No. 13: Medicare E-Rounds - 2008 Year in Review

Background: Medicare e-Rounds is a structured abstract series offered by the Canadian Doctors for Medicare as a means of ensuring that the literature on publicly funded Medicare, private insurance, funding, and delivery is available to, and understood by, Canadian physicians. In the first 8 e-rounds, we focused on the evidence that examined the impact and realities of private health care funding and for-profit delivery. The 9th e-round reviewed the effects of private managed care on teaching, research, and clinical practice in academic medicine, while the 10th and 11th e-rounds compared Canada’s health care performance to that of other countries. The 12th e-round examined Canada’s experience with waiting time management strategies for total joint replacement.  

Objective: 1) To summarize the evidence derived from 12 papers reviewed for CDMs monthly Medicare e-Rounds (2008) into an informed understanding of the influences that private health care has, or could have, on Medicare, and 2) to describe opportunities for improving Canada’s publicly funded Medicare system.

Synthesis: There are two main messages and conclusions that may be drawn from the 12 peer-reviewed papers that we analyzed in 2008 for CDMs Medicare e-Rounds. Chief amongst them is that private for-profit health care, when compared to not for-profit health care, does not confer better outcomes on its recipients (e-rounds 1 &7). In fact, mortality is worse (e-round 2) and, on average, quality of care is certainly no better and arguably worse (e-round 3). For instance, if you have chronic renal failure and are on dialysis, you have less chance of a transplant and a higher risk of mortality in a private for-profit facility than in a not for-profit facility (e-round 4). Moreover, and on average, patients treated in private for-profit investor owned facilities are less likely to be properly immunized; screened for breast and cervical cancers; receive regular eye examinations as a diabetic; or be placed on a beta-blocker following a myocardial infarction than those treated in not for-profit facilities (e-round 3). The Australians have shown that the introduction of private health insurance increased public waiting times, not the reverse, which is commonly argued (e-round 8). For academic medicine, selected and remunerative clinical activities increase, while research and educational commitments decrease in privately-funded and privately-delivered managed care settings (e-round 9).

While these papers suggest that publicly funded health care is as good as, or better than, privately funded health care in terms of cost, quality and outcomes, there is a second and equally important message. Canadian Medicare is under duress and substantial and necessary improvements are required to maintain the confidence and support of the public. Thirty-five years after establishing a publicly funded system for Medicare in Canada, the job remains incomplete. We know (e-round 6) that medical care makes the largest contribution to narrowing mortality amongst different socioeconomic groups. Despite this, there continue to be profound disparities in mortality from causes amenable to improved public health practice, arguing for greater emphasis on, and importance of, these practices in Canada. In addition, primary care practice in Canada, despite the efforts and rhetoric associated with its renewal, remains a key target for concerted effort and improvement in several key areas, as compared to other countries. These include, but are not limited to, the need for improved information availability and exchange, particularly during transitions of care; better after-hours coverage; and, reduced waiting times for emergency room and scheduled services (e-round 10). In comparing the care of sick patients across countries, Canada has distinct opportunities to improve deficiencies in care, pain management, and hospital-acquired infections (e-round 11). Moreover, medication and medical error rates are high in Canada, most particularly in laboratory error. On a positive note, there are salient examples of making a positive difference as, for example, with management strategies for waiting times, such as is the case for single-entry models, priority-setting mechanisms, and urgency-rating tools (e-round 12). More such examples will be presented in the 2009 e-rounds.  

Limitations: The Medicare e-Rounds authors have restricted source content to peer-reviewed literature. As such, the available evidence around public/private health care is limited and challenges our ability to generalize. Most of it comes from the United States, or is comparative to the United States, for good and obvious reasons, yet with some distinct limitations in our ability to extrapolate findings, outcomes, and attribution to the Canadian system of care. Moreover, most comparative surveys are influenced by sampling techniques and representativeness of the data, while the use of administrative data carries with it the problems of misclassification of diagnosis and incompatible statistics and data collection methods between countries. Various mechanisms have been used in the studies cited in Medicare e-Rounds to mitigate these problems and their consequences. Nonetheless, we acknowledge the argument that the evidence base relating to the successes and failures of private for-profit health care as compared to not for-profit health care is limited. Despite this, the burden of proof to show the value of private for-profit health care delivery or private funding is on those who argue for it. The available peer-reviewed literature thus far fails to show reduced cost or lower mortality rates, or improved quality or outcomes from private for-profit health care as compared to not for-profit health care. Moreover, we know that private care by no means serves to promote equity, whether in terms of inclusion, access, or care provision.

Summary: Medicare e-Rounds will continue to scrutinize and report evidence around private/public health care and opportunities to improve our health care system. The physicians who support Canadian Doctors for Medicare believe that Canada’s publicly funded model offers the preferred opportunity for high quality care, cost containment, and equity of access for all of us. However, as T.C. Douglas indicated 35 years ago, we have not finished building the delivery side of Medicare. Accordingly, evidence-informed changes will continue to be essential to support a sustainable system clinically, financially, and politically.

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