​Health and Long-Term Care Reform: the dilemma for accountants

Professor Richard Saillant, the noted Moncton-based economist and author of Over the Cliff, wrote a sobering article in the Brunswick News on March 4 in which he detailed the difficulty that the NB government seems to have with its fiscal projections.  The current government was elected on a platform of fiscal responsibility, attacking the provincial debt and reforming health and long term care, municipal government, education and other services.  Somewhat accurate fiscal projections are needed but are always elusive in the public sector.
At last count, according to Saillant’s summary, government was projecting a surplus in the current year of nearly $1 Billion.  And to staunch fiscal conservatives, that is incredibly great news.  This could not only stop the bleeding of expenditures but could also provide some capacity to actually reduce the public debt.

But not so fast.  Are you heeding what is really still happening in health and long term care?  Wait times for essential diagnostics are such that private clinics have been developed with the Federal government now “clawing back” over $1 million in health transfer payments.  Worse still are the continuing stories of people either not getting essential diagnostics and care on a timely basis, but still a disturbing number without access to primary care or on long wait lists for long term care.

As has been outlined by several informed thinkers, these are fixable problems; they are not fixed with another 1-800 number nor are they fixed with another glossy report or promise of a better day.  They are fixed when sound strategy based on reality, evidence, great organizational and governance principles are embraced with visionary leadership empowering the process. 

New Brunswick, with the guidance of its two trustees, has apparently been able to get some of these issues started but, as so many have pointed out, there is such a long way to go because reform and modernization has been delayed for so long.

It seems, to this writer, that those in charge of reform in the province must be driven by “cost reduction first”.  If that is the starting point, then the real opportunity for reform can get missed.  Based on reforms that have taken place elsewhere, and even in the municipal reform, there is a certain price to pay for reform.  But the price should be nullified by the serious benefits of reform.

For instance, it could very well cost some money to implement essential reforms in long term care.  but if the result is that we stop the suffering of those sequestered in hospital for months on end waiting for placement, or we enable hospitals to reduce the pressure on Emergency Departments caused by the steady parade of seniors in crisis, why would we not want to do that. 

You are a senior with heart symptoms that are causing you and family serious anxiety.  You are told that they will get to you with stress test.  So, you wait, and you wait.  In northwestern Ontario, our family doctors, having had some additional training by the medical school, were able to do cardiac stress tests with no waiting!  Similarly with colon cancer screening.  Real reform needs to first get to the root cause of the issues in the flow of care.  Why the delays?  Are they preventable?  How?

You are a senior struggling with the care at home for your spouse with dementia.  You had access to a family doctor who has left town and abandoned the practice.  It will cost you over $300 to get a copy of your records so that you can have them available for the after-hours clinic or some other temporary service provider.  And as you chat with other friends of your age, you learn that yours is not a unique situation.

You discover, in chatting with others, that there are options in other jurisdictions in Canada such as the Linda Lee Clinics, the PRIME Model, and others that have never seen the light of day in New Brunswick.

As a senior with multiple co-morbidities, you would be much better off to be registered in an integrated multi-disciplinary primary care clinic where you have access to a Case Manager who has access to your history and file and can direct you, on any visit, to the professional best suited to deal with your issues that day.  This concept of organizing primary care seems so logical and sensible.  How did we ever get to this far from efficient care.

One theory, probably more reality than theory, is that the control of health and long-term care lies with government.  That is not with politicians but with the civil service in which wonderful staff live and breathe on the budget.  The process of getting a provincial budget assembled and approved by the legislature is enormously time consuming, involving the attention and priority of very bright public servants for months.  It is a very closed and secretive system in which advice and counsel from knowledgeable people with expertise is often not sought in any structured way.

Every government in my lifetime has placed much pressure on public servants to “balance the budget” and present a budget that is reasonable and saleable politically.  The current government established as its priority the elimination of operating deficits and the attempt to assemble funds to pay down the deficit.  Many economists, business people and advocates cheer government on and it is hard not to.

But when the pressure is on to cut and show surplus of revenue over expense as the priority, knowing that your career will be influenced by the result, a good deal of creative thinking then is not allowed into the process, or at least so it seems.

The Alternate Level of Care crisis in hospitals, for instance, has been around for 50 years and now said to be at crisis proportions in New Brunswick.  It could be resolved or seriously mitigated in months with some small investment and collaboration.  That has been known for years.  Yet the essential ingredients have never seemingly gotten thru the system.  Similarly, the Emergency overcrowding and Primary Care systems have been creeping up on the province for decades; resolution may require seed funding as part of reform which is like investment in major change.

Reform in this sector is not, as many suggest, simply about recruiting more professionals.  Anyone who has turned a large organization around knows that reform requires a re-direction of how you direct and manage the organization.  Up-front cost to be sure, but in this sector it is possible to mitigate the huge growth in annual cost by fixing broken systems.  That has been shown over again in health and long term care.

But as Richard Saillant points out, the province is suggesting the largest surplus in recent memory.  That will make the proponents of debt reduction contented but it will do nothing for the key strategic issues in health and long-term care, all of which represent New Brunswickers failing to get the quality of care and service they need and deserve.  The large surplus is, therefore, a curse and a blessing.

Ken McGeorge,BS,DHA,CHE is a retired career health care CEO, part time consultant, and columnist with Brunswick News; he is the author of Health Care Reform in New Brunswick and may be reached at kenmcgeorge44@outlook.com or www.kenmcgeorge.com