Here’s what I just submitted:

Submission to the BC Legislature’s Select Standing Committee on Health

From: Seth Klein, BC Director, Canadian Centre for Policy Alternatives

Re. Sustainability of the Health Care System

Date: Jan 13, 2012

Thank you for this opportunity to offer this written submission to your committee’s deliberations.

Given the topic you are investigating, I want to make sure that you are familiar with some relevant peer-reviewed reports that have been published by our institute.

Of most direct relevance is a 2006 report by our senior economist Marc Lee entitled Is BC’s Health Care System Sustainable? A Closer look at the Costs of Aging and technology. The report can also be found here.

Like your committee’s mandate, this report estimated the financial implications of demographic trends on the health care system into the 2030s. Among the report’s key findings:

This paper finds that population aging, in and of itself, is but a small contributor to rising cost pressures in the health care system. Based on current projections there is little to suggest a demographic time-bomb about to go off. Instead, the real challenge for financing the health care system is advances in technological possibilities, broadly defined to include pharmaceutical drugs, new surgical techniques, new diagnostic and imaging technologies, and end-of-life care. These challenges can be addressed most efficiently and equitably in the context of a public system…

• Population aging has been a cost driver in the system, but a very small one compared to other sources. The impact of population aging was 0.9% per year over the 1995 to 2005 period. This is consistent with other studies of population aging.
• Inflation (as reflected in salary increases and higher cost of supplies) has been the biggest cost driver over the 1995 to 2005 period, with increases averaging 2.4% per year, followed by population growth at 1.2% per year.
• The expansion (or “enrichment”) of health care services over time (such as new technologies, long-term care, home care and pharmaceutical drugs) is also an important factor. The average British Columbian receives one and a half times more health care services as his or her equivalent 30 years ago.

I would also like to draw you attention to a number of other CCPA reports relevant to your work:

• Why Wait? Public Solutions to Cure Surgical Waitlists, by Alicia Priest, Michael Rachlis and Marcy Cohen (2007), available here.
• What’s in a Scan? How well are consumers informed about the benefits and harms related to screening technology (CT and PET scans) in Canada, by Alan Cassels et al (2009), looks at how unnecessary and sometimes harmful scans can drive up health care costs. It is available here.
• An Uncertain Future for Seniors: BC’s restructuring of home and community care, 2001-2008, by Marcy Cohen et al (2009), looks at how inadequate investment in community care is placing more pressure on the more expensive acute care system. It is available here.
• Innovations in Community Care: From Pilot Project to System Change, by Cohen et al (2009), is a companion paper that highlight successful innovations that, if scaled-up province-wide, could take pressure off the acute care system. It is available here.
• The Cost of Poverty in BC, by Iglika Ivanova (2011), looks at how poverty increases costs to the health care system. In particular, it finds that poverty in BC is adding an additional $1.2 billion per year to the province’s health care system. It is available here.

Thank you for this opportunity.

What have we learned from last year’s pandemic?  Read on…

http://tinyurl.com/23otvdw

Cholesterol drugs don’t help the healthy

The February Budget documents stated that:

To ensure that health services are protected in the current economic environment, the Ministry of Health Services and health authorities will be required to achieve efficiencies and administrative savings beginning in 2009/10.

For the health authorities these administrative savings came to $25 million annually.  Post-secondary institutions were expected to find $11 million in administrative savings.  School boards were told to cut the administrative fat by $12 million.

Contrast that to the government’s privatization agency, Partnerships BC, which published their administrative expenses in their Service Plan in the September update to the Budget.  It turns out that after an 9% jump in administrative costs in 2008/09, they are still planning for an increase of another 2.8% in 2009/10.  Next year they plan to bump admin costs another 6.5% and the year after that in 2011/12 they plan administrative costs to rise by 2.3% 

That is an increase of administrative costs of 22.3% in four years.

It appears the administration of privatizing government services is much more difficult than the administration of healing the sick and educating our children. 

Or perhaps Partnerships BC is just baffled at how to deal with these ballooning admin costs so let me offer a humble suggestion.  Perhaps they could randomly pick any elementary school principal in the province to advise them.  After all, people who actually deliver services to the public are used to being told to find fat to cut year after year even when they are down to the bone.

As the baby boomer generation ages, the need to strengthen and expand the supports available to seniors in their homes becomes more pressing. In our province, the pressures created by the aging population have been compounded by sharp cuts in the numbers of acute care and long-term care beds over the last decade, which shifted the burden of care for the frail elderly onto community-based services and individual families. Without adequate funding to match the increased need, access to home support has been reduced for those with more moderate needs, compromising the preventative functions of home support.

A newly released CCPA paper, Towards an Enhanced and More Accessible Home Support System for BC’s Seniors, puts forward a concrete policy proposal for improving home support in our province.The paper identifies three major areas of concern in home support — recruitment and retention, the organization of home support delivery and the level of service hours provided — and proposes tackling those in tandem. Our recommendations are designed to supports service integration and continuity of care, and to take into account the important interconnections between the quality of service for clients and the working conditions of staff. As a result, our proposed reforms would have mutually reinforcing effects and would ultimately result in better quality care and more accessible care for those who need assistance to remain in their homes.

We cost out our recommendations and call for an immediate increase of the home support budget of health authorities by $100 million per year to implement them. This represents just over 0.7% of provincial health care spending for 2007/08 and is entirely affordable even during a recession. And if this seems like a big number to you, just remember that while enhancing home support costs more at the start, over the long term these reforms can reduce health care costs elsewhere in the system.

Fundamentally, providing an accessible home and community care system for our frail seniors is not only the morally right thing to do for our elders, it’s also the smart thing to do in terms of containing health care costs. Caring for seniors in the community is considerably cheaper than keeping them in hospitals (which is what happens when there is no available spot in residential care for seniors who can’t live independently).

An op-ed published in the Vancouver Sun on Thursday calls attention to the serious problems in seniors’ care in this province. The authors, Jeremy Tate and Marcy Cohen, who co-authored a recent CCPA study An Uncertain Future for Seniors: BC’s Restructuring of Home and Community Health Care, 2001-2008, blame “years of poorly planned restructuring and a failure to maintain (let alone enhance) access to key services” for the decline in seniors’ care. They call for “leadership and commitment to transparency, public consultation, good planning and increased access to seniors’ care.”

But do the party platforms promise to deliver any of these things?

There are certainly important differences in the two parties’ approach towards seniors’ care. The Liberal platform mentions seniors 23 times, but seldom in the context of health care. The closest they come to seniors’ care is promising to invest in housing, more specifically 1,000 new homes for “seniors and people with disabilities.” Their health budget, however, tells us not to expect any meaningful increases in care beyond current levels.

The NDP platform, in contrast, explicitly acknowledges that seniors’ health care needs are not currently met as well as they should be, pledging to improve seniors’ care by adding 3,000 new residential care beds, re-opening some 300 beds in closed facilities (like Cowichan Lodge) and establishing a Representative for Seniors to address their issues and recommend policy reforms. There have been questions, however, as to whether the amount of money allotted for the cause would be sufficient.

The report estimates there are 400,000 British Columbians with some kind of addiction problem. The annual financial impact is $6 billion.

The BCMA says the burden falls mainly on addicts and their families, but it also falls on law enforcement, emergency wards and workplaces. The doctors call for changes in the way we look at addiction and they call “on the premier and the Minister of Health to formally recognize addiction as a chronic disease and increase resources for addiction treatment…”

Among the many issues addressed, the BCMA recommends the creation of “240 new flexible medically supported detoxification spaces across BC by 2012.” It quotes Health Authorities on the weakness of the current system. The Vancouver Coastal Health Authority makes the following comment:

While the intake system for detoxification facilities has been significantly streamlined in recent years, immediate access to withdrawal management services is still an unmet need among highly marginalized individuals, many of whom are homeless and have no safe place in which to wait for access to services. The result of missing or insufficient services is people not receiving treatment, inappropriately accessing emergency care, or staying for extended periods in more costly acute care.

The BCMA reports, “The number of people in BC with a severe gambling problem has increased since 2002 from 0.4% of the population to 0.9% in 2007.” Another 128,000 people have a moderate gambling problem.

On housing, the report says, “The current lack of appropriate housing programs for the range of addiction and mental health problems in BC undermines the effectiveness of and the ability to provide medical care and treatment.”

Responding to the report in the Sun, the Health Minister said while he agreed with the direction taken by the BCMA in these tough economic times the province is hoping to maximize the benefits of its health care dollars.

During the 1990s, the corporate health sector urged hospitals to focus on clinical patient care and to contract out non-clinical support to companies whose core business it was to provide such services (no conflict of interest there, of course). Provincial governments, too, encouraged hospitals to redefine their “core missions” in narrower and narrower terms. As administrators whittled away, Canadians saw laundry, food services, laboratory and many outpatient rehab services re-defined as non-essential, non-clinical supports that could be contracted out without compromising patient safety or quality. The mainly female hospital workforce who followed these jobs in to the private sector saw their wages slashed and their job security disappear.

What did Canadians get in return for this strategy? Here are a few enlightening statistics from a well-researched and documented booklet published by CUPE in January called Healthcare Associated Infections: A Backgrounder. The human and financial costs associated with contracting out are tremendous.

• Between 1995 and 2006 the Canadian Nosocomial Infection Surveillance Program found that rates of MRSA in Canadian hospitals had increased 17-fold.
• The rate of patients contracting C. difficile infections, the chief cause of health care diarrhea, increased almost five-fold between 1991 and 2003.
• The Norovirus, which affects mainly seniors in long term care facilities, doubled in B.C. between 2002 and 2007.
• Every year in Canada one in 9 hospital patients contracts Health Associated Infections (HAIs) which have been linked to between 8500 and 12,000 deaths per year. HAIs are now the fourth leading cause of death in Canada.
• In BC, 7% of all patients infected with C. difficile are readmitted to hospital for an additional 13.6 days at an additional cost of at least $18,000 per patient.
• In the Vancouver Coastal Health region alone, more than $3 million was spent by the health authority to treat 2,526 patients with C. difficule in one year (2002/03).

Are HAIs only a problem because services are provided by greedy multinationals? The answer is that infections are linked to understaffing, increased workload, high turnover and poor training of staff. The way that these companies earn the big bucks is by…hmmm… let’s see: reducing staff, increasing the workload, foregoing training of the workforce and maintaining poor wages and working conditions that lead to low morale and high staff turnovers.

On the other hand, studies have shown that when hospitals increase the number of cleaning and infection control staff, when they invest in training and education, and when stability in the workforce is maintained and encouraged, infections decrease.

The track record of increasing infections and related deaths in BC hospitals is the legacy of contracting out that started during the 1990s and continues to this day. Both the Liberals and the NDP should be challenged during the election to outline what steps they’re going to take to bring these services back in to the hospital system. But that won’t be enough: as CUPE’s excellent backgrounder emphasizes, we need evidence-based policies that protect patients from hospital acquired illness and death. That means ending and reversing contracting out. But that’s not all: we need reduced occupancy rates, trained staff, better wages for more workers in the hospital system, mandatory standards and increased transparency.

Read the booklet — it’s an eye-opener. If ever there was an overlap between the interests of health care workers and the public, this is it. And think about surgical services trotting down the same road.

A couple of weeks ago I wrote that Brian Day and his followers had launched a lawsuit against the province, alleging that, “in contravention of the value of individual choice,” the Medicare Protection Act restricts or prohibits patients from “accessing the private health care of their choice”. Day & Co. brazenly admit in their Statement of Claim that “Independent surgical facilities receive facility fees for the use of their facilities for the pupose of operations and other procedures”. The fees, according to the Statement, come from all and sundry — health authorities, the workers’ compensation system, other third party payers and patients.

And here I thought that Diane Marleau, a federal health minister from the long ago 1990s said plainly that facility fees “are objectionable because they impede access to medically necessary services” and therefore “violate the [Canada Health] Act“. Silly me.

Now, I’m sure many of you read about the lawsuit in the Vancouver Sun, the Globe and Mail and other media outlets. But I’m equally sure that, for reasons I cannot fathom, you didn’t read about the Government’s response, filed on February 20, in any of these same investigative outlets. I wonder if that’s because, as a Vancouver Sun editorial put it in 2007, when it comes to whether or not a facility might violate the Canada Health Act, “what matters in all of this is no longer the law”, but whether anyone in government cares. “It’s time to focus on what is really important here,” the editorial continued. “Two tier health care is here to stay.”

But I digress.

In its Statement, the government dismisses most of the points raised by Day & Co., and asserts that “there is no freestanding constitutional right to health care”. Heaven forbid. But the most interesting thing about the Statement is not the government’s defence of medicare, but rather the Counterclaims against the five Plaintiff Clinics and the Specialist Referral Centre (collectively dubbed the “Extra Billing Clinics”). The SRC expedites access to specialists (for a fee, of course). Here, in handy point form, are the key allegations in the Counterclaim:

1. That Cambie Surgery (Day’s outfit) and the SRC have refused to provide information or allow audit inspectors on the premises so that the Medical Services Commission can determine whether these two companies have violated the Medicare Protection Act. The goverment has asked for an injunction “restraining Cambie and SRC from hindering, molesting or interfering” with inspectors who are trying to carry out the audit.

2. That Cambie and the SRC charged patients for services listed on invoices as “surgery”, “overnight”, “administration fee surgery”, “facility fee”, “consultation/assessment”, “surgeon’s fee”, “anaesthetic fee”, “escort services” (escort services?), and “prepayment for surgery”. These services are either fully covered under MSP or, if charges are allowed, the charges exeeded the amount permitted. The government has asked for interim and permanent injunctions restraining Cambie and the SRC from violating medicare laws.

3. That the Extra Billing Clinics, jointly and individually, “have themselves been engaged in unlawful billing practices…and also have aided, abetted, assisted, and facilitated the unlawful billing practices of others who practised in the Exra Billing Clinics or who arranged payment through or with the participation of those facilities”.

4. The government also alleges that patients were required to sign “Acknowledgement Forms” which falsely informed patients that the services for which they were being charged were not covered under the Medical Services Plan and committed patients to forego reimbursement from MSP or any other public agency. The waivers also forced patients to agree not to file any complaint with any government body regarding the circumstances of the benefits provided by the Extra Billing Clinics. Patients also undertook” not to disclose any information to any government regarding the particulars of the beneficiary’s surgery”, including costs. If the patient does disclose, the waiver “purports to require the beneficiaries to indemnify the Extra Billing Clihic for damages and costs arising from [the] disclosure”.

Wow, if all of this is true — and if, contrary to the editorial assertion in the Sun, the law does indeed matter, these folks have really got themselves in deep doo-doo.

We’ve had a lot of budgets like this in B.C., so this one is in keeping with its right wing predecessors. During the 1980s, for example, the never-ending Social Credit government used to table budgets that gave the boot to working people in general, unions in particular, the poor, women, youth and, their favourite target, public sector workers. While they slashed services Socred ministers reassured everyone that the public would never notice the difference despite the fact that fewer people would be there to deliver them and that those who remained looked increasingly haggard and exhausted.

The Liberals are continuing this tacky boondoggle. This week’s budget boosted health care more than any other sector, which gives you some idea of how poorly everything else fared. Finance minister Colin Hansen claimed that the $4.8 billion for the health sector over the next three years constitutes 90% of all “new spending”. But as Marc Lee pointed out in his excellent post, very little of what’s gone to health actually is new money — last year’s allocation was brought forward to this year’s budget, with a dash of $25 million on top.

But this budget’s spending reflects a more general malaise in the provincial government when it comes to health care. As with many of the policies it pursues, all of the evidence should have pointed to a decidedly different direction in regard to the budget.

Take, for example, evidence about the social determinants of health, those factors that can prevent things like cardiovascular disease and Type 2 diabetes, the latter of which is now described as an epidemic. These social determinants play a greater role in preventing disease than biomedical or lifestyle behaviour modification. A 2006 paper by Dennis Raphael identified 11 key social determinants of health: Aboriginal status, early life, education, employment and working conditions, food security, health care services, housing, income and its distribution, social safety net, social exclusion, and unemployment and employment security.

David Gordon’s sensible Ten Tips for Better Health put these in language we can all understand:

THE SOCIAL DETERMINANTS TEN TIPS FOR BETTER HEALTH

1. Don’t be poor. If you can, stop. If you can’t, try not to be poor for long.
2. Don’t have poor parents.
3. Own a car.
4. Don’t work in a stressful, low paid manual job.
5. Don’t live in damp, low quality housing.
6. Be able to afford to go on a foreign holiday and sunbathe.
7. Practice not losing your job and don’t become unemployed.
8. Take up all benefits you are entitled to, if you are unemployed, retired or sick or disabled.
9. Don’t live next to a busy major road or near a polluting factory.
10. Learn how to fill in the complex housing benefit/ asylum application forms before you become homeless and destitute.

Gordon, D., Posting (April, 1999) Spirit of 1848 listserv.

The increase in the incidence of Type 2 diabetes in Canada — 69% between 1997 and 2007 — can be linked to the rising number of people who aren’t able to act on these good suggestions. People who are poor are not only more likely to get Type 2 diabetes than their wealthier counterparts, but they are also more likely to hospitalized with complications related to the disease. This has been shown to be the case by Canadian and international researchers, including those associated with the World Health Organization and the Pan-American Health Organization.

According to a 2007 study published by Ontario’s Institute for Clinical Evaluative Sciences,for example, Toronto neighbourhoods where poor people live also have much higher rates of Type 2 diabetes and obesity. “Areas with lower socioeconomic status (SES),” the report said, “had…higher diabetes rates. These neighbourhoods clustered in the northwest and eastern parts of the city. Conversely, neighbourhoods with a more advantaged SES profile tended to be clustered in the centre of the city and had lower diabetes rates.” In January 2006, the New York Times reported that in East Harlem, where incomes average $20,000 a year and the poverty rate is 38.2%, between 16 and 20 percent of residents have Type 2 diabetes. That compares to the Upper East Side, where the average income is $75,000, the poverty rate is about 6.2% and an estimated 1% of residents have the chronic condition. Like Clyde Hertzman (UBC) and others in Canada and internationally, Raphael has argued that the most important policy options for governments are ones aimed at reducing poverty. Poverty reduction is not just a human right, not just a moral and ethical obligation of government, but strategies to achieve that goal would reduce the strain on our health care system as well.

Does the budget have anything to do with the growing mountain of evidence about what people need to be healthy?

Hmmm… let’s see. The $8 minimum wage is frozen at $8 an hour, well below the “living wage” of $16.74 an hour. Wages in the public sector are to be frozen for the next couple of years and there is no strategy to raise wages in the private sector. The budget projects unemployment at 6.2% but by last month it had already reached 6.1% and the “up to” 88,000 new jobs it projects are clearly inadequate. The social safety net? The only reference to safety that I could find was in reference to policing and roads. Housing? The housing budget has been cut and market housing prices are 55% above the average family’s ability to pay. Those on income assistance will see an increase of one-half of one percent, while the ministry of Children & Families got only a one percent boost in the budget.

I would say the budget failed to ensure that the determinants of health are more accessible in these looming tough times — a 100% percent failure rate, in fact. But don’t worry! While the budget fails on health determinants side, the government has engaged the pharmaceutical industry in public-private partnerships to deliver chronic disease management (CDM) programs. So British Columbians with Type 2 diabetes and other chronic conditions — if they can afford to do so — will be able to dip in to the medicine chest to heal the wounds inflicted by this budget.