(Image Credit: pixabay.com; the image is at this link. Used without modification under Creative Commons Licence)
The foundational defect in Canada’s universal healthcare system is that its delivery is determined by an administrative process that is singularly focused on bureaucratic procedure, at the expense of actual medical outcomes.
In my previous article, ‘Bitter Pills’, I touched upon how a perfectly adequate supply of medical services (in terms of the ratio of physicians per 1,000 of population) still leaves over 1 in 7 Canadians without a family physician. My theory was that the delivery mechanism that connects the supply with the demand is responsible for this suboptimal outcome.
In the interest of fairness, this theory needs to be tested.
In this context, while we do have macro-level data (such as the number or proportion of the Canadian population without a family physician, helpfully organized according to province and age-demographic, as well as the wait times for obtaining specialist treatment etc.), it does not tell us why we have these outcomes. In this context, I think it will be useful to look at some actual cases that were reported in the media; this would help us to formulate possible explanations for these individual failures of our healthcare system.
Before we begin, however, let me reiterate my oft-stated reluctance to treat anecdotes as data. My objective here is to get the discussion rolling as to the possible causes that lead to unhappy experiences of Canadians as patients. Others may be able to offer more of these possible causes, based on other anecdotes that they may have.
If this exercise is done on a wide enough scale, we would then have a fairly comprehensive list of areas where we can focus our attention to make our healthcare system much better than its current dissatisfactory state (some would call it sorely inadequate.)
A CASE OF BLINDNESS
In December 2016, I came across a report by CBC about an Ontario teen named Aidan Wellsman, who was then 16 years of age and was suffering from a degenerative condition called ‘keratoconus’, which causes the cornea to get thinner and to change shape. If this condition is not treated, it can lead to blindness. I remember this case because I wrote about it in my weekly a column in a Gujarati language ‘community newspaper’ at the time.
What was more concerning than the medical problem of this teen was that the provincial health plan (OHIP) did not cover the treatment for keratoconus. According to the CBC report, the family was left paying $10,000 at a private eye clinic. It shouldn’t need to be stated that many families cannot afford such an expensive treatment on their own.
The point where this case ties into my theory about inefficient delivery of our healthcare system is this: the CBC report states that as of December 2016, the Ontario government had been ‘studying’ the issue since 2011. In a period of well over 5 years, the State machinery had not come to a decision as to whether the provincial health plan should cover such treatment or not.
The CBC report also refers to an earlier report from March 2016, that of Balin Vergunst, who also suffered from keratoconus. He was told that he would have to go blind first before OHIP would pay for his eye surgery. This family was able to afford private surgery after a donor from Brampton (who, most laudably, wanted to remain anonymous) volunteered to pay for the 13-year-old’s treatment.
If one were looking for a stereotypical example of government bureaucracy in ‘action’, one couldn’t find a better (or worse) case. And ditto for the kind-heartedness of Canadians (as the best example possible).
If you think that this adverse publicity spurred the Ontario government into action, you will be dissatisfied. In April 2018, CTV reported another case involving keratoconus, this time of Michell Boich of Ottawa, who faced an identical predicament. Remember that the government had started ‘reviewing’ this particular treatment since 2011 – we are now in 2018, and they haven’t reached a decision yet.
If Ms. Boich had lived across the river in Gatineau, the provincial health plan of Quebec would have covered the treatment. She stated that OHIP would cover her surgery after she went blind.
As of now (December 2021), the relevant link on OHIP website does not list keratoconus as being covered under its plan (however, it does list ‘corneal disease’; it is not clear if keratoconus falls under this heading).
THE PAIN OF LABOUR
In April 2019, I was pointed to a story from Nova Scotia about Yarmouth Regional Hospital issuing a warning to pregnant women (the term ‘pregnant people’ hadn’t come in vogue by then) that from the following month ‘there may be times when babies can’t be delivered’ at the hospital.
The report cited the reason for this: three out of the four anesthesiologists at the hospital had resigned.
The communication from the hospital asked expectant mothers who may feel that they need care to call the Women & Children’s Health Unit at 902-742-3542, Extension 1130. I can’t bear the thought a woman in labor pains having to wait while the voice recording on the phone line drones on about various situations and options, asking the caller to press 2 for this and 3 for that.
The communication further added that after speaking with staff, the woman may be directed to go to ‘another hospital’ to deliver her baby. Options included the Valley Regional Hospital in Kentville and the South Shore Regional Hospital in Bridgewater (both these are located some 200 kilometers from Yarmouth), as well as the IWK Health Centre in Halifax (located about 300 kilometers from Yarmouth).
I don’t need to point out – let alone emphasize – the absurdity of asking a woman having labor pains to go to a hospital situated hundreds of kilometers away to deliver her baby.
My main point of inquiry here is how this sudden 75% deficit in the availability of anesthesiologists came about at this hospital, and how it could have been avoided / prepared for by a system that existed in another paradigm.
The circumstances around the departure of the three anesthesiologists are, of course, shrouded in secrecy, but if we put our minds to it, as the people who are funding the healthcare system, we can perhaps ask the following questions:
- Was it known, or foreseeable, that these anesthesiologists were going to leave in April 2019?
- If it was, then what efforts were made to fill the staffing shortage?
- If these efforts were made, why weren’t replacements lined up in time?
- If such efforts were not made, who is responsible for that failure?
- If it wasn’t known that these anesthesiologists would leave, why wasn’t it known?
- What was the reason for 3 out of 4 anesthesiologists deciding to lave the hospital at the same time? (In this regard, records of any exit interviews may be helpful).
- Specifically, did they leave because their pay or working conditions were unsatisfactory to them?
I haven’t been able to locate any media reports asking or covering these questions. Perhaps such reports exist and I have been unable to find them. But in broader terms, this leads me to surmise that our general incuriosity about system failures on important issues allows administrative apathy to flourish. I firmly believe that citizens deserve answers of matters such as this – but those answers can only be forthcoming (even if grudgingly) if we ask the questions. But we seem to be living a peculiar version of the well-known ‘Don’t ask, don’t tell’ approach.
In the absence of those answers, we are left to speculate that (a) no one in the hospital administration knew (or cared) whether these workers were going to leave en masse, and (b) that they weren’t overly exercised about the resulting unavailability of a highly time-specific need for medical attention to patients. I am confident, however, that all the administrative paperwork was perfectly in order, so as to provide cover for all the administrators who were responsible for ensuring the availability of this service.
In September 2017, CBC reported that the federal government fought a $6,000 claim of a First Nations girl for dental treatment in court – and spent over $110,000 in legal fees for the case.
The claim for $6,000 related to braces for Josey Willier, a Cree teen living in Calgary. The claim, under the First Nations and Inuit Health Benefit Program, was denied by Health Canada. The girl’s mother took the matter to court, where the federal government, in its infinite wisdom, thought it fair to spend $ 110,336.51 over 15 months (from January 2016 to April 2017) in legal fees ‘as part of its fight to avoid paying for the procedure’. The legal cost per month alone is more than the amount of the denied claim.
In May 2017, the judge found in favour of the government.
As of September 2017, when CBC published the report, the judgement was being appealed (presumably by the girl / her mother). This can only mean even more money being spent by ‘Ottawa’ on legal fees.
The CBC story notes that the previous Fall, ‘the Liberals voted in support of a NDP motion that called on the government to stop fighting Indigenous families who are seeking access to services covered by Ottawa’. Talk about actions not matching claims. When the time came to walk the talk, the government had no legs.
But, as the CBC story quotes Health Canada, “The issue is that there is no clinical evidence to support approval of the claim …”.
Health Canada reached this conclusion based on the advice of four orthodontists of its own choosing – who did not physically examine the patient. Were these orthodontists paid for their consulting services as well? It would be reasonable to assume that they were.
The key point here is that the concept of cost-benefit analysis does not exist in the universe that Health Canada inhabits. They are willing to pay vastly more sums in legal and other fees than what is claimed by the patient (already over 18 times more than this girl’s claim before the appeal) in order to defend a position that is based on the ‘expert’ opinion of doctors who haven’t seen the patient.
In other words, it’s all about defending an administrative decision at all costs – literally.
SOLUTION IN TRADITION
If we are to make our healthcare system better (I would go so far as to say ‘adequate’ – because right now, it plainly isn’t), we will need to overcome our adherence to orthodoxy. We have a social environment where merely suggesting that certain things need to be improved in Canada gets one seen – and perhaps branded – as unpatriotic (conversely, stating that certain parts of Canada aren’t all that bad gets one called a ‘racist’).
But asking certain questions and challenging some deeply ingrained beliefs is a must if we are to ensure that all Canadians obtain access to good quality healthcare which they presently lack in a most demonstrably painful manner. Official data from reputable sources such as the World Bank, OECD, StatsCan and the Canadian Institute for Health Information (CIHI) clearly shows that our healthcare system is in dire straits – and that the main issue is its availability (thankfully, the quality of healthcare has so far withstood the decimation of physical and logistical infrastructure).
How do we ensure that all types of medical attention are made available to all Canadians? More specifically, how do we improve (or revamp completely if necessary) the delivery mechanism for healthcare to make it capable of delivering what it is supposed to?
Until we answer this question satisfactorily, our healthcare system will not be ‘universal’ in the true sense.