Canadian health care’s biggest ailment? Tidy narratives

Canadians should and do take pride in our public health-care system. Our deep-rooted willingness to make sure no one is left behind when confronting health challenges is a testament to our progressive values. It’s an undeniable part of our national identity.

But, as Canadians, it’s time to give ourselves licence to move beyond simplistic and defensive narratives to facilitate the scale of system innovation needed to address our present health-care challenges.

We need to give ourselves permission to be loudly frustrated with our access to care. We need to be OK with a relentless questioning of why quality of care isn’t evenly distributed across geographies, disease states and population groups. And we need to call out the fact that, though “free” at the point of use, Canadian health care is actually more expensive than systems scoring higher in global rankings.

We need to know that saying all this doesn’t invalidate a commitment to the universality of our provincial-territorial programs. It doesn’t dismiss the fact that our health-care organizations are jam-packed with hard-working clinicians. Nor should it dampen our celebration of inspiring survivorship stories from coast to coast to coast. All these things can be true, and felt strongly, and acted on, at the same time.

Yet, Canadians are plagued by a reluctance to poke at the complexities of our health care. We’re comfortable saying we want more, better, faster. But we’re much less inclined to peer into the “how” of our health systems, as if pulling at that thread will somehow unravel the grand tapestry of solidaristic Canada.

So, we forgo disrupting the imagined monolith that is Canadian medicare and proceed to tinker by means of ad hoc resource injections (a top-up here, an inflation adjustment there) and carefully engineered incrementalism (“let’s try a pilot!”). Of course, there’s nothing wrong with those measures. However, at this juncture in Canada’s health-care journey, we’ve got to admit those policies are mere table stakes. They’re what is done to keep the lights on; not what we need to be the best in the world.

To advance to the next generation of Canadian health care, we have to lean into the “how;” as a crucial prerequisite for such leaning, we must derive political energy from holding seemingly disparate policy concepts in tension. In our policy discourses, we need to grow more comfortable having words like choice, competition, private and profit sit alongside terms like universal, equitable, public and integrated. We need to recognize that what ought to unite all those weighty words is their service to the health-care holy trinity: quality, access and cost. Whatever combination of administrative tactics maximizes those three metrics should be embraced.

To put it even more bluntly, as a patient I shouldn’t care who signs my doctor’s paycheque. I shouldn’t give a hoot what logo appears on their scrubs. As a patient, my preoccupation should be the getting of world-class care, whenever I need it, as close to home as possible. As a defender of universal health care, I should want everyone to receive this care simply by presenting a provincial health insurance card at the point of service. And as a taxpayer, I should also mind the total cost of our health-care systems, for the sake of their longevity. But beyond these outcomes, we need to be as open-minded about internal incentive structures as possible.

This leap toward programmatic agnosticism shouldn’t be difficult since we’re already doing it in primary care, specialized care and diagnostic services. Although we rarely talk about health-care delivery in these terms, primary care in particular is a highly entrepreneurial private-sector driven domain in which family doctors are also small business owners. The price of entry to your family doctor’s office may be a provincial health card – suggesting an administrative harmony with your local hospital – but what happens in the back-office of your primary provider couldn’t be more different than the practices of larger public institutions. In that back-office, in addition to managing patient caseloads, our primary care providers are also on the hook for real estate, staff, payroll, billing, IT systems and the dynamics of patient recruitment and retention.

Critically, the plurality of these clinicians is operating on a fee-for-service or fee-per-patient basis. And as such, in addition to their moral motivations, they have a financial incentive to attract a steady flow of satisfied patients. These segments of our health-care system aren’t a bureaucratic monopoly. They’re a platform for any given provider to be better than the peer down the street. Is such an incentive structure strong enough to overcome the countervailing force of constrained health human resources? That’s a story for another day. The key point here is that the public vs. private dichotomy that we have built up in our minds and in our popular policy discourses is an absolute fiction.

But that then begs the question: What am I griping about? If, even without fully admitting it, we’ve already blended public and private, competition and universal access, what’s the problem? Can’t we just proceed with blissful generalizations of our health-care system, even if misinformed?

Alas, no!

No, because the muddying of our health-care literacy makes it harder for patients, caregivers and citizens to hold our systems accountable. No, because ignoring the already existing competitive and choice-oriented incentive structures of Canadian medicare gives false cause to forces wishing to caricature universality as anti-entrepreneurial. And triple no, because now more than ever, we need policy conversations about the rapid expansion of choice and competition within universal health care – and making such conversations constructive is harder when we overstate the disruptiveness of blended public-private delivery.

This last point gets a special no because while the predominant funding model for primary care providers and specialists is rich with nuance, the hospital funding model is not. While accounting for factors such as last year’s funding level and inflation, our habit of global budgeting for hospitals essentially side-steps an analysis of patient volumes and patient outcomes. For years, this model has been the subject of critique by bookish types, who begrudge its disinterest in value-based care and its dissimilarity to the financing schemes of our international peers. However, these lamentations rarely spill over into popular discourses; and when they do, they seem to incite dangerously defensive reactions (which, understandably, cause cautiousness among policymakers). Yes, there has been some of the aforementioned tinkering. But systemic reform in hospital funding has proved elusive.

The challenge presented by such elusiveness is that it’s impossible to imagine Canadian health care taking any great leaps forward without the hospital sector doing the same, and it’s unreasonable to assume the hospital sector will fundamentally change without its financial realities doing so. Unless policymakers are giving hospitals a compelling reason to want more patients to walk through its doors, hospitals won’t and can’t make the human resource and technology investments required to accommodate a growth in volumes. If being the least effective hospital at treating a particular disease state doesn’t have a fundamentally different impact on your budget than being the best hospital in that same category, how does a hospital plan for and resource continuous improvement? Sure, gumption can go a long way in driving performance. But which health-care organization isn’t already full of it? Which health professionals aren’t always striving to do everything they can for their patients? Funding reforms aren’t a matter of motivation; they’re a matter of more precisely and more rapidly aligning resourcing to value, to innovation, to growth and, ultimately, to the patient.

Which is not to say hospital funding reforms will be easy. The technical design may be, given that alternatives have been thoroughly tested in other jurisdictions. The culture change will be the hard part. Administrators will resist process changes. Results will take time to materialize. And though necessary increases in aggregate funding envelopes will help cushion the blow of shifts in relative funding, the shape of hospitals’ pie pieces will change and that will hurt feelings.

Bringing us back to the beginning of our story: the appropriateness of having big feelings about our health care. The imperative is to recognize that change can be less scary when we understand what it aims to achieve, and to realize that what seems to be change might merely be a scaling of something we’re already doing.

Change will disrupt our tidy narratives. But it may also clean up the actual performance of one of our nation’s most cherished institutions.