Saskatchewan’s Commission on Medicare brutally described the country’s health-care system last week in its report, Sustaining a Quality System.
April 17, 2001
Our publicly funded system is dysfunctional, Commissioner Kenneth J. Fyke’s report explains time and again, killing and injuring us in large numbers through clinical errors – he suggests these may dwarf the toll taken by highway accidents – and failing us in numerous other ways. It is “a system unintentionally designed to produce an unacceptable degree of error and waste. The most talented and committed individual can neither overcome bad system design nor compensate for the absence of timely and comprehensive information.”
Mr. Fyke, whose career in the Canadian health bureaucracy spans 35 years, understands that ours is a politicized system that largely operates for the convenience of the various special interests involved – chiefly the government bureaucracy and the various health-care workers who “have focused on their own entitlements rather than their obligations.” The rigid system that results creates obsolete practices, bad morale, general frustration and impersonal care that’s dispensed on a volume basis with little regard to the patient’s actual needs. Needless work is routinely performed. “Essentially the system pays for activity and is indifferent to result,” the report states.
The U.S. health-care system may have problems, but “it is inconceivable that American health-care organizations pay less attention to quality and service than ours given their competitive insurance structure and their litigation-friendly jurisdiction. In fact, given that quality has more funding and champions in the United States than in Canada, it is likely that, if anything, our circumstances are worse.”
Under the status quo, our doctors poorly dispense drugs – as one example, adverse drug reactions account for 20% of elderly admissions to hospital – and they operate whether surgery is called for or not. Instead of using medical resources better, the health-care establishment insists it needs more money, and typically gets it. Yet more money, Mr. Fyke believes, is part of the problem: “Adding money without changing the culture of the system provides only temporary relief.”
The culture that Mr. Fyke sensibly wants for us is less paternalistic and more customer-oriented. He shudders at a system that “would frankly be an embarrassment in any other human service industry. Long waits, anonymity, isolation, embarrassment, confusion, non-response, physical discomfort and infantilization are all common characteristics of health-care settings from patients’ and families’ points of view.” Why does a consumer of an automobile have access to superb information, the report asks, while consumers of health services are kept in the dark?
The answer, of course, partly lies in the auto companies’ need to compete for our business, leading them to lavish us with information. More fundamentally, the availability of myriad choices in the types of cars we can purchase, and the manner in which they’re outfitted, creates an industry of independent information providers skilled at understanding the many niches in the auto marketplace, and at conveying information about those niches to those of us who seek it. If the automobile sector were managed as a giant monopolized utility by auto bureaucrats deciding what cars with which options we needed and when – if it operated as the health industry does – we would have no meaningful choices, giving us little reason to gather data and giving information providers little incentive to gather it for us.
But amazingly, Mr. Fyke does not see that the culture that he deplores will not change as long as the system operates as a monopoly, without competition to give customers choice. To span the information gap, he suggests more bureaucracy in the form of performance indicators, a redesigned annual report by Saskatchewan’s health ministry and another government body – a Quality Council – that would, among other tasks, issue report cards.
These recommendations turn an otherwise insightful report into so much paper. And yet an answer to our medicare woes does exist, one which Mr. Fyke entirely ignored, even though it meets his desire to maintain a publicly funded, one-tier system. The answer, which goes by the name of health-care allowances, would provide every Canadian, rich or poor, with an annual allowance equal to what he currently costs the system, plus an annual top-up. It has been analyzed for Canada by one of the world’s top health-care actuarial firms and confirms Mr. Fyke’s finding that a publicly financed health-care system can deliver quality at lower cost by finding the kind of efficiencies that excellent systems find. But even more, health-care allowances would solve many problems that Mr. Fyke identifies, such as how to provide free prescription drugs without bankrupting the medicare system.
The Fyke report may yet prove valuable, however. The person who commissioned it, Saskatchewan’s former premier, Roy Romanow, is now heading up a federal inquiry into medicare and he plans to use it as a building block. Good. Mr. Fyke’s diagnosis of the disease is excellent: It’s his prescription that’s wanting.
Mr. Romanow has his foundation in the Fyke report. To make for medicare a magnificent edifice, he should now direct his energy to the one medical instrument – health-care allowances – that can deliver the quality and meaningful choices that will allow medicare to fulfill the dream that Canadians have for it.