Okay, so I am not a doctor (yet), but I do spend my 9-5 hours working as part of Canada’s health care system, and I do have a couple of degrees in which health policy played a pretty significant role, so I’m going to take this opportunity to make one of my (thankfully) rare digressions away from the typical subject matter of this blog and talk about health care.
My master’s thesis (which was a rather shabby affair) was partially focussed on the issue of wait times for critical services. Those of you who live in civilized developed countries will be familiar with this concept already. Those of you who live in the United States will probably need a refresher. Because there exists a finite pool of resources in the world, when a large group of people want to access something that is a one-at-a-time thing, there is a good chance that some people will have to wait. In Canada, because we have a publicly-funded medical care system, we run into wait times as the inevitable consequence of more people wanting a thing than the system has the capacity to provide.
I have, incidentally, discussed why Canada’s system is not only more fair but more economically sound than the American system in a previous post that I encourage you to read.
The vagaries of comparative international health policy aside, waiting lists are something that we have been trying to devote particular attention to here in the frozen North. A new report published this week by the Wait Times Alliance suggests that certain areas of Canada have been steadily slipping in their ability to handle medical services without undue waiting, and that the national average is similarly slipping. The specific comparisons aren’t particularly interesting (unless you’re a total health policy dork like I am), but I found this particular passage very provocative:
The group called for a national strategy to deal with illnesses such as Alzheimer’s disease and to factor dementia into the management of other chronic diseases such as heart disease and diabetes. Doing so could help prevent those patients from ending up in hospitals in the first place, they said.
Sometimes I like to imagine what I’d do if I was handed absolute power over the Canadian health care system, and that paragraph got me fantasizing*.
So here’s the problem…
The health care system that Canada and the United States (and, as far as I know, every other country with a sufficiently large economy to have had a health care system of some kind since at least the mid 20th century) has is based on an extremely outdated interventionalist model. The role of medicine was primarily intended to address issues of infectious disease and acute illness (like trauma, heart attacks, other things for which quick response is needed). We have made significant progress in preventing and responding to those threats, and as a consequence the type of illnesses we do have to deal with are quite different now.
The way I describe it to people is this: if we started from scratch and built a brand new health care system, it wouldn’t look anything like the one we have now. Hospitals would be ‘special-case’ destinations, not the default. Doctors would be part of an array of allied health professions rather than the predominant one. Prevention would be considered health care rather than public health. Perhaps most importantly (to me, anyway), decisions would be guided by evidence rather than tradition. We are moving toward all of these things, but if we could start over we’d already be there.
What works better?
We need a model of health care that is better suited to our contemporary reality – cancer, arthritis, respiratory illness – conditions that must be managed over a period of years, rather than hours or days. These are conditions in which people have to have frequent and ongoing interactions with the health care system. At first this necessitates intense management by highly-trained professionals who are familiar with the intricacies of the case. However, over time many of those cases can be managed adequately by professionals who are perhaps less rigorously medically trained, but who are familiar with a person’s health care needs.
How do we do it?
The first problem is that we are dealing with a system with severe resource scarcity. This is actually a much simpler fix than people think. One of the biggest problems in hospital-managed health care is what to do with people who have mental health issues. Whether it is depression, dementia or schizophrenia, hospitals are a terribly expensive and monumentally ineffective way of treating mental illness. Hospitals are set up for things that need immediate attention, not ongoing surveillance. Prioritizing mental illness management will free up much needed hospital beds and (consequently) financial resources.
Another idea that I support wholeheartedly is the community care management model of health care delivery. Basically the idea is to put a bunch of health professionals – a doctor, a pharmacist, a nurse practitioner, a dietician, a social worker, a psychologist, a dentist, an optician – in the same collective practice. You could think of it as a mini-hospital, but perhaps it’s better to think of it as a health strip mall. Have a handful of these in each community. People go to ‘their team’ for management – the various professionals all work together to manage each person’s issues holistically (this is the only context in which that word doesn’t make me cringe). So when someone has diabetes, hir illness is seen from a variety of angles, and a comprehensive plan is put together. The afflicted person has a variety of perspectives to choose from, and can tailor a plan that suits hir. Better still – ze can talk to any member of her team rather than having to wait for hir doctor’s advice specifically.
The last component of my wish-list is something that is perhaps counter-intuitive: I want to pay doctors more money. Not only because I think their job is hard, but because I want to shift the burden of care away from MDs and toward a variety of people. I want doctors to only have to manage tough cases where pharmacists, nurse practitioners, psychologists, and whoever else has run out of ideas. All medicine (including family medicine or ‘general practice’ as it is referred to in many places) should be treated as a specialization. Doctors should see fewer patients and spend more time with them, rather than the current model which incentivizes quantity and speed.
You’ll hopefully have noticed that I avoided talking about issues of equity or drawing emotional arguments. It’s not that I don’t think those are important to a discussion of health care – it’s just that it becomes far too easy to pigeon-hole the desire for reform as an arch liberal exercise in hand-holding. There are good reasons aside from the obvious to fix health care, and we can do it without sacrificing the aspects that make public provision a better idea than private-sector care. The answers are not mysterious or beyond our capacity to put into place; we’ve just been expecting the solution to come from a very different place. We have to fix how we think about the system, and the rest will fix itself.
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*Weep with me that my daydreams are about improving bureaucracy rather than, y’know… something cool.
A belated congratulations on your acceptance!
You might find this of interest.
Excellent stuff! You’d find quite a lot to be impressed with in the parts of the NHS which have not been eviscerated either by accountants or by the current idiot government.
Just one more thing on the management of long-term conditions. If you live alone you should be entitled to a hot-line to a named carer, to have time scheduled with the appropriate professional for a run-through of progress and any worries and to know who the hell people are when they come into your house and start poking at you. Things can go wrong in the best of health services – http://www.bbc.co.uk/news/uk-scotland-north-east-orkney-shetland-18277378
As most people are cared for at home with family at some stage we also need to see family carers as team members and also entitled to knowledge, training and a bit more credit than they sometimes get.
Keep up the good work.
Don’t let anyone tell you the U.S. doesn’t have long waits for care. We do, particularly for specialist care.
I was hoping the Twitter rant would become a post. 🙂
Sounds like a good plan to me. How do you plan to implement or encourage policy makers to implement it?
There are significant delays in critical services in the US, as Stephanie Zvan has already pointed out. They’re just more randomly distributed. Uninsured person A may have a 3 month wait time for the MRI insured* person B can get the same day. I’d much prefer a system where they both waited three weeks–and the person with an emergency that must be seen today gets in today 100% of the time, regardless of insurance, no arguments about pre-certification or other bureaucratic nonsense.
*Not that insurance is always any help. Some insurance companies make the rules for getting pre-certification for a procedure so arcane that it’s virtually impossible to get one in a timely manner.
That’s an entirely different question. Policy-makers are driven by a whole soup of things, which differ between individuals, parties, and temporal circumstances (i.e. how close you are to an election). I’m trying to learn where the footholds are for moving policy decisions, but aside from running for something and eventually iron-fisting my way into the job of provincial or federal health minister, I don’t have a lot of ideas.
The phrase “iron fisting” evokes the delightful mental image of you donning an enormous metal gauntlet and having anime-style fights with corrupt politicians until you’re appointed health minister by right of conquest.
Policy-makers are driven by a whole soup of things, which differ between individuals, parties, and temporal circumstances (i.e. how close you are to an election).
Excuse the cynicism, but are they driven at all by data? If so, then gathering and publishing good data might be step one. If they aren’t, get out your gauntlet and prepare for the conquest of the health department until you’re in a position to change the policy so that they are.
Policy makers are driven by data when making policy decisions to the same extent that people are driven by engineering specifications when deciding which car to buy. The majority of them want to use the data, but they’re usually not scientists. Scientists don’t help much, because we publish in very arcane language in terms that are written for other scientists, and always hedge our bets when it comes to what the data tell us. There are institutions like the National Institute for Clinical Excellence in the UK, or the Ontario Health Technology Assessment Committee who are explicitly tearing down the barriers between policy-makers and scientists, but it’s a hard slog.
Robert B – That’s not precisely the image that “iron fisting” gave me, but, uh… I guess I visit the wrong websites…
I agree with you and your concept of a best practices health care approach.
We already have that with the naturopaths who are trained in nutrition and give you prescriptions for medications or supplements that they then sell you from their own store. It puts all of the parties in a single person eliminating duplication of services. It eliminates all concept of science based medicine as well. Jack of all trades, master of none, certainly applies here; so does conflict of intrerest as they sell you what they recommend.
On the positive side, my mental health team consists of a psych nurse and a psychiatrist who work together in the same clinic (both are salaried rather than fee for service). I see the nurse on a regular basis, approximately monthly, and the psychiatrist once a year to evaluate my meds. If the nurse thinks I should see the pdoc more frequently, or I need an adjustment in meds, she sends me across the hall. This enables the pdoc to deal with the more critical or acute cases while providing management for those of us who are doing reasonably well.
Not so well done is my blood pressure meds that are prescribed by my Family Doc. If I need refills I have to schedule an appointment with him. He checks my blood pressure and if it is OK, he writes the scripts and of I go. Before he sees me, his nurse comes in and checks my blood pressure. He is on fee for service, and gets no remuneration if he doesn’t see me. In a better world, the nurse would determine the ‘no change’ and refill, and the dr would only see me if something has changed.
An effective bureaucracy is cooler than a thousand rock stars.
I missed that memo, too. Congrats, but somebody should have tell you that it’s dangerous to go to grad school alone! Take this.
I would also argue there is a certain normative approach to health care that comes from it being mostly setup by men.
I’m a healthy young woman, but I see a doctor a few times a year for things that are common in healthy young women. I need prescriptions for birth control, antibiotics for UTI’s, and the occasional yeast infection. None of these are serious, but they are all things I need to see a doctor so I can get those prescriptions, and they often need to be at specific times to avoid progression.
What I don’t understand is why I can’t just see a nurse of some sort. None of it is complicated, and none of it requires 4+ years of medical school to diagnose. And I bet if young men were prone to these things, there’d be a better system set up.
I don’t know how it is in other provinces but here in Quebec, the ‘collège des médecins du Québec’ (CMQ) and the ‘fédération des médecins spécialistes du Québec’ (FMSQ) are very powerful lobbies and you need their buy-in for any change to the health system.
So anything that would take anything away from their exclusive domain is usually met with strong opposition. Of course, if you increase what the doctors are paid, it could help get their support.
My take is that even if doctors start winning battles, they’re going to lose the eventual war. Younger MDs aren’t in lockstep with the medical associations the way they used to be, and the glow from the halo around the title of ‘doctor’ has dimmed quite a bit with the baby boomers. I think unless the docs are partners in reform, they’re going to quickly find themselves out in the cold. Increasing doctor pay is specifically aimed at getting the buy-in of the various medical associations. Ontario is wrangling right now with the consequences of trying to pay doctors less in order to pay for reform, and it’s anybody’s guess as to who will come out ahead in the ensuing fight.
But far rarer than a million rock stars.
Younger MDs aren’t in lockstep with the medical associations the way they used to be
Who are calling younger? Kids these days!
Another issue, possibly related, is that there are a number of medical associations of various sorts, some with conflicting interests. In the US, the AMA spends most of its time squabbling about medicare reimbursement. Ok by me-I’d like to be paid for seeing medicare patients-but hardly the biggest issue at hand. ASH and ASCO (hematology and oncology organizations) have been active in fighting drug shortages, a much more important issue in my mind. What no medical organization has yet addressed, as far as I know, are the various anti-abortion laws, some of which have provisions that will make it much easier for “pro-life” nuts to stalk and murder doctors who perform abortions. If any medical organization took on those laws, I’d be far more supportive of them than the AMA’s lobbying for $0.03 more per patient visit.
You are now my favourite blogger on FtB (over PZ…), and not just because you happen to be an epidemiologist-in-training, like me 🙂