Here We Go Again: Federal-Provincial negotiations on Transfers for Health Expenses
Some things never change! In 1965, when Judy LaMarsh was Federal Health Minister, the provinces were already sounding warnings of the rapid increase in health care costs, even though the Canadian Federal/Provincial Health System, had only been in place for six years! Years later, when Paul Martin was Finance Minister there was lots of federal/provincial debate about the costs as the federal government sought to slow down the growth by capping transfer payments. And so, it has gone with every government federally and provincially since the inception of the system in 1959 then Medicare in 1969.
So now they are at it again: the provinces, with legitimacy, arguing that the system that was supposed to be a 50/50 cost sharing has drifted a long way from that with the provinces left holding the bag for way more than was intended in 1959. The Hon. Dominic LeBlanc expresses the intent to have a resolution this fall while Mr. Higgs keeps pushing, as he should, for a larger fiscal presence by the Feds.
But it won’t stop there!
Whoever succeeds Mr. Higgs will carry the same theme with his colleagues to Ottawa. As one of my trusted physician colleagues said to me recently, “you can’t spend your way out of this problem!” And my learned friend is absolutely correct. The Feds may, and should, infuse more cash this time, again! But fundamental change is sorely needed that is well beyond system tinkering and these columns had made that point over and over. Let’s do a short re-cap.
First of all, the structure of the system begets annual cost increases of 2 to 3 times the inflation rate. Accountants go into denial at the very thought but it is true. The costs of health care are a product of demographics, labor contracts, technological advance, professional service contracts, regulations created largely by the professions and unions, staff mix that is driven by professional bodies.
As a CEO, I often had the experience of government announcing a 3% inflationary adjustment to our budgets while the union contract costs, including all direct and indirect expenses, were significantly more than 3%. And we were always given stern warnings to balance our budget when the die was cast before the announcement was made.
The basic business model of health and long-term care is based on models of care common in the 1950’s and thereabouts. That model has not changed to reflect the market place, the social and demographic changes, practice changes, technology and ever so much more.
Deputy Mayor Brennan of Blackville has circulated his position on the fragility of the rural ambulance system. He would be joined by mayors of other communities in expressing frustration over inconsistent rural service. The model of Ambulance Service is based on a model that seems to serve urban areas fairly well but serious issues have been reported for years from the rural areas. The system, as we now experience it, costs tens of millions of dollars more than the system that it replaced and was supposed to improve service province-wide. The old model worked fairly well in urban New Brunswick but the reported issues seemed to emerge in some of the rural areas in which service was heavily reliant on volunteers. Some other rural areas in North America still rely on local, volunteer systems that work pretty well. Is New Brunswick getting its money’s worth with what has been a fairly hefty investment. I profess no great expertise, but I did some service on the ambulance when I was a young man with first aid training. None of the heart attacks or accidents that I responded to died on my watch!
Primary health care is based on an old model that does not fit too well in 2022 and some strong directions need to be pushed. In 1992 the government of Canada published the Romanow Report. The author was a highly-respected Canadian provincial premier and his commission heard from people across the country about health issues that were of serious concern. Romanow visited the Sault Ste. Marie clinic and after his visit and learning of the power of the interdisciplinary primary care model, he dubbed that clinic as “Canada’s Best Kept Secret!” That model, emulated by a few in other parts of the country to an extent, provided a model of care that allows doctors to do only what 12 years of training requires with much of the day-to-day routine of primary care being done by social workers, case managers, nurses, physician assistants, Nurse Practitioners.
But the Romanow Report, as with the Lalonde Report from over a decade earlier, gather dust. The Federal Government, rather than simply passing out more money, could have and should have seized these reports and worked with the provinces to create new models of care for the country. Instead, each province is left alone to wade through the local political morass of trying to effect change.
Nursing education, deployment, workplace environment all beg for key strategic change. The “all RN staffing model” and the Baccalaureate degree as entry to practice have proven to be interesting goals and academic and political positions. The population loves nurses but is all too aware, from the crises that have been described in the media now for 20 years, that care is organized in a flawed model! The university education of nurses has created a class of RNs who are exceptionally well educated but the structures in which they function need overhaul, according to their representatives. There are elements of the “old model of training” that need re-examination.
Some ask the question: did we throw out the baby with the bathwater? Was it necessary to create such separateness in the training and education of these essential clinical specialists? And where do these questions get researched, debated based on evidence with a business model created that meets the needs of 2022 and forward.
And what of the health authorities? The regional hospital corporations were structured based on an old, some say irrelevant, form of organization in which accountability is quite lacking at various points in the organization. Employees are supervised often by good people that often are members of the same union as the employees.
There are more relevant models for structuring hospital services.
Another debate lies just under the surface surrounding the overuse and abuse of diagnostic procedures (lab tests, ultrasound, x-ray, CT and MRI scans) and drugs. In my training, I remember a seasoned family physician telling me: “most of my diagnostic work is done with my hands, my eyes, my ears; then the tests just simply confirm what I have concluded!” Fast forward to today in which patients feel somehow disadvantaged if the doctor does not order at least one, hopefully more, major diagnostic test and some new drugs.
And virtual medicine? Its development has accelerated during the pandemic owing to the fear factor, both doctors and patients. Used with discretion, it can be a superb adjunct to primary and consult care; but it is not a replacement for the real communication that takes place when the health professional and the patient (and family) are sitting in the same room!
And why should the Federal government take the leadership in promoting alternate models of care and organization? Because on the world stage, the Canadian health system is not exactly a beacon of excellence to be emulated. In the OECD publications, Canada does not rank where it should in terms of results vs expenditures, according to the New Brunswick Health Council. While the Federal government’s response has always been to announce increases in transfer payments in some form to respond to the province’s legitimate cry for more funding, the center core issue is changing the business model of so many elements of the health and long-term care in Canada. Leaving the provinces to simply try to adapt on their own is political suicide locally. The Feds need to offer the sort of leadership they were known for in the early days of the current system when they employed great people who really knew how the system works and collaborated at a practical level with the provinces.
We cannot spend our way out of fixing the health and long-term care system.
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 firstname.lastname@example.org or www.kenmcgeorge.com
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Ken McGeorge, BS,DHA,CHE is a career health care executive based in Fredericton, NB, Canada.