for our system provided ideas on health policy with medical (continued on page 10)
Volume 22, Number 4 - Spring, 2003 Medical Reform 9 AMERICANS STUDY CANADA: THE AMSA COMPARATIVE HEALTH POLICY TOUR (continued) system. Finally, the group explored dispelled any lingering doubts I had about knowledge to health policy reform in the challenges of providing primary care to the ability of a single-payer system to U.S. From a rather vague understanding the marginalized with inner city physician adequately fund hospitals”. of Canadian health care provision, they Philip Berger. The Canadian visit came on the heels of left with a sense of the complexities, To connect the talk with reality, they were an intensive one-day study session in struggles, challenges, and successes of led on a tour of the innovative Rotary Buffalo, N.Y., on U.S. health care policy our health care system. They left with Club infirmary for homeless men at the and structure, leaving the group primed the knowledge that a single payer model at Seaton House Men’s Hostel and were for comparison of the two countries’ is not “experimental” here, but functions then guided around key sites of health health systems. They were, as a group, in a real setting to provide Canadians with care provision in Toronto. impressed with the Canadian model of excellent health care. The students expressed surprise at the care. In the words of one student: “I For this Canadian host (and health care high standard of health care facilities in was surprised by how well accepted [the provider), it was encouraging to see the city: “I think it is crucial to see how health system] is by Canadians – I mean outsiders to our system of care so beautiful, clean, and well-apportioned all we ever hear about are the long waits, impressed with how it functions in reality. even the community health centers – yet the people are really proud of the While a vocal group within our health places where people with ‘no insurance’ fact that they all get health care”. care system continue to express envy of go to get care – are under the Canadian After four days of intensive studies in the American model of care, it was system” said one. After visiting the comparative health policy, the group was heartening to hear Americans express Hospital for Sick Children, another exhausted, but energized to apply their enthusiastic support for a universal and participant declared it was “beautiful, and equitable approach to health care.♦
CANADA’S DRUG REGULATORS-- WORKING FOR YOU, OR FOR THE INDUSTRY?
ou meet Paul Stolley, and you down on the job. The FDA is in condition is common. Depending on the find a gentle, soft-spoken, older partnership with industry. It should be definition, up to 20 per cent of the Yman with a delightful sense of negotiating, not in partnership. Why is it population suffer from IBS. Most IBS is humour. A perfect grandfather, or in partnership? Because it’s financially mild, a nuisance more than an illness. Not everyone’s favourite uncle. supported by industry.” the sort of condition that warrants a drug Yet, Stolley is one of the harshest critics What has led Stolley to his harsh with serious side effects. of the U.S. Food and Drug conclusion? Stolley had an outstanding In February 2000, the FDA approved Administration (FDA). The FDA decides career as a health researcher. His credits alosetron for treatment of women with whether there is enough evidence of include 8 years as Chair of the IBS who have diarrhoea as their main benefit for drugs to go on the market, Department Preventative Medicine in symptom. Several trials suggested that or enough evidence of harm to keep Maryland, and a term as President of Alosetron helps this subgroup of patients. them off. the American Epidemiological Society. But the effect was modest. About 40 per Stolley’s complaint? Since 1992, the In July 2000, he joined the FDA as a cent of the women taking placebo (a American government has required drug senior consultant. “sugar pill”) improved. An additional 20 companies to pay a big part of the cost Stolley’s first job was to check out a per cent improved with alosetron. of the drug regulation process. recently approved drug called alosetron. Stolley was assigned to look at the drug Companies now pay almost half the A giant company, GlaxoSmithKline, because of alarming reports of side FDA’s cost of reviewing drugs. markets the drug for “irritable bowel effects. These included severe constipation Stolley believes that the funding situation syndrome” or IBS. People with IBS leading to a leak in the bowel, and has made the FDA the industry’s servant. suffer from on-and-off diarrhoea, “ischemic colitis” or severe bowel “I think it’s a shame how it has fallen constipation, and abdominal pain. The (continued on page 11)
10 Medical Reform Volume 22, Number 4 - Spring, 2003 CANADA’S DRUG REGULATORS-- WANT TO RUN A FOR- WORKING FOR YOU, OR FOR THE PROFIT MRI: DONATE INDUSTRY? (continued) TO PROVINCIAL TORIES he Medical Reform Group has inflammation. Stolley raised a warning services. In many cases this is the person accused Ontario’s provincial cry, and in November 2001, the company or company who pays for the service.” government of selling out agreed to withdraw the drug from the The document gives the public secondary T Ontario citizens to pad their campaign market. status of “stakeholder” or “beneficiary”. coffers. The government has announced Almost immediately, however, the Is there any evidence that TPD is putting the companies that will run four investor- company lobbied for re-marketing the industry interests ahead of the public? The drug with restrictions. Stolley’s boss at TPD’s attitude to direct-to-consumer owned for-profit community diagnostic the FDA criticized Stolley for being too (DTC) drug advertising suggests the facilities offering MRI and CT services. negative about alosetron, and told him answer is yes. Two have donated substantial funds to it should be back on the market. In an earlier column, I described how the provincial Conservative party. Feeling shut out of discussions, Stolley DTC advertising leads to more “There are a number of reasons why left the FDA six months ahead of inappropriate prescribing, and escalation investor-owned for-profit clinics are bad schedule. By April of 2002, serious of skyrocketing drug spending. In news for the people of Ontario,” said complications of alosetron had led to Canada, as in almost all industrialized MRG spokesperson Dr. Gordon Guyatt. 100 hospitalisations, 50 surgeries, and 7 countries, DTC advertising is illegal. “First, they open the door to two-tier deaths. An FDA committee of experts TPD has become very lax in enforcing access to scarce diagnostic services.” suggested that alosetron be put back on the ban, allowing advertisements that This government has declared that only the market, but with severe restrictions. clearly violate the law. Worse yet, TPD those who do not need the services can The FDA decided to put the drug back is seriously considering following the U.S. buy themselves to the front of the line. on the market, but without the lead and allowing DTC advertising. “If clinics adhere to the government rules, restrictions the committee had Roy Romanow’s report recognizes the it means that people wanting scans for recommended. One member of the problem of TPD’s conflict of interest. unproven indications, like ‘yuppie’ committee, Dr. Brian Strom, one of the ‘In effect,” Romanow said, “a ‘firewall’ screening for cancer, will get the procedure first,” said another MRG spokesperson, world’s leading experts on drug use, must be established between the Dr. PJ Devereaux. People who really need thinks the FDA made a bad decision. industry¹s financial contribution and the it will wait longer. But they probably won’t “With alosetron, the risk-benefit ratio is Agency¹s work. Very stringent guidelines stick to the rules. Either way, it means that not worth it,” Strom has said, “unless for pharmaceutical industry contributions those who can’t pay will stay at the back the use can be restricted to those who should be in place to ensure the Agency¹s of the line.” really need it and who are likely to benefit independence from the industry it Another problem is that the for- from it which is a very, very small group.” regulates.” profit clinics will suck scarce radiologists Should Canadians care about this Whoever pays the piper calls the tune. and technicians from hospital MRI and worrisome situation? Like the U.S., since Should our drug regulators be putting CT facilities. Opposition to yuppie scans, the mid-1990s the Canadian government the industry’s needs above the public’s ♦ to two-tiered care, and to bleeding the has been charging industry to pay for the health? Not on your life — or death. hospitals has led the Ontario Association drug regulation and approval process. First published as one of Dr. Gordon Guyatt’s of Radiologists to strongly oppose the for- biweekly columns in the Hamilton Spectator Critics of the Therapeutic Products profit clinics. Finally, evidence from the February 21, 2003. Directorate (TPD), Canada’s FDA- US suggests that diverting money from equivalent, believe that the funding change patient care to profit decreases quality of has led to a similar inappropriate care, and can increase death rates. partnership between the drug “All rational arguments indicate that manufacturers and the drug regulators these facilities should operate on a not- here in Canada. for-profit basis,” Dr. Guyatt concluded. Critics point to an internal bulletin issued “But to our government, the company by a senior TPD official, Dann Michols, money speaks louder.”♦ in 1997. Discussing whom the TPD Released by the Medical Reform Group February should serve, Michols advised staff “the 24, 2003. client is the direct recipient of your Volume 22, Number 4 - Spring, 2003 Medical Reform 11 FEDERAL GOVERNMENT SHOWING THE RIGHT STUFF
rime Minister Jean Chretien and “We strongly encourage Jean Chretien to access to catastrophic drug coverage, Health Minister Ann McLellan are hang tough in his negotiations with the aggressive targets for the Pdemonstrating both courage and Premiers,” said Dr. Bayoumi. “The implementation of primary care wisdom in their determination to federal government has the money, and reform, and a national health care implement many of the Romanow the popularity of Romanow’s wise advisory body to make sure it all Commission’s recommendations, the recommendations, to bolster its happens. These are all key Romanow Medical Reform Group said today. bargaining position. There is no reason recommendations. “The federal government has set goals to back down on any of the key issues.” The MRG believes that you and your of adding home care to the Canada “The federal government’s current stance government are right to insist on Health Act, funding uniform access to is the strongest, and the smartest, they provincial accountability for the large catastrophic drug coverage, aggressive have taken for years,” Dr. Pellizzari increases in transfers to the provinces targets for implementation of primary concluded. “If they stick to their guns, that you are planning. In the past, the care reform, and a national health care all the effort that went in to the provinces have in effect used federal advisory body to make sure it all Romanow and Kirby reports will prove money intended for health purposes happens,” said MRG spokesperson Dr. well worth it.”♦ to fund tax cuts. Romanow and Kirby Rosana Pellizzari. “These are all key Released by the Medical Reform Group January both insisted that you use federal Romanow recommendations.” 31, 2003. money to ‘buy change.’ We commend The MRG believes that the federal you and your minister for heeding this government is right to insist on provincial TEXT OF LETTER sound advice. accountability to the federal government We are very aware that you may face for the large transfers it makes to the January 31, 2003. a battle with the provinces, which want provinces. Rt. Hon. Jean Chrétien all the money but with no strings “In the past, the provinces have in effect Office of the Prime Minister attached. Indeed, it is clear that some used federal money intended for health 80 Wellington Street provinces, Ontario for instance, purposes to fund tax cuts,” said another Ottawa K1A 0A2 would like to continue their prior MRG spokesperson, Dr. Ahmed practice of using federal transfers to Bayoumi. “Romanow and Kirby both Prime Minister: fund tax cuts. We urge you to be insisted that the federal government use The Medical Reform Group wishes to steadfast in the coming negotiations its money to buy change. It appears that congratulate you, and your Health with the Premiers. You have the great Ann McLellan is heeding this sound Minister, the Hon. Ann McLellan, for advantage of the popularity of advice.” demonstrating both courage and wisdom Romanow’s wise recommendations to The federal government may face a battle in pressing forward with the bolster your bargaining position. with the provinces, which want all the implementation of Romanow There is no reason you need to back federal money with no strings attached. Commission recommendations. down on any of the key issues. It is clear that some provinces, Ontario We are encouraged that you have set as Once again, we convey our admiration for instance, would like to continue their and congratulations to you and the goals the addition of home care to the ♦ prior practice of using federal transfers Canada Health Act, funding uniform Hon. Ann McLellan. to fund tax cuts.
12 Medical Reform Volume 22, Number 4 - Spring, 2003 PRINCIPLES AND POLICY STATEMENTS OF THE MEDICAL REFORM GROUP The Medical Reform Group believes that our profession must look to the social, political, and economic forces shaping health and health care in Canada today.
s we have been posting material from our organization, and similarly, independent hensiveness is subject to wide archives to the Internet, we have been of any other professional organizations. interpretation. The result is there is Areviewing the content of some of our appreciable heterogeneity in the services main policy items for continuing relevance and covered by the various provincial health applicability. Over the winter of 2003, the Steering plans. Committee has revised several of our founding Principles Recently, observers of the Canadian documents to reflect our continuing vision and The Medical Reform Group is a principles. Included in this issue are the results of health care system have suggested that it that review, with the expectation that members will democratic organization dedicated to the is time to more precisely define insured respond to the Newsletter Editor with a comment on following principles: services. Sources of pressure have any items they think should/should not be changed. • Health care is a right. The included members of the legal In the absence of substantial disagreement with the universal access of every person to high community, and voices warning us that, proposed changes in the preamble, principles and the quality, appropriate health care must be in the face of budget restraints, we can’t policy statements on the Definition of Insured guaranteed. The health care system must maintain the current level of public health Services, Health Resources Allocation and the be administered in a manner which care. The focus of the definition of Necessity for a Strong Federal Role in Setting precludes any monetary deterrent to insured services is on “medical necessity” Canadian Health Policy, which are reflected in the equal care. — the notion being that only medically following version, they will be deemed to replace the • Health is, in part, political and originals as of the Fall 2003 Members Meeting. necessary services should be covered. social in nature. Health care workers, Intuitively, the precise definition of including physicians, should seek out and insured services makes some sense. recognize the social, economic, Public values define what is appropriate occupational, and environmental causes coverage, and we establish uniformity Preamble of disease, and be directly involved in across provinces. We reduce the burden Canadian health care is subject to an their eradication. on public spending by eliminating ongoing struggle between advocates of • The institutions of the health inappropriate services from the domain public funding and not-for-profit delivery system must be changed. The health of the insured. Potentially, this allows us versus private funding and for-profit care system should be structured in a to continue with universal coverage for delivery manner in which the important the services that are really important. Our values dictate public funding for contribution of all health care workers There are, however, a number of major health services; evidence tells us that is recognized. Both the public and health problems with this approach. public funding is more efficient, as well care workers should have a direct say in First, it equates comprehensive coverage as more equitable, and that not-for- resource allocation and in determining with medical necessity. The two are very profit delivery offers higher quality care the setting in which health care is different. Many health services, including Science tells us that the roots of the provided. for instance dental care, are necessary for common causes of illness in Canada lie maintenance of health, but well not be at least partially in correctable social, considered “medically necessary”. economic, occupational and envi- Policy Statement on the Limiting exposure to environmental ronmental conditions. Because we Definition of Insured pollutants is necessary for maintenance believed that current organizations do not of health, but is even farther from some adequately represent these views, we Services peoples’ notion of medical necessity. formed the Medical Reform Group in Up to now, we have not had a clear Second, even if one accepts the limited 1979,as a voice for socially concerned definition of the insured health services scope of medical necessity, the process physicians. We are, by constitution, that provincial governments are of considering specific services makes independent of any political party or mandated to provide to the public. evident the difficulties of defining the Legislation stipulates that these services correct range of insured benefits. While be comprehensive, but compre- (continued on page 14) Volume 22, Number 4 - Spring, 2003 Medical Reform 13 PRINCIPLES AND POLICY STATEMENTS OF THE MEDICAL REFORM GROUP (continued) there are many services about which one current rationing strategy, limiting correct inequities between individuals can raise questions on the basis of public resource availability (hospital beds, high and groups in these three areas. versus individual responsibility (tattoo technology equipment, the number of • Societal Perspective-Taking a removal, for instance), one can almost health care providers) and letting health societal perspective has two major invariably think of instances in which one care providers work out the most implications. First, that the roots of would want these services covered. While efficient way of using the resources some ill health can be found in political, one can raise questions about the available, continues to be the most economic, and social policies and effectiveness of services (intensive appropriate. At the same time, we situations. Therefore, health may be psychotherapy, for instance) considering acknowledge that advances in medical improved more by spending money both the caring and curing functions of knowledge and technology require to correct the roots of ill health (and medicine gives one pause. adequate resources to deliver. thus spent outside of the health care The MRG has found that discussions of Our answer to the precise definition of system) than by spending within the the exact range of appropriate insured necessary services is that we don’t need system. Second, spending on health services quickly show that satisfactory such a definition. If pressed further, we care should be examined within the resolution is impossible. believe that we should not consider only context of total societal resource This makes us question the need for a what is medically necessary, but rather the allocation. For instance, we should see precise definition of insured services. The notion of comprehensive care required health spending as a proportion of Canadian health care system worked well to maintain and enhance health. Under GDP, and in relation to expenditures for 25 years without such a definition. this framework, we would use the on the military, or luxury consumer Provincial governments have maintained broadest definition of insurable services, goods. acceptable coverage, and there are few, including areas on the border of health • Effectiveness-Health care if any, gross violations of the principle care that nevertheless have an important diagnostic and therapeutic of comprehensiveness. Should there be impact on health. The health care technologies should be supported such violations, the federal government community should, for instance, be only if they have been shown to is in a position to withhold funds from involved in ensuring optimal improve outcome (i.e. the length and/ the offending provinces. So why the environmental standards. Our bottom or quality of life). The burden of current debate? line is that the debate concerning what is proof to establish this benefit should The debate is a function of the budgetary necessary medical care ultimately distracts be on those lobbying for the pressures on governments. The cost- us from dealing with the real issues in acquisition or dissemination of cutters see restricting the range of insured health care delivery today. expensive technologies. services as a way of trimming the system. Consideration of quality of life As it turns out, when one looks at what outcomes implies a “humanist” we will save by de-insuring the Policy Statement on perspective that may outweigh controversial procedures, the amount is Health Resource considerations of “cost-effectiveness” trivial. To really reduce public expenditure (when effectiveness is narrowly would require removing a wide range Allocation defined). An example would be of services. We believe the push for a We believe our position should be based allocation of health care resources to definition of insured services is another on the following four principles which the elderly. feature of the systematic attempts to we found very useful as a conceptual • Efficiency-The efficient undercut our universal public health care framework. These principles are distribution of resources (maximizing system. presented in their order of importance: cost-effectiveness) within the health With respect to definition of insured • Equity - Access to health care system should be one goal of the services, the system isn’t broken, and resources should be determined based system. This was seen as very definitely doesn’t need to be fixed. The solution on need, as determined from a broad the bottom of the list in terms of the to the problems of cost pressures on the perspective on health that takes into four principles. system include improving efficiency in account physical, psychological, and In the final part of the discussion, we health care, and revising our priorities on social wellbeing. The goal of health provide examples of how these the mix of public and private resource resource allocation should be to principles could be brought to bear on allocation within our society. Canada’s (continued on page 15) 14 Medical Reform Volume 22, Number 4 - Spring, 2003 PRINCIPLES AND POLICY STATEMENTS OF THE MEDICAL REFORM GROUP (continued) the current issues regarding health care • Occupational health: we might • care for the chronically delivery in Ontario. emphasize stands we have already psychiatrically ill • Equity-We would continue to taken in support of a safer work • chronic care facilities for the oppose any proposal, like user fees, place. handicapped which would compromise equity. We • Nutrition: we might support policies We believe issues of resource allocation would support proposals, like selective that would encourage the production will determine the future of health care allocation of resources to the and consumption of healthier foods. in Ontario. The MRG must take part in economically disadvantaged (for Conceivably, we might prepare a yearly what is certain to be a heated debate. instance, improved access to public commentary on the provincial budget Clearly, we hope the membership will in housing), or to the socially or physically from the point of view of its impact on general endorse the principles we have disadvantaged, that would improve the health of the people of Ontario, in outlined. Most certainly, we hope these equity. terms of issues such as those raised principles will be given thought and • Societal Perspective-In general, above. consideration, and useful alternatives or we would lobby for allocation of • Effectiveness-We could speak modifications will be raised. resources in ways that would improve against allocation of resources to any health outcomes, and against allocation new technology in which evidence of of resources in ways that would have improved outcome was not available. Statement on the adverse health consequences. This This would clearly mean knowledge Necessity for a Strong would be true both in and outside of of the evidence regarding the issue the health care delivery system. about which we spoke. Federal Role in Setting There are a number of specific areas in • Efficiency- There will be Canadian Health Policy which the MRG could lobby on the basis instances in which the MRG will want We believe that the issue of whether the of the health consequences of societal to speak in favour of efficient federal government should be involved decisions regarding resource allocation. allocation of health care resources. in setting and maintaining standards for Examples include the following: One might be expenditure on the delivery of social services is • Support for the tobacco farmers: development of new pharmaceutical fundamentally an issue about the model we might support allocation of funds agents which achieve little incremental of society we want for Canada. Within for switching over from growing advantage over existing agents (so-call health care, it is a debate about whether tobacco to other crops. “me too” drugs). Another might be we want to maintain a universal single- • Social programs which would expenditures on sophisticated imaging payer model, or whether we want to improve health: we might support technologies in which effect on health move to a privatized, U.S.-style mixed programs which would deal more outcomes is likely to be minimal. model, with much more payment by the effectively with homelessness, and Whenever such statements are made, health-care users. Evidence suggests that with domestic violence and its we feel that it is crucial to emphasize those who claim otherwise are either consequences. We could suggest that the areas to which the money saved disingenuous or misguided. the health costs of unemployment be should be allocated. Such areas might We shall cite three lines of evidence to factored in when the decisions include: substantiate our viewpoint. One is concerning employment subsidies, • home care for the elderly (despite historical, the second examines the job creation schemes, and the like are its cost-ineffectiveness) political orientation of those advocating considered. • palliative care reducing or eliminating the federal role • Road traffic accidents: me might • shelter for battered wives in maintaining standards, and the third support changes in the transport • social, environmental, and has to do with the nature of the federal policy that would decrease the nutritional intervention in pre-natal role. number of civilian casualties in care In the early 1960’s Canada had a mixed highway wars. • occupational health private-public system of health care, with • Alcohol: we might support policies • family planning clinics a prominent role of user fees and that would decrease alcohol • mammographic screening in 50 to financial disincentives for care. The consumption, and the consequent 60 year old women universal, single-payer system was solely deleterious health effects. • dental care
Volume 22, Number 4 - Spring, 2003 Medical Reform 15 PRINCIPLES AND POLICY STATEMENTS OF THE MEDICAL REFORM GROUP (continued) a federal initiative. Indeed, many in health delivery which was occurring at In health care, the debate over federal provinces resisted the move to the single an accelerating pace, and which appeared standards is a debate over universality, payer system. They adopted the system destined to end the era of equal access and should be treated as such. The only because the federal incentive (at that to high quality health care without Canadian public should know this. Our time, paying 50 per cent of the cost of financial deterrents. Each of the provinces current health care system suffers from services) was too attractive. enacted legislation ending physicians’ the financial pressures facing every health A compelling testimony to the provincial opting-out and extra-billing, and delivery system in the world. resistance is a comment made by John universality has been preserved. Nevertheless, we have achieved and so Robarts, then Ontario premier, about the Since the mid-1980s the provinces have far maintained a system that has achieved, federal governments’ plan for national periodically challenged the federal resolve to an extraordinary degree, its goals of health insurance covering all physician and to enforce the Canada Health Act. Prior universal, high-quality care. Canadians hospital services. “Medicare is a glowing to the recent federal decision to once strongly support Medicare. If we are to example of a Machiavellian scheme that again penalize provinces, user fees were maintain this system, continued federal is in my humble opinion one of the growing, particularly in Alberta and power in setting standards, and federal greatest political frauds that has been British Columbia. It is clear that without resolve to enforce those standards, perpetrated on the people of this federal action, the trend would have remain a necessity.♦ country.” This ‘fraud’ has turned out to continued. be our most successful and popular Historically, then, we see that universal social program, contributing in important health care would never have been ways to both Canadians’ health, and their instituted had it not been for the federal sense of self-definition. initiative, and would have been destroyed With the rapidly growing economy of had it not been for strong federal action the 1960’s and early 1970’s the new that has lead to its maintenance. universal single-payer system worked The second consideration has to do with very well. As the economy slowed down the political orientation of those and increases in physician reimbursement advocating ending Ottawa’s role in schedules decreased, tensions emerged. maintenance of social standards. The Physicians across the country began to Klein government has been the most increase their extra charges to patients aggressive in pursuing user fees, and their beyond what health insurance would enthusiasm for making the sick patient reimburse. Provincial governments pay lead to a confrontation with the increased user charges for other services. federal government. There is little doubt The fundamental goal of the program, where these governments would lead equal access without financial disincentive, their provinces with the freedom that was threatened. would follow from an end to federal The federal government, once again on standards. its own, responded to this threat. Over Finally, we note that federal intervention some provincial objections, Ottawa has been uni-directional. No federal introduced the Canada Health Act. As government has ever prevented with the initial introduction of Medicare, provinces from extending covered the federal government could not decree services (such as to dental care or compliance with its principles. It could, pharmaceuticals); the interventions are all however, penalize provinces that allowed related to attempts to dismantle universal, user fees for insured services by reducing single-payer care. Provinces wanting to transfer payments. strengthen health-care need not worry The effect of the Canada Health Act has about restrictions from the federal been profound. It has presented a government. formidable barrier against the backsliding
16 Medical Reform Volume 22, Number 4 - Spring, 2003 WHY LEAVE THE MRG? and WHY RE-JOIN THE MRG? Haresh Kirpalani Medical Reform Group policy formulation is generally an exciting, but not terribly controversial process. On most of the current critical issues, we are of similar mind. On occasion, this is not so, and the debates are contentious. The following is personal reflection of an MRG member on issues that he considers critical, and on which he feels the MRG has let him down. We encourage such critical reflections. From our point of view, the more the active debate in the group, the better. Responses, or parallel discussions expressing your own particular perspectives, would be more than welcome.
was recently shamed by a very good face of some astonishing short- condemnation of USA and UK friend who asked me “Why was a sightedness. imperialism in these actions, will not Iformer editor of the newsletter for Irrespective of the conduct of this accuse me of that. It is interesting that the “Medical Reform Group”, no longer ideological battle, it seems that the bulk on this matter – the NDP have adopted paying dues as a member?” of the MRG membership did accept a an open condemnation. And yet – the This was put to me by someone whose view that the cut-backs were iniquitous MRG has not. commitment to the progressives causes and unacceptable. Masked as the cut- Well – so much for my perceptions. How of the world at large, was totally beyond backs were, by a cloak of valid are these? question. So I was forced to take this “rationalization” – this was a difficult but Firstly, one should concede that the seriously. I had only one reason to leave important step. MRG continues to be the only game in the MRG in fact – I had lost my faith in Yet even when this step was taken, the town for those calling themselves the legitimate credentials to the term ethos of the MRG members remained progressives docs. “progressive” - of an organisation that only to challenge the source of these cut- Secondly, I concede that this is a United ducked out – on some very critical issues. backs, if they emanated from the Tory Front – confined to one aspect in essence, What were those issues I perceived that or Liberal parties. Sadly, the reality that the defence of universal publicly funded the MRG had “ducked out on”? How these cut-backs in Ontario were being health care. In this regard undoubtedly valid in any case, was my ‘loss of faith”? perpetrated by a social-reformist NDP the vanguard of the MRG has done The issues were (and I suspect still are): government – using its “progressive” some amazingly sterling work, led by A lack of appropriate critical distance camouflage – was simply ignored. It was P.J.Devereaux and G.Guyatt. It is from the New Democratic Party (NDP); too inconvenient. This attitude I found impossible to ignore that. But is that and, a lack of appropriate critical distance limited my view of the MRG as being enough? from imperialist organisations, actions “progressive”. Thirdly, I will accept that unless one is in and supporters. Let me first try to explain Secondly, “a lack of appropriate critical the mud pulling the cart across the plains, my point of view. We can then at the distance from imperialist organisations, that critiques from a distant cosy library end assess how “valid” these perceptions actions and supporters”. I am sure – are worse than unacceptable. or concerns might be. many of you might be astonished at this So – I would have to conclude that the Firstly a lack of an “appropriate critical assertion. However, clear blocks to saying time has come to get back into the mud. distance from the New Democratic Party anything about some international actions But I did think that an open explanation (NDP)”. I recall a bitter fight for a and violations of human moral codes – of my own perceptions was necessary. perspective within the MRG, over cut- were given. They usually (?always) Those of you who disagree – should backs. A benign view had it that cut- involved the state of Israel. come out and throw some mud back!♦ backs in health care were the actions of It is astonishing that an organisation that a ministry anxious to effect evidence considers itself as being for the well-being based medicine and public health. A of peoples, has not – for instance come more malignant view held that this was out with a condemnation of the last 12 capitalist cost-cutting - period. years of Iraqi sanctions; and worse – That was a difficult struggle within the does not attack the abominations of MRG, and it is certainly true that during what is happening in Iraq? Why not? By it, I personally may have been somewhat the way, I would suggest that it not be strident. I do apologise if that was the charged that I am a supporter of case. Nonetheless, perhaps a certain Saddam Hussein. I trust the MRG degree of stridency was called-for in the members who do not support an open
Volume 22, Number 4 - Spring, 2003 Medical Reform 17 TORIES TARGET HOSPITAL AUDITS, IGNORE THEIR OWN
ony Clement has a great idea. The hospital books is still a wise move, isn’t it? Despite the failed system, and contrary to Ontario health minister is Maybe not. the recommendations of the Provincial Tsuggesting that Erik Peters, the Mr. Peters, the auditor, has been calling Auditor and the Standing Committee on provincial auditor, receive a widened for widening his powers for a decade. If Public Accounts, the Ministry paid mandate. it’s such a good idea, why has the Accenture $66 million outside the original Ontario’s Ministries spend half of the government resisted for so long? $180-million payment cap. provincial budget directly. The other half Perhaps because the audit will be a waste Second example: The government has not goes to fund private not-for-profit of money. Hospital adminis-trators addressed issues in the delivery of mental institutions like hospitals and universities. already face a rigorous yearly audit health identified by auditors in reports The provincial auditor gets to check the supervised by their hospital boards. David over 15 years. The Ministry doesn’t have books only for the direct part of the MacKinnon, Ontario Hospital Association information needed to assess whether we spending. President, believes that an additional audit are caring adequately for mentally ill Our hospitals are not publicly would not uncover significant problems, people, and whether mental health dollars owned and managed. Because they belong and would generate substantial additional are being prudently spent. to their hospital boards and communities, administrative costs. The Ministry doesn’t know the number or religious institutions like the Sisters of Thinking about his own institution, St. of people receiving or waiting for St. Joseph’s, hospitals are out-of-bounds Joseph’s Hospital CEO Kevin Smith community mental health services or the to the auditor. Mr. Clement wants to believes there are better ways of spending waiting times to access services. Annual change that. resources than an additional audit. “I’d per person funding in the seven regions On January 13, 2003, the Minister rather spend the money on patient care.” of the province ranges from $11 to $60, suggested that the auditor should check If MacKinnon and Smith are right, why but the Ministry has not looked at whether hospital budgets to seek out waste, and to is the Tory government pushing the the variation means different levels of ensure hospitals spend money on the additional audit? service. programs the government intended. In an editorial otherwise supportive of the Third example: Annual spending on Mr. Clement chose an interesting venue move, the Spectator’s questioned Clement’s consultants under the Tories jumped from for his suggestion. motives. The Spectator suspects that the $271 million in 1998 to $662 million last For years, governments and hospitals have government supports the new audit not year. Peters cited a litany of cases that engaged in an elaborate dance around because of a commitment to suggest taxpayers are not getting good hospital budgets. First, the government accountability, but to strengthen its hand value for their money. doesn’t give hospitals enough. The in negotiations with hospitals. If Peters In one case, 40 employees of the hospitals cry foul, often with lots of finds problems, Clement can claim that Public Safety Ministry left their jobs and publicity. Later, the government backs it’s not underfunding that’s causing budget were rehired as consultants within days at down, and gives the hospitals some of the difficulties, but misuse or inefficiency. more than double their salaries. The extra money they are demanding. The government’s own record in provincial government allowed one consultant’s daily This year, the extra money amounts to audits sheds light on whether the fee to rise from $725 in April 2000 to $350 million. Mr. Clement raised the Spectator’s guess is correct. Consider $2,600 within six months, and hired a possibility of widening the provincial examples from the last audit. consultant who owed $110,000 in back auditor’s mandate during a press First example: In the mid-90s, the Ministry taxes. conference announcing the team that will of Community, Family & Children’s Will a provincial audit of hospitals lead to review hospital applications for the extra Services realized that its computer system more efficient hospitals, or simply waste $350 million. for social assistance payments needed an resources that hospitals should be spending Hospitals claim that not knowing how overhaul. It hired a private company, on patient care? The government’s failure much money they will have to spend until Accenture, to do the job. to act on what the auditor says about its late in their fiscal year prevents intelligent Accenture’s system has serious flaws. own internal spending raises serious doubts planning. They are right. Many service managers think the new about its motivation for an additional Well, so what if Mr. Clement made his system is inferior to the previous one. It hospital audit.♦ announcement in a context that reflects has resulted in unexplained errors, First published as one of Dr. Gordon Guyatt’s his government’s not-so-smart business including about 7,000 payments totalling biweekly columns in the Hamilton Spectator practices? Having the auditor check the $1.2 million to ineligible individuals. March 7, 2003.
18 Medical Reform Volume 22, Number 4 - Spring, 2003 STOP PRESS
The April 5 Caravan of Protest Against the For-Profit Hospitals and MRI/CT clinics has been moved to Saturday, May 10 due to concerns regarding the SARS outbreak. Thousands of hospital workers, radiation technologists, physicians, seniors, families will join cavalcades travelling across Ontario to stop the plans for the creation of the first for-profit hospitals in this province since Medicare’s inception.
The Toronto event is being rescheduled as follows: Saturday, May 10th at 2.30 pm, cavalcades will converge in Toronto to join a march starting at Front and Bay Streets.
For more information on local campaigns, call the Ontario Health Coalition at [416] 441-2502 or check their website at www.ontariohealthcoalition.ca.♦
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Volume 22, Number 4 - Spring, 2003 Medical Reform 19 MAKING CHANGE: ACTIVISM AND ADVOCACY IN MEDICINE Panelists:
Philip Berger, Chief, Family & Community Medicine, St Michael's Hospital Danielle Martin, President, Canadian Federation of Medical Students
Gary Bloch, Resident in Family Medicine, St Michael's Hospital
MEDICAL REFORM GROUP SPRING MEMBERS MEETING
Wednesday, April 30, 2003, 6.30 PM Room 2172, Medical Sciences Building, 1 King's College Circle, Toronto FREE FOR MORE INFORMATION: Medical Reform Group--([email protected]; [416] 787-5246)
Medical Reform Group Box 40074 RPO Marlee Toronto, Ontario M6B 4K4
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20 Medical Reform Volume 22, Number 4 - Spring, 2003