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Health Care On The Cutting Block: Ministry Hopes For Efficiency With Search And Destroy Tactics

By David South

Today’s Seniors (Canada), August 1993

It’s search and destroy time at Ontario’s ministry of health: search out savings and destroy inefficiency and waste. But many remain apprehensive that not all the cuts are going to be logical and fear the province’s health and well-being will be affected. 

As part of the social contract deal, the Ontario Medical Association must find $20 million in cuts from the list of services covered by OHIP. The OMA and the provincial government are currently haggling over which procedures and examinations will be cut. 

“We look at services that aren’t medically necessary,” says health ministry spokesperson Layne Verbeek. “Because we were wealthier in the past, we were able to cover some services. We aren’t in that position now. But I don’t see how eliminating medically unnecessary treatments will affect the population.”

The fallout of the Rae government’s attempts to reign in costs and recover lost revenues may take years to unfold, but it is already apparent that Ontarians will be paying more. 

“Access to necessary treatment should not depend on a person’s ability to pay,” says health policy critic Carol Kushner. “What disturbs me about any delisting program is that virtually every medical service could be termed medially necessary. There are very few services that are an out-and-out waste of time.

“We often point to the fact that Ontario spends $200 million a year treating the common cold. Well, most of that is a waste of time. But delisting even that kind of service would be a detriment to the public’s health, because a small group of patients really do need to see a doctor when they have a cold.”

OMA spokesperson Jean Chow says it’s too early to pin down the exact cuts that will be made. “It’s a little premature to try and speculate what the final list will be.”

The newly-created Non-Tax Revenue Group is hard at work finding fees, fines and penalities the government can add or hike to boost revenue from this source from $5 billion to $10 billion a year. 

The spring budget saw the first hit, with the addition of $240 million in non-tax revenue. 

A radical reshaping of medicare is taking place. Private sector services – for which consumers pay directly or through insurance companies – now make up 34 per cent of Ontario’s health care funding, compared to 42 per cent in the United States, according to a recent study by the Canadian Medical Association. 

Health minister Ruth Grier has also floated the idea of widespread hospital closures. Both the Toronto and Windsor district health councils (DHCs) are carrying out feasibility studies on “reconfiguration.” The ministry is remaining tight-lipped about which hospitals will get the chop. 

“One suspects there’s room for efficiency – there are a lot of empty beds in a number of different places,” says ministry spokesperson Verbeek. 

“All hospitals are being reviewed, with a view to closing one or two hospitals,” says health planner Lisa Paolatto, who is working on a feasibility study on “reconfiguration” for the Essex County District Health Council, along with Toronto’s DHC. 

Closing hospitals could present a serious political hot potato for the government. In Britain, the Conservative government is still recovering from the bad feelings surrounding proposals to close world-renowned hospitals in the London area. The public feels great loyalty to local hospitals, a feeling that has been further fostered by hospital charities that raise millions a year from the communities’ good will. 

“This is going to open up new discussions of money between doctors and patients,” says Kushner. “Seniors are a unique group in Canada because they remember what it was like before medicare – what it was like not to be able to pay for the doctor, to forgo treatment that they thought was necessary. They understand the financial hardship that could occur if they were unlucky enough to have a family member who needs expensive medical treatment.” 

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More from Canada’s Today’s Seniors

Feds Call For AIDS, Blood System Inquiry: Some Seniors Infected

Government Urged To Limit Free Drugs For Seniors

Health Care On The Cutting Block: Ministry Hopes For Efficiency With Search And Destroy Tactics

New Seniors’ Group Boosts ‘Grey Power’: Grey Panthers Chapter Opens With A Canadian Touch

Seniors Falling Through The Health Care Cost Cracks

ORCID iD: https://orcid.org/0000-0001-5311-1052.

© David South Consulting 2021

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US Health Care Businesses Chasing Profits Into Canada

Some fear corporate health care will kill equality of treatment

By David South

Now Magazine (Toronto, Canada), April 8-14, 1993

American-style private health care is slipping across the Canadian border under the noses of three provincial NDP governments, say researchers representing an association of health care workers.

Jackie Henwood and Colleen Fuller of the 7,500-member Health Sciences Association of British Columbia charge in a recent report that a combination of free trade and tightfisted government spending is undermining the universality of medicare and ushering in the beginnings of a two-tier system.

While the health care industry created more jobs than any other sector of the economy between 1984 and 1991, they point out, things have changed dramatically since the Canada-US free trade agreement came into effect in 1989. Now much of this growth is clustering in the private sector.

And they expect that this trend will continue under the forthcoming North American free trade agreement.

“NAFTA will accelerate trends towards a privatized, nonunion and corporate dominated system of health care in Canada,” says the report.

Binding provisions

Chapter 14 of the Canada-US free trade agreement opened competition for health-care facilities management services to US companies. Certain NAFTA provisions will bind all levels of government to consider for-profit health care companies on equal footing with public providers when bidding for services, and entitles them to compensation if they can prove to an arbitration board that they’ve been wronged.

“That represents a substantial encroachment on the democratic right of local, provincial and federal governments to make decisions,” says Cathleen Connors, who chairs the Canadian Health Coalition, which includes labour activists, nurses, doctors and other health-care workers.

This, in combination with health care cutbacks – both federal and provincial – is resulting in service and job cuts, bed closures, increased drug costs and an increase in privatization, the report says.

In the area of home care, for example – visiting nurses, physiotherapists, homemakers and other services – private firms now take in close to half of all OHIP billings. Many of their clients pay out of their own pockets for services.

The Ontario ministry of health doesn’t keep statistics on the private home health care sector in the province, but the Ontario Home Health Care Providers’ Association, a trade group, estimates that private firms in the industry now employ 20,000 people.

The industry is dominated by a small number of large firms, including Paramed, Comcare and Med+Care.

“It’s a market situation,” says Henwood. “If the services aren’t available to people within the public sector, they will go outside of it.

“We’ve seen this in other countries like England, where they had a public system and now have a parallel private system. If you erode a system enough that people get pissed off, they are going to start to look for alternatives, and the people with the greatest liberty are those with money.”

Connors says that because the Canada Health Act only covers the provision of hospital and physician services, the prinicples of universality and comprehensiveness don’t extend down to community-based services like home care.

The study also found that giant US private health insurers are positioning themselves to reap profits in the fertile Canadian market.

Last week, Wisconsin-based American Medical Security Inc. announced it will begin offering American hospital insurance to Ontario residents this month, citing a demand in Canada to bypass lengthening waiting lists for medical treatment.

Giant US west-coast insurer Kaiser Permanente declared in the March 1992 issue of Fortune magazine that they have targeted Canada as the next growth market. And American Express membership now offers the privilege of health insurance.

With private health care services sprouting up like spring weeds, says Henwood, provinces are placing yearly limits on the number of private services covered under provincial health plans, thus preventing people shopping around for services, no matter what their income.

Sheila Corriveau, corporate relations coordinator at Toronto-based Dynacare, Canada’s largest full-range private health care company – which operates labs, retirement homes, homecare services and consulting services – is enthusiastic about expansion plans, and says that removing patients from hospitals into their homes has been a boon for private health-care services.

“I think the health system will benefit, because what you are really doing is off-loading the cost from the public sector and from the treasury to private enterprise,” says Harry Shapiro of Dynacare. “Private enterprise depends on its own ingenuity for survival and its own levels of efficiency.”

But advocates of the public system say the free-market option now looming is being ushered in by the very parties that Canadians have come to rely on to defend medicare.

Medicare stance

Ontario’s new health minister, Ruth Grier, however, denies her government is jeopardizing medicare.

“I want to disagree with that as profoundly as I can,” she says, fidgeting with an ashtray during a recent interview. “Our government has reaffirmed its commitment to medicare. Over the last decade, under conservative and liberal governments, health care costs have increased in double-digit figures. The system would have collapsed at that rate of growth.

“I guess I haven’t found a way of blaming free trade for failures of the health care system at this point,” she says.

But critics say in the last year alone, Ontario’s ministry of health has capped health coverage for travellers abroad, removed coverage for physical exams requested by employers, chopped hospital beds and cut back the number of drugs covered on the provincial drug plan.

Grier says that the government’s vision relies on a new view of medical care seekers as consumers who are going to take more responsibility for their own health care

“Government can’t do it all,” she says.

Now Magazine (Toronto, Canada), April 8-14, 1993.

More investigative journalism by David South for Toronto’s Now Magazine:

Now Magazine (Toronto, Canada), November 12-18, 1992.

More healthcare reporting by David South from Canada’s Today’s Seniors

Feds Call For AIDS, Blood System Inquiry: Some Seniors Infected

Government Urged To Limit Free Drugs For Seniors

Health Care On The Cutting Block: Ministry Hopes For Efficiency With Search And Destroy Tactics

New Seniors’ Group Boosts ‘Grey Power’: Grey Panthers Chapter Opens With A Canadian Touch

Seniors Falling Through The Health Care Cost Cracks

ORCID iD: https://orcid.org/0000-0001-5311-1052.

© David South Consulting 2021

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Specialists Want Cancer Treatments Universally Available

By David South

Today’s Seniors (Canada), December 1993

A newly-formed group representing cancer doctors says it is fed up with the inhumane and bureaucratic approach to cancer care in Ontario. 

Dr. Shailendra Verma of Access to Equal Cancer Care in Ontario (AECCO) says he’s had enough. 

“My group has served the government notice that we’re fighting on our patients’ behalf,” says Verma, who faces gut-wrenching quandaries every day in his growing Ottawa practice. “In a public health system, I’m damned if I’m going to be divided into giving one set of patients a Cadillac treatment and the other Hyundai-type treatment; I don’t think that’s why we have a public health system.”

Verma says cutbacks to health care funding have meant that doctors must leap increasingly high hurdles to get the drugs their patients need. 

In jeopardy

While chemotherapy drugs administered in hospitals are still free, he says the important drugs necessary for patient comfort and treatment effectiveness are in jeopardy. 

These drugs were once free under the Ontario Drug Benefit Plan (ODBP), but now their status is tenuous. One drug, GCSF – which is crucial in helping patients between treatments of chemotherapy – is now listed under Section 8 of the ODBP and requires doctors to plead with the government each time for coverage. Often the bureaucracy moves so slowly that the course of chemotherapy is seriously disrupted, Verma says. 

“As an oncologist I’m particularly interested in ensuring everyone has access to all treatment. I think we are at a very sensitive crossroads. Over the last three or four decades we’ve developed certain treatments for diseases that more often kill than cure. And now we are at a point where we’ve got new treatments that can make the older treatments more effective. Or we’ve got brand new treatments that we are hoping to apply, and the one thing that is holding us back is cost.”

Cost

“The decisions are not based on science, they’re based on cost. It would not be an issue if treatments cost a penny a shot.”

Verma says colleagues can’t introduce some new drugs because the costs would be too high to offer it to everyone. So no one gets it.

“We have patients who walk in and say they would like to pay for it,” continues Verma. “Ethically, as a physician do you allow a patient to pay for it while sitting next to a similar patient who can’t afford it?”

Update: Cancer drugs that stay one step ahead may give patients 40 years of life (The Sunday Times, November 15 2020)

More from Canada’s Today’s Seniors

Feds Call For AIDS, Blood System Inquiry: Some Seniors Infected

Government Urged To Limit Free Drugs For Seniors

Health Care On The Cutting Block: Ministry Hopes For Efficiency With Search And Destroy Tactics

New Seniors’ Group Boosts ‘Grey Power’: Grey Panthers Chapter Opens With A Canadian Touch

Seniors Falling Through The Health Care Cost Cracks

ORCID iD: https://orcid.org/0000-0001-5311-1052.

© David South Consulting 2021

Categories
Archive Blogroll

Seniors Falling Through The Health Care Cost Cracks

By David South

Today’s Seniors (Canada), December 1993

When Orangeville senior Donald Potter was told he was too old to receive a bone marrow transplant, he paid $150,000 to get one in the United States. 

His case, recently made public by provincial Conservative leader Mike Harris, has raised the disturbing issue of health care rationing for seniors. 

Potter, who has Hodgkin’s lymphoma, says he was told the cut-off age is 55; since he was 64 at the time he needed a transplant, he was told last February it was too risky to obtain the procedure. Faced with a few months to live, he went to Rochester, New York, where bone marrow transplants were done on patients into their late 70s. 

Money

Potter believes the real issue is money. The government doesn’t have enough, so he couldn’t get the treatment that could save his life. 

Cost-cutting resulting from the provincial government’s social contract and expenditure control plans has left physicians with the quandary of serving more people with less money. This dilemma has led them to prioritize who gets services, though physicians maintain such decisions are based on many factors other than age, including lifestyle, prognosis and effectiveness of the therapy. 

Transplants

Bone marrow transplants are a particularly emotional issue for Premier Bob Rae, who in early October was driven to tears handling questions regarding rationing of this service. His brother died of lymphatic cancer in 1989 after a failed bone marrow transplant for which Premier Rae was the donor. 

“I can’t knock the system that hard, I just don’t feel the government spends the money properly,” says a calm and unresentful Potter.

Many seniors are frightened when they hear the government needs to make cuts, fearing they could be the first to go when it comes to allocating rationed services. 

“From the perspective of seniors it is a very scary time right now,” says David Kelly of Toronto’s Senior Link, a community social service agency. “Everything is being questioned, all our social services. Instead of looking at how to solve the problems, we’re just going to cut out things, and that’s going to be our solution. It doesn’t necessarily work.”

The issue of rationing services based on age is a dicey one. Ministry of Health spokesperson Layne Verbeek says the schedule of benefits makes no mention of age; and he’s right, because that would be unconstitutional. But when a doctor is presented with a fixed budget and a bulging sack of patients, the physician on the hospital ward has to decide who gets treated and with what. How a physician does this is theoretically based on a combination of factors, but doctors also have prejudices and misconceptions. 

Rationing

Many argue such queuing is a dangerous departure from the belief that the sick deserve to be treated. 

“Part of the problem is that few would admit to rationing on the basis of age alone,” says bioethicist Eric Meslin of Toronto’s Sunnybrook Health Science Centre. “Most clinicians I’ve spoken with and worked with recognize that age alone is not a relevant criterion. But most clinicians would agree age does play a role in thinking about limiting care.”

Meslin admits the idea of denying health services based upon age alone has been making the rounds among health care professionals. 

Ethics

“There has been a debate in the last seven years in North America over whether age-based rationing is ethically acceptable,” says Meslin. “There is of course a spectrum of views, including the very extreme that says after a certain number of years you have obtained your benefit from society and you should step aside and allow others to make use of those resources.”

Meslin doesn’t feel good about going through any kind of health care rationing without a public debate over society’s values and what to expect from the health care system. 

And he is adamant that anybody who focuses solely on attacking the high costs of high-tech medicine and an aging population is making a value judgement about how society should spend its money, not stating a fact.

“A clinician who chooses to discriminate based on age alone is not only unethical, but unconstitutional. Having said that, no clinician worth their salt would be telling the truth if they did not consider who the patient was in the fullest sense of the term, including their age. However, not giving treatment because they are 80 is a numbers game; there isn’t good enough data to support it.” 

Meslin suggests a public debate on rationing services needs to take place. 

Needs

“We need to ask the elderly population what they want. It may be that they don’t want the kind of things the researchers and clinicians believe they want.”

Kelly at Senior Link believes cuts to free drugs are already one example of rationing. 

“There are a lot of ways we can go about changing our social services without cutting income support or access to medication. The same goes for what procedures will be performed,” says Kelly. 

Potter’s case graphically shows the human cost of the heavy hand of bureaucrats in a public system trying to save money. But the high cost of U.S. health care also leaves a bad taste in Potter’s mouth. 

“In the States, the cost is horrendous. At least we have that protection. But I happen to be one of the unfortunate ones that fell into the wrong slot. And there’s a lot of people like me.” 

My background: 

CASE STUDY 5: GOSH/ICH Child Health Portal | 2001 – 2003

Hannah Institute For The History Of Medicine | 1992 – 1994

The archive for the Hannah Institute for the History of Medicine newsletter is held at the Wellcome Collection library in London, UK.

ORCID iD: https://orcid.org/0000-0001-5311-1052.

© David South Consulting 2017