Everyone wants better health care in Canada. But no one knows who should fix it. Who’s the most responsible politician (MRP)?
The provinces are in charge, according to the constitution.
But the federal government is in charge based on the Canada Health Act (CHA) plus billions in Canada Health Transfer payments (CHT).
It’s like two people in a rowboat, one on each oar, both trying to row in different directions. It’s fun to watch, but painful to ride.
I wrote “The Most Responsible Politician: Who’s the MRP for Health Care in Canada”, with the Macdonald-Laurier Institute this summer.
Here’s the press release summary.
For a 2-minute version, check out the blog below.
Who’s MRP for Health Care?
The MRP concept is old. Most Responsible Physician (MRP) now includes Practitioner, with NPs as MRP in some cases.
When dozens of people run from all across the hospital to help a patient who is turning blue, one person needs to be in charge of the Code Blue.
Every major trauma needs a Trauma Team Leader. Someone needs to lead and take responsibility for team decisions.
Admitted patients come to harm if they do not have a clear and explicit MRP.
Canadian healthcare has no clear MRP.
Provinces run daily operations. Their authority comes from the British North America Act (1867). But the feds have ‘spending power’, which is the power to make payments “for purposes on which it (Parliament) does not necessarily have the power to legislate” (PE Trudeau).
In other words, the feds use money to get power. Instead of seeking a constitutional amendment, they can give grants with strings attached, called conditional funding.
Technically, federal gifts are voluntary. Anyone can refuse a gift. The provinces could voluntarily refuse to accept the fed’s money. It’s called a Hobson’s choice: “You can eat your carrots or go to bed hungry.”
Going Nowhere Fast
If we want to resist change, our current system is brilliant. It guarantees that the health care boat will spin in circles. If we want a system that can change and develop, our setup could not be worse.
The average Canadian was 27 in the 60s and is in her mid-40s today. At the start of medicare, medical care meant hospital care. Today most people interact with the system as outpatients.
As people live longer, take more expensive medications, and use more sophisticated outpatient therapies, the ‘comprehensiveness’ of the CHA starts to look silly.
The current CHA/CHT approach rules out innovation by anything other than a one-size-fits-all federal solution. Since the provinces depend on federal largess to run provincial health care systems, provinces are not free to try anything new that might compromise federal handouts.
So we sit and spin.
Stakeholders shout at the feds to row harder towards national plans for everything from seniors’ care to pharmacare. Voters shout at the provinces to row harder towards funding for public health, autism, and hundreds of other important health related issues.
Solutions
We could rewrite the constitution. It sounds crazy, but we have amended it before with unemployment insurance (1930s) and with old age pensions (1950s).
However, it would mean that the provinces give up gigantic health bureaucracies. Over 50% of provincial budgets go to health care; over 70% for some Maritime provinces if you look at only program spending based on own-source revenue (i.e., eliminate spending on debt payments and money received in equalization payments).
Big bureaucracies have big budgets, which mean big power. Given this, how likely is it that the provinces will give up their right to run health care?
We could ask the feds to take a new leadership role. Does it make sense for the feds to collect $34.4 billion in GST and then pay it all back to the provinces in the $36 billion CHT?
The federal government will always play an important role in health care. It might have even greater impact and flexibility through a federal council on health, or some other structure.
Legislation, such as the CHA, is a blunt and clumsy force beyond the act of passing an Act.
How would you solve the rowboat dilemma?
- Maybe you could let one rower choose the direction for a set time period.
- Maybe you could give one rower a break and let the other row alone.
- Perhaps the rowers could play a round of rock-paper-scissors to see who gets to be captain.
We could dream up many solutions for our Canadian rowboat, but only one will work. One rower must stop trying to steer the boat.
Responding to change is one of the biggest challenges for any socialized industry. Right now, Canadian health care is spinning. Let’s hope politicians decide who’s in charge soon.
Beach in Summer. Man claiming to be drowning (triage ?), calling for help. Volunteer:”Is there a doctor on the beach?” Man runs up, but says he is not a good swimmer and has no boat. MBA raised money from the local population to buy a Lifeguard boat, so he is in charge of the boat, but has no experience in rowing, rescue or resuscitation. Two others rush up and get in the boat. They both live beside lakes up North. They each grab an oar and start to row. The MBA says he can see the victim better because they are busy rowing, so he will tell them what to do. They soon learn to row together. Who are they? He says he coaches the local hockey team. He is also a Family Doc on call to the ER. She does wellness and nutrition classes for pregnant women. She is also a Family Doc who spends one day a week doing General Surgery at the local Hospital. They pull the victim into the boat and the first doc starts Basic Rescue until the get ashore and form a CPR Team with minimal discussion. The victim rushes to his anxious and grateful family who ask if anything is owed. The MBA requests the names of all involved and an incident report so that he can write a report to show that the boat is useful, and the CPR MRP for billing and monitoring purposes. They tell him to forget it. By the time they write it all down they will have no vacation time left.
Disclosure: Victim of the CPSO for refusing to do “Unnecessary Tests”. (Now called “Appropriateness”, presumably for less spelling anxiety.)
Oh boy…so much packed in there, Roger. Thanks for posting! I hope readers take some time to unravel it. Most people don’t hear about the avoidable victims of the ‘violence inherent in the system’ (to quote Monty Python).
Thanks for posting!
A play on Roger’s comment…”a politician is a person who pushes a non swimmer off the dock into the lake…the non swimmer flails about in desperation…the politician throws a lifebuoy ring made of concrete at the non swimmer , grazing the head and stunning the individual who manages to reach the end of the dock..the politician walks over and bends over , and standing on the victims fingers asking if he or she could be of help…the struggling person , hanging onto the edge of the dock with crushed finger nails screams at the politician to b*##&r off…the disbelieving politician retreats…eventually the struggling non swimmer manages to reach the beach and lies there exhausted…the politician runs up to the prostrate individual expecting everlasting gratitude.
The main cause of crises in our health care system are “ solutions” to previous problems which were themselves caused by “solutions” generated by intelligent governmental intellectual fools ( many from the ranks of our profession) to previous problems which were themselves the result of previous “solutions” to perceived problems.
President Reagan started that the nine most terrifying words in the English language are “ I’m from the government and I’m here to help”…so, here we go again, our governmental politico bureaucratic elitists are about to impose their latest non solution onto our profession and our patients with their inevitable unintended negative consequences…not having any “ skin in the game” they will be lauded , awarded and promoted while we struggle to manage in the latest wreckage .
Again, you are WAY too creative, Andris. Very entertaining and informative comments. Thanks for sharing.
The Appropriateness Working Group (Ontario) has today rearranged the deck chairs on the Titanic. The Titanic is Medicare.
Solid comment, Perry. If the AWG is about limiting what medicare can offer, then it will help medicare live to see another decade. If not, then I agree. Medicare will sink under its own bloat.
Thanks so much for reading and posting a comment!
The Federal and Provincial political classes seized complete power over the Canadian health care system/ systems by passing the 1984 Canadian Health Act with its amalgamation of the 1966 Medical Care Act and the 1957 Hospital Insurance and Diagnostic Services Act.
They own it.
The present health care system (s) was/ were not conceived by the medical profession, not designed by the medical profession , not constructed by the medical profession and certainly not managed by the medical profession.
One thing for certain, the medical profession is NOT responsible for its present sad state of affairs.
Not only have the Federal and Provincial political classes ( and their bureaucracies) not respected, in their entirety, their own inventions, the Acts that they themselves passed —but they have also run away from the negative consequences of their creations with their increasingly expensive and bloated bureaucracies.
Not only do they still refuse to accept responsibility for the present sad state of affairs of their rudderless creation, but they have had the gall, the chutzpah, to blame its increasingly evident deficiencies on the shoulders of the innocents, medical profession, flogging their scapegoats mercilessly even as the boat runs aground onto the rocks.
The powers that be have “no skin in the game” ( read ‘Skin in the Game’ , Nassim Taleb)…the medical profession and its patients do…there has been no tarring and feathering of the “ intelligent idiots” that brought Canadian health care to this present sad state of affairs , instead they have been promoted and are still at it, busy plotting future disasters.
Quoting Petronius Arbiter yet again “ We trained hard —but it seemed that every time we were beginning to form up into teams we were reorganized. I was to learn later in life that we tend to meet any new situation by reorganizing, and what a wonderful method it can be for creating the illusion of progress while actually producing confusion, inefficiency and demoralization”.
We are caught in a déjà vu ,Groundhog Day type , Canadian medicare time loop…we all know how it’s going to turn out.
Andrus, your erudite comment is always appreciated.
I read that all major changes to health care requires MDs to be at the centre of the decisions – a compromise so that medicare was accepted by MDs back in the 1960’s. is this true? If it is, what is going on in Ontario with the approved OHTs being lead by hospitals and every application by physician-lead groups being rejected?
Thanks Leo.
I’ll let Andris respond more fully. I wonder where you got this from: “all major changes to health care requires MDs to be at the centre of the decisions.” I hear it from others, so do not feel bad for saying it. I just wonder where this idea comes from?
Government usurped control of medicine. Doctors were never given a say in the matter. Government socialized an industry in the same way it expropriates land for a highway. The landowners lose control.
Thanks for reading and posting a comment!
I believe it was a compromise to get Saskatchewan MDs onside when Tommy Douglas introduced medicare. It is known as the Saskatoon agreement. Basically all other Provinces simply adhered to it as the standard. But I also read it in an opinion article that cited a Federal law(?). I’ll see if I can locate it again.
Ok, that makes sense. It sounds like more of a principle or suggestion than a law or policy.
Thanks so much! No need to dig it out.
Cheers
The health care system is full of intelligent but compliant medical practitioner Quislings, tugging their forelocks to the health care politico bureaucratic elite , as they regurgitate off the hierarchy’s ideological hymn sheet.
They are scattered throughout our Potemkin like health care system and pointed to “ as you can see, the medical profession is central to all of our major decisions , we value their opinions and advice …” …one can almost hear the sniggering of our Canadian versions of Sir Humphrey Appleby within the health care bureaucracy.
Although I wouldn’t go so far as you do with you analogy, I do agree that the experts continue to promote the Potemkin narrative of “Private practice, public payment,” (Naylor, 1986). Doctors are not in control. While modern socialism no longer attempts to own the means of production outright, it seeks to control it at every turn thereby getting all the benefits of ownership without any of the responsibilities.
Again, thanks so much for taking time to comment!
After 30 years as a health policy consultant with the Ministry of Health, I can tell you that decisions are based on political will and favourite causes. For example Deb Mathews made the decision to fund birthing centres against the advice of her policy advisors( I was one.), against the advice of the College. She had met with the association of midwives, promised them and we had to provide the evidence- not an easy task.
Great comment, Martha! Very sorry I missed it earlier…I’ve been running around delivering kids to college, etc. Thanks again!
Some on this board may want to read more on the central role physicians are supposed to have in health care delivery in Canada.
From: Hutchison B., et al. 2011. Primary Health Care in Canada: Systems in Motion. The Milbank Quarterly 89: 256-288 (pg 257)
“Most of health care in Canada is publicly financed but privately delivered. The Medical Care Act (1966), which, together with the Hospital and Diagnostic Services Act (1957), established the basis for Canada’s universal, publicly financed health insurance system, known as Medicare, effectively enshrined private fee-for-service practice as the dominant mode of practice organization and physician payment in Canada (Naylor 1986). Physicians were brought into Medicare on terms that included the continuation of fee-for-service remuneration, clinical autonomy, and control over the location and organization of their medical practice. As
Carolyn Tuohy observed, this founding bargain or accommodation between the medical profession and the state “made no changes in the existing structure of health care delivery [and] placed physicians at the
heart of the decision-making system at all levels” (Tuohy 1999, 56). Indeed, federal and provincial policymakers have been hesitant to challenge this accommodation for fear of jeopardizing the medical profession’s allegiance
to Medicare. The leverage afforded to provinces and territories as the single payer for physicians’ services has thus been mitigated by the need to negotiate, rather than impose, changes in physicians’ payment systems and accountability arrangements.”
Naylor, C.D. 1986. Private Practice, Public Payment: Canadian Medicine and the Politics of Health Insurance, 1911–1966. Montreal: McGill-Queen’s University Press.
Tuohy, C. 1999. Accidental Logics: The Dynamics of change in the Health Care Arena in the United States, Britain and Canada. New York: Oxford University Press.
Dear Leo,
I would suggest that the government has been slowly moving the goal posts over the years.
1. In an attempt to enforce “equity” the Montreal General Hospital was taken to task for paying research heads (that is doctors being actively courted around the globe) extra money taken from the Hospital foundation. The govt, simply subtracted those funds from its payments to the Hospital. The effect was to drastically lower the status of Montreal General as a major world-class facility.
2. Also in the restructuring of the 80’s, queen Mary Hospital (also in Montreal was closed. this seemed rational in terms of the plan, however it was pointed out that people had made huge legacy donations to that hospital. Would they have done so knowing that government bureaucrats would simply erase their contribution by closing the hospital a few years later ? What is the chilling effect on private donation under such circumstances ?
3. The Government of Quebec has DEFINED euthanasia as “end-of-life-care” co-equal with Palliative Care. Please note that the medical status and ethics of euthanasia has been the subject of unresolved debate for centuries. In the present political context, there has been lots of speculation on what doctors think, here and now, but one thing is clear : This new definition of medical care was NOT the result of a careful in depth discussion among doctors, quite the contrary, everything was done to keep the relation of doctors to policy opaque. this was medical definition by decree.
The point however, is that, regardless of one’s ideas on this particular subject, for the government to pretend to have the authority to define “medicine” is a clear crossing of the Rubicon.
Unfortunately, medicine as a self-regulating profession is gone. And will remain so, unless and until, some serious change in direction is effected.
Best,
Gordon Friesen
thanasiediscussion.net
Great comment, Andris! One of your best.
I especially liked: “The present health care system (s) was/ were not conceived by the medical profession, not designed by the medical profession , not constructed by the medical profession and certainly not managed by the medical profession.
One thing for certain, the medical profession is NOT responsible for its present sad state of affairs.”
Socialized medicine has no way to rationally allocate resources. Bureaucrats do not risk their own resources nor do they need to atune themselves to the needs of those they deem to serve in the way that an entrepreneur must.
“…we all know how it’s going to turn out.” Indeed.
Thanks again for reading and posting a comment!
After 30 years as a health policy consultant and Director of the Women’s Health Bureau I witnessed how bureaucracy and stakeholder lobbying stalled decision making.
At the OMA my experience on decision making was much different and better. We researched an issue, consulted experts and took it to the Board for decision on the OMAs policy. My point is there was a process that was transparent, inclusive and efficient. This is not the case at the Ministry.
Wow. Sounds like the OMA has got everything together. Notice what is happening with the OHT’s? Vast majority of invited (i.e. will be approved) groups (more than 50) are hospital-led…zero approved applicants are MD-lead. Those that were MD-lead were sounldly rejected, including one that I know comprised of over 400 MDs. OMA is talking about “road tour” to get MDs’ opinions…the horses have left the barn and the OMA is trying to gauge whether they should close the barn door. LOL.
Good point about MD led OHTs, Leo. The hospital led teams have more sophisticated applications. Without MD leadership, these will fail (if the literature is any indication).
Great comments, Martha! Thanks for sharing. The pressures of politics and re-election make government work in strange ways, I fear.
Dear Shawn,
Your experience is truly priceless. I get a lot of hope from reading your blog.
Personally, I have always found great benefit in breaking problems up into smaller units. Health care, taken together is an unimaginable monstrosity. The scale, the scope, the internal contradictions.
In the interests of reducing the problem, it seems to me, that there is a natural division between public health, as in hygiene, vaccination, education, water safety, food inspection, on the one hand, and my hip replacement on the other.
These are such vastly different things. For such vastly different purpose.
Now the rule about splitting things up, starts with splitting the budgets. Yes, of course, these budgets are in competition. But all of the public budgets are in competition. There is no reason, really, that budgets for lifestyle education should be mixed up with budgets for curative medicine, any more than budgets for bridges are.
I know that nothing is perfect. And I am willing to take rough estimates. But there are a few numbers I would really like to know, particularly : total health budget all in ; total patient care (curative and palliative together) ; and the ratio of the two (that is, Patient over Total).
I am not saying that posters depicting apples are useless, or that academia is getting out of hand. However, I think taxpayers should be aware of what that ratio of Patient to Total actually is, because it is my belief, that when the common man ponies up for “healthcare”, he is thinking hip replacement, not apple-poster or medicine-and-climate-change.
And as stated, to make sense of complex responsibilities, you have to separate budgets, just as small business owners need to do the books before they reach in the till.
And from that starting point a rational debate is to be had on just how much individual health insurance (or equivalent) each Canadian can assume he or she is carrying. Government obligations should be in writing, just as they are in REAL insurance. (We will pay for this. But we will not pay for that. In writing) And then we could have different providers offering different packages all within the envelope, or envelope plus some possible extra contribution.
But maybe, I have just succeeded in demonstrating why these things are not happening. They are too obvious from an accounting viewpoint.
Politics is all about favorites and privileges and power. Simplicity is the enemy (and complexity is the friend) of any politician.
Efficiently servicing any market, including healthcare requires the diametrical opposite. Simplicity. Transparency. Division,
Bottom line then : Clarity. Two divisions of health to start with. Patient care on one side ; everything else on the other, and a simple ratio to express the two.
Best Regards,
Gordon Friesen, Montreal
http://www.euthanasiediscussion.net/
Thanks Gordon, very kind.
I like the point you make about separating out the budgets on medicine vs. public health. I plan to write about this soon but had not considered the budget angle.
Thanks again!
Shawn,
I think I forgot the crucial point : As a natural requirement of conceptual and budgetary separation/clarification : When we get a true MRP, we must also make sure we have one who is responsible only for medical service patient delivery. Nothing else.
Best,
Gordon Friesen, Montreal
Exactly. Agree totally. Thanks again!
Like Shawn, whole heartedly agree with your view