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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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Cut Services To Elderly, Says Doctors’ Survey… But Leave Our Salaries Alone!

“With a guaranteed income and job security, I don’t know one doctor who has suffered in the recession…”

By David South

Today’s Seniors (Canada), January 1993

If the results of a nation-wide survey of doctors are right, Canadian physicians love medicare but abhor government attempts to make them accountable for its costs. It also suggests that doctors are more willing to talk about cutting services to seniors and people with “unhealthy lifestyles” than to discuss cutting their own wages to save money. 

However, according to some doctors, physicians’s anger with the provincial government is founded on ignorance and poor analysis of the larger forces affecting health care. 

The survey, Breaking the Wall of Silence: Doctors’ Voices Heard at Last, was commissioned by The Medical Post, a national newspaper for doctors. It sent questionnaires to 12,000 doctors, receiving 3,087 responses. The Post also conducted in-person interviews to better gauge the mood of doctors. 

The survey’s title is somewhat misleading, considering that doctors have been making noise over a number of issues this year; targets included proposed right-to-treatment legislation, cuts to the Drug Benefit Plan, capping of yearly billings at $450,000, and inquiries into charges of sexual abuse by doctors. And most significantly, the last conference of the Canadian Medical Association passed a resolution calling for a two-tier health system in which those with money can hop the queue. 

Post editor Diana Swift says the poll shows fairly strong support for limiting services to the elderly, although the survey question is short on details: “I feel it is reasonable that access to high-cost services such as transplants should be rationed according to such parameters as the patient’s age and/or unhealthy habits.”

Yet just under 70 per cent of doctors opposed any capping of their salaries, despite 56 per cent of the public supporting this measure according to a 1991 Globe and Mail-CBC poll. 

When questioned, Health Minister Francis Lankin expressed surprise that doctors felt so strongly, and denied the government is considering rationing services to seniors. Lankin feels the volatile mood of doctors is a reaction to the rapid changes taking place in health care. 

Dr. Michael Rachlis, health care critic and author of the book Second Opinion, says the survey’s low response rate means that the answers reflect “redneck physicians, who are more likely to respond.” Swift admits to a high response rate from young male physicians, who since the 1986 doctors’s strike in Ontario, have been considered the profession’s most militant. 

One response which some may find alarming was towards the “Oregon model.” In that American state, medical procedures are rationed to seniors and individuals covered by medicare. Anybody needing uncovered emegency treatment has to pay for it themselves. A disturbing 65 per cent of survey respondents supported such a move. 

Dr. Gerry Gold, associate registrar at the College of Physicians and Surgeons of Ontario, feels that some doctors lack perspective. “The complaints are a reflection of frustration with increasing involvement of government. But if physicians understood the role of the government in the U.S., they would realize they, along with insurance companies, intervene far more.”

Gold says doctors have had the same complaints ever since the beginnings of medicare. “Many front-line doctors lack the information to make informed comment,” he says. “They aren’t being consulted or informed by the government.”

Rachlis says many doctors fail to realize how privileged they are. “Canadian physicians don’t realize medicare has protected their autonomy more than in the U.S.,” he says. “Doctors are always angry because they have large chips on their shoulders from being brutalized in their training. They don’t realize the government has given them a privileged monopoly over health services. With a guaranteed income with job security, I don’t know one doctor who has suffered in this recession.”

Gold doesn’t foresee strikes or job actions by doctors, but predicts further government cuts, and more services being de-insured by OHIP. A recent example involved removing coverage for third-party medical exams such as those requested by employers or insurance companies. As medical procedures end up outside of OHIP, Gold foresees physicians charging whatever they like. 

A perennial idea is the user fee. This is one of the few ideas that gathers support from a majority of doctors and the general population alike. But Rachlis feels these measures are meanspirited and avoid the real problems plaguing health care. “When Saskatchewan introduced user fees for physician and hospital care in 1968,” he says, “health costs remained the same and it discouraged the elderly, the poor and people with large families from seeking service. 

“When providers are allowed to charge users for care, as in the United States, where more than 20 per cent of health care costs are paid our of pocket, overall costs go up.” 

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

Psychiatric Care Lacking For Institutionalised Seniors

Don Weitz wears a T-shirt bluntly saying, “Fry rice – not brains.”

By David South

Today’s Seniors (Canada), November 1992

Seniors who live in nursing homes and homes for the aged are receiving an inadequate amount of psychiatric care, according to a study conducted by Toronto’s Baycrest Centre for Geriatric Care. 

Dr. David Conn, director of psychiatry at Baycrest and an author of the report, says action must be taken to remedy this situation, since at least 80 per cent of elderly long-term care residents suffer from some form of mental disorder. 

The issue of psychiatric care for seniors is complex. There are many, often strongly-held, opinions about the nature of this care and what measures will genuinely improve the mental well-being of seniors in institutions. 

According to The Senior Citizens’ Consumer Alliance for Long-Care Reform, Ontario has the highest rate of institutionalisation of seniors in the world, with 7.5 per cent of seniors over the age of 65 and 15 per cent over 75 in institutions. The Alliance demanded in its reforms in Ontario that seniors’ mental health problems be taken more seriously and be included in any assessment for care. 

Baycrest’s report surveyed 1,148 medical directors and nursing directors in over 500 nursing homes and homes for the aged across Ontario. The 601 who responded reported that 37 per cent of their residents received no psychiatric care, while only 12 per cent received more than five hours per month. The most common psychiatric problems under treatment were depression, agitation, wandering and physical aggression. 

“Recognition of significant mental disorders in nursing homes is a recent phenomenon because geriatric psychiatry is a relatively new field,” says Dr. Conn. “The usual approach has been to reach for the prescription pad. We know now that antidepressants have been underused and tranquillizers overused.

“To deliver effective psychiatric care requires more than just psychiatrists – teams of psychiatric nurses can also be involved. Hopefully the staff of these institutions will become better educated as a result of this report.”

Dr. Kenneth Shulman, head of psychiatry at the Sunnybrook Health Sciences Centre, feels the worst neglect occurs in private rest homes. 

“There is general lack of accountability when it comes to geriatric psychiatric services.” Schulman advocates a coordinated, comprehensive regional network of services. 

Dr. Conn is sensitive to reports of sexual, physical and mental abuse of residents in some institutions. He says staff as well as residents of institutions can benefit from psychiatric consultations. “If more psychiatric consultants were available, the staff could also receive help in working out their problems,” he says. “Unfortunately the fee-for-service system doesn’t include paying for visiting staff.

“Being in an institution is not easy for anyone. It often means being apart from family, living with strangers, loss of freedom and having to live by the institution’s timetable.”

One of the most controversial of psychiatric treatments is electroconvulsive therapy (ECT). ECT involves placing electrodes on the sedated patient’s head and passing 100 to 175 volts of electricity into one of the lobes of the brain to induce grand mal seizure and coma. 

Opponents of ECT say the procedure can cause memory loss and confusion, and in some cases proves fatal. A 1985 Ontario government task force report recommended against using ECT in certain cases: “For patients whose work requires a clear and precise memory, ECT is probably contraindicated.”

But many other sources say that while ECT has been abused in the past and, like many other medical procedures, may not be a pretty sight, it is sometimes effective in combating depression. 

Dr. Conn confirms that the controversial procedure is still being used on seniors. “ECT is used on very depressed people,” he says. “It is a hospital-based service. The patient is admitted to a psychiatric unit of the hospital. We do it at Baycrest. It is only a last resort and has often been life-saving.”

Don Weitz, a senior citizen and spokesperson for Resistance Against Psychiatry, doesn’t mince words about what he says is the adverse effects of electroshock therapy and psychiatric practice in general. He wears a T-shirt bluntly saying, “Fry rice – not brains.”

“We have known about the adverse effects of shock for years,” says Weitz. “Research from the ‘40s and ‘50s was very clear that there was brain damage.

“What doctors mean by improvement is in fact post-injury euphoria – the brain will overcompensate with giddiness, and this only lasts for two to four weeks. Doctors seldom test people for more than two or three months afterwards.”

“What we know for sure is that within the institutions, they would rather give drugs or shock than talk to seniors. I think this should be called elder abuse – what else could it be? Is it such a mystery why people are depressed in institutions where they are abused? Psychiatrists have a vested interest in billing OHIP for pushing the button.”

But Dr. Shulman disagrees with blaming the atmosphere of institutions. “It is simplistic to think that the environment is responsible for aggressiveness or other problems,” he says. “These people are cognitively impaired – it could be medication-related or something else. These are complicated issues.”

For any nursing home workers who want further advice about psychiatry, Baycrest has produced a “Jargon-free” guide called Practical Psychiatry in the Nursing Home. 

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