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February 7, 2007

Board of Trade Health Conference

The Board of Trade's February 6th Conference on Health Care was rewarding for a full house of 500 participants, most of whom had backgrounds that would have enabled them to serve as panelists. The format consisted of a day of presentations and panels with limited opportunities to present written questions. Unfortunately, the Board promoted its health care cost clock at every chance, frequently during the introduction of speakers. One officer of the Board asserted during his introductory remarks that all serious researchers know that health spending will reach 70% of the provincial budget by 2017 if something doesn't change. Groans could be heard in the audience. Toward the end of a 10 minute interview, former Deputy Health Minister, Dr. Penny Ballem, recently told a CBC Early Edition audience that there is no evidence to support the Premier's position with respect to the growth of health costs. Premier Campbell spoke to the Conference at noon and centered his remarks on questions about how to control costs. When asked about the reliability of the 70% figure, he responded that it might be 65% but it is not worth quibbling over such differences. It is more likely that health spending will represent between 40% and 45% of the provincial budget by 2017, but as astute readers have pointed out, measuring health spending as a percentage of the provincial budget is not helpful. If welfare is cut (as was done by the Campbell government), simple mathematics means that health increases as a percentage of what remains.

Serious observers look at health spending as a percentage of gross domestic product (GDP). Those figures are available from the Canadian Institute for Health Information (CIHI). Preliminary figures project total health spending (public and private) in BC to be 10.8% of GDP in 2006. Real GDP is expected to grow by 3.4 per cent in 2007, and adding 2.0% for inflation gives nominal GDP growth of 5.4%. That is lower than the 7.3% increase announced for the Ministry of Health in 2007-08, but in the long term 3% real growth is enough to cover 1% for population increase and a further 1% per year for the effect of an aging population, leaving room to spare when inflation is added to both GDP and health costs. The record shows that growth in health costs has varied but in BC it has been 4.0% or less for 10 of the last 14 years. The Conference received a wealth of data from Glenda Yeates, president and CEO of CIHI. She concluded that: "One of our greatest challenges is sorting out the truth from the anecdote."

Apart from the political agenda of the Premier and the Board of Trade, the rest of the Conference could have been called a celebration of public health care with recommendations on how to make it better. Dr. Kenneth Kizer, former US Under Secretary for health, Department of Veterans Affairs, told the Conference that the Veterans Health Administration is the largest integrated health system in the US, and it is a public health system. He described how it went through a transformation, beginning in 1995, that led it to be recognized as offering performance superior to U.S. Medicare (a fee for service reimbursement system) on 13 indicators between 1997 and 1999, and on 12 of 13 in 2000. Like many speakers during the course of the Conference, Kizer stressed that measuring and publicly reporting performance data using standardized measures is a power change strategy. That sounds like what Dr. Ballem regularly emphasized. When asked what he learned from the private health sector, Kizer replied: "nothing, our lessons came from other industries." As a large successful public health system there is a wealth of literature available for those who want to learn from the lessons of the modern Veterans Health Administration, including a review of its transformation in The American Journal of Managed Care and a comparison of quality of care between it and other systems in the Annals of Internal Medicine. Champions of increased privatization had to be disappointed by Kizer's presentation.

Things got worse for opponents of public health care when Dr. Jonathan Lomas, CEO, Canadian Health Services Research Foundation, spoke about myths and realities in health care. He debunked suggestions that a parallel private system would reduce wait times, that for-profit ownership is more efficient and that user fees would stop waste and encourage efficiency. Lomas questioned the concept of privatization, pointing out that it can refer to funding, ownership and/or delivery and that its purpose can be to supplement public care (e.g. private hospital rooms), to complement public care (e.g. dental care) or to substitute for public care (e.g. purchase quicker access). He cited evidence from Australia showing that the more money spent on private care, the longer the wait in the public system. He noted that private care means quicker care for those with deep pockets, but it means longer waits for everyone else, not just longer than the private system, but longer than would be the case is a purely public system.

Mark Britnell, Chief Executive, South Central NHS Strategic Authority, Great Britain, enthusiastically told the Conference how the NHS has been transformed so as to reduce waits for elective procedures to a maximum of 18 weeks by 2008. In 2000 the Blair government committed to raising spending on health care from roughly 6.9% of GDP in 2000, to 8.1% in 2006 and an expected 9.1% (the EU average) by 2008. That has been done with the use of private providers paid with public dollars, so from the view of the patient full first dollar publicly paid coverage is in place. Many of the changes described by Britnell resemble some of the ideas floated by the Campbell government in its Conversation on Health. Caution must be taken, however, when generalizing between systems that involve numerous differences. For example, NHS physicians are not paid fee-for-service; their pay is principally some form of capitation. Britnell spoke about increasing patient choice by allowing people to change physicians, but Canadians have had the freedom to see any physician they choose, and change as often as they choose, since the inception of Medicare. If some aspects of the change in the NHS are going to be considered in BC, then it is important to study all features of their system so that benefits attributed to one aren't actually due to the operation of others that are overlooked. Googling "NHS reforms" produces a wealth of reading material, including the view from the UK Department of Health website.

 
 

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