Thursday, December 02, 2010

Some Musing About the "Moving Forward"Leaked Health Policy Document

The cut and thrust of politics is heating up in Alberta, especially over health care.  Now the discussion is moving towards the place it should about - the fixing of the system.  The leaked "Alberta's Health Legislation: Moving Forward" document has been the catalyst for the policy discussion.  It has been lead by Dr. David Swann, leader of the Official Opposition and the Liberal Party of Alberta and the recently rejected PC caucus member Dr. Raj Sherman.

The details of the debate are well documented in the main stream media so I will not repeat them here. The implications of the debate are what is interesting to me.  I want to talk about the threat of a Two-Tier system that involves private insurance, and if docs can operate on both side of that street. I also want to talk about delisting health service elements contained in the Moving Forward document too.

Swann is pressing Stelmach on if there will be a two-tier health care system in Alberta.  He wants a promise from Stelmach "in writing" he will not allow doctors to work in both the system, a public and private side, at the same time.  There is nothing stopping doctors from option out of Medicare now and working strictly in a private patient pay system.  There are lots of private sector elements in our health care system now.   Any talk of keeping private enterprise out of health care is futile.  That is all ready the case and it is working well.  It is working well because there is a single-payer for health services, the government.  If we allow private insurance to be purchased and to pay for medically necessary services we are into the feared and reviled two-tier system and the unnerving possibility of doctors playing both sides of the street and eroding the effectiveness of the public health care system.

I do not expect Premier Stelmach to commit to writing that he will promise to not allow doctors to work in a private and public system at the same time...because there is no political will (today) to go to a two-tiered system.  That is now.  What about after the next election when the fear is major system changes will be imposed, including a private insurance possibility for health care.  That is what the government plan is according so some interpretations of the "Moving Forward" leaked document.

If it is of any comfort, I received a fund raising letter from the Progressive Conservative Party today signed by Ed Stelmach as Leader. In it he says "Your government (his government) firmly believes we can build a better (health care) system without moving towards a two-tier system with privatisation of health care."   Hardly a public statement since it is in a political party fund raising letter...but it is a commitment of sorts to the single-payer public health care system that we now have - and it is in writing.  But as Ralph Klein used to say when he "changed" his political mind for political purposes"That was then. This now."

It has a bullet about health providers working to full scope of practice.  That is a problem as Docs, Registered Nurses and Licensed Practical Nurses are all underutilized to some degree or other, due to the payment system that is used to pay docs.  More on that at some future time.  What Moving Forward talks about is providing health providers to opt-in and opt-out of the public health system as part of the new Health Act.  I have not reviewed the just past Act but know that doctors can to that now.  Why is it part of the "new" law?

The proposed policy shift in Moving Forward that is intended to bring "fairness" to this fictitious imbalance is to "Apply the same constraints to all health providers and allow government the flexibility to regulate health provider commitment in the public system."  That is very abstract language indeed and fairness to physicians is compared to the way midwives and pharmacists operate in a partially publicly and privately funded arrangement.  To meet the spirit and my sense of the intent to induce more fairness would mean we would need to make sure Midwives and Pharmacists would enjoy access to a fully funded public payer system for their areas of endeavour, including a fully funded drug program.  That way they and the docs would be on a level playing field under the current arrangements.I don't see that sense of providing fairness to druggists and midwives to be involved in the Moving Forward proposals at all. This framing for "fairness" to doctors to allow them to play both sides at the same time, if there were a public and private system, is disingenuous at best and intentionally misleading at worst.

Then there is the delisting section entitled "Process to Establish Essential Services."  The issue is stated to be that there is  not a clear process to determine essential services and current services are not based on a "regular, rigorous and evidence-based process."  That used to be more true than it is today and some medical services have been delisted.  There was a full review of what process should be used to see if medical services should be in or out of the public system done by an Expert Panel Chaired by Dr. Bob Westbury.

We at Cambridge Strategies were involved assisting with that review and there was a Progress Report issued to the Alberta government in December 2002..   The Expert Panel was commissioned by then Minister of Health and Wellness, Gary Mar.  The mandate was " review the current basket of publicly funded health services and, on an ongoing basis, to review new health services to ensure that Alberta's publicly funded health services remain comprehensive and sustainable for the future, and provide the best value."

The idea was an expert panel would determine what services were to be publicly funded or not.  Those determinations of what service was in or out of  was also to be done in an open objective way using criteria established by the Expert Panel to determine what new diagnostics, treatments and drugs would be added to the system too.

The review and recommendations made by the Expert Panel were sound and soundly shelved by the Klein government.  The next phase of actually setting up the process and structures to do a thorough and detailed review of current funding, new services, priority setting and specific services review was never allow to happen.  This sense of intentionality and rationality over what health care services should or should not be covered by the goes back even further in Alberta.

Premier Don Getty set up The Premier's Commission of Future Health Care for Albertans that reported in December 1989.  In Recommendation #8.0 sand " THEREFORE WE RECOMMEND that the Government of Alberta, in consultation with health care practitioners and consumers, define with is considers to be basic insured services covered by the Alberta Health Care Insurance Plan."  I will be doing a series of comparisons with the new Alberta Health Act to the recommendations made over 20 years ago in the Premier's Commission on the Future of Health Care for Albertans to see what is same, similar new and missing.  The old Premier's Council  spent two years and made 21 Recommendations and 66 suggestions for action.  The current Minister's Advisory Council on Health represents some very good work too.  It made four Recommendations with a total 20 sub elements including 6 Principles.  A thorough review and comparison will take some time but I think it will be helpful and useful for Albertans to have.

Perhaps the Stelmach government should revisit these reports and finally to stimulate a public conversation about what medical services Albertan want to pay for as a society or as individuals, and how they want to proceed to reconcile and rationalize the differences.  The recent truncated public consultation over the past summer on the new Health Act was not a serious effort at effective citizen engagement.  Premier Stelmach recently said about the new Health Act in the Alberta Legislature "The one thing that all members should focus on is the Bill (Bill 17 the Alberta Health Act just passed awaiting Proclamation) that we've debated in the house that says very explicitly that Albertans will have a say in the future direction of health-care delivery ..."  Go to the link and read Section 14 and see if that provision satisfies your test of if it amounts to Albertans having a say in the future direction of health-care delivery.

There is more to be sceptical about in the Moving Forward document but this post is too long already. My advice is that Albertans better not suspend their critical thinking faculties about this and other public policy directions that may be lurking behind the confidential and closed doors of the government caucus.  Time to use the cracks that Raj Sherman has caused to happen and that is letting some light shine in on what is really happening.  Sunlight is still the best disinfectant.


  1. Allan Hayman3:14 pm

    Ken, On Nov 25 the Parkland Institute release their latest report titled "Misplaced Generosity, Extraordinary profits in Alberta's oil and Gas Industry". You can read it on the Parkland web site and it is frightening. So far no one in the media seems to have picked up on this and to my mind it is the single most important issue we face in Alberta. While the Tories continue to subsidize the oil industry at staggering levels, they are running around telling us that we need to cut our services yet again while we go even deeper into debt just to pay the bills. They are also using this deficit as an excuse to underfund and privatize health care, education, infrastructure and everything else that was once quality public services that we have collectively agreed to pay for through our taxes. The parkland report coupled with the report done by Dr. Jack Mintz, U of C, titled: "Preserving Prosperity: Challenging Alberta to Save" that was submitted to the government in Dec 2007 but not released until almost a year later, show conclusively that the course the Tories are on is a course for disaster in Alberta. Mintz says that if this government doesn't start to get it's financial house in order we will be faced with tax increases in the order of 40% by 2030 just to fund the most basic of services. Another report was done in May 2010 by Kevin Taft et al, titled: "Follow the Money. Where is Alberta's wealth actually going?" and it shows how Alberta spends it's money and who benefits. All of this information is substantiated with verifiable statistics and collectively should be of considerable concern to all Albertans. How this province organizes it's finances affects every
    aspect of life in Alberta. The latest "crisis" in health care is just a symptom of the myopic focus of the Tories and shows us clearly who they consider their "real" constituents to be. Unless we either change our government or frighten the Tories into actually governing responsibly, this province is headed for bankruptcy, because when the oil is gone, and it will be gone eventually, Alberta will revert to what it was in 1947 when oil was discovered in Leduc, a bankrupt, have-not province, only this time we will have no way of getting out of that fix. How about devoting some of your blog to waking people up to the realities of what the Tories are doing with the wealth of this province.

  2. Stay tuned Allan - I will be posting comments and thoughts on that very thing. We have to start paying our way and not using one-time non-renewable oil revenues to subsidize a low tax regime. We are stealing from future generations and we have no right to do that.

  3. jerrymacgp8:40 am

    What sort of health care is "medically necessary"? What care is "essential"? these are value judgements to a large extent, and many Alberta residents are highly distrustful of the current government's values in this area.

    As a Registered Nurse, I see many examples of forms of care that are not covered by Alberta Health Care, and therefore must be paid for by the patient, either out of pocket or through private supplemental health insurance. One very serious example that has a significant impact on public costs is the investigation and treatment of "sleep-disordered breathing", i.e. obstructive sleep apnea and related conditions. Despite the fact that people with sleep-disordered breathing are at high risk for hospitalization and early death, and the fact the the condition contributes to such serious cardiovascular conditions as chronic heart failure and pulmonary hypertension, patients must pay for sleep testing, and also must pay for the special breathing device (called a CPAP machine) necessary to treat those who test positive for the condition. I have known a number of clients in my practice who have chosen not to undergo the testing, even though it is clinically likely that they have the condition, or declined to purchase CPAP equipment, due to cost; these people are likely to continue to cost the system much more in terms of ER visits and hospitalizations for the resulting complications.

    While many of the people with sleep-disordered breathing are obese, and therefore one could argue that it is largely preventable, it isn't as simple as that. Firstly, by the time an obese person develops sleep apnea, the person has been obese or overweight for man years; one can't turn back the clock. Also, sleep apnea leads to decreased exercise tolerance. How are they to be expected to lose any weight if they can't even walk half a block? Finally, what about those people with the condition who are of normal weight? These are the kinds of ethical questions we must deal with if we are going to adhere to a "blame the patient" mentality in health care, which is advocated by many of the same people who advocate delisting of services.