Cheap, fast, good — pick two?

Long wait times are the vulnerable soft underbelly of the Canadian health system. Canadians treasure our single-payer, publicly funded program of physician and hospital care, virtually as a defining part of our national identity. And yet, increasing legal and political pressure over quick access to elective surgeries—cataract extraction and joint replacement, for example—threatens to undermine that support. The Commonwealth Fund 2017 report ranked Canada last among 11 countries in timeliness of care. A case currently before the British Columbia Supreme Court aims to topple provincial regulations that limit private payment for medically necessary services, claiming that surgical wait times for elective procedures such as arthroscopic knee surgery violate the Canadian Charter of Rights and Freedoms. The truth is that few people anywhere in the world are in love with their health care system—Canada is no exception. Why? Modern health care is expensive—so expensive, at $5,900CAD per person per year in Canada, $9,900USD in the U.S. and £2,900 in the U.K., that it costs more than many people are willing to pay for, whether through taxation, insurance premiums or out-of-pocket payments. Many Americans still lack health insurance, and even insured Americans may not be approved for every treatment they desire. Among developed countries, Germany has the highest public support for their health system, but even there—Germany!—40 per cent believe the system requires fundamental changes or a complete rebuild. Sound familiar? But this does not mean that Canadians are doomed to long waits for elective surgery forever. There is actually much that can be done fairly easily without resorting to private payment. We can address the supply of surgical procedures, the demand for surgery, and improve coordination within the system to gain significant improvements. Increasing the supply of surgery can be achieved by paying hospitals using “activity-based funding” payments for each procedure they do for surgeries like joint replacements, rather than receiving an annual global budget in the hope that they will meet the demand. Reimagining the way we use hospitals, incorporating new anesthesia techniques and virtual care to transform common procedures like joint replacement to day surgery, can reduce costs and free up hospital beds to further increase the supply of surgical procedures. The demand for surgery is also elastic. Removing people who are not in dire need of surgery from waiting lists improves access for those in greater need of services. It also prevents the overtreatment of healthy people which is rampant in many areas of medicine—32 per cent of patients waiting for cataract surgery in BC had near-perfect vision, in just one example. Ironically, the current case before the B.C. Supreme Court—the most pressing legal challenge to the constitutionality of Canadian medicare—is in part about access to arthroscopic knee surgery, a procedure that might actually cause more harm than benefit in some patient groups. Wait times in Canada may be long on average, but they are not long everywhere. Take the example of knee replacement surgery in Ontario. At first glance, the waits certainly seem long: in 2017, only 78 per cent of people had their knee replacement within the recommended six months and 10 per cent waited longer than nine months. In spite of this, half of all people actually had their surgery within three months. Why is it that some people have surgery quickly and others wait? Mostly, because there is little coordination of surgical practices. Long ago, other industries adopted effective queue-management strategies that prevent situations where some people wait much longer than others. “Single-entry” models—where all people enter one queue and take the next available slot once they get to the front of the line—smooth out the waits and increase efficiency in banks, fast-food restaurants and at Disneyland. Centralized intake, triage and referral of patients to appropriate heath care providers —taking advantage of inter-disciplinary teams including nurses and physiotherapists—would go a long way to reducing variation in wait times and improving access to surgery. Medicare is not perfect, but it is still very good at providing excellent quality care to all Canadians who become ill and require hospital and physician services. Decisive action to improve wait times is necessary to maintain the public confidence that is required to preserve our unique health care system for future generations. The good news is that this can be done, by fixing medicare’s problems with surgical precision, without killing the patient in the process. David R. Urbach, MD is an expert advisor with EvidenceNetwork.ca, Surgeon-in-Chief at Women’s College Hospital, Toronto and Professor of Surgery and Health Policy at the University of Toronto. He is also Senior Innovation Fellow, Women’s College Hospital Institute for Health System Solutions and Virtual Care (WIHV). The Hill Times