Juno News - Why higher spending doesn’t equal better healthcare (Ft. Dr. Shawn Whatley)

00:00:00.000 you're tuned in to the andrew lawton show

00:00:05.920 let's turn to health care though as you would have heard yesterday perhaps justin trudeau

00:00:13.360 has decided to go to the provinces and offer up 46.2 billion dollars in new health care funding now

00:00:20.200 it sounds really big this is over the next 10 years and it is not condition free and what's

00:00:27.760 happening now is provincial premiers are saying yeah we're gonna take the money but uh you know

00:00:32.700 i don't like it but it was basically an ultimatum it was a one-size-fits-all offer and now the federal

00:00:39.740 government is wanting to put more conditions on this money which again the premier is not loving

00:00:45.220 but uh let's face it no one's going to turn down the cash when there is a health care crisis across

00:00:50.940 this country uh it's an issue dr sean whatley knows very well he literally wrote the book on ways that

00:00:56.920 the government could fix this and the fact that he hasn't been made a health minister is a great

00:01:01.600 shame here and he's the former president of the ontario medical association uh sean it's good to

00:01:07.640 talk to you as always here we talk about the system and oftentimes people can point to a number of things

00:01:13.760 that need more funding and and need more money but there's an efficiency problem here in that you can't

00:01:19.340 just write a check without re-evaluating in my view how the money is spent oh absolutely and that's

00:01:26.020 what i think the feds are using as a springboard to say this is why we need more control because we

00:01:32.660 need a whole bunch more accountability having said that no purchaser of services or products

00:01:39.680 has ever been able to renovate the delivery of those services or products if you walk into tim

00:01:46.220 hortons right now and tell everybody in your tim hortons hey i'm gonna pay for all your coffee and

00:01:50.740 donuts and then you walk up to management and say all right i want you to change the way you make your

00:01:55.700 donuts and i want hotter coffee and a little more cream in my double double management is going to 0.66

00:02:01.120 look at you and say you don't you don't know how to run a tim hortons what are you talking about yes

00:02:05.120 you've just paid for all the services but you can't change the management so i think that's what you're

00:02:09.760 getting at right there it's very very difficult for provinces and the federal government to change

00:02:16.460 the way services are delivered and we can't improve care without changing it at that fundamental level

00:02:22.120 that you're talking about yeah i mean anyone who's ever looked at government spending reports

00:02:27.000 which i suppose is not as amusing an activity as i'm making it sound but you'll know that there's

00:02:32.460 this thing called march madness where every march you have these government departments that just blow

00:02:37.180 money on new chairs new desks new computers because they had this room in the budget and they don't want

00:02:42.680 it to be taken away the next year so you have people that are spending up to their cap and it's not a

00:02:48.480 question of what's the best use of this money how do we best improve our performance and our output

00:02:53.360 and i fear that's what's happening here now i mean the federal government has not proven certainly not

00:02:59.040 this government that it has an ability to do any level of central planning so even putting this money

00:03:04.760 to provinces and saying here's how you need to spend it like i'm not seeing the roadmap on how

00:03:10.580 healthcare will be improved with this yeah so two points you raise there i'm glad you use the word

00:03:17.040 central planning and that needs to be more a part of our dialogue so understandably 200 billion

00:03:24.020 dollars captures the headlines and that's what we want to talk about and i'm glad you highlighted that

00:03:28.620 actually this is only 46 billion in new dollars the rest of that money was going to flow anyways

00:03:34.920 and it spread out over 10 years net having said that people still love to talk about the money

00:03:40.600 but really what we should be talking about is the control that's at issue so you look at their

00:03:46.500 long list of things they want changed even going back to march i'm looking at a list by health

00:03:51.700 minister duclos he said well these are our five priorities but if you look at them they're actually

00:03:56.940 more like 10 or 15 priorities so essentially they're setting the marching orders and it it's i can't

00:04:04.120 understand why they want control it's like a dog chasing the car what are you going to do when you

00:04:09.000 catch the car furthermore how do you even know you can control health care better than the provinces

00:04:14.240 and so it's a mixture of uh ignorance and arrogance and and to hear the our prime minister you know

00:04:21.020 almost fold his arms and say we need better performance and you're not going to get money

00:04:26.120 until you show me performance it's it's like saying that the beatings will continue until morale improves

00:04:31.260 i just i can't figure it out and you also made a comment though about march madness and funding

00:04:36.600 what we see in the hospital um um sector especially is that the worst performers often get the most

00:04:44.040 funding now governments tweaked into this a few years back and they realize now that if you really

00:04:49.840 come you know you really go over budget and maybe you need to be replaced as a board but never come in

00:04:56.320 at budget i never come in below budget because it means your budget will get cut next year and so

00:05:01.340 there's this bizarre political game uh going on when really patients want care and they want to know

00:05:08.240 who to hold accountable for delivering that care how much latitude do premiers have to be innovative

00:05:16.760 about delivery and and i i'm not talking about privatization here i am talking about uh private

00:05:22.740 alternatives you can have universal coverage and private delivery there's nothing as i understand

00:05:27.560 it that precludes that but but how trapped are premiers in this system so fantastic question

00:05:34.840 you're asking like someone who i think ran for paul political party perhaps basically they have almost

00:05:41.560 zero latitude so if you speak to these ministers of health or minister of long-term care they say listen

00:05:46.720 john the money's all tied up it's all tied up in salaries it's tied up in um in contract

00:05:52.440 negotiations and collective bargaining agreements that's the wording i was looking for and so

00:05:57.040 there's very little wiggle room as far as injecting some creativity in how our system functions by

00:06:04.100 tweaking the way funding flows having said that premier ford's uh recent announcement where he says

00:06:10.200 you know we're just going to shift more services outside of hospitals we've had this shift going on for

00:06:16.040 40 years it's it's a little bit absurd that people are saying oh this is terrible this is the end of the

00:06:21.500 world no we're just going to increase mris and ct scans in the community like we've been doing for

00:06:27.540 the last 20 or 30 years doing that though leapfrogs all of the management and the regulatory system

00:06:35.440 that is attached to hospitals and so for a short time you'll be able to see innovation on the

00:06:42.140 management side in these non-hospital facilities so ministers of health can do those sorts of things

00:06:48.340 but it's very difficult to actually use dollars and be creative like we would hope they could be

00:06:53.320 one thing i i know and i i've been very fortunate i've had a family doctor my entire life when my

00:06:59.980 doctor from childhood retired his daughter took over his practice and i i mentioned at the top of the show

00:07:06.000 that i i was just coming off a bout of pneumonia and i mean when i called my family doctor i had an

00:07:11.060 appointment a few hours later and and i know that a lot of people do not have anywhere close to that

00:07:16.120 level of access here and you are right because if someone can't get in to see a family doctor what

00:07:21.960 is it they want to do they want to go to a hospital they want to go to an urgent care system you've got

00:07:25.900 a lot of people in hospital that don't need to be there and this seems to be this catch-all

00:07:30.800 that no one has really come up with an answer to yeah i'm glad you mentioned uh privileged access

00:07:37.300 because you're a prime example of someone who has connections and someone who um the person at the

00:07:45.100 other end of the line will definitely pick up the phone and and the reason i i when i was a nobody

00:07:50.200 they still picked up the phone though so i i don't attribute it to privilege i just think it's a really

00:07:54.400 good doctor but carry on it's it's all privilege man it's all privilege no uh one of the core

00:08:00.200 fundamentals of our system is care regardless of the your ability to pay and it's sort of this

00:08:05.740 beautiful um uh truth that we we design our whole system around but really the reality is that people

00:08:12.760 who have some sort of access or they know somebody inside the system get better they are able to get

00:08:18.740 better care for themselves and their family so the issue of privileged access is key you also ask though

00:08:24.160 about um accessing care in different ways you know should the hospital really be the place that we go as

00:08:30.760 a default and canada has always had a hospital-based or a hospital-centric system and this flows you know

00:08:37.320 1957 the hospital insurance and diagnostic services act that was the first time we saw this dollar for

00:08:43.480 dollar cost sharing where the government federal government said listen provinces we'll pay 50 of

00:08:48.820 whatever you spend in hospitals and they repeated the same deal with the medical care act 1966 and those

00:08:55.100 are the two pillars of the of medicare as we know it as you know the first trudeau government turned off

00:09:00.660 that blank check approach of the 50 50 deal in 1977 with the established program as a financing act

00:09:07.480 and then provinces and the feds have been fighting about funding ever since and that's what we're

00:09:11.960 seeing right now well i mean on mental health care specifically i mean i've been very open about my

00:09:17.240 own experiences with mental health challenges but just looking at it from the system perspective here i

00:09:22.300 think one of the worst things you can do for a patient who is not in any acute medical situation

00:09:27.340 is to have police pick them up on a mental health call and bring them into a hospital where

00:09:32.400 the resources are are already tied up and already stretched thin and again i i would imagine there

00:09:38.560 is probably a much less costly and better quality alternative out there but it in quite it requires

00:09:45.560 a complete rethink of the the system well part of what you're getting at with mental health care and

00:09:51.360 many other services fall into this as well as that they are intangible it's easy to say we have a

00:09:56.780 wait time for hip replacements we know your hip is worn out we can measure it and we can you know

00:10:01.840 pay then for the number of hips being done mental health care is very difficult because um it's you

00:10:08.520 know james q wilson harvard professor talks about it being more a representative of a coping organization

00:10:13.940 it's more like education or like peacekeeping when a police officer is out keeping the peace how can you

00:10:20.680 tell how much peace they're keeping can you pay them more if they keep more peace or punish them if they

00:10:25.380 don't keep peace well peace is a metaphysical concept and and you're you're getting at that with

00:10:30.220 um health care as well how do we know that my advice to you to um uh change your diet or whatever

00:10:37.540 is going to do anything for you 20 years from now or 40 or 50 years from now will it make you live one

00:10:43.360 year longer how do we know that my advice was perhaps ignored and maybe you listen to someone else in

00:10:49.120 your house or your friend or your mom or whatever and so what you're getting at is the intangible

00:10:54.160 you're getting into an intangible thing where you know you hear not everything that can be measured

00:11:00.840 matters and not everything that matters can be measured and so now you're talking about something

00:11:05.560 that is very difficult to measure but it matters a great deal and so it tends to fall off the budgets

00:11:12.920 and spreadsheets and all these beautiful charts that you see from our health system planners but we end

00:11:19.000 up in the crisis that we're in right now because of it so suppose you are the health minister of

00:11:25.880 a province it doesn't really matter which one and the government has given you whatever your

00:11:30.620 province's share is of of this uh 46 billion dollars over the next 10 years which when you break it down

00:11:36.620 over 10 years plus over 10 provinces and three territories it's not even as huge it's even less

00:11:42.280 significant an amount but let's say you're given this what is the most in your view tangible change

00:11:48.920 you could put in place with that money so you've limited me to just talking about money usually i try

00:11:56.000 to answer that question by saying i want to talk about governance first let's do both i mean let's do

00:12:00.580 both how how can you most efficiently spend that money pretending that the current governance

00:12:06.160 restrictions are not there okay so it's usually three things i talk about number one we know we have to

00:12:11.360 figure out governance who's in charge right now canadians don't know who to hold accountable

00:12:16.380 do we hold the feds accountable do we hold the provinces accountable do we hold our local hospital

00:12:20.440 accountable who do we hold accountable for access to care so that has to be clear number one number two

00:12:26.140 we need to expand core services so when i talk about core services i'm talking about life or limb and

00:12:33.980 that's sort of the fundamental that's the moral high ground in medicine whatever you do when someone

00:12:38.660 comes in you have to save life or limb first mental health falls in there it is a life or limb issue

00:12:45.260 so we need to expand services around life and limb issues the second thing the third thing actually or

00:12:52.660 the second thing with with concrete things that i would change with respect to funding is to constrict

00:12:58.740 and this is the part people don't like to constrict things that are inappropriate so we have to have a

00:13:05.840 discussion first about appropriateness are all the services that we spend money on actually appropriate

00:13:13.240 for the current environment we live in right now medicine can offer far more than anyone ever dreamed

00:13:20.200 it could offer in the 1960s when we were coming up with this public health insurance approach in

00:13:26.100 canada and so we've massively expanded what we can do and what we can offer and then provinces are pressured

00:13:32.840 pressured to keep at offering you know pet scans or mris for anterior knee pain or you could go on and

00:13:39.540 on with the things that we probably shouldn't be doing the obviously wrong things are fall under the

00:13:46.600 choosing wisely campaign where they encourage doctors to stop ordering useless tests but that's only a

00:13:52.560 fraction we need to have a robust discussion to say what do we have medicare for is it simply a

00:13:59.060 redistribution program like roy romano calls it he calls it our great redistributive program in canada

00:14:04.840 or is it to provide a safety net for core life and limb issues so that's where i would focus on

00:14:11.240 expanding those services contracting the more useless ones but number one we have to get governance fixed

00:14:16.860 out fixed up yeah and and again we all get stuck and you and i have spoken about this in the past in this

00:14:22.860 very false dichotomy between a canadian healthcare system and an american healthcare system i was just

00:14:28.940 listening to a show my friend mark stein did and he just was talking about the difference between the

00:14:33.520 uk system and the french system they're both completely government funded but one is vastly

00:14:38.400 superior to the other so there are degrees of quality within every system within every permutation

00:14:44.040 and combination here and you know there are things that i think shouldn't be third rail issues one of

00:14:50.540 them and again i'm not even advising that the government does this but i i certainly think

00:14:54.100 there should be a permitted discussion is having a co-pay when you go to a clinic or when you go to a

00:14:59.120 family doctor perhaps everyone gets you know three free visits a year and if you go over that you have

00:15:04.080 to pay some nominal fee or something like that like but the fact is there are what i think are

00:15:09.940 ideological uh people that are resistant to any change whatsoever and they prioritize uh equality of care

00:15:18.380 over quality of care yeah great comments and you've really opened a wide up door wide wide door for a

00:15:25.080 whole bunch of discussions which is great as we're winding down just to like throw the bomb of copay in

00:15:29.940 there but anyway carry on so we have the 28 universal health care systems around the world and i think we

00:15:35.720 can be strong in saying universal care just means everybody in your country gets care there are many

00:15:40.580 different ways to achieve that in 28 different countries around the world have universal health care

00:15:45.680 23 of the 28 have some form of cost sharing now when you get into patient cost sharing

00:15:50.980 one of the mistakes people make and i just wrote a large paper on this actually for mcdonald-laurier

00:15:56.040 institute is that they think they'll get cost sharing to increase revenue in fact that doesn't work

00:16:02.540 the countries that use cost sharing they always have robust exemptions for the very old the very young

00:16:10.320 the chronically ill and that sort of thing so once you narrow who you're going to focus the cost sharing

00:16:16.960 onto you do have a measurable change in in how many times people will go to the doctor for the same

00:16:23.840 problem for their anterior knee pain which is the bane of an orthopods existence and so there there is some

00:16:29.840 role for it to play however however it actually may cost the system more if you imagine a long lineup at

00:16:37.520 tim hortons and everybody in that lineup wants you know one tim bit and there are two or three people

00:16:44.080 in there with a large order the average cost for that long tim hortons lineup will be very low whereas if

00:16:52.080 every single person in that lineup wants a dozen donuts and 15 coffees the average cost per customer is very high

00:16:59.680 it's the same with healthcare if you use user fees to get some of those low value people out of that line

00:17:06.160 you may drive up and most studies suggest you will drive up the average cost per patient but that's

00:17:12.240 the right thing to do so we should do it to improve efficiency and improve horizontal equity so that you

00:17:19.760 and i if we're earning the same amount of money and we have similar genetics and you go to the doctor

00:17:24.880 every two weeks and i go to the doctor once a year why do i have to play the same health premiums so

00:17:30.320 there's an argument to be made for them but it's not the magic solution that some people think it is

00:17:36.160 well i appreciate it very much and just on the note of etiology i have to share this comment there

00:17:40.880 was a service that started up in canada a few years ago called maple which lets people for a

00:17:45.600 a nominal fee whatever it is see a doctor virtually and and get a prescription if they need or anything

00:17:51.200 like that and in my as to my understanding all of the doctors on maple are employed within the public

00:17:57.440 system but in their off time they sign up and they take you know however many patients a day or a week

00:18:03.520 and it's a net increase in the amount of care available in this country it costs the public

00:18:10.240 system nothing it costs taxpayers nothing jagmeet singh last week was saying we need to prohibit it

00:18:15.440 we need to close what he's calling the maple loophole yeah so i i've uh i've been on a number of

00:18:21.840 interviews actually debating what what he's been saying he's been saying things like in bc they're buying

00:18:27.680 up all the private clinics and so i don't know we can have another you know air canada or whatever but to

00:18:32.960 your point about increasing access that's a key point that i think the public really needs to

00:18:37.920 know about and i'll use a concrete example so in ontario we have a certain number of ivf cycles so

00:18:45.040 people who can't get pregnant they want to get pregnant they go to fertility service and they

00:18:49.200 can get something called ivf in vitro fertilization ontario funds 5500 of those a year that number of

00:18:58.800 procedures could support you know five clinics a large clinic will do around a thousand procedures

00:19:05.840 a year because ontario allows private billing for ivf services infertility services we actually

00:19:14.960 currently have 13 clinics in ontario this is 2020 data so in other words people who want their publicly

00:19:22.960 funded ivf services now have clinics much closer to home we have them far up in the north all across

00:19:29.920 southern ontario so 13 instead of five or six because we've allowed a greater number of or a blend

00:19:38.080 of public and private billing for ivf and you have to realize that each one of those clinics hires staff

00:19:45.120 and they have rent space and they have equipment and so not only is it better for patients it's better for

00:19:50.800 the economy it's better for the healthcare workforce so it's better overall so this book this uh fear

00:19:57.200 mongering about um any any blending at all is just not borne out by the data dr sean whatley author of

00:20:05.440 the book when politics comes before patients why and how canadian medicare is failing but he doesn't just

00:20:10.960 come with doom he comes with a bit of hope and with suggestions and i think leaders in government

00:20:16.080 should very much heed those sean always a pleasure thanks for coming on today my pleasure thank you

00:20:21.280 thanks for listening to the andrew lawton show support the program by donating to true north at www.tnc.news

Juno News - February 20, 2023

Why higher spending doesn’t equal better healthcare (Ft. Dr. Shawn Whatley)

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