Wednesday, June 25, 2014

Is Hating the 1% worth Hurting the 99%?

Under a two-tier health system, the economically advantaged probably will get access to faster and better care than the average Joe and Jane Canadian on the street. They also send their kids to private schools, drive nicer cars and live in nicer houses in nicer neighbourhoods. Maybe they get to do those things because of a lot of hard work, and maybe they get to do those things because they got lucky – having either won lotteries or being the beneficiary of another’s good fortune.

Some take great satisfaction knowing that under the current system the economically advantaged do not have an advantage over the average Canadian when it comes to healthcare (they fool only themselves). It’s a kind of misplaced Schadenfreude – joy that should someone economically advantaged fall ill, they are at the mercy of the same system as everyone else. Perhaps some think that by forcing the economically advantaged to participate in the same system as everyone else that the economically advantaged will advocate for adequate funding of that system as they have a vested interest in its quality (again laughable, as by the time most people realize the reality of healthcare in Canada it is far too late to become an activist).

The thing is, it does not make a lot of sense to really worry about what the economically advantaged spend their (after tax) money on – be it better houses, health or education. It makes a lot of sense to worry that public systems are adequately resourced, provide an adequate level of access and quality of service and that taxation is fair. It makes a lot of sense to worry that what is provided publicly is done so with a view to both efficiency and effectiveness.

And it makes a lot of sense to worry that the prohibition on two-tier healthcare ultimately harms the public healthcare system and those who must rely on it the most – the middle class and economically disadvantaged.

As much as some people would like to think that the amount of money available via taxation is limitless – it is not. Yes, there likely is a fair bit of room for some tax increases – the GST used to be 7 percent and now is 5, however, there are also a lot of very significant challenges that are on the horizon – including an unfavourable demography, and an ever expanding number of conditions amenable to medical care. And don’t forget, that healthcare is not the only thing that is publicly funded – education, transportation, and economic development also deserve public funding. As such, it’s fair to assume that public resources available for healthcare, both now and in the future are indeed limited.

So what does the prohibition on private healthcare in Canada effectively do? It forces many people who would choose to spend their own resources on healthcare to spend public resources on healthcare (they are prohibited from domestically buying medically necessary services). That leaves fewer resources for those who would have absolutely no choice but to use public resources. It forces others to languish on waitlists, potentially disabled and unemployable because it assumes everyone has the same cost of waiting. Health inequities persist, because the best educated (and coincidentally more likely to be economically advantaged), are more likely to be aware of the health services available and to advocate for themselves for access. Some (if they are lucky enough to have the resources) are forced to go out-of-country to access care (and those who do may impose costs on the public system should the quality of care they receive abroad be inadequate, not to mention also bearing the cost of what would otherwise be unnecessary travel). Some spend their resources on unproven and ineffective alternatives to medical care (homeopathy is just a fancy word for water). And because resources are constrained, as demands on the system grow, the system becomes ever more focussed on urgent and emergent services, relegating medically necessary elective services to a kind of no man’s land where people feel disenfranchised for having paid into a system to which access is effectively barred. Further, the opportunities to expand into public provision of needed but not covered care (pharmaceuticals, optometry, and dental) remain limited. Some doctors, are forced to be either unemployed or underemployed – with some deciding to leave the country.

But, I guess as long as it is believed that the economically advantaged also got the shaft and that our system out-performed the US (albeit that’s the only system in the OECD our system outperforms), that it was worth the pain?

It’s time to quit worrying about whether or not someone else might get “better care” and to start worrying that everyone can get “adequate care” – this foolishness is costing many very average Canadians their health and well-being.

Thursday, June 19, 2014

And in 25 years?

In 25 years, I’ll be 60 and if I stay where I’m at, or even just somewhere else within government, I’ll have a full pension, my children will be grown, the house paid for. I will not have worried about prescription bills, or dental bills – as much of those would be covered under the extended medical plan.

And maybe, if I was still the person I was 6 years ago, I’d be content. Or perhaps, I wouldn’t be so passionate about healthcare or maybe I’d be passionate about something else (like education) and I could move away from health into some other area and happily work there.

But, I am not that woman. I’ve mourned her. I’ve lamented her absence. And in the years since – since I was pregnant with my daughter, since I became a mother – I’ve had to work hard to come to terms with who I am, now. To pick up the pieces of a shattered being and cobble together a mother, a woman, that I and my family can live with. Knowing that there is no way to change the past, there isn’t really any way to even get any accountability for it. There is only now, who I am now and all the days, months, and years ahead.

My work-outside-of-work has been a refuge, a life raft in an otherwise turbulent sea. This blog, a sanctuary. Twitter – an engaging space. Building the Cesarean by Choice Awareness Network – has given life to a community, of which I am privileged to be a member. The patient advocacy and provider engagement work I have done has been some of the most fulfilling in my career. Indeed, my work-outside-of-work has sustained me during some of my most difficult times and has challenged me to think in new ways about healthcare and the health system. It is meaningful and can and has affected change.

It is rather ironic then, that the work that has reminded me of how much I care about healthcare – about the system – is the same work that makes my work-at-work an exercise in tedium and toil. It is my salvation, my destruction and my reconstruction all at the same time.

For now, it is like I have learned many important and valuable things from my work-at-work – indeed at one time, my work-at-work brought me a lot of satisfaction and without that experience, I would be less effective at my work-outside-of-work. But because I changed, and in some measure it did too – there’s an uncomfortable conflict between myself and work-at-work and work-outside-of-work, and every day, a little louder, after I drop the kids at daycare, there’s a voice from within that says, “I don’t want to go to work.” Because going to work means spending another day trying to focus on things that I have a hard time focussing on, means spending another day supporting and defending a status quo, means lamenting all the other things I could have done that I would have found more fulfilling. It means spending another day being drained and in conflict with who I am.

I would love nothing more than if my work-outside-of-work aligned with what I’m paid to do – when there would be an effortless match between what I want to do and what I do. I’d love nothing more to be in a position where there was little gap between what I did, and what I could do. Where, the work was meaningful – and a source of satisfaction. Indeed, it is a shame that the work-outside-of-work does not come with a paycheque…because in 25 years, although I would not have a pension, I could have done some great things, things that matter and things that have meaning. Perhaps, after 25 years, I would have lived a life worth living.

P.S. I'm open to suggestions on how to make the work-outside-of-work come with a paycheque, provided they don't involve moving out of Victoria and are compatable with the demands of children.

Monday, June 16, 2014

What's Wrong with Mr. Picard's take on Birth in Canada?

This weekend I read an article in the Globe and Mail – and found myself seething. Seething because, here was yet another article bemoaning the use of intervention in childbirth – that seemed to be calling for women to be encouraged to use midwives and birth centres and homebirths. Questioning the real necessity of Cesarean delivery – and largely echoed what can be summarized as a “Campaign for Normal Birth” where normal is defined as vaginal and without intervention, including without epidural pain relief. Questioning the necessity of hospital use for 98 percent of births – and the supervision of physicians for the large majority of those births – Mr. Picard thinks fewer babies should be born in hospitals and more babies should be born under the supervision of midwives.

The man is entitled to his opinion – but it’s rather tragic that such a notable and respected health journalist has fallen for the ideology of natural childbirth, hook, line and sinker – and that his stance, and the campaign it reflects does ultimately harm the health and well-being of women and their children.

Let’s begin with the statement that the World Health Organization suggests that the optimum rate of Cesareans are between 5 and 15 percent. This is a zombie statistic – one of those numbers, that even though it has been debunked, simply refuses to disappear from the media. In 2009, the World Health Organization retracted this – stating in its “Monitoring Emergency Obstetric Care: a Handbook” publication that there is “no empirical evidence for an optimum percentage” and that an “optimum rate is unknown” and that world regions may now “set their own standards”. But perhaps Mr. Picard thinks that a higher rate of instrumental deliveries (they would be vaginal) and a higher rate of 3rd and 4th degree tears and their consequent risks of incontinence is worth it to have a lower rate of caesareans.

Mr. Picard notes the fact that 58 percent of women “opt for an epidural” – I want to correct Mr. Picard on this. Fifty eight percent of women giving birth in Canada actually get epidurals – we don’t track how many epidurals are wanted or needed but not available and I assure you, particularly in BC, there are plenty of women who would “opt for an epidural” but are denied access to one. But no worries – Mr. Picard assures us that “pain relief can be done outside the hospital, too.” Mr. Picard – exactly what kind of pain relief options are available outside of the hospital? Perhaps you should review the BC Perinatal Health Program’s Obstetric Guideline 4 “Pain Management Options During Labour” - note outside of hospital you would be limited to the first 3 options. The next time you are having a kidney stone – how about you learn some breathing techniques? Get someone to rub your back? Or maybe you’d like some saline water injections? Maybe a hot shower? Or would someone just reminding you that your “body was made to pass kidney stones” be adequate? Epidural pain relief is the gold standard of pain relief – and the other options that are even moderately effective, are only available in the hospital setting (for good reason). Denying access to pain relief – or leading women on to believe pain relief outside of the hospital is available is cruel.

Worse – there is some evidence that is emerging that inadequately treated pain during labour and delivery is associated with the development of post-natal Post Traumatic Stress Disorder and other post-natal mood disorders. How are the women who perceived their childbirths to be painful – or extremely painful supposed to take Mr. Picard’s assertion that out-of-hospital measures to address that pain should be adequate?

Yes, the vast majority of births are not complicated, however, this is only known retrospectively. Retrospectively, the vast majority of automobile trips do not involve any collisions – that does not mean that we should abandon the use of seatbelts, because most of the time they are not needed. Which brings us to a very interesting finding out of the Netherlands: Low-risk women who were treated under the care of a midwife had worse outcomes (rates of death and disability) than high-risk women who were treated under the care of an OBGYN (ACC Evers, HAA Brouwers, CWPM Hukkelhoven et al.” Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study.” BMJ 2010;341:c5639. (2 November.) The Netherlands has almost the highest perinatal mortality (death) rate in Europe – is this really the model Canada wants to emulate?

Mr. Picard then encourages us not to buy the “too posh to push” nonsense. Mr. Picard – I am that demographic that you are seeking to dismiss. Worse, I am that demographic who has had my needs dismissed and has suffered the consequences of that. Mr. Picard, the women who are choosing Cesarean are not doing so because, “when you medicalize pregnancy and labour, and don’t offer reasonable alternatives, you create uncertainty and fear.” They are doing so because they do not buy into the idea that vaginal birth is the best for themselves and their babies – they do not like the vagaries of vaginal birth itself. It is not the medicalization of birth that creates the uncertainty – it is the inherent nature of the process. Left to its own devices, birth maims indiscriminately. Some of the damage is not known for years – and that is what women who “Choose Cesarean” are seeking to avoid. Again, there is recent research that is demonstrating that when the needs of this demographic – the patient choice Cesarean demographic, are dismissed they are at an incredible risk of developing Post-Traumatic Stress Disorder (Garthus-Niegel, et. al. “The influence of women’s preferences and actual mode of delivery on post-traumatic stress symptoms following childbirth: a population-based, longitudinal study”, BMC Pregnancy and Childbrith 2014, 14:191 ). But let’s just call them “too posh to push” – and those who fail to have their needs met can be isolated and ridiculed. Mr. Picard – too little surgery, even on those who do not “medically need” it can be harmful too.

You declare that your article is not to harken back to earlier times – but that is exactly what you are advocating for when it comes to the care women and their babies should expect to get. You declare that only a small amount of maternal mortality is the result of obstetric interventions but do not provide any evidence to support that claim. You declare mothers are healthier as a result of a higher-standard of living and fewer pregnancies because of contraception.

Mr. Picard – that same high standard of living, has not exclusively done what you claim it has done. If you look at the women giving birth today – they are not in their early twenties. They are in their thirties and their forties. They are more likely to be obese prior to becoming pregnant. They are more likely to have used assisted reproductive technology to get pregnant. They are more likely to have underlying health conditions that make pregnancy and childbirth more risky. Further – many of these women are not willing to take the risks with the health of what may be their only one or two children. I beg to differ with your assertion that infectious disease and excessive bleeding are still the biggest risks facing mothers today.

To you birth has become unnecessarily tedious and costly but I would argue that much of that “tedium” and “cost” is money very well spent. Consider for a moment that those giving birth are likely to be actively engaged in the workforce – likely to have another 50 years or more of life to live after they have babies. Consider for a moment those babies who are likely to live 80 or more years. Now the consider the cost and tedium of raising a child who has been injured at birth – or living with the grief of a child who died at birth. Now consider that two out of three babies who die at a home birth ( might have lived had they been born in a hospital.

I am very much for a patient-centred health system – but to “stop treating pregnancy and childbirth like a disease” is very likely to cost mothers and their babies very dearly. Pregnancy and childbirth is a time of incredible health vulnerability – and to dismiss that is to deny an informed choice about the right care, in the right place, which for many mothers (the vast majority) is care under the supervision of a doctor in a hospital with access to all of the advances of modern technology. I agree a culture change in birth is needed – but that culture change is the recognition that every woman is entitled to make medical decisions (and they are medical) with respect to her pregnancy and childbirth – including the choice to avail herself of the technology available.

Friday, June 13, 2014

Cost Containment in Healthcare: Is it What Matters?

Increasingly, it is apparent that the health care system in Canada (and many other countries) is focussed on cost containment. Don’t get me wrong, cost containment is an important thing – the costs associated with duplicate tests, the costs associated with preventable ill health, the costs associated with inefficiencies and the costs of waiting – are all things an efficient and effective health system should seek to eliminate.

But, I have a confession to make: cost containment as a goal, in and of itself, is as about as sensible as using caesarean rates to measure the quality of maternity care. It is at best misguided – and at worse will pave the road to a health system that fails to meet the needs of patients and results in avoidable death and disability.

I have another confession to make: we don’t do a very good job of measuring costs in healthcare in the first place – nor do we do a good job of measuring outcomes. We are particularly lousy at measuring things from the patient perspective.

Admittedly we have a lot of excellent data (the Discharge Abstract Database, the Medical Service Plan Database, the Pharmacare and Pharmanet Database, the Home and Community Care Database, the Health Authority Management Information Database. There is also a lot of work being done to aggregate the information in those databases to look at use and cost of use “across the system” – but there are also a lot of limitations to that data. If something in the health system was done, and publically paid for we have (at least some) information on that.

However, here’s what we don’t have very good information on. Anything that was privately paid for we have next to no information on. If you went to the states (or elsewhere – India, Mexico, or a number of other countries with burgeoning medical tourism industries) to access care and paid out of pocket, we have no information on what was done or what it cost. If you had a private MRI or CT we have no information on that. If you went to a psychologist and paid out of pocket, again no information. Wait times – our information on wait times in Canada is severely lacking. The wait times that are measured, are generally measured (in BC) from the time the surgeon submits the booking form until the time the treatment is provided. I have heard rumours that some surgeons are not even submitting the booking form until they know the procedure can be completed within a specified period of time. We also have no information on the private cost of waiting – we have very little information on the level of disability or suffering experienced by those who are waiting, nor do we know much about their lost incomes. Further, once a procedure is completed – we do not know a lot about the impact on health that was experienced by the patient who received the treatment. We also don’t have good information on services that were provided under an alternative payment scheme – with some seemingly large gaps in information resulting. We have no information on services that were needed but never delivered.

Further, there are those who are very firm in their opinion that we have enough data and do not need to invest in more data or better data.

And maybe we don’t need more data or better data if cost containment is the only thing that matters in the health care system. Maybe all we need to do is set the budget – and let the pieces fall where they may. Care will be rationed – but it is unclear, if anyone really cares that that is the obvious outcome of a system focussed on cost-containment.

But if the focus is on a health care system that provides quality care – we most definitely do need better data and a better handle on the costs of the system – and just as importantly the outcomes and experiences of patients.

I would argue that, that is what needs to be the focus (quality care delivered efficiently and effectively) if we are to make progress to a high-performing system that delivers value for the resources used. There’s a good chance that it would need to be a hybrid and allow for private health insurance. It’ll probably cost some money – but there’s a very good chance that it’ll pay dividends.

Or we can continue down the path we’re on – the one where the system is very likely and chronically under-resourced. The one where patients are not having their needs met, but their voices go unheard. The one where providers are frustrated because they are not trusted and are hamstrung from delivering the care that they know is wanted and needed. It is wholly unsustainable to have a system that is focussed on “cost-containment” – but by the time we get around to focussing on what really matters (and measuring it), it might be too late.