Friday, November 28, 2014

On Dr. Danielle Martin's 3 Big Ideas

I actually think that Dr. Martin and I might have a lot in common. We are both passionate about healthcare. We both believe that Canada’s public health care system could do a lot better when it comes to serving the needs of Canadians who rely on it. We both believe that timely access to medical care should not be reliant on a person’s wealth. We both believe that social determinants of health (things like income, education and housing) drive health outcomes and the use of the healthcare system – and that by addressing those issues significant improvements in the health and well-being of Canadians could be realized. We are both young women with well-informed opinions (hers developed in the context of being a physician and my own developed as a result of being a health economist and first hand experiences as a patient) and a willingness to debate those opinions publicly.

Dr. Martin believes that a single-payer system that has a monopoly on medically necessary care is critical. Further, she believes the system could be salvaged if just 3 big ideas were implemented – National Public Drug Coverage, Less is More, and a Guaranteed Income Supplement.

In contrast – I have come to the conclusion that the single-payer system and how it is structured is a very big part of the problems that seem endemic to our system and that no idea is “Big Enough” to salvage it, and absent structural change that the most promising “Big Ideas” are simply not feasible. I believe there’s a reason why every other first-world country in the world with a universal public health system that out performs Canada’s also has a parallel private system that also provides medically necessary care. Single-payer is simply one of those ideas (like communism) that is nice in theory, but in practice and in the context of a complex reality fails to deliver the best outcomes and leaves many suffering the very real consequences of the system’s inadequacies.

Dr. Danielle’s first “Big Idea” is National Public Drug Coverage for the top 20 drugs used to treat chronic conditions in Canada. It is nothing short of shameful that Canada does not include pharmaceuticals as part of its public health system – particularly given that pharmaceutical therapy has become the cornerstone of effective medical care for many conditions. It is also shameful that the approach to pharmaceutical policy in Canada is a provincial/federal/territorial patchwork quilt. It is true that bulk buying the most common drugs would save the system money, and that providing access to those drugs would likely improve adherence among those for whom cost is the primary reason for lack of treatment adherence. National coverage of the top 20 pharmaceuticals would be a good start.

However, that is all this particular “Big Idea” is; a start. It is nowhere near big enough to actually remedy the larger problems and the larger reality that Canada’s health system is a patchwork quilt of practice and policy that is far from comprehensive. The fact that Canada runs more than a dozen different health systems (each province and territory effectively administering its own system, plus the systems run to address the needs of first nations, prisoners, members of the military, etc.) – is a massive waste of resources in and of itself. Further, while the lack of pharmaceutical coverage is lamentable, other big voids include the absence of coverage for dentistry and the services of many para-health professionals (psychologists, chiropractors, massage therapists, physiotherapists, etc.) and the absence of comprehensive coverage for long-term care. If we want a public health care system that is truly functional and comprehensive – the multitude of public systems would be collapsed into a single federal entity, and the system would be expanded to be truly comprehensive in nature to include pharmaceuticals, the services of para-professionals, and long-term care.

Dr. Danielle Martin’s second “Big Idea” is less is more. This idea is aimed at limiting the number of tests and procedures that are of questionable value or duplicative in nature. In retrospect there are a lot of things that happen in the health system that prove to be of little value, in retrospect there are things that are done that perhaps should not be done. In a perfect world – and even in this imperfect world, it is hard not to say that doing some things less would save the system money and not result in worse outcomes, in some cases, doing less might even result in better outcomes (for example the prescription of unnecessary antibiotics that lead to resistant strains of bacteria). This idea is alluring in its simplicity and echoes the environmental movement to reduce, reuse, and recycle in order to stretch what is available to the limit of its potential.

However, the idea of “Less is More” is deserving of scrutiny, particularly in healthcare. Born out of “Less is More”, are care protocols that exhaust conservative options first, denial or delay of access to diagnostic testing and denial or delay of access to treatment. The first thing to understand, is that healthcare decisions are not made retrospectively. There is no “way-back” machine to turn back time and make a different choice if the choice made proves to have been the wrong one – and for some the “less is more” will exact a terrible human toll. Further, patients are a diverse group of individuals with a diverse range of preferences and a diverse tolerance of risk. Not all patients want to wander through the conservative options first. Not all patients are going to be satisfied with denial and delay of access diagnostics or treatment. “Less is More” as a philosophy has the potential to deprive patients of informed choice and decision making with respect to their own bodies and has the potential of moving the system further away from being patient centred. Too many patients in Canada have already borne the brunt of “Less is More”, of having doctors put the needs of the system ahead of the needs of the patient – and absent any alternative route for patients to access, seems like an unjust infringement of rights that should be contested.

Dr. Danielle’s third big idea is a guaranteed income supplement. Poverty is highly correlated with levels of poor health. If you do not have an adequate income, you may not eat an adequate diet, you may not have access to adequate housing, you may not be able to make investments in your own skills to improve your chances in the labour market. Dr. Danielle’s answer is a straight-up hand out to the poor. She proposes that the tax system be used to directly transfer wealth, and that doing so will address the ills that poverty causes. Doing so will make the problems of inadequate housing, inadequate education and inadequate nutrition simply disappear.

However, this is another idea that is deserving of scrutiny and more than cursory thought. Simply giving money to the poor is attractive in its simplicity. It is what is done every time you walk down the street and give the panhandlers change. However, it neglects the reality that poverty is a symptom of underlying problems, many of which are not solved by a hand-out and for some, money may make those problems worse (in the case of addictions). It is also a bit of a “cop-out”, instead of trying to understand and address the causes of poverty and impacts on those impoverished, society buys itself out of the responsibility to be compassionate, the responsibility to give the impoverished a hand-up rather than a mere-hand out. Further, doing so would negatively distort individual decisions with respect to the development of skills, participation in the labour force, and other life choices. If the cost of making poor decisions is lowered, inevitably more poor decisions may be made. Further, it may generate even greater levels of disdain for those who are impoverished – particularly as significant tax increases on those who have made “good decisions” would be used to subsidize a share of the poor who are poor as a direct result of “bad decisions”. Merely giving money does not translate into better housing, better nutrition, better education and social integration. Canada needs to do the hard work in this area and truly get a handle on understanding poverty and its underlying causes as the solution is unlikely to be a mere hand-out. After all, it’d be a shame to spend all that money, and still have to contend with the results of inadequate nutrition, inadequate housing, inadequate education, and inadequate social integration – when that money could have been used to provide better nutrition, better housing, better education, and better social support. Good medicine is treating the underlying causes of disease and disorder, rather than ameliorating only the symptoms.

Big ideas are most definitely needed if we are going to get to a place where a truly comprehensive, universal public health system that meets the needs of Canadians is to be achieved, the biggest of which is the acceptance of the idea that it does not need to be a single-payer monopoly on medically necessary care.

Wednesday, November 26, 2014

Unintended Consequences: Information Resources Squandered

Freedom of Information and Protection of Privacy (FOIPPA) legislation was not intended to hamstring data scientists and policy workers. It was not intended to cause a culture of fear that inhibits the pursuit of knowledge in the public’s interest. It was not intended to cause the sharing of data and information to grind to a near halt. It was not intended to squander resources to ensure adherence to the letter of the law. It was not intended to result in the gutting of capacity to do valuable research on the efficacy and safety of drugs.

Yet, those are the very real unintended consequences – consequences that are difficult to cope with and understand unless you have attempted to grapple with them first hand.

When it comes to data and government’s use of data – many in British Columbia and Canada are in the dark about how it works and why it critically matters. Many are incredibly fearful of the use of their personal information, and the words “Data Privacy Breech” often elicit a tremendous fear of identity theft. Further, personal medical information is sensitive information that needs to be kept confidential as it has the potential to negatively impact an individual’s personal life. Protection of privacy and the mitigation of risks associated with sensitive personal information needs to be a priority. Those trusted with access to that information have a responsibility and a duty not to violate the privacy of individuals by accessing information to satisfy “personal curiosities” as was recently the case in Vancouver Island Health Authority ( or to sell that information for personal gain as was the case in Ontario a little while ago when a Rouge Valley Centenary Hospital clerk sold the information of birthing mothers to financial companies (

The collection of data (either directly or indirectly), use and disclosure of that information are all governed by FOIPPA legislation – collection, use or disclosure that does not meet the needs of the legislation are subject to significant sanctions including termination of employment, substantial fines or even jail time.

So what does that mean?

It means that every time Ministry A wishes to link individual record level data with Ministry B or to share information with the health authorities, there has to be a Privacy Impact Assessment (PIA) and an Information Sharing Agreement in place. As a result significant resources are used to undertake Privacy Impact Assessments and to draft Information Sharing Agreements. As a result, far less information sharing between different organizations that are publicly funded occurs than what might be optimal, simply because sharing data is an onerous activity. As an example, consider a program that is being tailored to improve upon the health status of “at-risk” families. It is suspected that families who receive welfare, families who are newly arrived, families who have a history of domestic violence, families who have low income are “at-risk” of poor health outcomes. However, much of the needed information is not collected by the Ministry of Health – but is collected through a variety of other ministries and organizations including Revenue Canada, the Ministry of Justice, the Department of Corrections, the Ministry of Social Development, the Ministry of Children and Families, etc.. Much of that information was not collected with the purpose of evaluating or developing health policies or programs. As such, even though “the Government” collects the information, it might be severely limited in the sharing of that information and its use and at a minimum would need to undertake a Privacy Impact Assessment and enter into one or more Information Sharing Agreements. If it is an outside researcher needing the information there would significant costs (thousands of dollars) and delays in the production of information. This would need to happen not just once, but for every project that requires information to be shared between ministries or outside researchers – and every project would have to specify the use and disclosure of the information collected.

Further, it means that once those charged with analysing the information have the data in hand – they are limited in the kinds of analysis and explorations that they may undertake. They are able to undertake the analysis for which they have been granted permission under the Privacy Impact Assessment and the Information Sharing Agreement (or via other legislation) only. Unfortunately, this often means that there is a tremendous opportunity cost that is incurred.

As an analogy, imagine for a moment, that a chef has been given the ingredients for a meal, but rather than enabling and empowering the chef to make the “best meal possible” with the ingredients that they have been given, the chef has also been given a precise recipe to follow and have been told that if they deviate from that recipe that they will be fired. If the chef wants to do something different with the ingredients that they have been given (and retain their job), the chef must first submit a revised recipe to their superior and only after that recipe has been approved by a joint board will the chef be allowed to make the revised dish – however, when the chef has suggested revisions to the recipe before, the suggestions are often dismissed out of hand either because of lack of time, or fear that the chef will produce something that is not palatable.

Imagine what that does for innovation?

Imagine what that does for job satisfaction?

Imagine how hard it would be to keep the best and brightest interested in public data?

Imagine the difference between what is done and what could be done?

Those who work with health data need to be empowered and enabled to make the most of the information resources that are available. They need to be free to explore the data and to make potentially profound discoveries about how the public can be served better. There needs to be a better way to protect the privacy and interests of individuals without sacrificing the potential to develop, implement and evaluate the policies and programs that are publicly funded.

Working with data is not just a science, it is also an art – and unless we are willing to enable and empower those who work with data to make the most out of the information resources available – the gap between what is and what could be will remain.

Wednesday, November 19, 2014

Focussing on the cost of health care won't make it sustainable

The sustainability of the health care system is a legitimate concern - worthy of attention and actions to ensure that it remains capable of meeting the health needs of the population in the decades to come.

Unfortunately, the conversation around sustainability as it relates to the healthcare system is often limited to the cost of providing healthcare. The focus is on saving the system money - almost by any means feasible. The focus is on demand management. The focus is on doing the things that will cost the least amount of money to do, or alternatively, choosing to save money by doing less, doing nothing or denying or delaying access.

There is no end of angst when people (some highly educated and informed) look at the historical patterns of health care use and growth in health care costs and apply current forecasts of population and forecasts of costs. The conclusion that things will go from bad to worse, is an easy conclusion to reach. If a person applies a pessimistic view to the trajectory of general levels of health and well-being (the consequences of less than optimal lifestyles) - a grey picture becomes darker still. However, it is folly to look at the future in this way - can you imagine if people viewed other industries similarly, with a view that how things are done will be the way that things will continue to be done and that demand would simply outstrip supply (note: such an approach does sound somewhat familiar with respect to worries about the food supply).

Almost paradoxically, by focussing on the money (on "taxpayer value"), on the cost of care - the sustainability of the system itself is being jeopardized, opportunities to advance the health and well-being of the population are being foregone, and things very likely will go from bad to worse.

By focussing on the money - policy makers put blinders on and are subject to thinking in the short-term, managing this year's budget and next year's budget - and perhaps if the government is newly elected maybe the budget 3 or 4 years down the road is taken into consideration. The ability to truly consider impacts for a generation or more is limited. The long-term view is abused to inspire "chicken-little" thinking. As such an investment in health that might take a decade (or more) to "pay-off" is likely to be foregone in favor of investments that have pay-offs in the short term. As such, short-term cuts to access become appealing because they improve the budget that is on the immediate horizon - the budget that becomes so central at the time of the next election. Cuts that impact a small group of people are chosen in order to please the majority of taxpayers with promises to keep expenditures "in-check". All the while, undertaking the business of healthcare, becomes ever more frustrating (and unsustainable) to both patients and providers, as innovation becomes an unintended casuality and provider burnout becomes an unintended side-effect of short-sighted cost-cutting.

However, consider for a moment, what might happen if the focus were to shift away from "taxpayer value" and towards a system intent on pleasing those who use it (patients), by doing what can reasonably be done to improve the health and well-being of patients. A system that truly values patients, and those who provide services to those patients. A system that is compassionate enough to understand that health needs often have soci-economic causes. Think about the kinds of wide-angle thinking that might be fostered - the kinds of innovation that might come to fruition.

If we desire a "sustainable health-system", the first step is fostering a shift in thinking and shift in focus, and to believe that "taxpayer value" will follow as a side-effect. I conceed, it is a radical leap to be made - but a critical one if true sustainability is the goal.

Perhaps, as some measure of evidence of the potential for this kind of shift, consider the results businesses have been able to achieve by making similar shifts. Consider the businesses that have shifted their thinking away from "shareholder value" towards delighting their customers - notable examples include WestJet, Telus, and Apple and in contrast, organizations who have refused to make similar shifts. Is there any real evidence that thinking a parallel shift in thought applied to public systems is foolish?

Monday, November 17, 2014

The Dawn

I will be blunt, in the year and a bit since I returned from maternity leave I have spent most of that year wanting to leave behind the place I have gone to work to for the past decade. I have spent most of that year frustrated and floundering. Most of that year stressed. Most of that year disengaged at best. Often quietly angry by the lack of what once was.

I have gone through 3 supervisors as a result of re-orgs in the past year.

The overall vacancy rate on our floor hovers around 30 percent (nearly 40 percent of all cubicles are empty and 10 percent of offices).

The vast majority of halls have remained as they have been for the past 10 years – barren expanses of cream.

The effects of the 2012 scandal continue to reverberate through the organization.

The scores of the Workplace Environment Survey had sunk to new lows and our branch, had gone from a group with some of the highest scores in the ministry to the group with the lowest scores in the ministry.

On a personal level, a good chunk of the time since my daughter was born has been a struggle (as illustrated by countless posts on this blog). As a result, it has required a great deal of effort simply to tread water, and to get back to a place where I feel that I can once again make headway on the things that I care about. For most of the past four years it was not possible to think about where I wanted to go, when as a consequence of what happened I was stuck on where I had been.

Then there was a dawn of sorts.

In the past 4 years I had not just “tread water”, I had not just kept my head above the level (although often times it had felt that, that was all I was intent on doing), I had made a difference. People had read my blog and for some what I had wrote resonated, for others I was allowed to help them achieve their goals or to better navigate the system, my perspective on the health system had shifted, my perspective on my work had change; I had built new bridges. I was once again at a place where I felt that I was able to not just “tread water” but to move forward in meaningful ways. I am at a place where I feel that I have learned a great deal of very important lessons, and that working to apply those lessons has a great deal of potential, even where I currently am at.

I could “abandon ship” – and indeed, if the right opportunity materialized, a position where the purpose of the position and my purpose and passions aligned, I would. However, in the interim, I could make where I am at, a better place. I could do what is feasible to align my work, my purpose and my passions. I could do things to improve upon the empty walls in the halls, I could do things to shift thinking, I could help others navigate towards being happier here (or elsewhere), I could make where I was at a place where at the very least, the little voice that says “This is not a place I want to be,” shifts, and says, “This could be a place where I’d want to be, if…” and then set about doing those things that will transform this place a little bit each day.

So 14 months after coming back from Maternity Leave, I’m finally, settling in, my boxes are unpacked and the cardboard has been taken to recycling and I’m making where I am at a place where I can do good work, that matters – a place where the difference between what is and what could be, gets a little smaller each day.

Ready. Set. Go. This is the starting line.

Tuesday, November 11, 2014

Cost versus Quality: Focus on What Matters

Money. It is a distraction from focusing on what matters. What happens when a business makes making a profit, it’s only reason for being? What happens when a government makes exceptionally low tax rates it’s only reason for being? In both cases, the organizations quickly forget why they exist in the first place and begin to make decisions that jeopardize and limit the potential of their organizations to do good (even great) work, that matters.

I’ll be blunt, saving the taxpayer an extra $100 or even $1,000 a year, is not going to motivate the kinds of public servants the province needs to innovate, to effectively run its programs and to deliver exceptional taxpayer value (services bought for the money spent). Similarly, making money for the shareholders of a business, likely will not be able to inspire employees to bring their “A” game to the office, day in and day out. A nameless, faceless shareholder or taxpayer simply fails to inspire and meet a deeper need for meaningful work. Even if those working are objectively paid well for the work that is done.

Meeting a deeper need for meaningful work is what enables people to go above and beyond, is what makes a difference between a job done well, and a job done exceptionally well. Finding passion and purpose in the work that is done, unleashes the potential to do not only good things, but, amazing things. People who have passion and purpose in the work they do, do not work 9 to 5, they work 24/7/365 because their work fills an intrinsic need beyond just paying the bills. A need to know that what a person has done matters, that it makes a meaningful difference to lives of others.

That’s not to say that the work that is done should be done without thinking about the financial impact of undertaking the work (resources are not unlimited), or that employees should be wasteful in their use of resources. Rather, it is to say, that in the long run focusing on what really matters is likely to yield much better outcomes.

Applying this thinking to the health system, think about the kind of system that results from focusing on the cost of care (taxpayer centered) versus the kind of system that results on focusing on the quality of care (patient centered).

If the costs of care become the focus, then what is in the best financial interest of the system becomes the priority when making a decision. In a system focused on cost, there is rationing of care. In a system focused on cost, there is a need to control information and decision-making, there is a need for “gatekeepers” and collateral damage becomes an acceptable cost of doing business. In a system where cost of care is what matters, even the needs of providers might be neglected. In a system focused on cost, it is not about what is possible, it is about what is affordable. A system focused on costs sacrifices the needs of both patients and those who provide services in order to appease the taxpayer – it sacrifices the great in favor of the mediocre.

If the costs of care are taken as a given (as much resources are used as are needed to meet needs), then the focus shifts to what is in the best interests of the patients and what is in the best interests of those delivering the services to patients. Information is no longer feared and hoarded. Innovation is embraced. There is no need for care rationing and there is a great incentive for shared decision-making. Further, the work becomes intrinsically meaningful as it becomes about making life better for others, and in particular about making life better for patients. The pursuit of better care and better outcomes becomes the goal. The possible is unleashed.

To highlight the difference between these two approaches, consider the work of Elizabeth Holmes and her company Theranos. In a system focused on costs of care, her work could be seen as a threat, as it opens the door to demands for health services that would otherwise be deferred or go unneeded. In a system focused on quality of care, her work becomes a tremendous opportunity to avoid bad outcomes from ever materializing in the first place. A system that might cost more, but might also deliver far more for the dollars spent.

So what matters, really?