Tom Kent (Cure it, or lose it, bit by bit, March 1) has ½ of an excellent prescription for health reform. He rightly emphasizes the need for national coordinated leadership and for up-stream investment in health promotion and addressing the poverty, exclusion and other social factors that underlie health inequalities. He alludes to Tommy Douglas’ call for a Second Stage of Medicare with dental, pharmacare, prevention and community-based care and support that would keep people healthy. (see the Bob Gardner’s letter as published in the Globe and Mail on March 2)
But sustainability will not be achieved by having individuals pay for care when they need it the most – i.e. when facing large hospital or treatment costs – and the impact would be harshest on the most disadvantaged, who already face poorer health and more complex care needs resulting from social inequality. What needs to change is the fundamental structures that drive costs, and one of the most important is how physicians are paid. Fee for service builds in precisely the wrong incentives: it fragments care into separate procedures, discouraging continuity; and encourages seeing more people faster than is good for quality. Capitation models in which clinics or practices receive a global budget for their population build in incentives to keep that population healthy and support the kind of coordinated multi-disciplinary care and health promotion Mr. Kent highlights.
Other key cost drivers are drugs and technology; both of which can be controlled far more effectively through stronger bargaining with industry and provincial and regional coordination.
Many of the solutions to sustainability and efficiency are already out there. There is a huge amount of front-line innovation going on across the country; the challenge is to create forums and mechanisms where lessons learned can be widely shared and the most promising initiatives can be rigorously assessed and scaled up where appropriate.