Will Health Care Infrastructure Survive the COVID-19 Pandemic?

This week, it appears that the “surge” of COVID-19 patients entering Ontario hospitals has begun.  In particular the number of patients on a ventilator (essentially life support) has gone from 62 two weeks ago, to around 200 today.  Additionally, the number of people in hospital with COVID-19 related illness has risen to about 740 as of today, with about 261 in Intensive Care.  Ontario has about 2000 ICU beds, so there appears to be some capacity, but if the surge worsens, this may disappear.

Unsurprisingly, the focus of the government has been to prepare the hospitals for inpatient care as best as possible.  This includes ensuring more staff, funding for ventilators, investing in PPE (although it’s unclear how this will arrive) and so forth.

However, while this is all appropriate, it’s important to remember that there are other areas of health care that will need support.  For example, hospitals perform many outpatient services like specialty clinics and diagnostic imaging.  There are also community clinics that provide patient services (your doctors office for example).  All of these clinics have been effectively shuttered due to the physical distancing guidelines, but all of them also keep patients healthy and prevent them for becoming inpatients.

There are likely to be four “waves” to his pandemic.  I would try to explain them all to you, but Dr. Victor Tseung has done a great job illustrating this, and, as they say, a picture is worth a thousand words:

victor

Currently, we are at the beginning of the first wave.  A lot of preparation has been done for this stage, and rightfully so.  I will also say that the Ontario Medical Association (OMA) has done a lot of work to anticipate the fourth wave, by offering virtual check in clinics for our members and by messaging the availability of the services we offer for help with burnout and stress.  I believe it was Dr. Mamta Gautam who coined the phrase “pre-TSD”, which is what many physicians are experiencing right now.  Better to address this head on now, then wait for it to turn into something worse.

Quite frankly I worry, that not enough attention is being paid to waves 2 and 3.  Canada’s health care system was already overburdened to begin with.  We were (sadly) famous for having ridiculously long wait times.  Along with those increased wait times comes increased morbidity.  Morbidity refers to the burden of multiple health conditions over time.  Supposing, you have terrible arthritis in your knee.  You don’t walk because of the pain.  Over time you become more sedentary and develop a blood clot in your legs, that then breaks off and goes to your lungs.  All of which could have been avoided if you had your surgery in a timely manner.  That’s morbidity.

See many (if not most) of the medical services provided to patients who will suffer in wave 2 and 3 are provided by outpatient physicians.  These physicians work at clinics in hospital, or their own offices or at what are called Independent Health Facilities (IHFs).  IHFs are non-hospital clinics with equipment (e.g.  X-ray, Ultrasound, Labs,  heart imaging).  They are provide the kind of care that reduces the load off our hospitals in difficult times.  By allowing doctors to diagnose and treat chronic illnesses sooner, they prevent morbidity.  Their work has never been so important.

What’s a good example of a wave 2 patient?  Supposing a patient has glaucoma, a build up of pressure in the eye.  Untreated, this will lead to blindness.  Many patients require laser surgery to relieve the pressure, but eye surgery has been stopped due to the current pandemic.  Eventually this will catch up to people.

Wave 3 patient?  Someone who has heart disease, but isn’t able to get their Echocardiogram (a type of heart ultrasound) to assess their condition.  Waiting a few weeks is probably ok, but at some point, their heart is likely to deteriorate further, and they will wind up in hospital, which is the last place you want to send someone these days.

What’s that you say?  Why can’t health care infrastructure just start up again in a few weeks?  Here’s where the business side of medicine, which no one likes to talk about, comes in.  Many clinics and IHFs are run on a tight budget after years of cut backs by previous governments.  So what happens is a patient comes in for a test, OHIP pays for the test, and the clinics use that money to pay for nurses, technicians, rent and leases on some of the equipment.  Some of the equipment can cost millions of dollars.

These are generally small businesses.  The simple reality is that without people coming in (which they aren’t right now as non-essential treatments have stopped), there is no money coming in, and so the overheads don’t get paid.  Unlike large companies like Apple or Google, these businesses don’t have much cash in reserve as the overhead is so high, so they will go under.  I know of many clinics that have laid off staff right now, in order to try and get an extra months rent and lease paid.

Of course, this is the same plight that faces all small businesses across Canada.  Certainly, it would be remiss of me not to point out that just about everybody is feeling economic pain right now.  Many people have been laid off, gone on EI and are suffering.

The thing is, health care is an essential service.  Without them, all of the ongoing outpatient care and preventative care I was talking about won’t get done.  If that happens, patients will get sicker and wind up in hospital.  Or worse.

These are difficult times for all of us.  But if we are to get through the COVID-19 crisis, not only do we need to take a short term view and address the immediate surge, but a much longer view must also be taken.  This means supporting health care infrastructure.  The well being of our patients depends on it.

Canadian Physician Growth Lagging Behind Demand, Other Western Nations

Note:  The following was initially published in the University of Toronto Medical Journal in Mid-March and is being reproduced here.  My thanks to the OMA staff for helping with the research.  As we enter the “surge” phase of the COVID-19 Pandemic, I pray that that our already short staffed physicians will come through this ok.

I have been a family physician for over a quarter century, and chose to practice in the small community of Stayner, Ontario. Working in a rural community has given me a closer connection to my patients, and a stronger understanding of the challenges in Ontario’s current health care model and how it could be improved. In the end, everything doctors do is in aid of better patient care and better patient outcomes.

What I’ve seen and experienced shows me that we need to change the landscape of medical care. It’s one of the reasons I became involved in medical politics. It’s something I continue to focus on as President of the Ontario Medical Association.

First and Foremost, We Need More Physicians in Canada

Our population is aging. Our patients are becoming more complex. The rate of growth of Canadian physicians to population needs to keep pace. How many more doctors do we need? Well, it really depends.

There is no straight-line comparison between these factors and the number of physicians required. I would suggest it also depends on the distribution and prevalence of specialties and sub-specialties, the age of physicians, their models of practice, and other resources (particularly allied health care professionals to assist physician led teams) available within the health care system. There are many nuances.

Although there is no magic target number to reach for, we need to look at making a significant investment into training and hiring physicians in Canada in order to fully meet the health care demands of our patients.

To those who say we cannot afford it, I pose an only somewhat rhetorical question: How much money does it cost right now to care for a high needs diabetic with COPD and heart disease who goes to the Emergency Room regularly because he or she doesn’t have a doctor?

Growth in physician ratios not keeping pace with need

When the Canadian Institute for Health Information (CIHI) reported that in 2018, Ontario had 2.34 physicians per 1,000 people – up from 2.26 in 2017 – this was heralded by some as a dramatic increase.1 Although I was very pleased to see growth in physician numbers – because I believe this is necessary to improve patient care – I would have been more bullish had I not noted four things that make this statistic somewhat less rosy.

  1. Ontario Ranks Seventh of Ten Provinces in Physician-Population Rates

Even with a 3.5% percent growth in physicians to population over 2017, Ontario still ranks seventh out of ten provinces. Ontario was ahead of only PEI (1.97), Saskatchewan (2.05) and Manitoba (2.25). Ontario is also below Canada’s rate overall of 2.41 physicians per 1,000 population.1

  1. Recent Growth is Making Up for Past Stagnation

The growth in Ontario’s physician-to-patient ratio is a relatively recent phenomenon.

A review of CIHI data for the period 2001 to 2018 shows that the number of Ontario physicians has grown an average annually of 1.6% more than the growth in the province’s population.

However, the rate of growth during the period 2001-2008 was essentially flat, with the ratio stuck at about 1.8 physicians per 1,000 people for eight years. Therefore, some of the recent increase in annual growth is actually catching up to meet demand from the past.

Additionally, whether or not the rate of growth of physicians meets or exceeds the population growth is not the whole story. It’s simply not enough to say that the population has grown by, say, one percent so we need one percent more doctors, as there are many other determinants of the need for physician services, such as aging and increasing clinical complexity and multimorbidity.

  1. Ontario Sees an Annual 3.6% Growth in Physician Services

Ontario experiences a 3.6% annual average growth in services provided to Ontario patients, representing the cumulative impact of population growth, aging, patient complexity, advances and availability of technology, and other factors.2

Recent analysis carried out by the Ontario Medical Association’s Economic, Policy and Research department demonstrates that prevalence of multiple chronic conditions in Ontario has grown from 2008 to 2017.

This has caused an increase in something called patient resource intensity. As of 2017, the number of patients with at least one out of a baseline list of 84 chronic conditions was estimated to be 9.8 million, an increase of 11.0% from 2008. Multimorbidity also rose. The number of patients with two or more chronic conditions increased by 12.2%, while those with three or more increased by 13.5%.

This means that Ontario patients are becoming more complex, and thus require more time, resources and physician manpower to look after. Given that the majority of health spending can be attributed to multimorbidity, these findings have major implications for population health management and health care spending.

Although this analysis is based on Ontario patients, it is hard to imagine that the same demand does not exist, in whole or in part, in other jurisdictions across the country.

Advances in technology to both diagnose and treat have also increased the ability of physicians to provide care to their patients, which puts further demand on physician resources.

All of this illustrates that patient demand for services is growing significantly, and we need more doctors each year to meet it. The ones we have will have to work ever harder. According to the Canadian Medical Association, doctors already work an average of 52 hours a week, and in many cases work more hours being “on-call” on top of that. It is not sustainable or even tenable to ask doctors to work more.

  1. Canadian Physician Rates Are Low Compared with Other Western Countries

In contrast with other comparable countries, Canada’s physician-to-population ratio is low. While there are many factors determining the optimal number of physicians, it is hard to argue that Canada has too many physicians relative to its peers.

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What does this all mean? The reality is that Canada often gets lambasted for poor health care metrics in the press (e.g. wait times). However, it is clearly impossible to meet some of the noble goals when there simply aren’t enough physicians to do the work. We can invest in programs like public health, telemedicine, pharmacare and so on. These are all good and noble causes that have been clearly shown to benefit populations of patients. But until we recognize that our main problem is a shortage of physicians and that the growth needs to accelerate even more, our overall health metrics will not achieve those of the countries we aspire to.