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Wednesday, July 14, 2004  The Halifax Herald Limited

Medicare: converting promises into realities

By TARUN GHOSE

CANADIANS are closely watching how Prime Minister Paul Martin fulfils his promise to fix medicare. Mr. Martin will be meeting with the premiers and territorial leaders this summer to agree upon long-term reforms of the system.

Since the health accord of 2003, Mr. Martin has added $42 billion for health care in current and planned spending to 2005-06. This includes approximately $15 billion to bring the federal transfer for health to 25 per cent of the total health care budget, as recommended by Roy Romanow. However, it is widely recognized that money alone will not solve medicare's problems, and effective reform will need extensive changes throughout the system.

Shortening waiting times is everybody's top priority. In general, waiting times depend upon the reserve capacity within a system and efficiency of management. Mr. Martin has targeted $4 billion for major waiting time reduction in five years, but funding alone will not reduce waiting times.

Emergency room overcrowding and waiting can be controlled only by reducing the inflow of patients (e.g. by providing 24/7 care in primary-care centres or by multi-disciplinary family physician groups); increasing manpower and resources in emergency rooms and by providing more acute-care beds to move patients out of emergency rooms. At present, about 15 per cent of acute-care beds are occupied by patients who should be in chronic-care facilities, which also have persistent shortages of beds due to downsizing.

Shortening waiting times in emergency rooms requires far-flung changes, including replacement of the present fee-for-service method of physician remuneration by salaries. This will facilitate 24/7 care through primary-care and group-practice facilities, allow long-term planning and help cost control. Because present average net incomes of family physicians and specialists are reasonable ($148,674/year and $183,775/year, respectively), physician salaries will not affect the health care budget.

To shorten waiting times for medical imagings, there has to be enough equipment, trained technicians and specialists. Currently, there is a shortage of both radiology specialists and technicians in Canada. Privatization will only exacerbate the problem by taking away scarce manpower from the public sector. Several U.S. hospitals have cut waiting times by outsourcing imaging data to specialists in India. Such outsourcing may be useful in Canada, where 50 per cent of patients waiting for surgery are waiting for pre-operative imaging. Outsourcing of imaging also saves money - about $9.3 million a year if 10 per cent of imagings are outsourced.

Offering out-of-province and out-of-country diagnostic service and care will not only shorten waiting times, but also introduce the element of choice which medicare now lacks.

The manpower shortage in health care was created by cuts in the intake of medical students, nurses and residents. Mr. Martin's promise to increase enrolment in medical (about 1,000 new students per year) and nursing schools is timely. Another $75 million has been allocated for fast-tracking the accreditation of foreign-trained doctors. This allocation is designed for 1,000 foreign doctors, but there are not enough openings for them in the residency programs. In fact, 600 foreign doctors are already waiting for entry into residency programs.

The number of unemployed foreign doctors in the greater Toronto area alone is estimated to be about 5,000. Yet, 1.2 million Ontarians have no family doctors and three million have no regular physicians. Ontario and Quebec immediately need 1,500 and 1,000 new physicians, respectively.

Provisions for making prescription drugs affordable, such as basic level and catastrophic drug coverages, are essential because of the spiralling costs of prescription drugs - an 11 per cent increase in 2003 alone. The increased cost is due to higher drug prices, a switch to newer (and more expensive) drugs and an overall increase in prescriptions. The federal government intends to lower the cost of prescription drugs mainly by bulk-buying.

Multinational pharmaceutical companies price drugs on the lucrative principle of what markets can bear. Even though the big pharmaceuticals claim they need their astronomical profits for research and development, these companies topped the list in profitability in the annual Fortune 500 survey, yielding a return of about 17 per cent on investment.

A substantial part of the research is for discovering "me-too" drugs (to compete with similar drugs in the market) or drugs that sell well in affluent societies. Clinical research for drug evaluation is, in reality, part of the regulatory approval process. Their research expenses are tax-exempt.

The best way to control the price of drugs will be to reintroduce compulsory licensing, which allows competing pharmaceutical companies to market the identical drug (the generic version), with a pricing system that compensates patent holders for research and allows a reasonable profit.

Attempts to control the price of drugs have been consistently thwarted by big pharmaceutical companies' powerful lobby. It is therefore gratifying that Canada withstood the joint pressure of this lobby and the Bush administration, and took leadership in amending the Patent Act so that cheaper, generic versions of patent drugs can be provided to African countries. The same courage is necessary to reintroduce compulsory licensing domestically.

Discouraging over-prescription by physicians will also lower expenditures and reduce the risk of adverse drug effects among the institutionalized elderly who are notoriously overprescribed.

Plans for long-term care should carefully consider changing demographics and patterns of diseases. Canadians are living longer, and the burden of age-related diseases on the economy will soar. As the baby boomers reach the cancer age, in about 2010, cancer will become the leading killer of Canadians, and the high costs of treatment and care will strain the medicare budget.

Health care for the homeless has been neglected. The number of homeless has been increasing by a factor of two to three over the past two decades. The homeless in Toronto have a three to five times higher mortality rate than the general public; the rate among young homeless women is 10 times higher than in similar, housed women. Many diseases among the homeless are lifestyle-related and need specially designed care.

The promised reforms in health care undoubtedly need constructive and critical re-examination during the upcoming federal-provincial meeting, but Canadians are weary of unproductive wrangling based on myopic regional interests or political ideology. All levels of government must realize that Canadians fervently look forward to close federal-provincial co-operation so that they can have sustainable and easily accessible medicare.

Dr. Tarun Ghose is professor emeritus in pathology at Dalhousie University.

Copyright 2004 The Halifax Herald Limited