Priorities in health politics and policy making

Observing the current federal and provincial political scenes makes one wonder why anyone would become a politician. The same question may be more valid when considering medical politics which, as Dr Pat McGeer implies, is more demanding and less well paid than the real thing.[1] Many of us have tried, without achieving the level of satisfactory outcomes that we hoped for.

Major themes that our national and provincial medical organizations have focused on include physician health and burnout, and increased funding for seniors care and Pharmacare. However, when it comes to policy determinations, we have not followed the usual axioms in medicine, that prevention is better than cure, and that diagnosis and causation should usually precede treatment.

Forty years ago, physician health problems and burnout were not so prevalent. I suggest that this is in large part because, despite often working exhaustive hours, we were extremely happy with our work. We did not experience the frustrations of extreme rationing or the access issues of today. Physicians had an important and respected role in determining health policy.

Who can argue against additional funding for seniors care? Well, as a senior, I can. I received a Gold Care Card from the BC government that afforded me greater health benefits based on age. Since two-thirds of Canadians’ wealth is held by those over 65, what sense does that make? Why should poor young families subsidize richer seniors? As Canada’s population doubled between 1961 and 2017, per capita spending on health rose sixtyfold. Wealthy baby boomers will receive $4000 more care than their lifetime tax contributions fund. Millennials and iGens will pay $18 000 to $27 000 more in taxes than benefits received. We are imposing long-term debt on our youth.[2] The emphasis on seniors is misguided. Low-income groups of all ages need adequate care and, as happened previously with family allowances, a means test is needed.

Government Pharmacare is another ill-advised initiative. Private insurers (such as not-for-profit Blue Cross) already provide drug coverage for 70% of Canadians. A new costly bureaucracy will mean further rationing of existing services, and perhaps long lineups to see a pharmacist. If Pharmacare (and dentistry, physiotherapy, etc.) are to be added as benefits (and they should be), it should not be through an expanded bureaucracy but through funding or subsidizing premiums for those who lack coverage.

Governments are inefficient at providing services. Stats Canada data show the poor and underprivileged covered by government plans suffer the worst health access and outcomes. Indigenous health services are a prime example.

Doctors are blamed for systemic weaknesses that governments have built into a rationing-based system. Provincial medical associations are hampered when it comes to confrontation with their health ministry employers, with whom they negotiate their own reimbursement. Collaboration may become a harmful synonym for appeasement. However, in policy making, our national association should not fear confrontation when collaboration fails.

Governments like to assign blame for cost overruns to “overpaid” physicians. I recently paid $576 for a 30-minute house call to unblock a sewer drain. That’s 6 or 7 times the fee for an equivalent family doctor visit; perhaps we need to consider teaching doctors to clear drains. An entity called Choosing Wisely often focuses on inappropriate actions of doctors as a factor in escalating costs. There are good aspects to their work, but in championing it the CMA must protect the rights of patients and physicians. The group bases protocols on expert opinions and peer-reviewed studies, many of which are without merit.[3] Experts opine on inappropriate investigations or procedures, and I am aware that they sometimes base their recommendations on inaccurate analyses. Like Feynman, I believe “Science is the belief in the ignorance of experts.”[4] Clearly, not everyone with a headache needs an MRI. But ask a patient whose symptoms did not fit a protocol but who benefited from an early diagnosis that saved their life if their so-called inappropriate test was worthwhile. If I spend 45 minutes doing a complete physical and find a rectal tumor, was I not choosing wisely when I examined areas that were normal? Negative clinical exams—and yes negative findings on laboratory and imaging studies—are an empirically important and relevant part of practising good medicine. Physicians cannot be blamed for accessing what they consider appropriate and available diagnostic tools. Choosing wisely must not violate the rights of patients to override the societal directive or protocol and choose for themselves when their own health is involved.

Finally, I am disappointed that the CMA, as the main sponsor of a recent Economic Club of Canada event titled “Is It Time to Revisit the Canada Health Act?” agreed to the assignment of our president as a moderator while three nonphysicians (some of whom blame physicians for our system’s failings) espouse their opinions and recommendations. Our talented CMA president, Dr Gigi Osler, should have been front and centre as the main speaker at that event. Our professional bodies should not deviate from the principle that physicians should lead, rather than moderate, important discussions on the future of our health system.        
—BD

References

1.    Day B. Visionary plus pioneer equals Dr Pat McGeer. BCMJ 2017;59:127-129.

2.    Emery JCH, Still HD, Cottrell T. The School of Public Policy, SPP Research Papers. Can we avoid a sick fiscal future? The non-sustainability of health-care spending with an aging population. 2012. Accessed 8 April 2019. www.policyschool.ca/wp-content/uploads/2016/03/emery-generational-balances-final.pdf.

3.    Amrhein V, Greenland S, McShane B. Nature. Scientists rise up against statistical significance. Accessed 8 April 2019. www.nature.com/articles/d41586-019-00857-9.

4.    Trubody B. Philosophy Now. Richard Feynman’s philosophy of science. Accessed 8 March 2019. https://philosophynow.org/issues/114/Richard_Feynmans_Philosophy_of_Science.