Indeed, Fox’s letter is a cogent re- of user pay schemes) increased from minder that the introduction of the 13% in 1992 to 14.6% in 2002. electronic medical record (EMR), which holds great promise for stan- John H. Kolkman dardizing data collection, archiving Edmonton, Alta. important information and facilitating the sharing of patient records among Reference 1. MacKinnon JC. The arithmetic of health care physicians and institutions, may never- [editorial]. CMAJ 2004;171(6):603-4. theless enforce the tendency to divorce DOI:10.1503/cmaj.1041622 the data from the patient. This con- cern is particularly prominent if the focus of an EMR is on collecting in- anice MacKinnon’s health care arith- formation that can be coded and cate- Jmetic is incorrect.1 She uses a figure gorized. In contrast, if electronic sys- of 8% as the annual rate of growth of tems adopt the approach of explicitly health care costs in Ontario, but this reminding practitioners to record daily value is based on current dollars and narratives, the EMR could increase the therefore does not take into account in- use of narrative medicine principles. flation or growth of the population. Perhaps we should encourage techno- The correct calculation should be logically inclined house staff to “blog” based on per capita spending of constant rather than to “chart” information for dollars. The Canadian Institute for their patients! Health Information gives the following figures for annual rate of growth in these Ahmed M. Bayoumi terms: 2.6% from 1974 to 1991, –0.03% Inner City Health Research Unit from 1991 to 1996, and 4.4% from 1995 Peter Kopplin to 2003.2 It is highly probable that the Division of General Medicine negative rate of growth for 1991 to 1996 St. Michael’s Hospital corresponds to the decrease in health Toronto, Ont. care transfers that occurred during the early 1990s; the subsequent increase in Reference rate of growth is due to the replacement 1. Bayoumi AM, Kopplin PA. The storied case re- port. CMAJ 2004;171(6):569-70. of part of those funds. DOI:10.1503/cmaj.1050017 Furthermore, MacKinnon’s refer- ence to the increasing percentage of provincial budgets devoted to health care1 is almost irrelevant, since the per- More arithmetic centage depends on revenues as well as of health care on expenditures. The provincial gov- ernments have decreased their revenues ontrary to the claims of Janice by cutting income taxes but have then C MacKinnon,1 the most recent data implied that the increased percentage from the Organisation for Economic spent on health care is due to an in- Co-operation and Development crease in expenditures. (OECD), for 2002, show that Canada Finally, all the figures quoted so far ranked sixth, not third, in terms of have been for total health care expendi- health care spending as a percentage of tures, but what we should be debating gross domestic product (GDP) (data are expenditures for the public health available through OECD Web site at care system (and the services provided). www.oecd.org/home/). The cost of our medicare system is the Furthermore, Canada is the only amount spent by the provincial govern- OECD country where health spending ments, equivalent to 63.8% of total as a percentage of GDP actually de- health care costs.2 clined over the past decade (from 10% in 1992 to 9.6% in 2002). By contrast, Norman Kalant health spending as a percentage of GDP Jewish General Hospital in the United States (with its multitude Montréal, Que. Correspondance

References References care services. Why not debate what 1. MacKinnon JC. The arithmetic of health care 1. MacKinnon JC. The arithmetic of health care [editorial]. CMAJ 2004;171(6):603-4. [editorial]. CMAJ 2004;171(6):603-4. should be paid for, why and how? 2. National health expenditure trends 1975–2003. Ot- 2. Yalnizyan A. Can we afford to sustain medicare? Just as governments could not con- tawa: Canadian Institute for Health Information; A strong role for federal government [position 2003. p. 5. paper]. Ottawa: Canadian Federation of Nurses sistently spend more than they collected Unions; 2004 Aug. in revenue in the 1990s, health care DOI:10.1503/cmaj.1041621 3. Health care in Canada, 2004. Ottawa: Canadian costs cannot increase indefinitely at a Institute for Health Information; 2004. faster rate than government revenue. anice MacKinnon’s commentary1 is a DOI:10.1503/cmaj.1041640 Also, such increases are crowding out Jclassic: her arguments are resilient, spending on education, the environ- used time and again regardless of their [The author responds:] ment and poverty reduction, key factors flaws. in promoting a healthy population. It is all about the denominator, he Conference Board of Canada which in this case is revenue. Health T study1 that I referred to in my Janice MacKinnon care expenditures are indeed rising commentary2 compared 24 OECD Professor faster than revenues — that is apt to countries, rather than all 30, and University of Saskatchewan happen when revenues are foregone be- Canada was third in overall spending Saskatoon, Sask. cause of tax cuts. on health care in that comparison. My According to the economist Armine arithmetic on Ontario’s health care References 2 1. Understanding health care cost drivers and escalators. Yalnizyan the rise in health care expen- spending — an average annual increase Ottawa: Conference Board of Canada; 2004. ditures of all provinces and of the fed- of 8% per year for the last 5 years — is 2. MacKinnon JC. The arithmetic of health care [editorial]. CMAJ 2004;171(6):603-4. eral government since 1996 has been based on information published by the 3. Annual report and consolidated financial statements, $108 billion, an arresting figure. How- province’s finance department.3 If con- 2002-03. Toronto: Ontario Ministry of Finance; 2003. ever, this increase pales in comparison stant dollars are used for health care 4. MacKinnon J. The arithmetic of health care. Pol- with the revenue foregone by the same spending, then government revenue has icy Matters 2004;5(3):1-28. Available: www.irpp jurisdictions over the same time frame, to be stated in comparable dollars. The .org/fasttrak/index.htm (accessed 2005 Feb 2). which amounts to $250 billion. result would be the same: in the last 5 DOI:10.1503/cmaj.1050015 In other words, governments in years Ontario’s health care costs have Canada have given priority to tax cuts increased by 42% while revenue has over social programs. Ontario’s Pre- grown by only 31%, a gap that is not Corrections mier Dalton McGuinty, whom MacK- sustainable. innon quotes, won an election by giving Measuring health care costs relative n a recent Public Health article,1 the priority to social programs over tax to GDP omits key costs, such as the I correct dosage for erythromycin cuts. It is those priorities that need to debts of hospitals and health boards, should have been given as 500 mg (not be debated, not the question of disman- and the cost of replacing outdated 50 mg) four times daily for 14–21 days tling the single-payer health care model equipment and facilities — about $10 (depending on severity and response to in favour of more expensive and less billion in Ontario alone. Also, govern- treatment). safe alternatives. ment revenue does not increase at the Other facts, no doubt well known to same pace as the economy grows and is Reference MacKinnon, do not make an appear- projected to decline relative to GDP in 1. Weir E. Lymphogranuloma venereum in the ance in her commentary, such as the the next 20 years.4 differential diagnosis of proctitis. CMAJ 2005; fact that health care expenditures as a Even left-wing provincial govern- 172(2):185. percentage of GDP are at the same ments have reduced corporate and in- DOI:10.1503/cmaj.050189 level as 10 years ago.3 This is not the come taxes to compete in attracting picture of out-of-control growth she is investment and highly educated peo- n a Public Health article on SARS,1 trying to portray. ple. Raising taxes is no panacea and I two errors have been identified: Yes, change is needed, and the could undermine the economic BUN should be urea and creatine sooner the better. That view is unani- growth that generates revenue for should be creatinine. mous across Canada. But privatization, health care. taxing the sick and other related “reme- What does rhetoric like “privatiza- Reference dies” are not the answer. tion” and “taxing the sick” mean? Our 1. Borgundvaag B, Ovens H, Goldman B, Schull M, health care system is already a mix of Rutledge T, Boutis K, et al. SARS outbreak in the public and private: Are doctors public Greater Toronto Area: the emergency depart- Robert Y. McMurtry ment experience. CMAJ 2004;171(11):1342-4. University of Western Ontario servants or private practitioners? Peo- London, Ont. ple already pay directly for some health DOI:10.1503/cmaj.050190

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