Thursday, December 20, 2012

What Can America Teach Canada About Health Care Reform?

{The following post was written as a column for the  January 2013 edition of  the Anahim - Nimpo Lake Messenger. --MC}

Last month,  I commented  that  in the future we in Canada may be able to  learn a lot  from American  health care reforms.   You may wonder how that could be possible , given that the United States has by far the most expensive system in the world, and has failed to provide basic health insurance coverage to over 45 million of its citizens. 

The reason is that President Obama’s Affordable Care Act, if successfully implemented, will strengthen that nation’s primary care foundation.  (By “primary care” I just mean basic, preventative, and other non-specialty services provided by nurses,  and family physicians.) And that is something we in Canada need to do, too.

Although Canada  will continue to have much better  coverage and cost-containment than the U.S. for the forseeable future, due to our universal single payer system of public insurance, it  shares many  of America’s  failings on the delivery side:  over-reliance on doctors and hospitals, which are the most expensive health care providers;  relative under-funding of public health  as compared to acute care; slow adoption of electronic health information technology;  a fee –for –service system that simply rewards the number of patients seen rather than the number of patients cured;  and a crisis in long-term care for the elderly.

Canada’s single-payer system gives us the greatest institutional capacity  of any country for meeting our health care challenges  in an equitable  and cost-effective fashion,  but  that potential is stymied by our lack of a strong primary care foundation.  We should be world leaders in payment reform, health care technology assessment, and electronic health records, but we aren’t.  Because our sacred Canada Health Act  was only designed to fund hospital use, it has been economically rational to treat many long-term patients (mostly elderly) in a hospital setting, despite its higher costs.  (Physicians have also been reluctant to discharge many patients who would have trouble paying for privately-owned long-term care facilities.) The result is that hospital beds are utilized by many who do not need acute care, which makes shortages in  hospital wards and emergency departments worse.

In the United States, the Affordable Care Act will provide financial bonuses  for primary care physicians, nurse practitioners, and physician assistants that provide 60% of their services in primary care, or who provide these services in areas where there is a shortage of health professionals.   The Act also encourages and funds the widespread adoption of Patient-Centred Medical Homes  to provide coordinated patient care by teams of health care providers,  and “health homes” for  Medicaid (senior) patients with chronic conditions.  The most expensive hospitals and physicians will no longer be the front line of care, but the last resort.   Providers will be compensated using bundled payments for health care outcomes, not fees for listed treatments.  Special provisions of the Act  are made for application of these principles to less healthy minority populations through the creation of community-based collaborative care networks.

How could such an aggressive program of primary care reform be applied to a place like the Cariboo-Chilcotin?  We already have health stations on six Indian Reserves and in Alexis Creek, including a largeFederal-funded nursing station at Anahim Lake, and a provincially-funded IHA facility with a local physician in Tatla Lake, along with a hospital in Bella Coola. Several nurses and doctors visit  the smaller stations rotationally on a weekly basis; and a medical van shuttles patients in and out of Williams Lake.  The First Nations Health Council and First Nations Health Association have plans to support First Nations communities to develop their own strategies.  

Now imagine how effective those strategies could be if  health care providers were all paid for preventive care as much as for treatment; and if communities could share in all the savings that prevention by least-cost providers  can generate.  Each case of fetal alcohol syndrome costs  society a million dollars over the life of the patient; its reduced incidence can be measured and rewarded in a very few years. The same is true of obesity and diabetes, where the costs and potential savings are enormous. 
We should follow pilot projects being undertaken in the U.S.  under the auspices of the Indian Health Service and the Affordable Care Act for more good ideas about how to achieve these and other worthwhile health care goals.

Mark Crawford is an Assistant Professor at Athabasca University. He can be reached at .

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