Panel Discussion: Chronic Disease and Aging: Financial Impact and Health Policy Implications
Mr. Levine moderated a question and answer period that for the most part brought up points on healthcare costs.
An audience member wanted to know what political decisions were made after the economic crisis of the 1990s. Additionally, since provincial healthcare spending came down around that period, was there more of a transfer towards the private sector for healthcare needs?
Dr. Béland addressed how at the end of the 80s the conservative government started reducing transfers and it was anticipated that by 2000 the healthcare transfers would be reduced down to zero for all provinces. Transfers continued to decrease during the economic crisis that was to start in 1989. Towards the end of the crisis, around 1996, there was a severe drop in the transfers as the positive economic cycle started climbing. Even though more provincial funds were available, faced with such a drastic decrease in federal transfers, the provinces had to continue cutting healthcare spending. When the liberals took power at the federal level, they re-implemented healthcare transfers.
He states that these issues are linked to the federal debt and that the Martin government took charge of reducing the debt that was accumulating since the Trudeau government. The end of the 80s and the 90s were fiscally troubled times and the provinces were hit hard. During the crisis, from 1989 to 1992, many hospitals in Montreal and in Ontario were closed.
However, it was much later that the provinces started considering the idea of private insurance. The Chaoulli court case brought this to the forefront when a doctor denounced the Quebec law that banned private insurance of publically insured services (medical, hospital). The Chaoulli verdict in the Supreme Court a few years ago stated that if wait times in the province of Quebec put people’s lives at risk, the ban on privately insured services is unconstitutional and goes against the Quebec charter of rights. It is at this time that the Quebec government opened up to the possibility of Quebec residents acquiring private insurance and receiving private healthcare services, thereby allowing the formation of specialized medical clinics. Dr. Béland pointed out that certain doctors who support healthcare privatization cite Quebec as an example to be followed for the rest of Canada.
Mr. Levine asked what the general thinking is about the value of the management of chronic disease across Canada. Have we come to the understanding that we need the management of chronic diseases in order for the healthcare system to progress?
Dr. Ballem commented that she does not believe we have had a comprehensive look at the management of chronic diseases. Dr. Béland referred to a publication that defends the point of view of the management of chronic disease. It argued that over the next four to five years we would need to invest one billion dollars to save 1.6 billion dollars over the next six years. Dr. Béland expressed his doubt as to whether any provincial healthcare administrator would buy into this. There is contradictory literature on the topic. Some say that the management of chronic disease does not bring about savings but that care is better, while others state there is a decrease in costs. One article states that the prescription for the chronic care model is good medicine. Why would there be the need to invest a billion dollars if doctors need only practice good medicine? Mr. Levine argued that he is uncertain that the methods of payment favour good medicine. He believes however, that savings are currently generated based on the frequent visits to the emergency room and the chronic clientele.
Dr. Béland cited a report where the author emphasized the importance of the quality of practice on efficiency. Physicians are professionals that take satisfaction in a job well done. Dr. Béland believes that our policies have the power to destroy this important characteristic of the physician’s professional activity, that which is professionalism.
One audience member commented on how healthcare spending does not seem to be related to healthcare needs but rather to the amount of money available. He offered examples where it would seem the government is spending more than it needs to. He also expressed the concern that the strategic plan calls for more research, when it has been shown that research is a strong driver of increased expenditures. He stated that the need for research has not been demonstrated, as post-implementation surveillance has not been done to show that these programs are effective.
Dr. Béland acknowledged that he spoke on how healthcare costs are linked to a variety of factors, but did not negate the link to healthcare needs. He believes they would be important at some point.
He said that when we speak of intervention methods, some happen at the level of the individual (clinical relationship). It is at this level that efficiency is gained and costs are controlled. It is not known how this gain of efficiency is transmitted to the hospital budget or the general budget of the state but we need faith to believe it will happen. He went on to say that the government tries to influence general healthcare costs, albeit in a meaningful way, by making radical decisions, such as it did in the early 90s in Quebec and Ontario by cutting healthcare costs. If it tries to influence the doctor-patient relationship, it does so unsuccessfully.