The meeting of the federal and provincial/territorial health ministers in Halifax on Thursday will be preoccupied with the sustainability of health expenditures and the coming negotiations over the renewal of the health care accord. Naturally, the provinces want to ensure that federal transfers continue to rise to meet their needs while the federal government will be focused on the rate of increase of its health transfers as well as the need to ensure value for money from those transfers.
The rise in provincial government health spending and the tendency for its growth rate to outstrip revenue growth has been well chronicled. However, another dimension to health spending is its distribution.
The dispersion has been decreasing over time. Figure I plots for each province the ratio of its real per capita provincial government health spending to the provincial average for the period 1975 to 2009 using the CIHI NHEX data and the graph suggests that the range seems to be narrowing. Over time, there does seem to have been a move towards greater “equity” in real per capita health spending but the gap is still large. In 2009, for example, Newfoundland spends 20 percent more than the national average while Quebec spends about 11 percent less. Ontario tended to be a bit above the average until the late 1990s and has since slipped a bit below. To me, these numbers tell me that where you live in Canada invariably will affect the quantity and quality of the public health care you are going to receive.
However, there have also been some very interesting long-term shifts. Quebec has gone from being 10 percent above the average in the 1970s to 10 percent below at present while Newfoundland has gone from 20 percent below to twenty percent above the national average over the same period. The question that arises is if you are spending twenty percent more than the national average, is the quality of your health care twenty percent better? If not, are there substantial savings from adopting the practices of the lower spenders? After all, if every province had its real per capita spending on health match Quebec’s, you would be looking at saving billions of dollars in government health spending. Is Quebec doing something in the public health care field we should emulate? Are the provincial health ministers interested in finding out?
Jacques may kindly correct me but I have been checking on health care in Quebec because a job opportunity has come up for me in Montreal and as a Type I Diabetic it matters to me. Plus I would like care in English and if you want that you have to live in certain health districts in Montreal. It looks like I may want to live in the Plateau.
Quebec appears to have moved very strongly to a community clinic/health team model where the doctor is just one practitioner along with nurses, dietitians, even pharmacists. Thus the expensive doctor with his high billing rates has a clear work practice not to take care of everything himself but to move patients over to the cheapest/most effective provider. You'll see the nurse a lot more often under these set ups. Replicate that across the province (these clinics are widespread in Montreal at least) and you will cut into the billing rates and therefore total costs.
Having been in the health system for years with Diabetes I can say that integrated teams are the best, most direct and often cheapest way to deliver clinical results, especially for multiple symptoms/parallel problems.
Posted by: Determinant | November 23, 2011 at 03:19 PM
The Plateau has moved towards the Groupe de Médecine Familiale (Family Medecine Group) concept you describe but Montréal remains a problematic area compared to Québec City or Sherbrooke. Getting on the list may be a little bit slow but given your condition you might get priority..I am diabetic II and belong to a GMF in Sept-Îles. The concept works rather well.
English health care in Montréal is very high quality and easily accessible especially in the downtown area, and even the French hospitals will have bilingual personnel. A lot of people in Montral simply use the nearest hospital, whatever theirs and the hospital language ( the Jewish General is particularly popular among francophone).
The main problem is the latency period when you move from province to province.
Posted by: Jacques René Giguère | November 23, 2011 at 04:40 PM
I was going by the Quebec Ministry of Health website. I read that certain districts like the Plateau and Mount-Royal have an English service mandate. More for my family doctor and diabetic needs, my spoken French just isn't good enough yet for me to have a productive discussion in French about Diabetes. If they send my along to an endocrinologist then I imagine they'd pass me along to McGill. Mature Type I's without serious problems are rare birds.
No complaints about the rules, but I am not going to butt heads with the system if I can get an apartment in a certain area and have the system work for me. Other than my routine diabetic stuff I hardly ever darken the halls of a hospital.
Latency shouldn't be a problem; OHIP cuts out the day Quebec's plan kicks in. Unless doctors have problems billing an Ontario card.
Ontario is moving to the same philosophy as Quebec. "Rostering" or other names for a similar concept. My family doctor is part of a Family Health Team. It means that when your primary physician takes holidays they are automatically covered by the rest of the team. The referrals and management within the team are excellent.
Ontario and Quebec are tring to address the same issue: a legacy of the physician-dominated health system that Medicare took over was that patients had a firm idea that "treatment" meant "seeing the doctor", even though that is expensive and often not necessary. For routine items the nurse is perfectly adquate, for chronic conditions like diabetes dietitians are as important as the doctor himself. Formerly the doctor had to be in control and did a lot of really unnecessary consulting. We are changing that behaviour.
Though if I get the job it is a mixed blessing for you Jacques, the federalist cause and the NDP will both be solidly reinforced.
Say it not in Longueuil, nor in Sherbrooke, nor in the streets of Sept-Iles; amongst the sovereigntists there was much wailing and gnashing of teeth when Determinant moved to Montreal.
Posted by: Determinant | November 23, 2011 at 05:15 PM
Livio, interesting material.
"Where you live in Canada invariably will affect the quantity and quality of the public health care you are going to receive."
It is unlikely that differences in population health status between provinces could be attributed to funding levels. More specifically, it might be the case for those health indicators whose variance is highly correlated with health care interventions, such as cancer survival, ortho surg wait times and outcomes, and geographic proximity to trauma centres, but you really have to mine the data to find that. But quality of health care--the timeliness and accessibility of the right care, reasonable management of iatrogenic risks, and accurate diagnosis--is something that is unfortunately endogenous to the patient more than to the system. Educated, above-median-income patients will have good outcomes in many systems; minimum-wage high school dropouts will have poor outcomes even if they get flown to Massachussets General.
I think human capital factors and income may be more rigorously predictive than percap NHE.
Posted by: Shangwen | November 23, 2011 at 05:15 PM
Sorry: percap NHE = per capita national health expenditure.
Posted by: Shangwen | November 23, 2011 at 05:17 PM
Thanks Shangwen. Of course that leads to the next question. Has Quebec come to this realization and substantially trimmed its spending?
Posted by: Livio Di Matteo | November 23, 2011 at 06:06 PM
Take a look at this report from CIHI.
On p. 36, you can see that the Quebec growth rate per cap is not as frightening as other provinces, and their level is under $3,000 per head. That is pretty good, though it says nothing about quality or policy. I doubt very much, though, that empirical evidence informs spending decisions at the margin. It doesn't anywhere else--increases are either consumption related (for non budgeted items like MD services) or budgetary expansion for hospitals and outpatient care. If we had empirically-driven health systems design, provincial healthcare would be 20% smaller and 30% cheaper.
Speaking of human capital, of great interest is the robust expansion of private health insurance from 1988-2008. My guess is that is driven largely by the expansion of the labor market and workplace benefits in particular; individual purchase would have little to do with it.
Determinant's comment suggests that there has been innovation in delivery models in QC--I don't see it. Quebec has the most conservative regulatory regime for health occupations (few nurse practitioners, and endless exams and incorporeal "bodies" to regulate people). You also see telltale signs of low-cost-effectiveness spending: more specialist clinics, public health programs, etc.
Posted by: Shangwen | November 23, 2011 at 07:45 PM
Shangwen:
Private Health Insurance in Canada does not pay directly for publicly insured services. You cannot substitute private insurance for public medicare. Extra billing is also banned. Expanding private coverage does not supplant or affect public spending, each have separate spheres. No private insurer in Canada pays for physician or hospital treatment for Canadians with medicare.
What private insurance does cover is prescription costs which were not taken into the Medicare system, though they were incorporated into the NHS in the UK. There is still a market for private prescription group coverage. Private health expenses primarily mean prescription drugs in Canada.
There are also minor things like semi-private or private rooms, nurse attendants, medical equipment, chiropractors and dentists.
However, prescription coverage is almost entirely related to the workplace group market. The individual health market is small and specialized. It consists mainly of provincial Blue Cross plans, Manulife and a couple of obscure specialty insurers.
Manulife, of oh so many CoverMe commericals is the operations of the former Ontario Blue Cross, which was sold by the Ontario Hospital Association, it's operator, to Liberty Health in 1998. However the Canadian Blue Cross Association did not permit them to take the name and created another Ontario Blue Cross which is operated by Quebec Blue Cross, is is the same corporation, Canassurance Hospital Service Association.
All Canadian Blue Cross plans have strict medical underwriting for their prescription drug coverage and all except Medavie in the Maritimes have strict dollar coverage limits.
Coverage for existing conditions outside of employer plans is almost non-existent except for provincial last-resort payment plans. This is the untold market failure of Canadian health policy.
Lastly, Quebec mandated private prescription drug coverage or RAMQ prescription coverage for all employers and individuals in 1998; this was the largest policy change to the public/private health mix since the Canada Health Act in 1984.
Posted by: Determinant | November 23, 2011 at 08:14 PM
@ Determinant: Yes, I understand the legal limits about payment methods. I think I broke an unwritten rule in my comment by not addressing you directly.
I have to say the biggest surprise in the chart is Alberta: I would have thought their spending per capita soared. Of course, absolute spending did increase dramatically as they pursued their loony dream of becoming an international health care centre, and generally blowing oil revenue on non-productive initiatives like tax rebates and HC spending. However, their population has also increased dramatically, and the chart is per-cap, not absolute levels.
Now consider this (source):
There's some per capita for you. I'm not aware of the Portuguese, Americans, or the French being exceptionally healthy compared to us. I know for a fact that the Finns are healthier then us. So PCNHE does not tell you much. Switzerland and Iceland are about as far apart as Quebec and Nfld, but their general health is comparable.
I recall seeing once, though I can't recall the source, a table showing PPP-adjusted PCNHE as a function of health status measures correlated with health intervention (i.e., excluding longevity etc.), and the country with highest value for money was Estonia. If I find it, I'll post, but it was well under $1500 USD.
Posted by: Shangwen | November 23, 2011 at 10:51 PM
I know of no rule, written or otherwise, I just know more than I probably should about the system's plumbing. And individual health insurance is my particular bailiwick.
But I'm telling you that Quebec is moving in Community Health Centres in a big way. There are a lot of them.
Easiest way for me to find a doctor in the Plateau over the internet.
About your correlated study: why exclude longevity?
Posted by: Determinant | November 23, 2011 at 11:44 PM
Given the extent to which Canadian labour costs are driven by wage competition with the US, I wonder how much the Quebec discount is driven by a linguistically and culturally captive labour supply. Is the cost difference driven principally by doctor and nurse incomes?
Posted by: K | November 24, 2011 at 12:30 AM
@ Determinant: Longevity and some other health status indicators should be excluded from evaluations of health care systems because they have no correlation with the consumption of health care. They are largely determined by income and education.
Posted by: Shangwen | November 24, 2011 at 05:55 AM
K: "Given the extent to which Canadian labour costs are driven by wage competition with the US, I wonder how much the Quebec discount is driven by a linguistically and culturally captive labour supply. Is the cost difference driven principally by doctor and nurse incomes?"
I wondered about that too. On the other hand, that works in reverse as well, the global pool of English speaking medical professionals is almost certainly a lot deeper than that of French speaking medical professionals given the status of English as the lingua franca of the world's scientific and medical communities, so English provinces can recruit nurses and doctors from other, lower wage, countries (the practice of attracting doctors and nurses from South Africa, for example, has drawn some criticism given the health problems in that country).
In any event, what's interesting about the chart is that BC seems to have experienced a similar decline in relative health care spending. Their spending hasn't fallen as far as Quebec, of course, they but started at a higher level. In fact, the patterns of relative spending in BC appears to closely track that of Quebec. What are they doing out there?
Posted by: Bob Smith | November 24, 2011 at 08:51 AM
Presenting provincial expenditures as a percentage of the average, without discussing what the average is and what's happening to it, is pointless. The numbers take on completely different meanings depending on what is happening to the average. For example, if a given province's average hardly changes, while the national average changes significantly, that tells a much different story than if a province's expenditure-as-a-percentage-of-national-average stays the same while the national average plummets or skyrockets.
We can't draw any conclusions from the figures cited above, unfortunately. You've only given us a small part of the story.
Posted by: Ryan | November 24, 2011 at 09:15 AM
Hi Ryan:
Spending on health by provincial governments has gone in three broad phases. A period of increase from 1975 to 1990, a period of retrenchment from 1990 to about 1996 and then a period of increase since then. Real per capita spending has increased for all the provinces but for some it has increased faster than others. I've put in a graph of real per capita provincial government health spending by province at the bottom of the post.
Posted by: Livio Di Matteo | November 24, 2011 at 09:47 AM
Quebec can and does attract immigrants from former French colonies in North Africa and from Haiti.
Though for doctors I believe they would run smack into the licensing requirements the same way English-speaking immigrant physicians do in English Canada.
Professional licensing makes a mockery of our immigration system. Engineering is the same way.
Posted by: Determinant | November 24, 2011 at 03:44 PM
Per cap spending is indeed a very coarse measure, as both Ryan and I commented. However, it remains one of the core tools of political communication about "commitment" to a viable health care system, and not surprisingly it is the one most easily grasped. Who can fault the public for that? So in that sense, per cap is very important. What is lamentable is how, with very different policies, one could keep the level nominally stable (i.e. let it drop with inflation) yet still improve the ability of the health care system to improve human health. Disease survival, long-term care, and chronic disease management (e.g., diabetes) are areas of relatively high impact, many other areas are not. But, there you are running into the core political problem of health economics.
Posted by: Shangwen | November 24, 2011 at 05:18 PM
The issue is equity of what? There is a difference between equality and equity. If the goal of the health system is to maximize the increase in health on the population then directing more resources to provinces and demographic groups with health deficits may be considered appropriate. Equal per-capital expenditure is not equivalent to saying that health resources are equitably distributed. Take a look at Culyer, A. J. (2007). Equity of What in Healthcare? Why the Traditional Answers Don't Help Policy - and What to Do in the Future. HealthcarePapers, 8(Sp), 12-26.
Posted by: Jciconsult | November 25, 2011 at 04:14 PM