(released at the CMA General Council - August 23, 2010)
Canadian Medical Association in 2010: A Re-Commitment to Medicare
For the last several years the CMA General Council has witnessed contentious debates over the issue of health care privatization. For many in the profession, it is exciting to look forward to a General Council in 2010 that is instead focused on championing the values physicians share and discussing a policy paper that looks at enhancing the health care system Canadians value so deeply.
It is gratifying but not surprising to see the CMA pursuing this course. Certainly the evidence supports it. As the CMA noted in its health care transformation report, the principles that underlie the Canada Health Act have the ‘unwavering’ support of the Canadian public. While most Canadians agree that our health care system should be improved, we should work to ensure that reforms are made, as the CMA notes, “in a manner consistent with the spirit and principles that have guided Medicare from the beginning.”
As members of the CMA, we at Canadian Doctors for Medicare applaud the CMA’s call for “all Canadians [to have] timely access to an appropriate array of medically necessary services across the full continuum of care, independent of their ability to pay.” Despite a vocal and prominent minority that has garnered headlines in recent years by advocating for market-driven health care, the medical profession must reassure Canadians that it fully embraces the notion that patients should access care based on need, and that the introduction of private funding or private insurance for services covered under Medicare would be wholly inappropriate.
As delegates enter General Council this year, they do so armed with a document that embraces the principles of the Canada Health Act. We hope this will provoke a constructive debate about how to improve Medicare. By clarifying the debate over sustainability, and by placing equity at the core of its recommendations, the medical profession can help continue to make important contributions to the future of Canadian healthcare.
Exploring Practical Solutions
The CMA’s transformation policy document contains a number of specific recommendations for changes within the health care system. Some of these prescriptions are long overdue. Canadian Doctors for Medicare is unequivocal in our support for the CMA’s efforts to advance electronic prescribing and accelerate the use of information technology to improve patient care. We applaud the introduction of ideas, such as the Patient Charter, which have been implemented with success in other jurisdictions.
The purpose of the General Council meeting is to explore and discuss challenging ideas and to applaud and support the good ideas, but some ideas in Health Care Transformation in Canada seem to ignore the experiences of other jurisdictions or the risks that accompany seemingly attractive solutions.
Experience elsewhere shows that if implemented thoughtlessly, activity-based hospital funding can lead to more harm than benefit. Activity-based funding (ABF) is not a panacea – it could lead to the closure of small and rural hospitals, avoidance of “unprofitable” patients by individuals and institutions, gaming of the billing system, expensive bureaucracy, and the privatization of health care services. For more detail about the experiences of ABF in other countries, please see the executive summary of our backgrounder on ABF, which is appended.
We and others have concerns about pay-for-performance (P4P). The largest pay-for-performance initiative the world has seen to date took place in primary care in the United Kingdom. Pay-for-performance did improve primary care, but the initiative was much more expensive than anticipated, and it is not yet clear whether the initiative provided value for money, and consequently whether it should be viewed as a success or a failure. Pay-for-performance should be just one of several options that the CMA and others examine when thinking about how best to improve the quality of physician care.
Tax-deductible long-term care insurance would be highly problematic. Because tax subsidies are usually proportional to the marginal income tax rate, wealthy people benefit far more than poor people. In fact, most Canadians of modest means would not benefit at all from a tax-deductible long-term care program, because they would not be able to afford private long-term care insurance. Private long-term care insurance would likely leave poor people with even worse quality long-term care than they have now.
Equity: The Umbrella Principle
How should physicians approach the debate over ideas like those proposed by the CMA, which are complex, and which international experience has shown to have mixed results? We return to the original premise of the CMA’s document, which states that “new demands for adaptation must be addressed starting now, and in a manner consistent with the spirit and principles that have guided Medicare from the beginning.” The principles of Universality, Accessibility, Portability, Comprehensiveness, and Public Administration identified in the Canada Health Act (CHA) are all important. But the most important principle is the one that underpins all of these, the principle which Canadians identify with most strongly: that principle is Equity. Our public system is based on the principle of access for all Canadians to the care they require based on need, not ability to pay.
The principles of Accessibility, Universality, and Comprehensiveness can be realized only if they apply to everyone equitably. Introducing more for-profit, market-driven care means that some physician and hospital services might be available only to those who can pay, and that the best services might increasingly be restricted to people who can access the private market.
The challenges faced by the United States offer a good illustration. In the United States, most people have access to some kind of health care, but their incomes restrict the amount and quality of that care. Because the system does not offer comprehensive insurance coverage to the whole population, access to care is restricted and quality care is not universally available. Consequently, the best and most comprehensive care is available only to those who can afford it. The services that diagnosticians might deem best may be out of reach for some people, who would be forced to settle for less than what science dictates. Families bankrupt themselves to pay whatever it costs to access the care they need, and thousands of lives are shortened by the lack of financial means to access insurance.
The principle of Portability similarly reflects the CHA’s commitment that every Canadian should have access to care, no matter where they find themselves in the country.
Public Administration, which may strike some as an unusual principle, is rooted too in the underlying principle of Equity. We can be assured that our health care system will remain accessible, comprehensive, and universal because it is based on a single-payer insurance model that we all share and own equally, a model that is able to deliver significantly more efficient and cost-effective care than a private insurance model.
When considering how ideas like activity-based funding or pay for performance could be adopted, the CMA, as well as governments and policymakers, should ensure that the principle of Equity is protected. This approach will ensure that the changes we endorse will resonate with Canadians. The activity-based funding model used in the United Kingdom, for example, would require considerable scrutiny to ensure that it does not undermine the public system. A commitment by the CMA to pursue only those models that support equity would go a long way toward reassuring Canadians that ABF and P4P would be applied in ways that are consistent with the Canada Health Act.
Contributing to Solutions
We can agree simply maintaining the status quo is not acceptable: Canadians deserve a health-care system that continually gets better. Like everyone who works in the system, we as physicians are not exempt from the need to make changes to ensure that the system remains sustainable and continuously improves. While doctors play a crucial role in health care, the CMA’s report falls short of recognizing the extent to which we also contribute to our system’s challenges — by ordering too many expensive tests, prescribing medications unnecessarily, contributing to the lack of coordination in the system, and sometimes failing to embrace necessary changes that put our power or our established ways of doing things at risk. What then, should we commit to at this year’s General Council? How can we contribute to reducing inappropriate variations in practice and unnecessary wasting of public resources? Can we commit to greater attention to public health and disease prevention alongside our renewed efforts to address weaknesses in the health care system? As we call on governments to implement massive changes to the health care system, how can we contribute?
The Canadian public and our patients will be glad to hear that the doctors of Canada have re-committed themselves to fixing our health care system while remaining true to the values that underpin it. We need to endorse specific recommendations that enhance equity, and we need to show governments, policymakers, and the public that we are prepared to participate in the changes that need to happen.
Click here for the PDF version: CDM Response to CMA_Health Care Transformation Policy.
