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Myths and demystification
• Canadian health care spending is out of
control
– universal health care is unsustainable
– health care crowding out other public spending
• parallel privately funded care can shorten
waiting lists
• the private sector always does it better
– efficiency gains with private funding, for-
profit delivery
Health care system
Funding Delivery
Private Public Public Private
For-profit Not-for-profit For-profit Not-for-profit
Myths and demystification
• Canadian health care spending is out
of control
– universal health care is unsustainable
– health care is crowding out other public
spending
• parallel privately funded care can
shorten waiting lists
• the private sector always does it
better
– efficiency gains with private funding,
for-profit delivery
According to OECD
Health Spending as % of GDP, Canada
11.0
10.0
9.0
8.0
7.0
6.0
5.0
75
77
79
81
83
85
87
89
91
93
95
97
99
01
03
05
06
19
19
19
19
19
19
19
19
19
19
19
19
19
20
20
20
20
Total Spending Public Spending
Source: OECD Health data, Organization for Economic Co-operation and Development (OECD) 2008
Total Expenditure on Health (% GDP) in 1992
United States
Canada
Germany
Switzerland
France
Denmark
Netherlands
Italy
Sweden
Iceland
Norway
Australia
Belgium
Greece
Austria
New Zealand
Spain
Portugal
UK
Japan
Czech Republic
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Source: OECD 2004
Total Expenditure on Health (% GDP) in 2005
United States
Switzerland
France
Germany
Belgium
Portugal
Austria
Canada
Denmark
New Zealand
Netherlands
Sweden
Iceland
Greece
Italy
Australia
Norway
UK
Spain
Hungary
Luxembourg
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Source: OECD 2008
Isn’t health care eating up
provincial budgets?
• 1980
– health care 30% of Ontario budget
• 2004
– health care 45% of Ontario budget
• but public health care expenditure as
% of GDP down, not up?
General Gov't Outlays
(From http://www.fin.gc.ca/frt/2008/frt08_e.pdf)
60
50
Percent of GDP
40
30
20
Canada
10
US
0
73
76
79
82
85
88
91
94
97
00
03
06
19
19
19
19
19
19
19
19
19
20
20
20
What are we spending less on?
• education
– universities from 0.5% GDP to < 0.18%
• employment insurance
– 80% eligible to 40% in Ontario
• social support
• urban infrastructure
• subsidized housing
Ensuring sustainability
• wait time initiatives
• centralization of lists
• integration of care – specialized surgical facilities
• interprofessional Care
• right provider, right place, right time
• chronic disease management
• self-care pathways
• home care and community-based care
• electronic Health Record
• duplication minimization
• safety and quality
Examples of Success
• Hamilton
– 70% decrease in referrals to psychiatrists
• Alberta
• reduced wait times for hip and knee
replacements from 19 months to 11 weeks
• Sault Ste. Marie
– 50% reduction in readmissions of heart
failure patients
• Nova Scotia South Shore
• no ventilator associated pneumonias in 14
months
Is high quality universal health
care for all sustainable?
• health care as % of GDP
– total stable over last 15 years
- public even less
- Canada 2nd 15 years ago, now middle of pack
- tax cuts, not health spending, has compromised
other social spending
- innovation can further increase efficiency
- Romanow: Health care as sustainable as we
choose it to be
Myths and demystification
• Canadian health care spending is out
of control
– universal health care is unsustainable
– health care is crowding out other public
spending
• parallel privately funded care can
shorten waiting lists
• the private sector always does it
better
– efficiency gains with private funding,
for-profit delivery
Logic and logical problems
• more money from private funding
– more resources, wait times shorter
• physician and nursing shortage
– private funding won’t train more
– publicly funded facilities lose best
trained
• privately funded care can only exist if
waiting lists for publicly funded care
Access
More private care More public care
Duckett. (2005). Australian Health Review 29. 87.
Hurley et. al
Myths and demystification
• Canadian health care spending is out
of control
– universal health care is unsustainable
– health care is crowding out other public
spending
• parallel privately funded care can
shorten waiting lists
• the private sector always does it
better
– efficiency gains with private funding,
for-profit delivery
Private Funding is Inefficient
Total expenditure on health as a % of GDP
18
16
14
12
10
United States
8 Canada
6
4
2
0
1960 1965 1970 1975 1980 1985 1990 1995 2000 2005
OECD Health Data (2007)
Administration as % of Total HC Exp
35%
30%
25%
20%
15%
10%
5%
0%
US CAN
S Woolhandler Int J H Serv 2004;34:65-78.
Administrative cost difference
• developing insurance packages
• selling insurance
• evaluating applications
• documenting use of services
– hospital and physician offices
• assessing claims
• executive salaries
• profits
Cost Control
• public pay
– physician services slight decrease
• 15.4% 1991 to 13.4%
– hospital marked decrease
• 45% (1976) to 28%
• pharmaceutical increase
– 9% (1984) to 17.4%
Analysis of deaths considered “amenable to health care”
in those under 75 years of age in 19 industrialized countries
Systematic review health outcomes in
Canada and US, 2007, Open Medicine.
• 17 leading US/Canadian researchers
• comprehensive search yielded 38 studies
• compared outcomes of conditions with identical diagnosis
• cancer, cardiovascular disease, renal dialysis, cataracts...
• 14 studies showed better outcomes in Canada
• 5/10 with broad populations, statistical adjustment
• 5 studies favoured the U.S.
• 2/10 high quality
• 19 studies had equivalent or mixed results
• 3/10 high quality
Summary
• single public pay more efficient
– administrative efficiencies
– effective cost control
• single public payer cost-efficient
– equal or better outcomes than much
more efficient U.S. system
Health care system
Funding Delivery
Private Public Public Private
For-profit Not-for-profit For-profit Not-for-profit
Debate
• advocates of investor owned private
for-profit health care delivery argue
– for-profit providers deliver care more
efficiently
• advocates of not-for-profit health
care delivery fear
– for-profit facilities compromise care to
maintain investors returns
For-profit or not-for-profit?
• for-profit initiatives
– Ontario: home care, MRI/CT, P3
hospitals
– other provinces, surgical clinics
• systematic reviews
– investor-owned for-profit vs nfp
• hospital death rates
• dialysis death rates
• hospital charges to payers
Systematic review
and meta-analysis
• systematic review
– focused question
– explicit eligibility criteria
– comprehensive search
– assessment of validity of primary
studies
– eligibility and quality assessments are
reproducible
• meta-analysis combines the results
of several studies
Screening process
• 8665 unique citations
• teams of 2 individuals
– independently screened the titles and
abstracts
• 805 full text publications
– identified for full review
Assessment of study
eligibility
• masked results (i.e. blacked them out)
• teams of two individuals
– independently evaluated each masked
article to determine eligibility
• disagreements resolved by consensus
• agreement was excellent (Kappa 0.83)
Results
• all studies
– comprehensive search, top quality studies
– published in top peer-reviewjournals
• hospital mortality
– 38 million patients between 1982-1995
– 2% more deaths in for-profit
– 2,000 deaths in Canada (MVA, cancer, suicide)
• dialysis mortality
– 500,000 patient years 1973 to 1997
– 8% more deaths in for-profit
• charges 19 greater in for-profit
Summary: overall
• pressures on health spending but:
– Canada better than most other countries
– problem is tax cuts, not health spending
• private pay won’t shorten waiting lists
– will just make ability to pay, rather than
need, the criterion to get to the front
• single payer maximizes efficiency
– not-for-profit more efficent than for-
profit
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