Dr. Brian Day @DrBrianDay Twitter

  • Past President Canadian Medical Association
  • Past President Arthroscopy Association of North America
  • Honourary Associate Professor University of British Columbia
  • 2014 Doctors of BC Don Rix Leadership Award

The High Cost of Waiting for Care

Jan 15, 2008

Economic Club of Toronto

Dr. Brian Day
Canadian Medical Association

Thank you very much for that introduction, Dianne, and thank you to the Richard Ivey School of Business for sponsoring my address today, and for your tremendous contributions in developing new health care leaders through your special heath sector MBA programme.

Ladies and gentlemen, it is a pleasure to be here today at the Economic Club of Toronto, and to speak to you as President of the Canadian Medical Association.

The CMA represents over 67,000 doctors in Canada. Its strength and success are related to an ability to adapt to the changing world of medicine.

Remember, Darwin did not promote survival of the fittest or strongest, but rather those best able to adapt.

Well, our health system must adapt to the new reality of 21st century medicine. We can, and should have the best health system in the world. To achieve that we must reject continued indifference to the need for change.

Political leaders across the nation know, but need to be reminded that our system faces serious challenges.

Everyone in this room knows this.

Today, the well being of patients is all too-often trumped by posturing, and politics. We must create a system that revolves around the needs of patients, not the other way around.

Let's face it. Decision makers in the past have repeatedly made mistakes in health policy. Have they learned from those mistakes? Many have. Some so well that they have repeated the mistakes, with great precision, over and over again.

For example, 15 years ago they listened and succumbed as experts advised them that an oversupply of doctors was increasing the costs of health care.

Then they listened as self proclaimed health advocates and coalitions, persuaded them to forget accountability, keep the status quo, and simply pour more taxpayers' money into a failing system.

They listened again as other experts assured them that health care was immune from all accepted economic principles.

Each time they were wrong.

Today I will talk about what the CMA sees as the "unfinished business" of Medicare in Canada - Medicare for the 21st century.

I will share dramatic data that shows the staggering economic impact of long waits.

I will show that waiting for care is a double curse. A curse on patients who suffer and deteriorate while waiting. And a curse on the economy of our country.

Finally, I will announce a major campaign that will drive forward the CMA's recommendations on building a health system that puts patients first.

A system that embraces healthy competition, consumer responsiveness and empowerment.

A system that ensures accountability for governments and health providers.

A medical system for the 21st Century.

Despite what some believe, health care is not immune to established economic pressures and principles.

Existing policies have led to financial disincentives. They encourage health providers:

Not to treat. Not to innovate. And, not to pursue excellence.

Our failure to reward productivity, healthy competition and creativity, has contributed to our situation.

A situation dominated by excess and costly waits for care.

In recent years, governments have tried to reduce wait times, and there have been a few successes.

This action was sparked, in part, by continued warnings from the physicians of Canada regarding the tragic human cost of waiting for care.

This cost takes many forms.

The elderly waiting in pain for a hip replacement.

A child waiting for desperately needed mental health care.

Family members living with the pain and suffering of their wife, their son, their grandfather.

I know there are people in this room who are waiting for care.

These costs are real. They exact a real toll. They represent a real failing of our system.

How much does it cost to wait for care? Sadly, no one has really measured this cost. Until now.

Today I am releasing new research done for the CMA, by the Centre for Spatial Economics. It proves that, in addition to the human health cost, waiting for care results in dramatic and excessive costs to our economy.

Researchers addressed just four priority areas targeted in the 2004 First Ministers Health Accord. They used government and other data to determine how many Canadians were waiting longer than the maximum medical consensus established by the Wait Time Alliance.

(aside... Dr. Bellan, Chair of the WTA is with us today)

Selected for analysis were: joint replacement, cataract surgery, heart bypass grafts, and MRI scans.

Costs, as calculated for all provinces varied from $2,900 to over $26,000 per patient.

The cumulative cost of waiting in 2007, for treatment in just 4 areas, was $14.8 billion.

This reduced economic activity lowered government revenues in 2007 by $4.4 billion.

The reduction in economic activity included the impact of the patient's inability to work while waiting, and direct losses from decreased production of goods and services, reduced income, and lowered discretionary spending.

It is important to note that the figure of 14.8 billion dollars is based only on patients that exceed designated maximum waiting times in just 4 clinical areas. In the example of hip replacements, the research only factored in costs for waits that exceed 6 months.

Of those waiting longer than the maximum recommended time, average waits were 1 year for hip and knee replacement surgery, 7 months for cataract surgery, and twice maximum for heart bypass surgery. Those who didn't make the MRI target waited an average of 12 weeks.

Reduced economic activity included informal caregiver costs.

These costs are generated when caregivers reduce work hours to care for family members on wait lists, or attend appointments with family members.

Patients languishing on wait lists also incur additional costs for drug and other treatments that timely care would eliminate.

Estimates in this study are extremely conservative.

They address only the wait time to treatment after a specialist's consultation and recommendation.

And exclude the growing, and significant costs of waiting to see the GP or specialist.

They do not include anyone who is not working.

They do not include the costs, short and long term, of the deterioration that occurs while waiting.

I want you to imagine the costs if all of these were included, in all areas of clinical care.

As an orthopaedic surgeon, I have seen patients develop chronic and severe irreversible damage, addiction to painkillers, and depression.

It need not happen.

Governments have a legal, moral - and economic duty to deliver timely care.

Let's recognize the economic costs and financial liabilities of waiting patients for what they are: an unfunded liability on the books of governments.

I strongly believe that auditors general should insist that finance ministers write this debt into their annual budgets.

Remember. The $14.8 billion in costs, and the $4.4 billion in lost government revenues, are recurring annual expenses.

Remember. These costs are for just 4 targeted areas.

Yes, we have established maximum wait time benchmarks, but they are far longer than many doctors accept. A rich country like Canada should not keep so many patients waiting, for so long.

There are many countries without wait lists, and yes, they have universal care. So I reject the view that wait lists cannot be eliminated in Canada

Some of you will remember that the 2004 First Ministers Health Accord set a deadline to announce targets to achieve priority benchmarks by all jurisdictions. That deadline passed 2 weeks ago.

That did not happen.

A commitment was ignored.

I am here to tell you that the 67,000 members of the CMA will not let this matter rest.

So let's talk about how we eliminate harmful wait lists. And note, I say eliminate, not reduce wait lists.

The CMA believes this can be done by investing in five key areas.

  1. We must invest in preventative care, health promotion, and emphasize self-responsibility and patient-consumer empowerment

  2. Invest and embrace patient focused care, productivity and excellence

  3. Invest in innovation and technology

  4. Invest in repatriation and retention of doctors and medical students

  5. Invest in training the doctors we need

Note, I say, "invest", not "spend". These investments will realize substantial returns as wait lists are progressively eliminated.

Let me touch on some of these 5 areas.

The economic impact of demographics on our health system cannot be ignored.

The combination of an aging patient population, many with multiple chronic diseases, and an ageing, shrinking medical work force is a recipe for disaster.

Competition, consumer choice, and market principles do not feature prominently in our health system.

The little competition that exists now is the wrong sort of competition.

We suffer from a de facto government monopoly on the funding and delivery of hospital and physician services. In Canada, patients serve the system.

That's the wrong way around.

The consumer receives poor value as governments control spending, and control service delivery and location as well as training and employment of all workers.

Forcing patients to endure pain and suffering in order to sustain a social program is wrong. It is contrary to the principle that all persons should be treated as equals.

The Chaoulli decision at the Supreme Court of Canada meant that governments act illegally when they force patients to suffer prolonged waits for care.

Governments must drastically reduce wait times, or suffer further legal challenges and defeats.

Patients should not have to sue for access.

A legacy of the Chaoulli decision is that all governments must be accountable to patients. In practical terms, this case has had the effect of updating the Canada Health Act.

Where unacceptable wait times exist, the Supreme Court has directed that individuals CAN pay privately for health care services.

From experience, I can tell you that this need not be a debate between public and private. It can be a collaboration. It has helped in a number of provinces.

It has improved efficiency and performance and helped reduce wait lists. The partnerships can work well.

Far from destroying Medicare this has the potential to place patients ahead of the system.

In Canada hospitals rely almost exclusively on block funding. They receive annual global budgets, largely independent of efficiency or productivity.

This is an undesirable, but defining, feature of our system.

It is bad for management, bad for patients, bad for taxpayers and bad for governments.

If we want an efficient health delivery system, we must incorporate valid and effective market principles and financial accountability.

Let's reward performance and patient satisfaction.

Let's promote excellence.

Let's incentivize health providers to deliver successful outcomes.

Let's treat health professionals, hospitals and, most importantly patients as value centres - not costs that consume an annual budget.

The introduction of "patient-focused funding", where revenue follows the patient, will increase efficiency.

As wait lists disappear, new opportunities will open up.

There is an inseparable bond between economics, efficiency, excellence and information technology.

Improved record keeping, communication, data and information sharing - will lead to better, safer and cheaper patient care.

The 2007 National Physicians Survey of 20,000 doctors showed that a significant number of physicians now use electronic medical records.

We still lag well behind many other countries, and in a 2006 survey of 7 developed countries we came in last.

We are suffering the consequences.

Electronic health and medical records are essential to achieving our goals of excellence in patient care.

We spend a third of the OECD average on IT in our hospitals.

This is a significant factor in Canada's poor record in avoidable adverse effects and hospital deaths.

We must document, measure and analyze all data relating to hospital, physician, and patient services.

Patient care and safety often require us to share medical information. Without electronic records this is cumbersome, inefficient, and often fails to occur.

We need IT to establish and track outcomes and perform measurements that will, in turn, drive improvement.

Today's patients are informed consumers. The Canadian Institute for Health Information deserves praise for reporting on the performance of our health institutions.

After all, you own the health system. And, you have a right to know how it performs. You have a right to know how different hospitals compare in results and outcomes.

You have a right to information on the performance and quality of health providers, and how treatment and services in different cities and provinces compare.

These measurements require improved reporting and data management.

Technology is crucial, but let there be no doubt about the critical significance of the looming doctor shortage.

In 1970, Canada ranked in the top four among developed countries in the number of physicians per capita.

We now rank 24th.

Misguided experts in the early 90's advised governments to cut back medical schools based on a theory that an oversupply of doctors increased costs. They got their facts backwards.

An undersupply of doctors and a policy of rationing have led to increased costs.

And, that has left 4.5 million Canadians without a family physician.

The facts are clear. Patients who have a family physician cost the system less, and receive better care.

How many of you in this audience have a doctor in their 50s or older?

Who do you think will look after you when you are older and need medical attention?

Our recent survey shows 4000 doctors are about to retire.

To achieve the OECD average of 3 physicians per 1,000 people Canada would need to add 26,000 new physicians right now.

It is a disgrace that 50 per cent of all newly trained orthopaedic surgeons and neurosurgeons leave Canada within five years of graduation.

Twenty of the last 25 spine surgeons trained in BC have left Canada.

Between 1991 and 2004, the equivalent of two full medical schools of graduates left Canada each year.

They leave because of a system that encompasses rationing and restricted access, leading to the peculiar paradox of a doctor exodus in times of a doctor shortage. This leads me to announce a new initiative by the Canadian Medical Association - one that needs your support.

Today the CMA is calling on Canadians to help build a stronger and better Canadian health care system by joining our "More Doctors, More Care" campaign.

As an international medical graduate, I do believe that Canada should be self-sufficient when it comes to physician supply.

Our situation also demands that we increase training posts for non-Canadian graduates. Now.

It is shameful that, as I speak to you here today, 1,500 young, highly educated Canadians are in medical schools outside of Canada. They should have had that opportunity here. The vast majority will likely never return to Canada.

There has been progress in adding capacity to our medical schools but, to achieve self-sufficiency, much more needs to be done.

Meanwhile, we must try and repatriate Canadian medical students and doctors who are working and studying abroad.

And, we must act now, before things get worse. With a looming federal election health care must be returned to the political agenda.

Over the next few months, the CMA will mobilize Canadians to demand that policymakers take measures to end this country's physician shortage.

Our message will be very simple. Canada needs more doctors, and more care. I hope you will review the relevant materials that are available here today.

Today, I have presented sound economic reasons to invest in the elimination of wait lists.

I have described how these costs are both human and economic.

That fact that waiting for care in just 4 areas costs the Canadian economy a minimum of almost 15 billion dollars, should be a sobering finding, even to our most intoxicated naysayers. The elimination of wait times is achievable and will reduce the costs. We must act immediately. Governments must fulfill their pledges to fix health care.

It is not our role as physicians to passively accept the prolonged suffering of patients. We want to manage patients, not wait lists.

As an orthopaedic surgeon, I am trained to fix, not break things. However, I believe we must break the back of wait times in Canada. Canada should have the best health system in the world. With your help, it is a goal we can, and I believe will achieve.

Thank you.