A Viable Health Care System for Canadians

J. K. Walker BSc, MSc, PhD

88 Starwood Rd., Nepean, ON K2G 1Z5

(613)224-3570

The authors of the 1966 Canadian Medical Care Act could not foresee the large increase in cost of medical facilities, equipment, fees and services, which is characteristic of this field but also of politically based systems.  The Federal government's share of the cost of Health Care, which was initially 50%, has fallen to about 20% including the so-called Federal Tax Contributions (tax percentage points).  This is because it first reduced its large deficit in the late 1990s and more recently it has been paying down some of its very large debt.  However, the latest and somewhat illogical Harper budget (March, 2008) does not have any surplus for debt reduction and for hard pressed industries in Ontario and elsewhere.  In some provinces 48% of the budget now goes to health care and it is increasing at an unsustainable rate.  Despite this increase in funding, the rising costs have squeezed health care to an unacceptable level as well as education and other provincial services.  The Federal government will probably be putting $40 billion more into the system over the next several years, which should help; however, even more will be needed unless more choice and other controls are put in place.

The present health care system is overtaxed, untimely, and essentially unaccountable and has limited choice and limited competition.  It is also politically based which limits the reliability and quality of the service.  Poor health and unnecessarily slow recovery of ill workers retards economic growth and the well being of many citizens.  Furthermore, the Canadian health care system is not universal but is effectively three tiered.  Also, some provinces charge substantial fees and some seldom pay for services to its citizens provided by other provinces.  Perhaps equally crucial is the large debts and their large service fees that numerous misguided politicians have got the Federal and most provincial governments into which constrains future resources and options.

Canada is in a global commercial world now and taxes cannot be significantly increased without degrading our competitive position even if taxpayers and politicians are so inclined.  Global warming is of the utmost importance and it may soon lead to a runaway event with catastrophic worldwide effects and increased health risks.  Greenhouse gas emission into the atmosphere must be reduced by ~90% just to stabilize the climate at an enhanced temperature.  The International Energy Agency estimates that it will cost 45 trillion dollars just to reduce the GHG emissions by 50% by 2050.  Hence every effort must be made during the next few decades to improve the efficiency of heating and transportation systems, power systems and also farming and population control in order to reduce the greenhouse gas emissions into the atmosphere for a viable climate.  Ever effort must be made to limit birth control to two offspring per family in the developed world and one in the developing world, if at all possible.  Every women and every family should be well informed on birth control methods and the new more effective methods.  Free abortion clinics should be readily available.  There will be significant new costs to mitigate these climate change problems and also for improved security.

Some politicians have closed down numerous efficient and critical hospitals in some provinces in a blind attempt to control costs.  Others have reduced the enrollment for medicine at Universities and some limit the use of expensive drugs and diagnostic machines.  The baby boomers will be retiring in a few years and health care cost will then rise even faster.  Furthermore the reproduction rate in Canada is only 1.5 per family and the immigration policy is ineffective and there is probably an extended recession and so tax revenue will possibly decrease during the next few decades.  While it is difficult to get a compromise for an improved Medical Care Act, as there are few extra resources at the federal and provincial/territorial levels, politicians should explore all possibilities.

A more reliable health care system may require more opportunities for the users and providers with more local and individual control and somewhat less in the political arena.  Any imposed tax based system, such as the Canadian health care system, should be minimal but with numerous options.  Quebec is interested in having a user fee, which is an excellent idea, but it would require a change in the Act, nevertheless it should be explored or the regulations enhanced to accommodate such fees.  The recent Castonguay report recommends a $25 fee for every visit to a clinic.  Quebec is also interested in a two tier system and seemingly working towards such a structure.  At the 2007 meeting of the Canadian Medical Association 48% of the doctors voted in favor of co-payments and health savings accounts.  With careful management of provincial and federal budgets over the next few decades to reduce their debts this would free up significant resources.  Then with such options for more individual freedom and modest changes to permit selection and more professional members for more competition and for optimization of the facilities and services, most provinces might eke out a more viable health care system.  As a first step it is recommended that a 5% tip be implemented ASAP for those provinces and territories that would be interested in exploring this concept.

Sustainable Funding

Health care for 2006 required ~$104 billion from the public sector and ~$44 billion from the private sector (see CIHI); or specifically, about $3000 per person but it costs the average taxpayer nearly $6000, which is considerable.  However, a family of four are paying about $12,000 for their 'health insurance' for a less than mediocre service (Canada is ranked 30th) and those on higher incomes even more which is unfair.  The rate of cost increase for the last few years has been about 7% for the public sector and soon needs to be reduced so it’s more consistent with the rate of increase of the GDP (~2% for the next few years of this recession).  The combined debts of the Federal (~$480 b) and provincial/territory governments ($370 b) and the municipalities ($60 b) are about 70% of the GDP and the cost of servicing these debts is about $50 billion annually in taxes.  The President of the Conference Board of Canada and many others feel this is high and should be significantly reduced.  Australia’s debt is now about 5% of its GDP and hence far fewer tax dollars are wasted servicing their debt and Canadian governments should aim for a similar figure.  The first objective of a government should be to minimize taxes and so it should pay down its debt as tax dollars should not be wasted servicing debts.  Canadians have not been involved in a major war or in a great depression for over 50 years and most politicians have contemptuously neglected these debts far too long.

The Federal government should refrain from paying down its debt by transferring (stealing) a whopping $30 billion from the civil servants and armed forces pension plan as the despicable Chrétien bill C-30 permitted and also with the 52 billion surplus in the EI account.  A concerted effort at both the federal and provincial levels of debt reduction could possibly free up ~$10 billion more each decade of which perhaps half might be available for health care and the other half should be used for green programs.  These challenges amount to paying down about ten billion at the Federal level and about $6 billion at the provincial level, on average, each year, which is not insuperable at either level.  Obviously the Harper government’s unwise reduction of the GST to 5% and other cuts has resulted in a constrained budget with limited ability to pay down debts or support our struggling industry or even fund research and mitigation programs for critical health care and climate change initiatives.

The Equalization program has not improved the productivity of the have not provinces and is abused by most of these provinces and it is now grossly unfair to those in struggling Ontario.  The new formula of Prof. Dan Usher (Queens U.) should be explored which divides the total real personal income of a province by the real tax revenue which produces an objective per capita measure of wealth.  Then calculate the national average and those below get only some support from those above.  This $12 billion program is excessive and should be reduced by about 5% a year for the next decade or so.  It should only provide support that is essential and it should also be audited to reduce the abuse and misuse.  The USA and the EU do not have such support systems.

It is suggested that at any forthcoming First Ministers meeting that the Ministers all agree to explore a new viable Medical Care Act and one percent budgeted debt reduction per year, if at all possible, for the next few years as a first step.  This should gradually increase to about 3 percent per year by the end of the decade.  This fund could also include the contingency fund and is just slightly more than that which is set aside at present by most prudent governments.

A watchdog is undoubtedly necessary to keep politicians on this difficult road of debt reduction.  Such a watchdog could be an elected and more effective Senate, hopefully with a few members of the caliber of Auditor General Sheila Fraser.  The four larger provinces should also consider a Senate to keep watch over their sometimes misguided Legislatures.  These senators need to keep tabs on both the federal and provincial governments for sound fiscal, environmental and health care management.  The senators should sit for two terms (8 years).  The elections should be about 2 years after a Federal election unless a term is less than a year.  The senators should not be elected at large for each province but should be elected by ridings with each Senate riding generally corresponding to three contiguous ridings for members of the House of Commons or the Provincial Legislatures.  However, the three territories should have one senator and one MP each while P.E.I, which is presently far over represented with 8 parliamentarians, should have only two MPs and one senator as it now has a fixed link to the mainland.  These ridings will ensure representation from all parts of the province and hence fair representation for rural and remote regions (see Senate note).

The process of an elected Federal Senate should be started in October 2009 so that the monitoring of budgets can begin to have some impact on the Federal and provincial debts within this decade, as revenue is limited at both levels of government.  The four larger provinces should also explore having an elected Senate to strengthen their governments.

A significant reduction of the debt and better governance at both the Federal and provincial levels would also help stabilize the dollar which is now linked with the price of Alberta’s reckless oil production.  This would make all Canadians wealthier and hence able to afford extra health care if necessary.

The Harper government is to be commended for the recently improved charitable contributions by permitting transfers of investments and fixed assets to charities without the capital gains tax.  This provides a significant incentive to individuals and corporations to donate such investments and also fixed assets that have large capital gains to charities.  Many hospitals and associated research institutions have related charities and they should see improved contributions from such donations.

Accountability

Health care is a provincial responsibility and consequently the federal government should only provide basic support for the low income segment much as it does for social housing and for catastrophic health and drug costs.  Hence the federal government should vacate some of its tax authority for the provinces and territories and also reduce the social and health transfers so that the provinces can provide most of the necessary funding.  The EU has just developed a new health strategy and Canada’s health care system should be similar to it as the provinces are somewhat similar to the different countries that make up the EU.

The federal government needs to significantly improve the capabilities of Health Canada so that it has competent management and staff for doing independent drug and health research as well as validation of drugs and new diagnostic and other instrumentation which is limited at present.  It also needs to improve the integrity and competence of senior management.  It should reinstate any scientist retired/fired for simply being outspoken on questionable management decisions.  However, the federal government should monitor the delivery of health care for all Canadians regardless of where they live in Canada and ensure the portability section of the Canada Health Act and freedom of choice.  The Canadian Institute for Health Information has an excellent data base of health care and it should be used to identify and clean up problem areas and to optimize the various parts of the system.

Health Canada should also have up-to-date information on its web site of the various ailments and possible remediation for them much like those of the Mayo Clinic but with good videos that would explain in more detail the nature of the disease and how it can be best diagnosed, treated and managed.  The personnel digital health files could then be linked to the appropriate web page for further information on specific ailments and hence patients can become better informed of a suitable course of action or remediation.

The Federal government should also consider raising the Child Tax Credit and basic tax exemption level to say $12,000 so the very poor can better afford basic shelter, food and drugs.  It should also consider increasing the GIS cutoff to say $15,000 so seniors have some capability of providing their own basic care.  However, for the disabled the tax exemption level should be at least $16,000 and for disabled seniors the GIS cutoff should be about $17,000 per year.

The taxes that support the health care system for public facilities are often administered at the local level by appointed boards either by the province or from a close group of supporters for the service or hospital.  Such unelected boards are not accountable and hence undemocratic.  Furthermore, some provincial agencies have been known to close down and actually blow-up hospitals that are essential to a community.

Most provinces now have local health networks.  The health care facilities in Ontario are now integrated into 14 local health integration networks.  These LHIN will be responsible for: public and private hospitals; long-term care homes; community health centers; mental health and addiction and community support service agencies.  This is a significant step in bringing control over health care back to the region.  However, there should be some elected members on the board of directors for each of the LHIN.  These members (councillors or trustees) should provide the link with the local municipalities or governed by a board of elected trustees with the assistance of outside experts and thus form a more accountable governance system.  The chair should be elected at large with the municipal elections in each LHIN district. (E.g. see 'One City and Six Divisions Concept for Ottawa' article at the pages.istar.ca/~jwalker web site which suggests one hospital for each division and hence one in Kanata should be started ASAP rather than refurbishing the Ottawa Civic campus.  Also see study #19 at MEI'S PUBLICATIONS .at iedm.org).  The meetings of the board should generally be open to the public and the financial records audited.

Generally the local councillors or health trustees can make better decisions on the allocation of scarce resources than can unaccountable officials or bureaucrats far removed from the health region.

The health care funds that come from the Federal level and transferred down to the provinces and then to the hospitals and other medical services are sometimes withheld by the province for extended periods.  They are sometimes even used for other unrelated purposes.  Indeed, some provincial governments, such as the old Harris one in Ontario, have even downloaded public heath care and support for the handicapped and others onto the property tax base.  The property tax base of the municipalities is limited and should not be used to fund social and health care facilities as it now does in some provinces.  Furthermore, hospital boards and their communities often have to raise millions of dollars by charities and other cumbersome ways before the provincial government will provide supporting funds for new facilities or equipment.  To mitigate some of these problems it is suggested that the municipalities receive some direct funding for such facilities and for other extenuating municipal circumstances from the national revenue system.  This could readily be calculated on each income tax form and the money tallied for each municipality or health care district by Canada Revenue Agency and then distributed directly to the municipalities and health care centers much the same as it does for each of the provinces and territories.  The councillors and health care trustees for each municipality would decide on the percentage of revenue (say up to 5% of taxable income and the Federal and provincial shares reduced by ~3% or 1% of the provincial sales tax).  Thus it would be an accountable system and based on the progressive income tax system and hence fairer than the property tax system.  It would also be more reliable than the present political based system of getting grants from the province and monies from lotteries and charities for new facilities and equipment.

The direct cost (tax) for health care and that for public health care should be listed on each individual tax assessment by CRA much like the CPP contributions or like some municipalities that itemize the costs of major municipal services, so the public is fully aware of the costs of health care.  Furthermore, this tax should be capped and transferable to any not-for-profit health care group of choice much like the educational segment of the property tax for the different educational systems in some provinces.

The new Medical Care Act should impose accountability on the health system for both financials concerns and medical systems for each province and territory and for each associated health care districts.

Hospitals should not be supported by block funding as many are at present but they should be deregulated and supported by the amount and type of individual service they provide to the patients much like in the UK and in private facilities.  B.C. is experimenting with this concept and also providing a small bonus if done in a timely bases and has seen a 10% improvement in assessment times.  Then a modest user fees should gradually be introduced so that the user might pay at least a few percent of the cost and consequently the patient will seek out the best hospital and price for their income level and thereby stimulate competition.  This would set the stage for new community or private not for profit hospitals or possibly PPP hospitals.  The provincial governments should then provide extra incentives for such hospitals much like the Ontario Power Authority has for entrepreneurials for new clean power generation.  Service-based funding would also promote the establishment of specialized clinics offering lower prices such as the Shouldice Hospital in Toronto.  The private sector has sound experience in applying international processes and behavioral standards to achieve high quality results.  The Quebec government has recently passed Bill 34 that now permits 56 surgical procedures to be performed in private clinics from the 3 before this bill.  There are new oversight measures that will be implemented to insure these operations are done safely.  These changes will encourage specialization and more efficiency and generally better care.

There are about 4.1 million citizens in Canada without a family doctor.  Many doctors will be retiring in the next decade along with the baby boomers and the shortage will make it even more difficult to get timely treatment at clinics and at hospitals.  Some provinces have increased the number of spaces in medical schools but many more are needed (about 25,000) for the many (~80) different branches of the health care field established by the Royal College of Physicians and Surgeons of Canada.  Most of the cost for medical training comes from the public purse so graduates should have to intern in Canada and spend at least a few years practicing in the Canadian public health care system to repay the tax payer for some of their medical training.  However, numerous foreign students are trained in Canada and the Federal government should fully support these students.

Fairness and Choice

At the upper tier of the Canadian health care system are the professional athletes, executives, some politicians, WCB patients, many doctors and others who have special doctors and avenues that provide rapid care for any injuries and other ailments that might limit work or life style.  The lower tier consists of seniors, aboriginals, vagrants and many others without a family physician who are often given inadequate care, if any, or sometimes shuffled around the health care system.  There is obviously a need for the expensive high profile patient and workers in critical positions, which should be recognized and provided for, in the health care system.  Hence the new Health Care Act should probably outline at least a three tier system for those provinces that would be interested in such a system but a provinces would only have to provide a basic service if it so chooses.  The Federal government should pay for half of those on low incomes in the lower tier system.  The upper tiers could take the form of a surcharge of a few to several thousand dollars.  Such a plan would be expensive for these individuals but might be of interest to perhaps 20% of the population.  Eventually some additional facilities, much like the Mayo Clinics, might be developed for this group which would probably be available to others at times.  This would reduce the demand on the public system and on public facilities and at the same time provide the health services community with more modern equipment and some competition.  It also provides a choice and it would be a more reliable service as it would not be subject to the whims of politicians and their occasional zany plans.  To this end the Canada Health Act and provincial legislation should be revised to remove monopolizing provisions and replaced with some individual freedom for access and choice much like in the UK.  This would also provide some much needed competition in our health care system.  There should also be some incentives and bonuses within the system based on quality and efficiency, and not on price.

Guidelines for the core health care services have now been developed and those for the main and high profile group could be set by a panel of experts, possibly under the direction of a joint Federal and Provincial agency and with the aid of agencies such as the CIHI, so they are consistent across the country.  This should also include separate but fair access for the public (say daytime) and those paying extra via special insurance for the service (perhaps evening or weekends) for use of a public facility/service.  Urgent care such as that for aggressive cancer and patients with intense pain should have a higher priority.  The health care providers should not obtain extra benefit by providing services to say only the high profile users.  The three territories and also the four Maritime Provinces should probably work together to have a single enhanced insurance plan as these territories and provinces may not have enough members to form a viable insurance group for the high profile group.

It is important that people have real choices and a safety net but most people have poor saving habits.  A tax-sheltered Registered Medical Savings Plan, similar to that of the RRSP, which encourages saving, should be explored for medical, pharmacare and home care expenses but might also be used during periods of unemployment.  This plan could be separate or combined with the individuals EI plan.  For any medical expense they would have the option of using cash, private or provincial insurance if a member, drawing on their RMSP/EI or using only the basic public facilities.  At death any balance of their RMSP/EI plan could be transferred to a beneficiary's RMSP/EI plan or could be taxed and paid out as a benefit.  This would off-load the public system while providing people with a safety net.  It would also encourage people to consider costs and thereby bring market forces into the system and thus put pressure on the often monopoly enhanced fees for services, tests and drugs.

The Income Tax Medical Expenses should be more generous and also revamped to include all forms of medical expenses including home care and palliative care.  It should provide refunds on a timely basis for the low income segment when medical expenses are more than several thousand dollars and possibly ten thousand or so for the others.

Optimization of Care and Medical Facilities

Superbugs now attack one in nine patients in Canadian hospitals and nursing homes.  C. difficile caused about 2000 deaths in Montreal in 2003 which went unannounced to the public.  Dr. R. Zoutman estimates that hospitals and institutions for the elderly sicken about 220,000 patients a year and they silently bury about 8000 - 12,000 with hospital acquired bugs.  One of the biggest killers is methicillin-resistant Staphylococcus aureus (MRSA) which causes blood poisoning, flesh-eating disease and pneumonia.  This disease stems from overcrowding and poor hygiene and is seldom reported.  Fortunately, next year hospitals will have to report their rates of C difficile and MRSA or lose their accreditation.  The Public Health Agency of Canada has developed a plan and resources are now available to start implementation to eradicate the MRSA superbug.

However, this important data won’t be made available to the public because the authorities do not want the public to know how bad the problem may be at times.  This obviously must change so that the public can make informed decisions about where they might go for elective surgery and retirement homes and other institutions.  The University Health Network in Toronto now reports such infections on its web site.  All hospitals must report these superbug infectious diseases, which then puts pressure on them to mitigate these often deadly infections.  Hospital and governments should not be allowed to be complacent about the dangers of superbugs.

Microbial flora from a patient can fill a room in a few hours.  Hence many infections and superbugs can be contained if the patients are kept in private rooms with their own bathroom and fresh air system and facilities to wash hands.  The older hospitals should be modified to provide more private rooms and of course nearly all the rooms in any new hospital should be private.  The Federal government should develop plans and guidelines forthwith for hospital renovations and for new hospitals as well as providing some support.  This will save money as it will reduce the spread of such infections by at least 50% and in some place it has reduced the rate by 70% and saved hundreds of lives.

Recent CIHI statistical data indicates there are at least 9,000 to possibly 24,000 deaths in Canada each year owing to mistakes and delays in access to appropriate procedures or diagnostic equipment.  This rate is 3 times that in the USA.  Some effort is being made but a major change is needed to significantly improve the Canadian Health Care system.  Diagnostic facilities should be used in the early stages, if at all possible, in the event that the tumor might be malignant.  However, in Canada there is reluctance for this approach in order to save money which significantly reduces the health and well being of many Canadians.  The delivery of each type of health care and associated diagnostics techniques should be modeled, where appropriate, and optimized to make them more cost effective using the tools of modern operational science.  Typically, the cost of a service can be reduced by 10-15% with careful analysis and modeling of the service.  It is suggested that the CIHI, The Public Health Agency of Canada and each provincial health department, each health district and major hospitals have a small staff of operational scientists solely to optimize the different services of health care and use of associated expensive facilities, procedures, equipment and administration.  For instance, most tumors need to be fairly large, say the size of a bean in some cases or a golf ball in others, before they can be detected by conventional means or cause a perceptible influence on an individual.  If the tumor is malignant then it may well have spread to other parts of the body and become difficult to eradicate.  However, much smaller tumors can readily be detected with 3D ultrasound, CT, MRI, PET and now infrared facilities and hence periodic examinations with such facilities might preclude extensive and expensive surgery, chemotherapy and recovery or possibly loss of life.  An analysis of such situations can optimize the well being of the patient and also reduce the cost of care.

Special clinics for seniors should be established in most cities to more effectively and efficiently deal with their health problems.  Most hospitals have a large number of long-term care patients which should be relocated in special facilities to free-up this expensive space in the hospital.  The wait times in Ottawa are excessive and new hospitals should be established first in Kanata and then in Orleans and Barrhaven.  The recent Castongauy report recommends some private hospitals as well as clinics for Quebec.

A startling 24,000 patients who undergo surgery in Canadian hospitals each year die after being struck down by what doctors call the silent killer: blood clots.  If those patients were provided with prophylactic blood thinners, most deaths could be prevented, according to Bill Greets, a thrombosis specialist at the Sunnybrook Health Sciences Centre in Toronto.  Those figures, he said, are extrapolations based on data from the United States.  The Canadian Patient Safety Institute will announce an initiative to prevent venous thromboembolism, but it should be routine by now to provide a blood thinner for the patients for all operations.

There is a significant amount of misuse and some abuse of the health care system by both the users and professional providers and also administrators and some governments.  Because our health care is seemingly 'free', few question often unnecessary prescribed tests or procedures requested by a befuddled doctor.  Steps should be taken to reduce this waste of public resources.  For instance, physicians and surgeons might take a refresher course every decade or so to update their skills.  Token user fees would encourage the patient to ask questions concerning the best test or procedure.  Physicians and surgeons should keep patients well informed about the disease and treatment and all reports should be available to them at the cost of reproduction.  All operations should be monitored with a video camera so that the surgeons and CEOs might learn from mistakes and the patient might better understand and appreciate the procedure.  It could also be used to spot any material inadvertently left in the patient during the operation.

It would also be very beneficial if general physicians and other specialists would first listen carefully to what their patients are relating to them.  Many patients are intelligent, are well educated, well read and computer literate and can communicate what the problems is IF these doctors took the time to listen.  Instead some doctors DO NOT LISTEN because the patient’s 5 minute appointment slot is expired and it is on to the next patient.  Some doctors love to send these patients for more ultrasounds and x-rays thinking that all patients are ignorant.  When the test results are available often these same doctors tell the patient everything is normal but in fact, when the patient has obtained a copy of this same report, the information the doctor has given the patient is incorrect or fudged to be normal while that was NOT what the report indicated.  The patient should have access to all reports and to his or hers medical files, both the hard copy as well as the digital one.

The provincial regulators should closely control the practice of kickbacks and other benefits from referrals to other physicians or surgeons and independent health clinics, diagnostic labs, and free medications from pharmaceutical firms.  They are ethically wrong and do a disservice to the medical system and to the patients.  Some family physicians in Ontario are now practicing one ailment per three minute visit to reduce wait times and possibly enhance their remuneration.  Others do rapid diagnosis and sometimes misdiagnose to reduce time with patients.  These practices significantly reduce the quality of health care as many problems may go undetected for a longer period of time and it will generally cost the system more and reduce wellness and life expectancy.  Obviously this should be discouraged and such patient and system abuse should be reported and those responsible reprimanded.

Market Forces and User Fees

At present, the public has no clue regarding the cost of the doctor's services or even if the charges are legitimate.  The general physician gets paid before he or she even begins a conversation with the patient regarding this individual’s medical problem.  Many a time the patient receives absolutely no medical advice and the patient’s problem is not addressed nor is a referral given to a specialist when requested or sometimes a referral is even made to the wrong type of specialist.  The reason for this is that many GPs do not take enough time to understand the patient’s prognosis because they are too concerned with their new rule of one ailment per three minute visit per patient.  God help you if you have more than one medical problem on one day.  At least 15% of such diagnoses are incorrect and if the patient is in any way suspicious he/she should be able to have a second opinion ASAP and a refund if misdiagnosed.  These are tax dollars and every step must have checks and accountability.  Many taxpayers may be far more discriminating than the government or professionals in finding competent health care that falls within their budget.  Hence they may start taking a much more active interest in preventative health care for themselves.

Japan has one of the most efficient health care systems in the world which costs about 7.8% of their GDP while in Canada it is over 10%.  They also have many more imaging devices on a per capita basis than in Canada and hence access is generally immediate or the next day.  There medical care is also better and their system is all on a competitive basis.  The user pays between 20% and 30% of the costs but low income groups are exempt.

Obviously market forces can significantly reduce waste and improve the efficiency of a service (see studies by Regina Herzlinger).  Hence, part of the costs of the services, and preferably a percentage, should be paid directly by the user so that the amount of service required would be minimal and the user will seek out the best value for his or her dollar.  However, low income groups should generally be exempt from such fees.

The user fee could initially be a token fee or tip of say 5% of costs under $200 for a few years.  This ‘tip’ should be implemented ASAP and paid after the service has been provided by a public agency and only if the patient is satisfied with the service.  Subsequently it should be raised and inversely proportional to the cost and in round numbers and implemented in steps.  Say 10% for fees under $200 for the next few years.  The typical cost of a visit is about $30 so the user fee would be all of $3 which most anyone can afford.  Then in a few years say 8% for fees from $200-2000 and then after a few more years ~5% for fees from $2000-$5000.  Then possibly much later a fee of 2% for services from $5000-$20000 and 1% for those above.  These fees should increase by say 5% every decade or so until they are about 25% of the cost if the province is so inclined.  However, the higher fees should be limited or possibly optional for those on modest incomes.  This is consistent with the Castongauy report of a user fee for each visit to a clinic.

The number, average cost and the success rate of the different diagnostics, tests, drug treatments and operations performed at labs, clinics and hospitals should be available to the public on at least an annual basis so they can select the appropriate facility and best value for their dollar

Such fees and information will also develop some competition in the system and perhaps stem the monopolistic tendencies and associated enhanced costs of many elements in the healthcare field.  Not-for-profit and some private facilities should be permitted in larger centers to improve choice and provide some competition to the public facilities.  Not-for-profit facilities might be supported with some public funding.  Furthermore, only the medically necessary routines and checkups should be supported from taxes.  A panel of experts should be established to determine these criteria on a regular basis.

Each province should also develop a special unit of professionals to thoroughly check all aspect of each hospital, special clinics and nursing homes on a regular base to ensure it meets a reasonably high standard and is also efficient, clean and free of abuse.

Shared Funding for Gray Services

The doctors, pharmacists, nurses and patient should work together to address any medical problems and also for preventative care.  Some doctors and surgeons are not as communicative as they might be and consequently it can be difficult for the patient to fully understand the nature of an ailment or importance of a remediation program.  Some physicians have even been known to take a bird over discussions of delicate complications or a written document by the patient explaining some observations and concerns.  It can also take years of discussion with some physicians to get an appointment with say an urologist and some GPs have even refused to send patients for important colonoscopy checkups.  Copies of all reports by doctors, surgeons and specialist should be available to the patient in a timely fashion so they can review them and ask questions about them if something is unclear.  The patient can then develop an independent medical history at home which could be reviewed at anytime and would also be available in the event the one at the primary care provider became lost or corrupted or not fully communicated to the patient.  These records should of course be in a digital format ASAP and the patient should also be able to access these digital records and diagnostic imagery remotely at any time.  Alberta now has perhaps half of the population’s health care records in digital form and Ontario should move rapidly on this front, first with patients that need urgent care or surgery.

The typical annual checkups are generally of limited merit and seldom are the results returned to the patient.  At least a brief report should always be sent to the patient.  GPs should really have an ultra sound handy so they can more readily and quickly identify irregular organs, bones and any tumors.  It is suggested that a more comprehensive checkup be available every few years that would involve at least a 3D ultrasound or CT or preferably an MRI scan and other tests be included with a complete report by the physician.  Executive Health Services in Ottawa specialize in this type of checkup and they provide a very good analyses and report of one’s condition.  The extra cost of such services could be shared with the provincial healthcare agency as could the cost of some prostate tests for men and the CA 125 blood test for ovarian cancer for women.  MRI diagnostics for breast cancer are very sensitive but expensive and hence the incremental cost could also be shared.  Digital mammograms might also be considered as the old X-ray machines can trigger malignant cells and should be used with caution.  Some patients following a difficult operation or delivery may prefer an extra day or so of rest in the hospital and this incremental cost could also be shared.  Most women who have had a mastectomy and some reconstructive surgery would undoubtedly appreciate attractive natural implants, stick-on prosthesis and nipples which should be available in Canada.

Most provinces now have a surcharge for supporting health care costs which generally increases with the net income of the individual.  This could be changed so that healthy individuals would pay say half of the surcharge but those that are obese, smoke or drink heavily, participate in extreme sports, work in dangerous environments, are undergoing treatment or generally misuses the health care system should pay the full surcharge.  This reduced charge would provide some incentive for slovenly citizens to improve their life style.  The assessment could be made when the person’s health records are changed to digital ones so the additional information can be readily passed on to the CRA and their income tax forms.  However, the system should also accommodate those who might prefer to have some extra diagnostics, cosmetic surgery or a thorough annual checkup done so they would continue to pay the full surcharge.

Cancer

About a third of the population will have cancer sometime during their lifespan.  New treatment now provides a survival rate of about two thirds after five years.  Death rates are falling thanks to early detection and prompt removal and treatment with surgery, radiotherapy and chemotherapy but the cost is in the billions.  However, cancer treatment in Canada is uneven and somewhat sporadic and should be improved.  About 25% of the cancers stem from our diet.  Nitrates in meat are particularly related to cancer and the consumption of bacon and sausages should be minimized.  Red meat and excessive salt and sugar are also of concern and should be limited.  Sugar suppresses the immune system and should be used sparingly.  The new book “Cooking with Foods that Fight Cancer” by Dr. R. Beliveau and D. Gingras provides many researched links and relations for cancer free foods.  There are now many carcinogenic chemicals in the environment and Health Canada should be constantly checking for them and issuing safe guidelines on their levels and use.  Health Canada is to be commended for examining a fair number of chemicals for their toxicity.

Vitamin D helps to keep one’s immune system up and recent studies indicate we need about 1000 IU a day.  This is best obtained from about half an hour of sunshine on lots of skin as it then produces the important vitamin D3 which helps to fight cancer.  It can also be obtained from vitamin D pills.  During the long cool season in Canada the natural vitamin D can still be obtained by sunlight streaming through a window as most glass will transmit the UV A&B rays.  A strong immune system helps to fight cancer.

A new technique that use doped implants to fight cancer is showing promise. The implants are tiny biodegradable discs that are impregnated with a substance called granulocyte-macrophage colony-stimulating factor which attracts dendritic cells, the main orchestrators of immune responses. The dendritic cells are temporarily captured by pores in the spongy implant and exposed to the chemical cocktail that prompts them to take the cancer cells to the T-cells so that they can be destroyed.  It has destroyed 90% of the melanoma induce in mice.

Early detection of cancer is the key to cost control and survival but it seems many GPs are averse to periodic checks and a lot of patients are also ill-informed of this need for checkups or are simply negligent.  With electronic health records it should be possible to monitor the various checks for cancer and the patient and his or her GP should then be advised to make the necessary appointments.  A group in Oxford University has trained dogs to detect prostrate, lung and skin (melanoma) cancers with 95 - 98% accuracy.

A colonoscopy is the best check for colon cancer.  However, some GPs are very reluctant to arrange for this test despite repeated requests by some patients and recommendations by authorities.  Such misguided physicians should be reported to the CEO of the health district or possibly the provincial CPS.  Every mature adult should also have a package of Early Detect litmus like paper that readily detects blood in the stool.  These inexpensive tests can be performed on periodic bases at home and also by frequent monitoring the color of the stool for a change to black.  This generally indicates blood in the stool and may have resulted from cancer or a broken polyp, a precursor of colon cancer, and a check should be made with the Early Detect test to determine if blood is present in the stool.  GeneNews Ltd has recently developed a more accurate blood test which checks for biomarkers, in particular RNA which indicates specific genes are responding to active colon cancers.  The test is called Colonsentry and is available in Ontario.  However, it cost $750 but hopefully this could be shared with the province as it would significantly reduce the need for expensive colonoscopies.

The PSA blood test for prostate cancer should be done on an annual basis but it misses about a third of the cancers and is even less accurate for obese patients.  If the PSA level is creeping up then test should probably be made on a more frequent bases.  ASA has been found to slow the growth of prostate cancer.  The author has also found that ~2000 IU of vitamin D or lots of sunshine can reduce the inflammation in the prostrate which can restrict the passing of urine.

Proton radiation therapy is now becoming available and its beam is much more accurate than that for X-rays while chemotherapy generally has many hideous side effects.  It is particularly effective for prostate, head, neck, lung and bone cancers.  However, these machines are expensive (~$30 million) but there are now several in the US, Japan and also in Europe.  Canada should initially acquire one ASAP as it can treat many patients a year.  The first one should probably be in Ottawa to treat patients in eastern Canada and a second machine could be in Edmonton to treat patients in the western Canada and the western territories.

Breast cancer is now fairly common.  Excessive alcohol has recently been found to be associated with breast cancer and other diseases but it also helps to reduce clogged arteries and heart problems.  Merlot wine has been found to reduce some tumors.  Consequently a woman should limit her ethanol consumption to a few glasses of red wine a week.  Women should also check each breast on a regular base.  Her GP should also check them frequently and at least on an annual base otherwise they should be reprimanded.  If a lump is noticed, then a 3D ultrasound should be used followed by an MRI or digital mammogram, if necessary.  Early detection and a prompt biopsy to determine the nature of the tumor and then followed by prompt surgery, if necessary, can minimize the loss so that only a lumpectomy may be necessary.  If the tumor is malignant the patient should be promptly informed and also advised of the type of cancer.  Women are very concerned about their appearance and every effort should be made to preserve as much as possible of the breast including the nipple.  Breast cancer is very depressing for a woman and her partner should be very understanding and affectionate as the testosterone and other mood altering drugs in semen pass into her blood stream about an hour after intercourse and are very good antidepressant drugs.  Consequently, a married man should not have a vasectomy for birth control purposes but some other method should be used.  A vasectomy can be reversed up to a decade after the surgery.

The four month delay in Ottawa for some patients for combined breast and expander cosmetic surgery following a positive biopsy is unacceptable as the cancer can spread or mutate to an aggressive form which is both dangerous and expensive to eradicate.  A new florescent scorpion toxin lights up malignant cells and should be applied after the surgeon has removed the malignant tumor.  Also see lighting up cancer cells.  It should also be applied to the excised tumor and any positive spots should be identified and noted on the corresponding breast tissue.  If the test is positive then further tissue should be removed until the test is negative.  The toxin should also be applied to the inside of milk ducts and they should be removed if the test is positive.  It should also be applied to the underside of the nipple and only those parts that are positive should be removed.  It is important that as much as possible of the nipple be left intact so the patient can retain most of her appearance.  Radiation should then be applied in the opened incision for a few hours to stifle any nearby malignant cells.  Meanwhile a pathologist should examine the excised tumor(s) and if no malignant or aggressive cancer cells are detected in these tumours then probably no aggressive chemotherapy may be necessary.  Otherwise, the pathologist should advise the surgeon before the incision is closed to check and possibly remove the appropriate adjacent tissue in the breast.

The nearby lymph nodes surrounding a malignant breast tumor can be exposed with a special florescent dye (ICG) and a new special infrared light and camera made by Hamamatsu which is better than using radioactive chemicals and complex detectors.  The sentinel node and others can readily be seen through a few centimeters of tissue with this instrument and only those that are distorted (malignant) need be removed.  This can significantly reduce the chance of lymphedema and hence give the patient a greater quality of life.  Expanders for breast implants are painful and every effort should be made to minimize the duration of use.  It should be used for only a few weeks following surgery and then removed and the implants inserted so that any chemotherapy can commence shortly after this procedure and the patient does not have to wear the expander during a long period of chemotherapy.  Wearing the expander during such long treatment periods is most uncomfortable and indeed painful at times.

Follow up checks should be made frequently and occasionally with a PET scan if at all possible.  Unfortunately, the use of PET machines in Ontario is limited to only a few procedures because of government regulations.  It is strongly recommended that this government reexamine this misguided practice as PET diagnostics are very sensitive to cancers and could save expensive and unnecessary surgery and chemotherapy and of course lives.  Body scans can also be made with radioisotopes such as 99Mo and 99mTc linked to methylene diphosphonic acid and they can reveal metastases of a cancer.  The MDP binds to bone and accumulates in areas of cancer.

There are numerous types of chemotherapy drugs but unfortunately, only about half of these drugs are available in Ontario.  Some of them have various and sometimes insidious side effects.  Some of the drugs to mitigate these side effects, such as codeine, should be used with caution as it has mood altering effects which can upset family relations.  A few new types of drugs that attack more specific cancer cells are being developed and Health Canada should have some researchers in these complex but important fields and also help to speed up the decade long clinical trials.

Euthanasia should be available to patients who are in uncontrollable intense pain or have rampant cancer, are horrifically deformed, fully incapacitated, have major brain damage, have limited vital signs or self-awareness, are in an extended coma or near death.  At the end of the day death is inevitable; health care resources are limited; health care professionals have an obligation to steward those resources; and patients and their families must try to accept these limitations.  However, any contested case should be promptly heard by a special federal justice who has a medical background and understanding of such disorders.

Addiction Control

The cost of addiction to the economy is in the billions and at least a thousand lives and such sickness generally degrades the individual’s performance and well being and also that of family members and friends (See Avoidable Costs of Alcohol Abuse in Canada 2002).  About 10% of the gamblers become addicted.  Casinos should not be advertising and spending millions deceiving gambling addicts.  It is estimated that about 200 gambling addicts commit suicide a year and about $15 billion is spent on gambling which is increasing by a billion each year.  The amount that one invests in lotteries and casinos should be limited to at most a thousand dollars or so a week for most players of modest means and the casino can also tally this when chips are purchased.  Furthermore, the use of VLT should be limited to about 3 hours per day every other day and any addicts should be put on a blacklist for a few months.  The Ontario Lottery and Gaming Corporation have recently developed a facial recognition system that can be used to control the amount of gambling for every individual to about 3 visits per week.

Significant addiction and impairment can put the lives of the abuser and associates at considerable risk as well as the public.  There should be full information provided to teens and young adults on the health consequences of gambling and of alcohol, tobacco, marijuana, ecstasy, crystal meth, crack cocaine, and also OxyContin, Percodan and other addictive drugs to help young people understand the specific dangers of the different drugs.  It is also necessary to explain how the drugs work.  Governments, schools, colleges and universities must do all they can to help the different users and mitigate the effects on the inveterate users to minimize harm to themselves and the public.  Repeat bootleggers and drug pushers should be subjected to increasingly severe penalties.

The provincial governments should not be in the business of selling alcohol or running casinos or even lotteries as they are then in conflict with the rules and regulations, such as for advertising, that are necessary to limit these activities.  The Alberta government sold off its liquor business a few years ago and Ontario should consider doing the same.  It is strongly recommended that advertising for alcohol be severely limited as it has been for tobacco products.  The LCBO should not be putting out flashy brochures every other week for their products.  Alcohol products should have warnings on them regarding the potential for abuse, addiction and for increases in accidents.  Binge drinking can significantly reduce life expectancy and drinkers should be advised of this affect.

To mitigate this addiction the amount of alcohol (ethanol: spirits wines and beer) that an individual can purchase at one time should initially be limited to about one liter every other day.  Then, a year or so later it should be limited to about one liter per week.  The amount of ethanol is known for each product and a simple computer system can tally this and also keep track of each person’s purchase with the aid of a photo id such as a health (OHIP) card or driver’s license which can be read by a scanner for the computer.  The LCBO could also use the facial recognition technology that the OLGC have developed to limit the amount that can be purchased in a bar which should also be limited to about one modest drink per hour.  The blood alcohol limit for drivers should be reduced to 0.05 and the legal minimum age for drinking, smoking and gambling should be increased to 19 years.  Repeat offenders of driving under the influence of alcohol or other drugs or of impairment in a public place should be blacklisted for several months by a justice so that they can learn to control their use of these addictive and dangerous drugs.  A blacklisted individual can readily be inserted in the computer monitoring system so that their purchases could be limited.  A black listed individual should have to take a remediation course for several weeks as they do in Portugal.  This could save many lives and families from the misuse of alcohol.  Addicts should be directed to an addiction clinic by the proprietors of the casino or beer, wine and spirits retailer and certainly not enticed to come back again.

One can become addicted to smoking after only a couple of weeks of moderate use.  The amount of tobacco that one can purchase should also be limited to about two packs of cigarettes per week or say 10 cigars.  Eventually these limits should be lowered and any heavy drinkers, smokers or gamblers should be put on a special list of minimal acquisition of alcohol, tobacco, casino chips or use of VLTs to help prevent further abuse or becoming full addicts. 

The treatment centers for addicts are generally limited and some of those that are available need to be updated.  However, the Royal Ottawa Hospital has a new intense program for addicts that have demonstrated a few months of abstinence which appears to be effective.  More research is needed on how to treat patients with severe addiction and how to mitigate the frequent abuse of the spouse or partner.  The costs of treatment in such facilities for the first few weeks should also be shared.

The provincial legislatures should establish an interparty standing committee to oversee the laws and regulations for lotteries, casinos, VLT, bars and for beer, wine and spirit outlets and also for strip clubs.  Obviously the provinces should gradually remove themselves from all of these businesses so that they are not in conflict with regulating them.