Ethics, Evidence and Economics: A Dissection of the Canadian Health Care System

1. Ethics, Evidence and Economics: A Dissection of the Canadian Health Care System Timothy Christie, BA(hons), MA, MHSc, PhD Regional Director, Ethics Services, Horizon Health Network Adjunct Professor, Department of Bioethics, Dalhousie University

2. Contact Information Dr. Timothy Christie Regional Director, Ethics Services Horizon Health Network Saint John Regional Hospital (506) 647-6579 Timothy.Christie@HorizonNB.ca

3. Full Disclosure Conflict of Interest: No

4. Full Disclosure Conflict of Interest: No Bias: Probably

5. Full Disclosure Conflict of Interest: No Bias: Probably “Bias has been defined as any systematic error in the design, conduct or analysis of a study that results in a mistaken estimate of an exposure’s effect on the risk of disease.” Gordis, L. Epidemiology, Second Edition. W.B. Saunders Company, 2000: p. 204.

6. Full Disclosure Conflict of Interest: No Bias: Probably Inference: Yes “A conclusion reached on the basis of evidence and reasoning.” Concise Oxford English Dictionary, p. 725.

7. Full Disclosure Conflict of Interest: No Bias: Probably Inference: Yes Disclaimer: All of the material in this presentation , and the opinions expressed here in, are mine (T. Christie) and they do not represent the views of Horizon Health Network, any of the Universities with which I am affiliated, or any other institution. And that’s a damn shame.

8. Outline • History of Health Care Funding and Counter Productive Government Responses • Supply and Demand Framework for Analyzing Healthcare Spending • Conclusion

9. Take Home Message • Perverted means to “distort or corrupt the original course, meaning, or state of (something)…” (OED, on-line) • Any system, no matter how good it is, can be perverted. • Although very well intentioned many aspects of the Canadian healthcare system have been perverted. • Therefore, my intention is to highlight these unintentional, but very real, outcomes.

10. 1-History of Health Care Funding

11. Facts

12. Facts

13. Canadian Institute for Health Information, National Health Expenditure Trends, 1975 to 2008. November 13, 2008

14. What is $191 Billion? Day $523,287,671 Hour $21,803,652 Minute $363,394 Second $6,056

15. What is $191 Billion? • 1 Billion seconds equals 31.7 years. • 1 Billion seconds ago the year was 1979 • 191 Billion seconds equals 6055 years = 4044 (BC)

16. Health Care Funding in Canada • 1997 - $79 Billion • 2007 - $160 Billion • 2009 - $171.9 Billion • 2010 - $191 Billion • This is a 2.4 fold increase in health care spending in 13 years.

17. 13% Aging 13% Population Growth 26% Inflation 48% Increased use of Services

18. Health Outcomes

19. Health Outcomes Ecological comparisons do not prove causality. Therefore, we cannot conclude that increases in health care spending are responsible for these modest improvements in health outcomes.

23. Access vs. Outcomes • Excessive wait-times and wait-lists are consistently identified as a major problem throughout the country. • 15% of the population do not have a family physician. • Canada has 190 physicians/100,000 population, which is the lowest among G8 countries. • Aboriginal health status is atrocious.

24. Summary of Facts • Relentless spending increases on health care, e.g., $191 Billion in 2010, which is 2.4 fold increase in spending in 13-years. • Modest improvements in health outcomes, e.g., less than 2% improvement in life expectancy at birth and 65-years. • 48% of the increase in spending is the result of increased utilization of health services. • Endemic access problems, e.g., excessive wait-lists and wait-times. • A number of countries spend less on health care but achieve better outcomes. • Unacceptably poor health outcomes for Aboriginal populations (First Nations, Inuit and Métis).

25. Government Actions

26. “In Canada you may wait a very long time to see your doctor, but once you do, three consecutive ECHCI reports have shown that quality of the care you receive will generally be quite good.”Eisen B and Björnberg A. Euro-Canadian Health Consumer Index 2010. FCPP Policy Series, May 2010. p.2.

27. Federal Initiatives • 2004 - $41.3 billion in a 10-year plan to strengthen health care: • Address the shortage of health human resources • Increase the Medical Equipment Fund • Increase the Canada Health Transfer • Improve Aboriginal Health • Decrease wait times in five strategic areas: cancer, heart, diagnostic imaging, joint replacement and sight restoration.

28. Provincial Initiatives • Crowding Out is what happens when provincial governments reduce funding in other areas of responsibility in order to sustain the growth in healthcare. • New Brunswick 2011 Provincial Budget: Health received a 3% increase in funding and all other government departments received a 2% decrease.

29. Supply and Demand Framework

30. The Canada Health Act • “…protect, promote and restore […] physical and mental well-being…” • to prohibit “financial or other barriers” that limit reasonable access to insured health services.

31. The Canada Health Act • Insured Health Services • ““insured health services” means hospital services, physician services and surgical-dental services provided to insured persons, but does not include any health services that a person is entitled to and eligible for under any other Act of Parliament or under any Act of the legislature of a province that relates to workers' or workmen’s compensation;”

32. Disorganized System • Health care is administered according to the principle of “responsibility for payment.” • It is not the patient’s responsibility to pay for insured health services. • This causes a ‘disequilibrium’ between Supply & Demand.

33. Disorganized System – Supply Side

34. Disorganized System – Supply Side

35. Disorganized System – Supply Side

36. Disorganized System – Supply Side

37. Disorganized System – Supply Side

38. Publicly Funded and Publicly Administered Hospital Services Public Health Extramural/Home Care Public Funded and Privately Administered Physician Services Government Prescription Drug Programs/Pharmacies Nursing Homes Special Care Homes Private Payment and Public Administration Research Private Payment and Private Administration (30% of Government Spending on Health in Canada) Dental Services Ophthalmologic Services Prescription Drugs (other than welfare and seniors)/Pharmacies Disorganized System – Supply Side

39. Demand Side 5) Demand • Physicians • Hospitals • Dental • Prescription Drugs, Catastrophic drug coverage • Housing • Education • Nursing Homes • Special Care Homes • Dental Services • Public Health • Ophthalmology

40. Classic Problem • The Demand for healthcare services exceeds the Supply, or our ability to meet that demand. • Therefore, what do we normally do?

41. Red Herrings • When the Demand exceeds Supply we can: 1) Increase price, • Privatization of health care, i.e., user fees, private insurance, etc 2) Increase the supply, • Spending more money on health care, i.e., spend more money 3) A combination of 1) and 2) or, • The US Model • “In the United States, the finest medical care in the world costs twice as much as the finest medical care in the world.” Uwe Reinhardt 4) Decrease demand • One of the more promising options.

42. Strategies for an Organized System: Addressing Perverted Consequences

43. Publicly Funded & Publicly Administered

44. Strategies for an Organized System • Publicly Funded and Publicly Administered • Ethical Principles: Efficiency and Effectiveness • Practical Tools: • Decrease cost but improve quality, i.e., Cost-Benefit Analysis. • Avoid the Law of Diminishing Returns

46. Cost Benefit Analysis Example • For every dollar invested in an effective tobacco cessation program the return is $19 in costs avoided. We can make the following observations: • It will cost $208,000 to post-pone one death from sepsis in the ICU using Drotocogen Alfa. • $208,000 x $19 = $3,952,000 • Conclusion, redirecting that money could eventually avoid more than $3.9 million in costs. • I do not know how many lives this equals, however, I think that it is substantially higher than 1 (measured by 28-day survival).

47. Law of Diminishing Returns

48. Law of Diminishing Returns • This patient has a 36% risk of Myocardial Infarction (MI), if nothing is done.

49. Law of Diminishing Returns

50. Law of Diminishing Returns $3/day $3/day $3/day $3/day