The ongoing debate surrounding health care in industrialized economies did not spare Québec. My home province is facing growing health expenditure well beyond the growth of its GDP : the former has grown at 6%, while the latter has recently grown at around 4%. From 1980 to 2007, health expenditures have grown from 30.6% of the overall budget to 44.3% (see report referred to below). It is estimated that this proportion could reach almost 50% over the next decade if nothing is done.
Quebec's population faces a high tax rate, and many feel we do not get what we pay for. There might be no free lunch, but this one is especially expensive! This situation has led the province's government to formulate various reforms over the last 2 decades, and ordering multiple reports has resulted, sadly, in minimal changes to face the trend of increasing health expenditures (HE). Today, the "father of health insurance" in Québec (RAMQ), Claude Castonguay, and the Task Force on the Funding of the Health System, have published the awaited report "En avoir pour notre argent" ("Getting our money's worth").
It was, obviously, a much required exercise. Taxes can't be increased much beyond their actual level for Quebecers to be happy. Moreover, it is difficult to limit the availability of medical interventions, even with rigorous economic evaluations . Such evaluations limit the opportunity for patients to choose their preferred options, it can be subjective (thresholds are often subjective... how much is a life worth? QALY vs ageism?), and is ultimately political as lobby groups can pressure governments to change their minds (Herceptin) or challenge them in court (Aricept and other Alzheimer's drugs). And incentivizing intelligent and imaginative people is not always straightforward and can produce unforeseen results...
As a society, however, we still need to take serious actions to ensure the survival of our health care system in Québec. The "Castonguay report" is a move in the right direction, as it shows a profound understanding of the issues at stake. Moreover, the objectives and principles described in the report are right. Unfortunately, the main propositions and recommendations aimed at improving access are inappropriate, and I disagree with the report conclusions on these matters. Note that the vice-president of the Task Force, Michel Venne, has also expressed a dissident position. I'll summarize the key points of the report first, and will provide a critical analysis in my next blog.
If you are lazy, you may prefer to listen to Mr. Castonguay : Français or English
- Values on which the report is based :
- Universality
- Solidarity
- Equity
- Efficacy
- Responsibility (accountability)
- Freedom and choice
- Universality
- Stakeholders involved and what they should aim for :
- Citizens : responsible
- Medical profession : right service to the right patient at the right time
- Health managers : guardians of efficiency
- Lobby groups : need for them to give the government some flexibility
- Government : need to be coherent
- Private sector : increasing role (it is currently virtually absent)
- Citizens : responsible
- Quantitative limit : adjust the growth rate in health expenditures to GDP growth.
- Qualitative limit : restrict public coverage and define priorities through a systematic review of public coverage è suggest a permanent, credible and legitimate mechanism : "L'institut national d'excellence en santé" (NICE equivalent)
- Service delivery : the right service by the right professional
- Focus on prevention and primary health care
From these objectives, the task force has come to 4 major propositions to improve access to healthcare
- Transparent relationships with affiliate medical clinics
- A well delimited extension of medical practice to the private healthcare sector
- Increase the possibility for patients to contract health insurance
- Increase the use of hospital assets, by giving access to private healthcare to public hospitals' resources
According to the report, the focus of the Ministry of Health should be to regulate and evaluate the health care system regularly from different perspectives (stewardship role)
- Clinical
- Economical
- Patient satisfaction
- Transparent and publicly available
Other themes are also discussed :
- Specificities of the ageing population (ch 8) : 6 propositions
- Support to live at home despite decreasing autonomy levels
- Ensure universality of professional services at home
- Admissibility to a tax credit through a revenue test
- Nursing home operations è concession to the "appropriate resource"
- Support to live at home despite decreasing autonomy levels
- Improved utilisation of pharmaceutical treatments (ch9) : 2 elements
- Cost effectiveness
- Reinforce the rules of the "exceptional medication"
- Create a unique organism to evaluate : "L'institut national d'excellence en santé"
- Reinforce the rules of the "exceptional medication"
- Improved financing rules for the Medication Insurance Scheme : each beneficiary group should finance their costs
- Governance (ch 10) : 4 principles (with 2 as bonuses)
- Distinguish the Ministry of Health from service providers : stewardship role
- The regional agencies should translate the ministerial orientations è strategic implementation
- Increase autonomy and accountability of service providers
- The health care system should be based on rights and obligations of every stakeholders (contractual engagements)
- Every regional agency (administrative entity similar to the NHS trusts) and hospital should have a board composed of independent members (competent and paid)
- Involve citizens
- Monitor performance
- Distinguish the Ministry of Health from service providers : stewardship role
- Resource allocation (ch 11)
- Abandon historic budgets è services will be bought
- Abandon historic budgets è services will be bought
- Service provision (ch12)
- Promote efficiency and dynamism
- everyone should have access to a family physician by 2013
- registered clinic will have the right to charge annual fees to registered patients
- registered clinic will have the right to charge annual fees to registered patients
- Promote efficiency and dynamism
- Create "L'institut national d'excellence en santé" (ch 13)
- Develop the IT infrastructure to serve the patient and the manager (ch14)
- "Dossier de Santé du Québec"
- Opt-out approach
- "Dossier de Santé du Québec"
- Financing : promote a durable financing mechanism for the long term
- Durable and diversified revenue sources (ch 15)
- For the portion corresponding to GDP growth : general taxation revenue (solidarity through fiscality)
- For the portion above the GDP growth : a Stabilisation fund dedicated to health care and modulated based on :
- Fiscality (solidarity) è a portion of TVQ (sales tax)
- Service utilisation (individual responsibility) è deductible
- Fiscality (solidarity) è a portion of TVQ (sales tax)
- Over ≈10 years, the task force estimates that HE growth will be reduced to GDP growth
- For the portion corresponding to GDP growth : general taxation revenue (solidarity through fiscality)
- Other sources
- Eliminate accessory fees in primary care
- Regulate (negotiate) accessory fees in specialist care
- Rationalization and payment of services (?)
- Eliminate accessory fees in primary care
- Health account (ch 16) is explored
- The ministry should produce its annual health account for review in Parliamentary Commission
- The ministry should produce its annual health account for review in Parliamentary Commission
- Legal context : the Canada Health Act would require some changes.
TBC...
1 comments:
First of all, congratulations for taking the time to extensively examine this report, which proposes many different solutions to improve “Our money’s worth” as Quebec citizens and potential users of the health care system. I personally applaud the recommendations towards a greater implication of health care users and citizens in the health care system, including the development of a permanent mechanism to legitimately “restrict public coverage and define priorities” through a systematic review of the public health coverage balancing cost-effectiveness considerations and, hopefully, democratically chosen values.
I would nevertheless advise caution regarding the information on the costs and expenditures of the health care system.
Some recommendations are justified by the increase of the public expenditures in health since the development of a public health system (increase of 202% from 1975-2005) .
The greater increase of the private expenditures over the same period are overlooked (increase of 324% over the same period).
Another serious omission is that the proportion of the GDP (Gross Domestic Product) spent on all (private and public) health care expenditures and on exclusively public health care expenditures hasn’t changed much. In fact, the public expenditures in medical and hospital care represented 4.5% of the GDP in 2005 instead of 5.0% at the beginning of the 80s and 90s.
Consequently, Mr Castonguay is putting together two unrelated figures (the famous 4 vs 6%) to create the impression of fiscal imbalance and unsustanability of the system: 1) the increase in the percentage of public expenses over the total government expenses (which has increased in large part because overall government expenses have been reduced since the 1990s); 2) the increase in the proportion of total health care expenses (private and public) on the overall GDP (of which much of the increase is due to increase in private expenses). Where is the real crisis?
I would also like to comment on one of the solutions proposed in the Castonguay report. The report recommends that doctors should be allowed to practice in the private and the public sector only if and when the provincial objectives of medical manpower in the public sector will be reached, hence not tomorrow morning! However, this futuristic recommendation is not based on any solid evidence that an increase in the private funding of the health care system can improve the accessibility, quantity or quality of the health care services. Evidence against these presumptions are easier to find... The fact that the proportion of private expenditures in health in Canada is comparable to other Western countries with public health care systems such as the UK and France is furthermore ignored. Indeed, in 2005, 30.1% of all health care expenditures in Canada were covered by the private sector, while the same statistic was 27.7% in France (2003) and 16.8% in the UK (2002).
Finally, as a primary care physician, I am concerned by other “solutions” presented in the report: bringing “each beneficiary group to finance their pharmaceutical costs”, and service provision with “annual fees” or “user fees”. I am very doubtful that better primary care health care can be given with increased costs for those who need it the most. I hate to state the obvious, but it is now well demonstrated that poverty and illness are unfortunately often related.
References:
Colombo F & Tapay N, Private Health Insurance in OECD Countries: The Benefits and Costs for Individuals and Health Systems, Paris, OCDE, OECD Health Working Papers #15, 2004
ICIS, Tendances des dépenses nationales de santé, 1975 à 2005, 2005.
François Béland; http://www.santepop.qc.ca/chaoulli/docs/chaoulli/financementpublicprive.pdf;
Post a Comment