The Canadian Institute of Actuaries recently painted a frightening portrait of Canadian health care, with projected costs growing to the point where little money will be left in provincial budgets for anything else — roads, schools, jails. While the report is solid, it is gentle in identifying the real issues we need to tackle.
The actuaries start with Canada’s growing and aging population, which they identify as one important factor. They then look back at how fast health-care costs have been growing over and above population growth and aging. But when they project using these historical rates, the result is too implausible, with health-care spending going over 100 per cent of provincial budgets. So the actuaries just chose their own lower growth rates without any basis in fact — slow enough that their main projections are not wildly implausible, but still scary.
It is true that the elderly consume more health-care services than the non-elderly. For example, the Canadian Institute for Health Information estimates provincial spending for those aged 40 to 45 at $2,100 per capita, while it was $26,000 for those 90 and over in 2010.
But the University of B.C.’s Centre for Health Services and Policy Research continues to stress this is a “zombie” explanation for rising health-care costs — it has been slain repeatedly by the evidence, but keeps rising from the dead. Indeed, a 2013 study from Alberta Health pegged aging at a manageable 0.8 per cent of its health-care cost increases over the past decade, while wage and other inflation and “unknown” factors accounted for a 6.6 per cent increase.
So what’s actually driving our health-care costs? A large part of the increase comes from three main areas: new technologies such as diagnostic tests, drugs and physicians.
There have been miraculous technological advances, but the diffusion of many new technologies is largely uncontrolled. Many MRI and CT scans, for example, provide life-saving benefits. But others have no impact on the patient’s course of treatment, wasting both skilled professionals’ time and health-care dollars.
Same with drugs. One recent study randomized a group of seniors who were regularly taking an average of nine drugs. Half continued while the other half were advised by an independent physician to drop, on average, four of their drugs. The result: Those on fewer drugs felt better and were healthier.
Another major cost driver completely unrelated to population aging is the incentives facing physicians, the gatekeepers to health-care and to health-care costs. If a doctor does more surgery, he or she makes more money, becomes more proficient, and gains prestige.
Proficiency is important — health care should be organized so that services are concentrated in high-volume centres where specialized expertise can better be applied. Unfortunately, Canada’s health care is not always so organized.
More importantly, more surgery is not necessarily better. A 2009 study looked at 30-day survival after treatments for heart attacks (bypass surgery or angioplasty). For many health regions, there was no difference at all while the proportions treated ranged from 20 per cent to 60 per cent. There are several possible explanations, one being this three-fold difference results from overly aggressive — and costly — treatment that in the end was unnecessary.
How can such inappropriate use of health care persist, especially when the economic stakes are so high?
One major issue is lack of information — we simply do not have the data to assess whether a given hip-replacement prosthesis has a good track record, when longer-term side effects from pharmaceuticals are emerging, or why some surgical teams have better results than others.
Why are these data lacking? It’s not the computer science. We should look instead to physician resistance and an insidious but pervasive “privacy chill.”
No one likes someone looking over their shoulder at their work. Most of us have no choice. But physicians are in uniquely powerful positions, and a critical mass have subtly but successfully resisted needed information being assembled and analyzed.
But as patients, we should welcome the significant improvements in quality of care — and as taxpayers, improved cost-effectiveness — that would result.
Fears about personal privacy are also delaying needed health information. Some concerns are legitimate, but these are surmountable. Health-care leaders have all kinds of opinion polls and focus-group results showing that Canadians are more than willing to have their health-care records analyzed statistically by bona fide researchers if it will improve health-care quality.
Let’s not blame an aging population or generalized pressures for increased health-care costs. We need to focus on real causes — not least, the missing information and analysis that will make some doctors and health ministers uncomfortable, but in the end, make us all better off.
Michael Wolfson is an expert advisor with EvidenceNetwork.ca and a former assistant chief statistician at Statistics Canada.
