We need results-based management of how we spend our medicare dollars to make our money go further, says Carolyn Bennett, a Liberal MP [ruling centre-right party in Canada] and doctor who just visited the clinics of Havana
Carolyn Bennet
Thursday, August 31, 2000
When the first ministers meet on Sept. 11 to work on the sustainability of Canada's health-care systems, I'm relieved to note they won't just be uttering a predictable cry for more dollars. They went on record earlier this month with a commitment to find systems that provide quality health services and also "promote the health and well-being of Canadians."
Despite the fact that a huge demographic, the boomers, is moving into late middle age, we must somehow reduce the demands on Canada's health-care system. To find ways to do so, it's instructive for Canadians to look south: not the south of George W. Bush, but farther south, to Cuba, which long ago decided that it wouldn't be able to afford to have its citizens get sick and so would focus on keeping them well. Despite our serious concerns about Cuba's human-rights record, it's a mistake not to steal good ideas wherever they exist.
This summer, I was asked by Health Canada to attend the International Association of Health Policy Conference in Havana. Cuba's deputy minister of international health organized a tour of the country's system of family medicine and maternity homes. I'd never heard of one of it mainstays -- a "policlinic" -- but, on arrival, I was smitten. In his tiny, loudly air-conditioned office at the Plaza Policlinic, Dr. Pedro Pons described his facility: open 24 hours a day, seven days a week, offering after-hours care, a laboratory, a pharmacy, and specialists who rotated through for half-day clinics. The facility serviced 32 family practices in the district (each with a doctor and nurse), all within walking distance of the clinic. An epidemiologist on staff worked with Dr. Pons and each family doctor to develop a specific health-promotion and disease-prevention program for the patients.
We then crossed the street to the small Consultorio #21 of Dr. Jorge Sancristobal Diaz, a family physician, and his nurse, Maria Estrada. It was a tidy bungalow, like the other homes on the street. The inside was spartan, with old but functional equipment, and posters warning about the dangers of cholesterol on the walls -- just like most doctors' offices around the world.
What was different was the impressive charting system and the practice's
annual report. Each of the Policlinic's patients had been classified by age
and gender, then designated with a risk rating: I, Healthy; II, With
Risks;
III, With Disease; IV, With Disability. Each household was rated
with respect to hygiene and socioeconomic factors (including incidents of
violence). The doctor explained that visits and follow-ups were organized by
the risk rating: On quiet afternoons, he'd make a house call on any risk
III
and IV patients who'd not been in for a while.
Each year, the risk factors of his patients are tabulated. In l999, the practice had 66 smokers, 45 with stress, 14 obese, 16 with high cholesterol and 15 considered sedentary. All diseases were noted, as were the outcomes of each pregnancy. Even the education levels were documented year by year.
The report boasted of the doctor's 13 "accomplishments," including the two patients who had stopped smoking and the three who had had vasectomies. And it mapped a "plan of action" for the following year, which included using medicine only when absolutely necessary, getting more patients to stop smoking and ensuring that adolescents didn't start. (Even Fidel Castro has given up his cigars to be a better role model.)
In my Toronto practice, it would have taken a raft of summer students combing over the charts to produce a document such as this Cuban family doctor's annual report. But it's a great idea. To judge how we're doing, we need information. We need to know how many babies there are in our practice and how many have had their shots, so we can call the ones we're missing (something Canadian veterinarians have been doing for years). We also need to know the number of women over 50 within the practice and, of that number, how many have had mammograms. Our current system -- paper charts without even the most urgent data computerized -- is from the Dark Ages. It places us far behind Cuba in giving health-care workers the ability to know how to manage our health-care system properly.
In Canada, federal initiatives such as Canada's Food Guide, the Participaction exercise promotion scheme and various campaigns to encourage people to stop smoking have been important. Yet we have never really adopted an approach at the family-doctor level to promote accountability and real management. Thus, it's not surprising that in the United Nations Human Development Report (which names Canada as the best country in which to live), Cuba surpasses Canada with 99 per cent of its babies immunized against measles as opposed to our 96 per cent (and the United States' 86 percent).
Most governments and businesses embrace results-based management. They accept the principle that, if you take measurements, you notice problems. And if you notice problems, you deal with them.
A results-based system in medicine -- in which a practice must produce
its own annual data, not only of disease and trauma but also immunization,
waiting times, all health determinants -- would surely result in better
outcomes. A system that simply rewards volume, and only worries
about
quality when there has been some medical misadventure, will never be
able to sustain itself.
That's our system, and it's in trouble. If Canadian doctors were
required to provide a policlinic-type report every year, it might offer an
incentive for them to move to broader results-based management (and move to
keeping
electronic medical records). The World Health Organization has
placed Canada 30th in overall health-system performance; Cuba is 39th. Canada
was 10th in health expenditure per capita (valued in international dollars),
Cuba 118th. WHO's main criticism of Canada is that we're not getting value for
the dollars we spend. At the extreme, the U.S. ranked No. 1 in spending, yet
37th in performance. The American situation is clear: Pockets of excellence
don't make up for millions without coverage.
On the actual level of health, Canada came 35th, Cuba 36th and the United States 72nd. One could interpret this as a vote in favour of universal medicare systems; or you could argue that what's also affecting the statistics are factors such as poverty and violence. Either way, countries that have decided to look after one another do better than those who have chosen survival of the fittest.
Cuba is not without problems. There are hardly any drugs or technology, although Cuba has more than twice as many doctors per capita than Western countries. A physician's monthly salary is equivalent to what a busboy in a Cuban resort can make in tips in one day. But Canada has problems, too. We must focus more on prevention, organize primary care, and measure and use health information.
At their Winnipeg meeting on Aug. 11, the premiers committed themselves
to every one of these efforts. Better accountability, better reporting to
citizens, the federal government has made clear, is not about "big
brother"
Ottawa checking up on the provinces. Rather, it's about all levels
of government assuming the responsibility of reporting to Canadians about the
effectiveness of our system. As the first ministers prepare again to meet, I'm
excited by the prospect of an emerging consensus. We do know what to do. Let's
get on with it.
Dr. Carolyn Bennett is the Liberal MP [ruling centre-ring party in Canada] for St. Paul's riding in Toronto and an assistant professor in the department of family and community medicine at the University of Toronto. She is the author of Kill or Cure? How Canadians Can Remake Their Health Care System.
Source: Globe & Mail, August 31, 2000