Dr. Brian Day
Canadian Medical Association
Thank you for the introduction, and I am very pleased to be here today and to represent the CMA as its President.
Since beginning my term two-and-a-half months ago in Vancouver, I have tried to bring what I call "an orthopod's focus" to the discussion on how we can improve the health care system for patients.
Orthopaedic surgeons are often looked upon as the not too smart medical mechanics or carpenters of our profession. When bones or joints are broken or not functioning well, we try and fix them. I don't believe the Canadian health system is functioning well. It needs fixing. Like many of you, if I didn't think that was possible, I would not be here today.
My remarks today will focus on three key areas in which leadership and action on the part of governments can make a difference for our patients right now.
The first is in information technology.
The second is in health workforce - specifically addressing the dire shortage of doctors, nurses and other health care professionals.
And last, but not least, how do we as physicians help lead the way forward on behalf of our patients.
At a meeting earlier this week in Ottawa a representative from Canada Health Infoway reiterated their goal of having an electronic health record system in place for half of all Canadians by the end of 2010.
Whether or not that goal is achieved has everything to do with regional and provincial efforts such as those undertaken on behalf of SMA physician-members here.
The 2006-2009 agreement here between the SMA and SaskHealth includes the type of long-term commitment to a sustainable program to support electronic medical records that is required to encourage physicians to make the transition to EMRs. Without physician implementation of EMRs there can be no national electronic record system as envisaged by Infoway.
I understand that the EMR program here is currently under development, with the SMA working with Saskatchewan Health organizing the RFP process to select vendors. The CMA firmly believes physicians must have a choice of vendors but only among those who meet a certain set of standards.
The benefits of moving to electronic medical records are widely promoted and evidence is growing that they can improve patient outcomes and make care more efficient.
Record keeping, communication, data and information sharing will lead to better and safer patient care and better coordination of care among providers. For physicians it is no longer a question of if they should invest in an EMR, but rather, when.
The CMA continues to remind governments that, they will reap the most significant cost savings, which is why were are asking them to step up to the plate.
Physicians are subject to a free market in expenses, but not in revenues. Governments must understand that the adoption of EMR by doctors will require additional resources, but the return on investment for patient care and health care costs will be substantial.
I bought my first computer, a Radio Shack Tandy in 1978. In 1979, I sponsored a paper on electronic medical records by then-orthopaedic resident Dr. Myles Clough. A UBC summer student of mine became so interested that he switched from commerce into computer science, later becoming an assistant VP at Microsoft in Bellevue. He retired as a very wealthy man in his early 40's.
Moving toward new technology in medical practice involves growing pains - and I understand that has been the case here in Saskatchewan.
However, the CMA is committed to helping put the pieces in place to build a system that benefits patients and physicians.
One of those efforts is around lobbying the federal government to invest a further $1-billion in Infoway so that funds can go directly to helping physicians automate their offices. We need the federal government to step up, show leadership and commit to making EMRs a reality in Canada.
With Infoway, we have the federal body that can lead the way. We need that federal vision to trickle down to real support for doctors like those here in Saskatchewan who are looking to make the plunge.
Proper funding, choice for physicians and proper protections to ensure physicians remain the stewards of patient data in an electronic environment are the cornerstones of the CMA's efforts in this vitally important area.
As we look to make change in our practices to embrace new technology, we cannot forget that providing medical care is still a hands-on process and right now in Canada we do not have enough hands on deck.
In 1970, when public insurance was first fully applied to physician services in Canada, we ranked in the top 4 among developed countries in the number of physicians per capita.
We now rank a lowly 24th. Each year, between 1993 and 2004, the equivalent of two full medical schools of graduates has left Canada.
Fifty per cent of all newly trained orthopaedic surgeons and neurosurgeons leave within five years of graduation. They leave because we can't offer them the resources they need to work. They graduate with average debts of $160,000, and are forced to factor in their debt as they make career choices.
Compounding this issue, young doctors rightly look at my generation and say "get a life". Similarly, the feminization of medical schools is a statistical reality and brings with it different practice patterns.
Preventative medicine is wonderful, but does not always save money and keeping us alive longer is desirable, but it's proving to be costly.
Health care is facing a demographic tsunami as our society ages and we see more and more chronic diseases. There will be an astounding 43% increase in the over 80 population in Canada by 2011, and their health care costs will create an economic crisis.
Consider just one operation in my specialty: Tell me who will perform the projected 670% increase in the number of knee replacements? Who will fund them as the general workforce shrinks to a level that will not provide enough tax revenue to pay for them?
Currently, we rank near the bottom of OECD countries in access to technology. It seems that as new technologies evolve, we will just not have access. How can that be when we are a rich country that spends so much on health care?
Here in Saskatchewan, the government is to be commended for starting construction on the new university health centre. This, coupled with the increase of 28 medical student places over the next three years is a significant step forward.
Leadership of Physicians
Having touched on some of the challenges we face, where do we go from here?
We stand, right now, at a critical juncture both here in Saskatchewan and nationally.
The SMA has recognized this opportunity by releasing Health Care in Question to focus the minds of your political candidates on the need for:
That, is showing leadership for the people of Saskatchewan.
The CMA is pressing for the rejection of waiting periods that exceed all ethical and medical standards. They do not exist in many other countries with universal care, and they need not exist here. Wait time guarantees and benchmarks were no more than a good start. Their limitations and the potential for litigation are issues that are now being raised.
Waiting patients deteriorate as they suffer physical, emotional and financial hardship. Wait lists impose a huge financial burden - many billions of dollars - on the health care system.
Governments need to understand that it will be cheaper to have no wait lists. Their elimination will prove a worthwhile investment.
Two years ago, the highest Court in the land - in the Chaoulli decision - ruled in favour of the right of patients to insure their health when the public system fails to deliver on its promises. Similar - indeed more persuasive cases - are coming soon to Ontario and Alberta.
Governments appear to be in denial of this reality, even as patients wait for care and physicians grow more frustrated at being unable to provide timely access. This is where governments should put their efforts - in making things better for patients.
Governments must address access and wait list issues.
Frustrations with wait lists led me, in 1995, to found the Cambie Surgery Centre in Vancouver - the first private facility of its type in Canada. The motivation behind our group was simple. Our services were being rationed. Personally, my OR time dwindled from 22 to 5 hours a week. That is 10 hours less than the minimum recommended for competence by the Canadian Orthopaedic Association.
We built our own place to work because the public hospital would not allow us that privilege. Our centre spawned others, and we have become a valuable part of the BC health system.
For our troubles, we have been accused by unions, some so-called consumer groups, and by even a fringe doctors' group of promoting a so-called 2-tier, American-style system.
Demands for health care increasingly exceed supply. The World Health Organization has stated: "if services are to be provided for all, not all services can be provided." Let's face up to this fact.
Advocates of the status quo ignore that we already have a multi-tiered health care system that allows selected Canadians, such as WCB, RCMP and others, access to quicker and better care.
They ignore the fact that the terms "Medically necessary or required" are used widely in legislation, but have never been defined.
They ignore the fact that patients are charged for "upgraded" implants and devices by public hospitals, and a host of other items prescribed by physicians.
They ignore this fact even though it has been an issue since the signing of the Saskatchewan Agreement just a few blocks from here back in 1962.
That historic agreement stated:
An agency must distinguish between its normal enrolment fees and premiums levied to cover the cost of fringe benefits. There is no need at present to embody these details in legislation. They are matters which we trust can properly be dealt with by discussion between the agencies and the Commission.
Sadly, these were not dealt with. Not then, not when the Canada Health Act was born and not since.
Until I get answers, I will continue to ask how can crutches used after breaking one's leg, or an ambulance for someone who has had a heart attack, not be "medically necessary"?
How can antibiotics prescribed to fight an infection, or painkillers to relieve pain, not be "medically necessary"?
Is it not time to update and modernize the Canada Health Act, whose principles were developed over 45 years ago? That was an era when there were no CT scanners, MRI's, by-pass surgeries, joint replacements and so on. Efficiency, Effectiveness and Responsibility - principles that Tommy Douglas described as essential parts of any health legislation, need to be added to ensure accountability.
What is the role of private insurance within the public system? Since 70% of Canadians have it, let's not ignore the fact, but figure out how to use it better.
Why is the implementation of good business and market principles restricted in our public system?
We need a system that treats health workers, including physicians, hospitals, and most importantly patients as value centres - not as cost centres. The elimination of block funding as the main payment mechanism for hospitals will breed efficiency.
Patient-focused funding, where the money follows the patient will bring increased market efficiencies into the system. We are the last OECD country that almost exclusively block funds its hospitals.
The introduction of patient focused funding will both empower patients, and allow government institutions to generate revenue from our health industry.
The world's biggest consumers in the 40-billion dollar medical tourism business are the Americans. This is a business that doubled in size this year, as half a million Americans travelled abroad for care. They did not travel just slightly north to a modern country, with superb health workers and facilities.
This is a potential massive new industry for Canada, and could grow to be our biggest. A pre-requisite is the elimination of our own wait lists - and that is an attainable goal. Remember, since Canada has virtually no non-government hospital infrastructure, the potential income from medical tourism will benefit public hospitals and unionized workers.
Let me make one point clear. Canada's doctors believe that access to quality health care services must be available to all Canadians based on need, not ability to pay.
However, I do support a role for the private sector. If certain services can be delivered better and faster and perhaps more cheaply in the private sector, then governments have a moral and fiduciary duty to use taxpayers' resources wisely.
The public/private debate in this country is, in my judgment, largely irrelevant. Much of the rhetoric is not about saving Medicare, but about defending unionized jobs.
We understand why union-funded groups, such as the various so called health coalitions, continue to advocate for their members. But let us be clear. They are fighting for the rights of their members, which is understandable since that is their job. They are not fighting for the rights of our patients.
In closing, we are focused on putting patients first. How can we achieve our goals? We must fight the tedious public-private rhetoric.
We need more resources for rural health and chronic care, especially mental health. We can generate those resources through savings achieved by the introduction of market principles into the public acute care system.
The CMA and provincial medical associations must insist on urgent reform and action. We are a rich country, and Canadians should not wait for access.
While our system may be bent and broken, I do believe that we can fix it. I stand ready, as I know the physicians of Saskatchewan do, in helping get on with the job of fixing it.