Heath care will only succeed through collaboration, not through competition: Toronto Star

Dr. Danielle Martin is a professor and chair of the Department of Family and Community Medicine at the University of Toronto. This essay is drawn from her argument at the C.D. Howe’s latest Regent Debate: Be It Resolved, Competition Will Save Canada’s Broken Healthcare System.

In the real world of health service delivery, the last three years have taught us a great deal. The pandemic has been a test of endurance for health care workers for sure, but it has also tested our ability as a collective system to do something we don’t do enough of: work together.

Here is an incomplete list of the results:

• We procured massive quantities of supplies and distributed them across the country: Personal Protective Equipment; swabs; hand sanitizer; ventilators.

• We massively ramped up testing capacity; stood up assessment centres, drive-through clinics, mobile outreach teams.

• We trained and retrained health care workers; instituted billing codes and protocols for COVID@Home clinics and virtual care for people with acute and chronic medical problems.

• We opened field hospitals and tents in parking lots. We participated in clinical trials to determine which drugs to use and at what doses.

• On the basis of data about who was most impacted by the virus, and only because of unprecedented collaboration, we allocated resources accordingly when they were scarce — like testing, drugs and vaccines.

• We moved patients out of hospitals that were overwhelmed, whether that meant from Scarborough to University Avenue or from Saskatchewan to Ontario.

• We sent teams of workers into long-term care facilities to try to stem the impact of decades of poor design, understaffing, and underresourcing on our elders.

• And we stood up one of the world’s most successful vaccination campaigns, learning from early design mistakes and adopting community-based strategies that were unprecedented at that scale.

• The result was a world-class pandemic response, built entirely on collaboration and co-ordination. Resolving to eliminate competition and work together was the key to every success we had.

  Competition, on the other hand, is what happened in New York City, where in the first wave safety net hospitals were overwhelmed with COVID patients while for-profit facilities up the street stood empty.

  Competition is also what happens in the most dysfunctional parts of our Canadian health systems, where value for money is most elusive and frustration is highest.

• Pharmaceuticals: where we have competition between multiple public and private insurers, among the highest drug prices in the world, and millions of Canadians not taking their medicine because of cost.

• Long-term care: Where for-profit homes in Ontario competing to care for our elders had a 78 per cent higher mortality rate from COVID-19 than not-for-profits.

• Electronic records: where vendors compete for our business but have seemingly no incentives or requirements to be interoperable with each other.

• Competition, in a true market for any good or service, requires a set of conditions, including a large number of buyers and sellers making homogenous products; perfect knowledge among buyers and sellers; and mobility of the factors of production. None of these exists in health care, in Canada or anywhere else. Patients are not savvy consumers choosing between near-identical products on the basis of price or the bells and whistles. They are sick people in need of compassionate care close to home.

  And providers are not in endless supply, able to move freely around the market. They are highly trained, expensive resources, who need to be marshalled to the area of greatest need. The World Health Organization is projecting a shortfall of 10 million health workers by 2030, and in Ontario alone, there will be a shortage of about 33,000 nurses and personal support workers by 2027-28. Where will the supply come from for competition exactly?

  We have a long road to recovery ahead. To suggest that other countries have it better is to ignore the reality plaguing us all: nurses are on strike for the first time in the history of the NHS in England, and President Macron has declared that he’ll be completely overhauling the French health care system, for example. Health care workers have been on strike over working conditions and wages in the Netherlands, Spain, Germany and more — there is no system, no matter the mix of payment and delivery, that is not struggling today.

  We are in tough times in Canadian health care and there are more tough times ahead. Service backlogs. Human resources shortages. Mental health impacts. The co-ordinated effort required to manage recovery will probably dwarf what we have just achieved. More competition and fragmentation is the last thing we need. Collaboration is our only hope.

Published in the Toronto Star

To fix Canada’s health care crisis, we need free-market competition, private options: Globe and Mail

Shaun Francis is the CEO and chair of Medcan Health Management, one of Canada’s largest providers of health and wellness services. This op-ed is drawn from his arguments at the C.D. Howe Institute’s latest Regent Debate: Be It Resolved: Competition Will Save Canada’s Broken Healthcare System.

Twenty-five years ago, I secured the rights to a state-of-the-art telehealth system and brought it to Canada. Patients called a number to receive instant advice about their medical issue and be directed effectively to a proper level of care. I thought it would greatly benefit Canadians and save insurers millions.

In a single-payor system, like in Canada’s provinces and territories, my solution would have reduced the burden on emergency rooms and helped minimize staffing demands for hospitals.

But the Ontario government didn’t buy it. It ended up buying a low-cost nursing telephone line designed to generate revenue for hospitals, encouraging callers to visit a hospital emergency room.

Why? Because the upfront cost was cheaper – and the decision maker didn’t have responsibility for the operating costs of the hospitals. This type of short-sighted decision-making is characteristic of what happens day in and day out at government monopolies.

This is why we need a competitive private alternative to our universal public program, with a mix of private and public providers and competitive private insurers. Competition and the innate market-driven incentives that exist when customers can select from an array of options serve to improve care. This is what will solve our health care crisis.

Consider the debacle around Phoenix, the federal government’s disastrous payroll processing software. Launched in 2016, its development and problems cost several billion dollars, yet its errors have affected 500,000 federal public service workers over the past few years. It’s so bad, and so riddled with errors, that the federal government is now replacing it with a new system – at yet another enormous cost. What about the now infamous ArriveCan app? Experts have said the $54-million cost could have been less than $1-million – over 50 times more than necessary. Not to mention the cost overruns and delays endemic to the purchase of the Canadian military’s badly needed F-35 fighter jets.

What do all of these stories have in common? All were the product of government monopolies.

In some ways, as Canadians, we’ve learned to expect such mismanagement. Yet so many of us hang on to the illusion that the monopoly in the insurance and provision of Canadian health care is somehow different. Our steadfast belief in a health care monopoly has resulted in a broken and outdated system.

Consider that the median wait time between your referral with a general practitioner (family doctor) to consultation with a specialist is more than 12 weeks. This wait time is about three times longer than in 1993, when it was about four weeks. And if you’re in Ontario, do you know how your primary care doctor makes that referral? By fax. A technology so outdated and flawed it’s the leading cause of unauthorized disclosure of personal health information. Nearly 5,000 privacy breaches related to misdirected faxes were reported to the privacy commissioner’s office in 2021 alone. It’s astonishing that faxes are still being used today.

Consider, too, that the cost of public health insurance for the average Canadian family (two parents and two children), adjusted for inflation, has increased more than 80 per cent since 1997 and by almost 108 per cent for a single Canadian. We spend about 12 per cent of our GDP on health care, more than 27 other comparable countries in the Organization for Economic Co-operation and Development. But among those countries, Canada is 32nd out of 38 in amount of hospital beds, 27th out of 31 in number of medical doctors, and 17th out of 30 in nurses.

Emergency rooms across the country are shutting down simply because hospitals don’t have enough staff. Foreign medical professionals can’t get licences. And too few medical school spots exist for Canadians. Canadians are literally dying before they get the care they need.

Some might say we just have to fund this system properly, hence the new health care accord between the federal government and the provinces. But let’s recognize that for what it is: a stopgap solution. How many times have we already seen the federal government provide a new deal to the provinces?

Health care is already the single-largest budget item for every provincial government in Canada, while across the country our population is aging. Per capita spending on health care is significantly higher for those 65 and older than for younger individuals. The per capita expenditure for the 80-85 age group was already more than twice the spending for all age groups in Canada in 2017. Assuming no change in the prices of inputs to the provision of health care services, the growth in the number of Canadians 65 and older will result in an increase in health care expenditures of approximately 88 per cent from 2019 to 2040.

As we run out of money, ideological dogma has given us one of the developed world’s worst-performing health care sectors. Often, we consider the United States as our only alternative. No one is suggesting we adopt what the Americans have. But in Canada, we don’t have a health care system; we have a queue system. And if Canadians want world-class care, we need to embrace world-class thinking.

Every system around the globe that ranks and operates better – Switzerland, the Netherlands, Germany, Japan and Singapore, to name just a few – has a competitive private alternative to their universal public program. These systems place the patients at the centre of their processes.

Only a model with more public-private competition can give us a more efficient health care system, with more innovation, reduced wait times and care that is superior to what we have today.

Published in the Globe and Mail