Canada’s Health Care Landscape has Changed Since the Canada Health Act

I’m honoured to have Dr. Silvy Mathew guest blog for me today. She’s a former member of the OMA Board, former member of the Physicians Services Committee, has a Master’s in Health Policy and Economics, a Certificate in Global Health and is hands down one of the smartest people I know.

Health care in Canada is governed by the Canada Health Act, a federal act that essentially states that medically necessary care provided by physicians and hospitals, will be covered by public insurance and administered by each province. 

The Act was passed in 1984, and is reflective of the type of acute medical care practiced at the time. However, in 2023 (and for at least a decade prior), medical care, through technology, medical advancements and aging, has changed drastically. Publicly covered care now, however well intentioned, is sorely lacking. Ironically, because of that, it is also very expensive.

For exampe, we lack public pharmacare  for adults despite being promised this by 2006 by then Prime Minister Paul Martin. (There is some pharmacare for seniors and children).

We lack dental care. We lack appropriate home care in an aging population that is getting weaker and frailer. We lack coverage on physiotherapy. In an era of increasing mental health burdens we lack psychotherapy.

The list goes on and on, notwithstanding the severe social issues that contribute to many of these issues (healthy food, exercise, housing and all the other social determinants of health).

Because we have not invested upfront, we pay significant costs in expensive procedures, prolonged hospital stays, and medications much of which could be minimized or avoided.

Why does it matter?

McKinsey Global Institute published a prospective analysis of 200 countries, looking forward on the impact of 52 diseases over the next two decades to quantify the social and economic gains if health is made a priority by government and private sector.  They quantified the value of health to the economy and showed that if using the existing interventions we have today, we can reduce disease burden by 40% in the next 20 years and extend “active middle age by 10 years”. This translates to an economic return of $2-$4 for each $1 invested. That’s remarkable. 

What’s the hold up? The lack of foresight, upfront cost and political inertia is costing us.

We have a shortage of healthcare professionals, and we use the ones we have, in extremely inefficient ways. For example, the lack of a proper digital health infrastructure in Ontario (like they have in Turkiye!) results in duplication of services, poor coordination, and inconsistent delivery of health care. Even the electronic services we DO have don’t capitalize on Artificial Intelligence (AI).

Technology advancement is a double edged sword. There are benefits to patients in terms of ongoing updated guidelines for care. But health care workers are having to do more, monitor more and change practice styles more, all leading to more individual HCW time.

Each test, often results in further testing or reassessment down the line, which compounds the problem. It’s rare that physicians just close the door on one issue a day.

Again, at the time of the Canada Health Act, we were practicing acute, limited health care. Today’s world is focused on prevention and chronic illness with monitoring. That shift has placed a huge burden on physicians time to review, inform/educate, coordinate new referrals and remind individuals to do monitoring.  Much of the time, it seems like we still don’t know how much benefit we will get from this. Hopefully the data will show we were correct to do this.

To collect and review the data though, we would need better digital systems to capture the information, which we don’t have.

Some people imply this will be managed with more “healthcare team members”. I think a huge solution for this particular issue is investing in technology and AI solutions.

Right now, we are trying and failing at holding back an avalanche.  We have technological advancements, but limited access to those. We have lack of integration of our digital infrastructure. An ageing population is leading to increased needs. But an aging health care work force is seeing retirements and illness leading to less access. New providers are available but their impact is less clear due to lesser training and duplication of services leading to increased costs. Delayed diagnoses are leading to worsened health outcomes and more expensive care. There is less preventative care due to a shortage of family physicians which leads to delayed diagnoses, worsened health outcomes and more expensive care. Lack of care giver support and home care support means that people are leaving the workforce to care for ill relatives which leads to hospital dumping. Burnout is endemic in health care, due to a feeling of disrespect and an inability to practice best patient care.

And so, physicians are in all areas of the country are giving up and closing their practices.

In the meantime, while we wait for our wishes to come true, there is opportunity to push the envelope and to drive change. People are desperate and they want options.

When access to health care is inadequate, people will choose out of jurisdiction options for delayed procedures and even screening tests. There is a moral hazard involved. People are taking risks by going elsewhere under the assumption that they will be taken care of properly.

However, with any challenges, there are opportunities. Some “non-medically necessary” medical tests (eg. screening for vitamin D) are not covered by medicare. However, it’s increasingly viewed as an early intervention. We will only see technology increase these options as better screening methods become available, and governments delay paying for them. Perhaps instead of waiting for open heart surgery or stenting, there may come a day where preventative procedures can be used to dissolve plaque in the heart arteries.

Health care faces inescapable and exponential change. However, it is unlikely, at least in the near future, that Canada (or any country’s) public health system will be able to keep up with technology and demand.

Oh for some strong, principled leadership that can see these challenges and address them head on, without resorting to political sound bites.

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Canada Should Look to Turkiye for Health Information/Data Systems

Disclosure: I have a business relationship with Medicte, a firm that provides high quality medical tourism services for Canadians. They provided me with some information for this blog. If you are on a prohibitively long waiting list for medical or surgical services, and are willing to consider travelling out of country to have treatment, contact Dr. Abdullah Erdogan at: medical.developer@mestassistance.com

I’ve written previously about Health Data Systems and what a poor job Ontario (and indeed all of Canada) does at using information technology (IT) to help with health care. Let’s look at country that does things the right way, Turkiye (formerly Turkey). I appreciate this choice may come as a surprise to many, but Turkiye has a very modern, highly efficient health care system, and had to go through their own period of transformation from a fragmented system to a more integrated one.

The long version of how Turkiye evolved their health systems can be found here. The short version is that in 2003, the Turkish government came up with the political will to introduce the Health Transformation Program. Over the next ten years this act, and unyielding political will, transformed the Turkish health care into a fully integrated system. In many ways, it’s a model for what Canada needs to do.

I had the honour of being invited to do a talk for the Canadian Turkish Business Council on the Canadian health system (along with my smarter and more esteemed colleagues Drs. Nadia Alam and Silvy Mathew). In preparation, I studied up on how Turkiye handles health data (with the help of Medicte). I cannot tell you how impressed I was with their system.

Drs. Nadia Alam, Silvy Mathew and yours truly speaking at a meeting sponsored by the Canadian Turkish Business Council

In Turkiye, the federal government has mandated that all hospitals in Turkiye use the Hospital Information Management System (HIMS). Now to be clear, different hospitals in Turkiye still use some different modules of software, but they are all compatible with HIMS. The data for all citizens of Turkiye is then backed up securely.

Then, every citizen of Turkiye is offered a patient portal called e-Nabiz.

Official logo of Turkiye’s patient portal.

What does this portal allow patients in Turkiye to do? According to Medicte:

“When people enter their E-Nabız profile, they can make appointments at all public hospitals and access the records of these appointments. They can review all of their examination, diagnosis and treatment data in the health facilities they visit and access the details of all the tests performed during this process. This includes all data related to the process, such as all laboratory tests and radiology images with their reports, prescriptions, diagnoses and drug usage details.” 

Further more, the app can be used to allow other health care providers access to patients health information (with consent). Let’s say a resident of Istanbul happens to travel to Antalya (a truly lovely tourist destination about an 8 hour drive away). If that person gets ill, they can use the E-Nabiz portal to allow doctors in Antalya to see their previous health information to help guide their care. Not only that, information about their visit in Antalya will automatically be available to their family doctor in Istanbul, including lab work, diagnosis, and prescriptions. I can’t even get health information on patients of mine that go to a walk in clinic in Barrie, and that’s only 30 minutes away from my office.

Not only does this system allow for much better communication between health care professionals of all kinds (physicians, nurses, pharmacists, home care and so on), but having knowledge of a patient’s previous health history significantly reduces duplication of tests. And leads to more optimal outcomes.

For people who are not citizens of Turkiye, but go there for medical tourism (Turkiye is one of the top medical tourist destinations in the world), their travel companies can offer them similar access to their health care records. For example, Medicte will soon offer the MestCard app via its parent company MestGroup.

Screenshots of the MestCard Apps

Essentially, a patient of mine, who choses not to wait the 13 months that they currently have to wait for a hip replacement in my area, could go to Turkiye next month, get their hip replaced AND have much better access to all their health records than a patient of mine who got that done in Canada. (And yes, all of these apps/software/portals are compliant with recent security standards).

But that’s not all, this tight integration of IT allows for other benefits. For example, Health Systems Consultant Matthew Lister, who spoke at the same event, informed how this allowed hospitals across Turkiye to manage their supply issues. If one hospital was short on something (tubing, a drug, IV fluid or so on), it can immediately check the inventory of nearby hospitals and request a transfer. No phone calls, no double checking. It’s all online, backed up, and available for hospital management to see. He also emphasized that this has been the case in Turkiye since at least 2011!

Matthew Lister speaking at the Canadian Turkish Business Council event.

In Canada, given the disastrous current state of our health care system, there have been calls for system transformation from multiple sources. Whether from what are viewed as conservative organizations like the Fraser Institute and Postmedia News, or progressive organizations like Canadian Doctors for Medicare and the Torstar Media group, everyone from all sides of the political spectrum agrees that health care is need of a fix.

Here’s thought. Rather than start from scratch, let’s look at countries like Turkiye, that have taken their own fragmented health care systems, unified them and leapfrogged Canada to develop a much more efficient health system. Then just do what they did.

The benefits to the citizens of Canada would be enormous.

Post Script: While it’s true that Turkiye has a modern, high functioning health system, even such a system can be overwhelmed by a disaster like the recent Earthquake that has claimed at least 50,000 lives. To help the victims of the earthquake in both Turkiye and Syria, I encourage you to donate to the IDRF Earthquake Relief Fund.

It’s Time to Make Health Care a Federal Responsibility

Health care is consistently viewed by Canadians as their number one priority in any federal or provincial election.  It is the largest portfolio of provincial government budgets and is responsible for a substantial proportion of the federal budget.  Yet despite all this expenditure, it continues to fail the citizens of Canada.

As I’ve repeatedly said in the past, our health system needs a bold and innovate transformation if it’s to provide care to Canadians in the 21st century.  In a previous blog, I had promised to come with some ideas on how to do that.  I submit the first step should be to make health care a federal responsibility, and not a provincial one.

Parliament of Canada, the seat of the Federal Government

I know, I know, this will require an amendment to the Canadian Constitution, a dizzyingly complex process.  But I have an idea for that as well, that I will get into later in the blog.

For now, let’s look at just some of the reasons why we should have a National Health Care system.

Canadians Already believe we have a National Health Care system

Regardless of how the division of authority is laid out, the reality is that Canadians feel that no matter where they go in this country, they will get health care paid for by their taxes.  “You shouldn’t need a credit card to pay for your health care” is a mantra that is oft repeated by politicians.  It’s part of the Canadian identity say other pundits.  Logistics aside, politically speaking, this simply is in keeping with what Canadians already think.

The Canada Health Act puts provinces in a no-win situation. 

Somewhat unbelievably, I find myself defending some politicians here (I’m just as shocked as both of my loyal readers are).  The argument presented to me by political leaders with whom I have spoken in the past was that premier’s don’t want Ottawa telling them what to do, or how to spend dollars. Certainly, we saw some of that in the wrangling over the most recent health care accord where premiers pushed back on simple things like data collection.

But I feel that it’s the premiers who are in a bind here.  The feds can go around saying, “hey, we are going to support the five principles of the Canada Health Act” and then……well do very little about ensuring that.  The premiers are stuck because they can’t violate the act. However, they have to figure out how to manage the system with declining revenues. And of course, take the flack when the system is failing.  

It’s time to make the level of government that boldly proclaims that Canadians don’t have “pay out of pocket” for health care responsible for implementing it.

The efficiency of the system will increase

I’m serious (honest).  Once again, let’s look at the most recent health accord.  The federal government agreed to increase spending on health but in return requested health data management.  In order to do so the feds propose to have “tailored bilateral agreements” with the provinces and territories.

That’s right, instead of having one team come up with a national data standard, there now have to be 13 committees to hash out how to do it.  Which means, you guessed it, 13 times the number of bureaucrats.  In 13 times the number of meetings.  If the feds ran health care, they could just have one committee to oversee the changes for the whole country.  

The same would apply to just about every other aspect of health care.  Whether determining what services are covered (there is intra provincial variation), to determining things like public health policies and so on, a unified Canada wide health system would be far more efficient.

Who knows, they might even be able to take the money saved from having 1/13th the number of bureaucrats and invest that into hiring more health care workers………nah, they’ll probably put it into more $6000 a night hotel rooms for our effete Prime Minister.

Unified Rules/Licensure requirements across the Country

The Canadian Medical Association (CMA) is strongly advocating for pan-Canadian licensure to deal with the physician shortage (so much so they almost make it sound like a panacea).  I support national licensure of course. Although I wish the CMA would focus on getting us pensions and getting the government to reverse the tax changes that so harmed physicians in 2017.  That would really help their members (the ones they are supposed to be serving).

But let’s be real, national licensure ain’t gonna happen with 13 separate provincial regulatory bodies all trying to generate income to run their organizations with licensing dues. 

BUT, make Health Care federal, and you only need one regulatory college that can set Canada wide standards (for all professions, not just physicians).  

Similarly, programs like national pharmacare (the one then Prime Minister Paul Martin promised us by 2006) and other programs can all be implemented more easily.  

So what are the next steps to take?

There are undoubtedly many other examples of what could run better with a single, Canada wide health system.  The big question of course, is how do we change the constitution to allow this?

Canada is due for an election by 2025.  It might happen sooner if NDP leader Jagmeet Singh tires of the foppish behaviour of our current Prime Minister and pulls his support for the “confidence and supply agreement”.  I propose that whenever that election is, there be a referendum on altering the Constitution.  (It would be better than having two separate votes).  

Canadians would go to the polls, vote for the candidate of their choice, and then have a question to answer as to whether they support amending the constitution.  Make it binding on the provincial governments.  If there is Canada wide support for this, then the provinces would have no choice but to agree to the amendment (and as pointed out earlier, it would be better for them politically anyway).

Canadians have long viewed their ability to access health care without paying out of pocket as a quintessential Canadian quality.  Having the provinces run health care may have made sense in the days of paper and telegraphs, when integration was nigh on impossible anyway. But in the 21st century, when integration is paramount to running a health care system, it makes no sense.

It’s time for the federal government to take over health care, so that the system can be run in the best interests of all Canadians.

Federal-Provincial Health Care Deal Fails Canadians

This blog has been updated to reflect that the fact that the offer from the federal government has been accepted by the provinces.

Lots of chatter about what is an agreed upon funding formula for Health Care between the provinces and the federal government. Some astronomical dollars are being thrown around and called investments in health care. But at the end of the day, will this deal mean better health care for Canadians? The sad answer, is likely no.

One of the advantages(?) of being old is that you’ve lived through lots of things, and can see the past repeating itself. Case in point, in 2004 then Prime Minister Paul Martin introduced a health care “accord” that was designed to “fix health care for a generation“. Essentially the federal government ponied up an eye watering amount of money then, and the provinces were to implement targeted programs that would:

  • Reduce wait times
  • reform Primary Care
  • Develop a National Home Care program
  • Provide a National Prescription Drug Program (by 2006!)

Now Primary Care reform did happen in Ontario, with the development of capitation based payments to family physicians. Think of it as a salary with performance bonuses and you get the gist. There was also the implementation of some Family Health Teams. I’m unaware if any of these were implemented in other Provinces. I do note with interest that British Columbia is only now getting around to reforming primary care with their own new payment model for family physicians.

But both of these programs in Ontario were summarily slashed by then Health Minister Eric Hoskins and his servile deputy Health Minister Dr. Bob Bell in 2015. Indeed their unilateral freezing of the capitation model significantly damaged primary care in Ontario, and the effects of their folly are still being badly felt today by the 2 million residents of Ontario without a family doctor.

OMA Board Vice Chair Audrey Karlinsky put it best on Twitter.

Wait times for surgical procedures however, continued to rise, and I have no idea whatever happened to the National Home Care program.

For those of you paying close attention, the same Eric Hoskins who stopped Primary Care reform in Ontario, went on chair a federal advisory council with the goal of creating a National Prescription Drug Program……….in 2018. Which hasn’t been implemented yet. I suppose being 17 years overdue is not bad by government standards.

By the way, this whole process is basically recycling a failed politician to recycle a failed government promise. And politicians seriously wonder why average Canadians like me are so cynical??

So now, 19 years later, Canadians are being told that the provinces have accepted a federal government proposal to put an eye watering $196 billion into health care, according to Prime Minister Trudeau. But wait they were committed to $150 billion anyway so it’s really only $46 billion more, but wait, when you take out the planned budgeted increases it’s only $21 billion more. Whatever.

In return, for however much money it really is, Trudeau promises there will be “tailored bilateral agreements to address“:

  • Family Health Services
  • Health workers and the backlog of health care
  • Mental health and substance abuse
  • Modernized health care system

Our politicians need to study Albert Einstein a bit more.

Here’s the sad truth about our health care system that no politician, of any political stripe seems to be willing to admit. The system is dying and in need of radical surgery. It needs a bold, transformative vision that will completely change the way we deliver health care and will leverage technology appropriately. Anything less is simply more of the same, and will not stave off the inevitable collapse of the system.

How then do we achieve this transformation that is essential to the well being of Canadians? I will go into some further thoughts about this in future blogs, but first I would implore our political leaders to stop listening to old voices who have been advising for decades (if their advice had been good we wouldn’t be in this mess). It’s time to seek out some newer voices who have bright ideas on how to restructure health care delivery in Canada.

It’s also time to wrest control of health care data management from the current group of bureaucrats in charge of it. We can’t transform health care in Canada without a robust health care IT infrastructure and the current group simply is not getting it done.

As mentioned, I will put some more though into how, in my opinion, health care can be transformed in the future. But for now, just know that whatever the numbers or promises being tossed around, the blunt reality is that it all amounts to trying to spend you way out of trouble.

When has that ever worked out well?

Ontario’s Heading For Another Family Doctor Shortage

This is the follow up blog to my last one, originally published in the Huffington Post on June 13, 2017. Reprinted here so that I can keep track of my old blogs, and also to once again point out how warnings of a crisis in Family Medicine were ignored for years.

The Barer-Stoddart report. Ask any physician of a certain age and the immediate reaction is likely to be disparaging. Written in 1991, it purported to help chart the course of the physician workforce into the 21st century. 

While it’s true that much of the report was ignored by the Ontario government of Bob “Super Elite” Rae, it’s still widely remembered for suggesting that the number of physicians in Ontario needed to be cut by 10 per cent. To accomplish this, medical school enrollment was slashed in the early 1990s.

Given that the population of Ontario continued to grow and age, the result was completely predictable. A massive doctor shortage (particularly in family medicine) hit the province at the end of the decade. It has taken the last 15 years to come close to correcting that. We’re not there yet (we still have fewer doctors per capita than Mongolia), but we were improving.

Alas, Ontario Health Minister “Unilateral Eric” Hoskins and Deputy Health Minister Bob Bellwere unable to remember the old saying, “Those who cannot remember the past are condemned to repeat it.”

Former Health Minister Dr. Eric Hoskins

Last week I blogged about how Hoskins and Bell need to support family medicine. Because they are not doing so, many physicians who graduate from family medicine residencies are not starting comprehensive family practices. Instead, they are doing things like hospitalist work, sports medicine and even medical marijuana clinics.

However, the situation is even worse than I thought. It was pointed out to me after my blog was published that the number of medical students applying to family medicine programs has dropped considerably this year. In Canada, to become a practicing physician, you first have to graduate from medical school, then do a residency (essentially a training program) in the specialty of your choice. To choose a residency, you apply to CARMs — which is a Canada-wide program that matches medical school graduates to the residency of their choice.

This year’s CARMs match shows some alarming results for family medicine in Ontario. Ideally, we should have 45 to 50 per cent of all graduates from medical school apply to family medicine for a sustainable workforce. However, only the Northern Ontario School of Medicine achieved that goal. While it’s a great school, it’s still the smallest of Ontario’s six medical schools.

By comparison, only 24 per cent of graduates of University of Toronto applied to family medicine, 27 per cent of Queen’s graduates, 32 per cent of Ottawa’s graduates, etc. Multiple studies show that comprehensive family medicine is responsible for decreased health-care costs, more efficient utilization of the health system, better patient outcomesand decreased hospitalizations. It is essential for a sustainable health-care system to have a strong family medicine component. The fact that so few medical school graduates chose family medicine, on top of the fact that recent graduates are not opening practices, should be setting off alarm bells.

So, why is this happening? First and foremost, it’s because Hoskins and Bell have refused to support family medicine. They have talked loudly about how they want to cut payments to higher paying specialties so that they could fund family medicine. Hoskins even went to the trouble of doctoring (pun intended) a chart to accuse specialists of overbilling. 

(Seriously, see the picture in this article. Notice how he made the pie chart on the right larger — the whole circle, not just the wedge showing percentage of billings. Makes the red area look LARGER than it really is, and makes the specialists look they are billing disproportionately more than they are.)

Unfortunately, while Hoskins and Bell were saying this in public, what they were actually doing is cutting family physicians. They unilaterally cut the number of physicians who could apply to the capitation (salary plus performance bonus) models of funding that I mentioned last week. This is the preferred method for paying physicians for newer graduates, and also for health care bureaucrats who like a predictable budget. Additionally, they cut a number of the performance bonuses family physicians got for looking after complex patients.

Medical students are not dumb. They saw all of this going on, and realized that family practice was no longer preferred by Hoskins and Bell. So they made career choices accordingly.

Currently, the Hoskins/Bell legacy is not a pretty one. It’s one of internecine disputes with doctors, laid-off nurses, hospital deficits, patients in stretchers for days and egregious wait times. At least with family medicine, they have an opportunity to begin to correct this mess by once again allowing new physicians to enter the capitation model, and restoring the various performance bonuses.

Failure to do so will mean that many years from now, as patients struggle to find a family physician, Hoskins and Bell will be remembered with the same disparaging legacy as Barer-Stoddart.

Hoskins and Bell Need to Support Family Medicine

The following is a reprint of an article that I wrote for the Huffington Post on June 5, 2017. Re-posting here so that we can see how the seeds of declining family physicians was planted by Drs. Eric Hoskins and Bob Bell, and also so that I can refer to it in the future if needed.

For the past 23 years, it’s been my pleasure to be a preceptor with the Rural Ontario Medical Program based out of Collingwood. As a preceptor, I have had the honour of supervising a wide variety of Medical Trainees, from first year Medical Students, all the way up to those in their last year of Residency. 

I often find I learn as much from them as they learn from me (it’s good to be questioned by students about why you do things the way you do). I clearly have some experience on my side, and they have more recent book knowledge. It’s a great combination for patient care.

Unfortunately, I can see that we are once again heading for the same situation as the late 1990s/early 2000s, when many medical trainees stopped going into comprehensive family medicine. The reasons then were due to increased workload, better opportunities in other specialties and an extremely poor relationship with the government of the day. 

At one point, only about 25% of graduates from medical school applied to Family Medicine Residencies. To suggest that there was a crisis in family medicine would be dramatically understating the issue.

However, the Conservative government of Mike Harris finally realized you need to co-operate with doctors if you want to improve patient care. In 2000, Health Minister Elizabeth Witmer rolled out something called Primary Care Reform (PCR) in co-operation with the Ontario Medical Association (OMA). This, over the next few years, led to a revitalization of Family Medicine, and now, close to 40% of medical school graduates are once again choosing Family Medicine as their specialty. 

While not the sole part of the PCR, a major component was a new model of paying physicians known as capitation. Capitation is essentially salary plus performance bonuses. Family Physicians would be paid a certain monthly rate to look after their patients, regardless of how often they saw them. They get bonuses based on how many complex (eg. Diabetic) medical cases they take on. This was in stark contrast to the old system known as Fee For Service (FFS) where physicians were essentially paid piecemeal (only got paid when they saw a patient).

The capitation based models were extremely popular with both Family Physicians and government. For Family Physicians, it allowed them to spend the time needed with patients during just one visit, instead of requiring multiple visits. For the government, it provided a predictable funding envelope. I appreciate this will come as a surprise to a couple of the frequent critics of my articles (in the comments), who have long implied that I was critical of Health Minister “Unilateral Eric” Hoskins because I was allegedly supporting the FFS model, but I actually have been in a capitated model since 2004.

UHN President and CEO Bob Bell

Drs. Bob Bell (left) and Eric Hoskins

Did PCR work? In 2001, the population of Ontario was 11.4 million, and almost 3 million people didn’t have a family doctor. In 2016, the population of Ontario was 13.9 million, and only 800,000 did not have a family doctor. So over 4.5 MILLION people got a family doctor.

Then along came the hapless “Unilateral Eric”, and his widely disliked sidekick, Deputy Minister Bob Bell. “Unilateral Eric” likes to claim that he himself is family doctor. The reality is that he has NEVER provided the cradle to grave care that comprehensive family doctors in Ontario do on an ongoing basis. He does work a day a month at a walk in clinic, and I understand he donates that income to charity – which is good of him, but it’s hardly the same as what comprehensive family doctors do. 

Bob Bell for his part, likes to boast about how he used to be a family doctor back in the 1970s, but he seems to be unable to grasp that family medicine might have evolved since then.

Acting with the same level of competence as Tweedle Dee and Tweedle Dum, the infelicitous duo of Hoskins and Bell unilaterally cut the number of family physicians who could apply to capitated funding models. Again, this is likely a surprise to a couple of the critics of my columns, who have long been demanding that physicians go on salary. Surprise, it was Hoskins and Bell who unilaterally stopped the salary style models, not the OMA. They also unilaterally cut some of the performance bonuses (for things like diabetic care, medical education and so on).

The result was clearly predictable to anyone who understands Family Medicine in the 2010s. Over the past three years newer graduates from Family Medicine programs are avoiding comprehensive care. Many of my trainees are choosing to work solely in areas like emergency, anaesthesia, sports medicine or others. And while there is a need for doctors in all fields, the reality is that it’s comprehensive Family Medicine that leads to health system stability. 

It’s comprehensive Family Medicine that reduces hospitalizations. It’s comprehensive Family Medicine that when supported properly, reduces costs of health care.

In response to this, the dolorous duo of Hoskins and Bell unleashed something called the New Graduate Entry Program (NGEP) to provide new family medicine graduates with what they claimed was a capitated funding model. Alas they attached so many conditions including a morass of bureaucratic oversight that I understand only two new graduates have taken them up on this offer.

Hoskins and Bell have left a legacy of a crumbling health care system with their arroganceand unilateral cuts. 

However, they still have the ability, and opportunity to begin to correct one of their most egregious mistakes. A new crop of Family Medicine Residents will graduate on July 1. Hoskins and Bell can unilaterally reverse the cuts to the capitated models and performance bonuses. No one from the OMA will complain.

It’s time for them to recognize the important role of comprehensive Family Physicians, and support that with actions, not just words.

Moving Procedures to IHFs is a Step in the Right Direction

Let’s say you are a patient with high blood pressure in Ontario. It’s time for a check up. If you are lucky enough to have a family physician, you will go their office. Your family doctor will check your blood pressure and perform additional physical exams as necessary. If you are due for additional tests, they will order that and renew your medications. They will likely be paid fee code A007, currently set at $36.85. Out of that $36.85, your family doctor will put some aside to pay the staff, some for cleaning, some for rent, some for other expenses. The remainder, the “profit” if you will, your family doctor will keep for themselves.

Additionally, your family doctor will be required to keep their medical equipment in good order, vaccines in a fridge at consistent temperature, sterilize their equipment and so on. Medial charts must be kept legible and comprehensive. Your doctor will be subject to inspections from their governing body, the College of Physicians and Surgeons (CPSO) to ensure they comply with this.

None of this is new, and it’s how health care has worked in Ontario for decades.

It’s therefore amusing to me to see the righteous indignation on social media when the Ontario Government announced that it would allow more procedures to be done outside of hospital, in an attempt to start to catch up on a backlog of health care that some estimates place at 20 million procedures. The frenzied cries of how this is scheming to create two tier health care where you pay with your credit card have come from the usual suspects.

Premier Doug Ford and Health Minister Sylvia Jones announcing the expansion of Independent Health Facilities

Ontario has had Independent Health Facilities (IHFs) for decades. This is not a new concept. Just like your family doctors, these IHFs bill OHIP for services that are insured, and in return perform a procedure/test/examination on you the patient. They are subject to inspection by the CPSO (just like your family doctor) and have to stay up to standards.

As technology has evolved, many procedures that were once done only in hospital can now be done safely outside of hospitals. Cataract surgery for sure. Colonoscopies/Gastroscopies as well. Arthroscopies are safe and even some joint replacements can be done as outpatient surgery now.

And, just like a visit to your family doctor, you would go to the IHF, the physician would get paid for the work they do by OHIP, some of what they get paid would go to cover their overhead, and the remainder, the profit, they would keep for themselves.

Philosophically, there is NO difference between these two scenarios. So it is extremely curious that people are raising such a furious response to this. Essentially they are saying “it’s ok for family doctors to own their own clinic and keep a profit but it’s not okay for a specialist to do so.” Talk about two tier!

Now that’s not to say there aren’t some practical considerations that need to be thought out.

  1. Where will the support staff (particularly nurses) come from?
    • My feeling on this is that right now we do have a number of nurses who have left hospitals because of the stress of working there. They are never going back. If we build these outpatient surgical centres as part of the hospital bureaucracy, not only will it take longer (hospital bureacrats have never met a committee they didn’t like) but when the hospitals go to hire staff, they will likely want the staff to be able to work in other parts of the hospital and take call. The nurses who left the hospital will NEVER agree to that. Maybe some of these nurses would work in an IHF if they were guaranteed daytime hours. I don’t know how many. But it will be more that the zero that will go back to a hospital owned facility.
  2. Where will the surgeons come from?
    • Fun fact that you may not know. We do have a shortage of doctors. But we also have 150 unemployed orthopaedic surgeons in the province. I’m serious. And I agree with Canadian Medical Association Journal that this is a sign of poor planning. The real problem for most surgeons is lack of operating room time. Having IHFs with operating time will allow them to work and catch up on the health care back log.
  3. Will there be charges outside of OHIP?
    • The reality is that OHIP only covers some things. If you need a Drivers Medical for example, OHIP does not pay for that. Your family doctor will charge you. Same for sick notes, prescription renewals without a visit and more. Philosophically, there is again, no difference between what your family doctor would do, and IHF would do if you wanted something that OHIP didn’t cover (an upgraded cataract lens for example). My father paid for upgraded lenses when he had cataract surgery (in a hospital), and that was something like 15 years ago.
  4. How will we ensure appropriate care?
    • This is a biggie, and the one area that we really need more details on. One example, if I order an MRI of a spine on a patient, I have to fill out an “MRI Appropriateness Form”. This form ensures that clinically, the MRI is required and if the patient doesn’t meet the clinical criteria, the MRI is declined. This is process is only in place at some hospitals. We do need something similar in place if we are to have IHFs do MRIs and other tests.
  5. How do we ensure physician coverage at hospitals?
    • Another biggie. And another area where we really need some more details. What happens if someone has, say, a gall bladder is removed at an IHF and unfortunately the patient has complications? Obviously they will need to go to a hospital. Off the top of my head I would suggest that an IHF only get a licence to do surgical procedures if all of the surgeons have privileges at a nearby hospital so that they can manage their own complications. There may be other ways around this. But there clearly needs to be some work done here as well.

In short, Ontario is finally taking some steps that have the potential to reduce the overwhelming backlog of medical care that patients are experiencing. Instead of throwing up egregious “two tier American style health care tweets” based on ideology alone, we need to work on the practical details of this move to ensure that the roll out is done in the most effective manner possible. Even with that, it will still take years to make a meaningful dent in the backlog of health care.

But I can tell you that if we listen to what the politically motivated folks on Social Media want (have the hospitals run these facilities) it will instead, take decades.

Will Pharmacy Prescribing Improve Health Care?

Pharmacists do a great job as part of a health care team. In hospital and nursing homes, I get expert guidance on dosages of potentially dangerous medications. I am also fortunate to have community pharmacists on a secure electronic messaging platform to discuss issues around medication complications/interactions/dosages and so on for my patients.

But, will it improve health care to let them treat minor conditions?

I expressed my displeasure on Twitter about the recent move to allow pharmacists to treat certain minor ailments:

A few pharmacists were not amused. It was pointed out to me that Ontario is one of the last provinces to allow this, and that it has “worked well” in other provinces.

But what exactly is the definition of “working well”? Politicians love it, mostly because it allows them to say “see we are taking steps to make your life easier.” Patients love it because they can say, “Jee, I think I have a bladder infection, now I can just get the antibiotic when I want.” Of course patient satisfaction will be high.

Unfortunately, as I wrote about a few years ago in the Huffington Post, patient satisfaction does NOT correlate with good health care or outcomes. As counter intuitive as it may seem, higher patient satisfaction scores correlate with a 9% higher cost per patient AND a 12 percent higher hospital re admission rate. Patient satisfaction should not be used as a metric to determine any health care policy.

On Twitter, Nathan McCormick suggested that pharmacists have a lot to offer and linked to an article from New Brunswick on how it’s worked well there. Unfortunately (and I stand to be corrected) the article suggests the diagnosis of urinary tract infections was made without a urine culture, or even a urine dipstick test (which is less accurate but still something). So there’s no way to sort out how many people had a true bladder infection, or simply “felt” like they did, which happens. The article also puts a strong focus on patient satisfaction and convenience, which as mentioned above, is not the same as good health care.

Nardine Nakhla asked me to familiarize myself with an article she wrote about how Ontario developed the process. There’s a lot to like in what’s written there:

  • A recognition of overprescription of antibiotics as a world wide problem
  • a focus on ethical standards based behaviour by pharmacists
  • A minimum amount of training for pharmacists before treatment minor ailments
  • The requirement for pharmacists to contact the family doctor or nurse practitioner when treating a minor ailment

Once again this doesn’t really reflect true health care outcomes. It also references the aforementioned New Brunswick article and specifically stated there was high patient satisfaction there.

Let’s look at just one area of concern, antibiotic usage.  Global overprescription of antibiotics is a world wide concern.  It leads to increasing antibiotic resistance and the formation of new, drug resistant bacteria.  A look at Canadian data shows that there is intra provincial variation in the number of antibiotic prescriptions.  Newfoundland, where pharmacists have been treating minor ailments for years, has the highest rate of antibiotic prescriptions. British Columbia, where pharmacists are expecting an expansion of their scope this spring, had the lowest.  

From CMAJOpen: Interprovincial variation in antibiotic use in Canada, 2019: a retrospective cross-sectional study

World wide , of the ten countries with the most antibiotic use, Cyprus, Romania, and Greece allow them to be purchased directly from pharmacies. (I stuck to EU countries with more modern health systems for examples).

Kristen Watt wrote a piece in the medical post criticizing physicians for complaining about these new powers and asked me on Twitter to provide evidence from other locations.  She stated that Ontario was “15 years behind the trailblazing Alberta”. And yet the data in the CMAJ article above shows that Alberta has a higher rate of antibiotic prescriptions per capita.

One area I do agree with her is when she wrote:

“the government roll-out video, shot in a noticeable big box pharmacy, didn’t help us”

That big box is Shoppers Drug Mart, and their CEO Jeff Leger is seen promoting this change on the video.   Shoppers Drug Mart recently invested $75 million in Maple, a virtual care company.  Maple’s home page still shows the following:

Screenshot from Maple as of Jan 12, 2023

Gee, if you think you have a sore throat, you can just call a company (that Shoppers invested in), and get an antibiotic without a throat swab (who cares if it’s really strep) and lo and behold, there just happens to be Shoppers nearby that will deliver it to you. Yes, I know patients can request the pharmacy of their choice, but….

Look – there are other aspects of this process that need review.  Accurate diagnosis of a rash for example (several of the new pharmacist powers are for skin ailments). Or communication with the patients family physician about the treatments given.  Probably more.

I WANT pharmacists to help.  I really truly am grateful that so many are willing to step up in a time where our health care system is collapsing faster every day. But I want pharmacists to help in ways that support good health care outcomes.

 Might I offer three suggestions for how pharmacists can do that:

  1. As a group, they can petition Shoppers Drug Mart to put pressure on Maple to change the example on their website.  It’s great marketing (focusing on convenience) but terrible health care.
  2. Get involved with Choosing Wisely, Canada’s leading group looking at all ways to pick the right health care treatments.  There doesn’t appear to be a pharmacist in looking at their leaders.  I think pharmacists could provide extremely valuable information on not just anti-biotic stewardship, but also overall medication management (eg. reducing pill burden in the elderly)
  3. Strongly lobby the government for a unified integrated electronic health system that will allow them secure communication with physicians and access to limited health care data (eg creatinine clearance).  We’ve got this in my neck of the woods, and it’s a huge benefit to physicians, pharmacists and most importantly patients.

In order to save what’s left of our health care system (if that’s even possible now) we need to focus on health care outcomes, and ensuring proper an appropriate care. Doing the three things I listed above would be a big help in that direction.

Open Letter to Nadia Surani, Director, Primary Health Care Branch of MOH

Dear Ms. Surani,

On November 21, 2022 you wrote a letter to primary care organizations requesting that they offer seven day a week availability. For those who may not have seen this letter – I’ve attached a copy for upload here.

The response to your memo has been probably not what you expected. You’ve got one Past President of the Ontario Medical Association calling it dumb. Mind you, that guy always was a bit of a boorish loudmouth. But you’ve got another, much more eloquent past President of the Ontario Medical Association also calling you out on this:

You can’t even say you didn’t know the consequences of your letter, because you’ve got the really smart Dr. Premji warning you against blaming family docs FOUR DAYS before sending your letter:

There’s a lot more upset physicians (and other health care professionals) on social media and elsewhere, but you get my drift. This letter was, to put it far too mildly, not well received. In light of all this, might I humbly suggest that I re-write your letter for you.

From: Nadia Surani, Director, Primary Health Care Branch

To: Family Health Teams, Nurse Practitioner Led Clinics, Indigenous Primary Health Care Organizations

Re: Important Ministry Request

First and foremost, on behalf of the Ministry, I want to thank each and every one of our primary care providers for working tirelessly through the pandemic. I know that there are not enough of you to take care of all the health care needs of Ontario’s residents. Despite that, you continue to do your best and have been working at 110% capacity for longer than seems humanly possible. Your efforts have not gone un noticed and are truly appreciated.

Unfortunately, we are now experiencing a difficult and complex fall season, full of the respiratory illnesses that many of you had predicted. The combination of earlier than expected Influenza A, returning RSV infections and ongoing Covid-19 is pressuring our healthcare system like never before. The paediatric sector is particularly hard hit and sadly, we are expecting high volume pressures across our health system throughout the winter months.

As a result of the above I would like to offer you what support I can to help the residents of Ontario get care during these challenging times. You are all on the front lines, and you see the day to day challenges of providing care first hand. You see the inefficiencies and you see where things can be made better. Many of you may have ideas as to how better manage the flow of patients and many of you have some unique solutions that will help us cope, despite the shortage of health care workers.

Knowing there are limited resources, I obviously can’t promise that we can implement everything suggested. But I want you to know that every reasonable suggestion that will increase the ability of your organization to see patients and alleviate pressure on the health care system as a whole will be considered. If you feel that there will be extraordinary costs associated your suggestions, please contact your ministry representative.

Thank you once again for your ongoing commitment and dedication in the fight against the pandemic and other urgent system pressures. I truly appreciate it and I will do my best to support any innovative solutions you may have.

Please connect with your assigned ministry contact with any suggestions you have for enhancing your organization or any other questions.

Nadia Surani, Director, Primary Care Branch, Ministry of Health

There you have it. I hope that was helpful.

Sincerely,

Your humble servant.

Euthanasia (MAiD) Activists Put A Dollar Value on Human Life

Recently, a patient of mine who I was really fond of, chose euthanasia. The politically correct would prefer to call it Medical Assistance in Dying (MAiD) since it sounds “softer.” But the fact of the matter is we are killing people (presumably to relieve suffering) which is the clear definition of euthanasia. Let’s call it what it really is.

My patient was a nonagenarian, had fairly advanced cancer with probably about 6-9 months left to live. They were still walking (albeit in some discomfort) and toileting independently. They did their own taxes, and anyone who can do their own taxes is mentally competent if not a genius. They looked at the natural course of their illness and, said to me:

“You mean I’m going to spend the last 3 months of my life, likely bedridden with some stranger changing my diapers and wiping my butt?”

And they chose euthanasia, which was provided to them this past year.

The above scenario represents exactly what most Canadians believed they were getting when euthanasia was legalized in 2016. Truth be told, even people like myself, who have qualms about the concept of healers taking lives, completely understand why my patient felt that way. It’s impossible to argue against the autonomous wish of a competent individual.

However, almost as soon as the euthanasia was legalized in Canada, physicians were warning that this was going to open up a slippery slope of ever loosening criteria and increasing permissiveness for euthanasia. Pro Euthanasia types derided these arguments for using “the fear of the unknown“. And yet, six years later, as a nation, we are now on the verge of expanding criteria for euthanasia to include:

And finally, we have a report promoting what many all along thought was the real reason for allowing euthanasia. Basically, that it is cheaper for the health care system.

To be fair, one of the authors of the report, Dr. Aaron Trachtenberg does state that the work is meant to be “theoretical.” He also goes on to state:

“We are not suggesting that patients or providers consider costs when making this very personal and intimate decision to request or provide medical assistance in dying.”

But the blunt reality is that the authors put out a report broadly suggesting to the general public that there are cost savings if, you know, you did the decent thing and just ended it all when you became a burden on the rest of us. Intentional or not, the implication is clear that there is a monetary worth to your life and at some point, you dear patient, are no longer “worth it.” Reminds me of the Star Trek The Next Generation episode “Half a Life“, where the intrepid crew of the Enterprise meets a planet where everyone commits suicide at age 60.

It’s not only people like myself (who have been demanding conscience rights because we saw this coming) that are upset about this. The Toronto Star had a column saying Canada was going too far with euthanasia and warning of the dangers of abuse. The Canadian Society of Palliative Care Physicians has been expressing concern about euthanasia for some time. The Council of Canadians with Disabilities points out that the disabled cannot access supports to live a dignified life but can now access euthanasia. (I’m guessing Dr. Trachtenberg’s report did nothing to ease their concern). Dr. Sonu Gaind, a psychiatrist who himself has done euthanasia assessments has expressed significant concerns about the many flaws in the guidelines for those seeking death when their sole reason is mental illness.

Most tellingly, the National Post reported on a “crisis” in supply of doctors willing to provide euthanasia. Among the reasons cited are the “increased “legal risk and moral hazards” related to ever-widening eligibility.” Also a noted was that many euthanasia providers were curtailing and limiting their practice to those patients for whom the law was originally intended. You know you have a problem when even providers of euthanasia are telling you the rule changes are going too far.

Now perhaps some of the recommendations (like the one around babies) won’t make it through to legality, but the blunt reality is that the slippery slope that was warned about when euthanasia was legalized has come to pass. Its due a combination of lack of foresight and the ineptness of the initial legislation that we are at this place.

It was one thing to allow competent people (like my patient above) to self determine what to do in the face of an incurable illness or suffering. But it’s quite another to recklessly expand criteria . And it the case of those with disabilities, or mental illness, to not provide adequate supports as an option seemingly pushes them in the direction of choosing euthanasia.

Is this really what Canadians wanted?

As for the dollar value of a human life. The study authors write:

“we expect that net health care costs would be reduced by $33.2 million per year if 1% of deaths are due to medical assistance in dying”

This was based on their estimate of about 2,700 cases a year (there were over 10,000 last year). Based on their numbers however, your life is now worth $12,296.30