Health care by the numbers

Once again I feel the need to reiterate that my comments about health care are personal opinions only, and do not reflect anyone’s positions but my own.

Part of the reason I am so opposed to the private delivery of health care is that the market tends to work on a principle of caveat emptor – let the buyer beware. The problem with this generally-sound skeptical principle when it is applied to health care is that people are not “buyers” of health care, nor can they said to be “consumers” in the same way as someone walking into a hardware store or restaurant. A hefty proportion of our interactions with the health care system are in times of crisis, meaning that it is unreasonable to expect us to do the kind of cold, rational calculus that one might expect of someone choosing a realtor or a bottle of fine scotch.

Congruent with this issue of need-based service consumption is the incredibly high bar of education required to understand how the health care system works. Most people are capable of understanding a basic supply chain, and can usually navigate the hoops needed to ensure they don’t get screwed on a car loan or a warranty on their stereo (although not always, which is why we have consumer advocacy and protection groups). The kind of education needed to understand health care is, to put it mildly, extensive. Regardless of which country you live in, health care systems are often fragmented and convoluted. Even those who work within the system have difficulties navigating it – how could a lay person possibly expect to do better? This question becomes more acutely important when you consider the fact that those laypeople are in crisis while trying to do it.

It is for this reason that we are best served when treatment decisions are made based on the evidence, as interpreted by people who are educated enough to understand it. While it seems unfair that your medical care might be guided by someone you’ve never met, it is far preferable than being pressured into decisions you don’t understand – particularly at a time when you are particularly vulnerable to either manipulation by outside agendas that may not have your best interest in mind, or when you are psychologically less able to make rational, informed choices. While patients must have the right to make the ultimate choice about their care, we are best served as individuals and as a system when the choices available to us are based on the best evidence rather than our own ‘best guesses’.

Well, maybe not if you ask this guy: [Read more...]

Health care dollars, health care sense

This will be one of my (rapidly becoming less) rare posts in which I discuss something I’m actually qualified to talk about – health care and economic allocation. The reason I do this so rarely is that I emphatically do not wish to have my blogging here confused with my day job. Nothing that I have written here should be seen as reflective of policies or attitudes endorsed by my employer, any university I have been or may become affiliated with, nor any person other than myself as a private individual. While I recognize that this kind of disclaimer carries no legal weight with it, I just want it to be as clear as possible that my comments on health care are as affiliated to my professional life as my comments on racism or religion are – not at all in any way.

With that out of the way, it’s not an accident that I landed in the line of work I am in. I am curious about science and always have been; however, I am also passionate about the idea of publicly-administrated health care and the need to fight for its sustainability. I strongly believe that not-for-profit health care delivery funded by the public sector is the best method of delivery, and that if we approach the challenges inherent in the idea (i.e., waiting lists, resource scarcity) through evidence-based decision making, then we will have far better outcomes than a privately-funded scheme.

To this end I have pursued (and achieved, to a certain extent) some measure of fancy book learnin’ on the subject of useful models for health care delivery and the issues surrounding the way we allocate health care resources. The problem with the way we (I am referring explicitly to Canada here – the American system is a whole other bag of stupid that I have attempted to tackle elsewhere) deliver care here is that it is based on a model that establishes hospitals as the best method of providing service. At the time the relevant legislation was passed, hospitals were where one would expect to go for the most common types of ailments. However, in the past few decades the burden of disease has shifted away from infectious and acute causes toward chronic and end-of-life ones. The system, which should have shifted along with it, did not.

Why is this a big deal? Because it means we are burning money: [Read more...]

Canada doesn’t have a race problem – Attawapiskat edition

Canadians have a reputation as being polite and rather passive. I am not sure what in our history has given us this docile stereotype, or if it is even actually true that Canadians are more well-mannered than our American cousins. What I do know is that there is no faster way to completely invalidate the myth of Canadian civility or progressiveness more quickly than bringing up the fraught relationship between the government of Canada and our First Nations people.

Immediately upon bringing up reserves, or federal cash transfers, or treaty rights, or ceded lands, even the most self-effacing and convivial Canuck is likely to start frothing at the mouth and denouncing the “culture of poverty” or the “laziness” and “corruption” that apparently runs rampant through every single First Nations community in the country. It’s amazing how quick my fellow countrymen are to lay all blame for the problems affecting our indigenous peoples at the feet of the victims.

A commenter last week remarked how much better the relationship seemed between Canadians and our First Nations, compared to Americans and their aboriginal populations. I decided not to step on the point too hard, because I knew that this week I’d be talking about this story: [Read more...]

Anti-abortion or anti-contraception: pick one

One of my favourite bits of trivia about Christianity specifically is that the teachings attributed to Jesus say far more against hypocrisy than they do about sex. This, of course, does not seem to faze his ‘followers’ whose anti-sex crusade seems to be taking notes directly from Orwell (who are we kidding? They’ve never read Orwell). While the weird pre-occupation of the religious with sex is well-understood, this does not seem to dissuade the throngs of pious outrage from trying to interfere every time someone drops trou.

While we here in the north agonize with our southern cousins over the disgraceful erosion of that most sacred American ideal – the separation of church from state – a little known fact is that Canada has its own religious right that is intentionally mimicking the tactics of the “Moral Majority”. A bit of background before I launch into this news tidbit. More than a decade following the landmark decision in Roe v. Wade that found anti-abortion laws unconstitutional in the USA, Canada’s Supreme Court made its own finding that no laws could be passed against abortion in Canada the current abortion laws were similarly illegal (thanks to ibis3 for the correction). While Roe v. Wade was couched in the right of privacy enshrined in the Fourteenth Amendment, Canada’s court was a bit more explicit. It was ruled that anti-abortion laws violated the security of the person, as laid out in our own Charter of Rights and Freedoms. Most of this legalese is unimportant, particularly to those that don’t live in the USA or Canada, but bear with me.

Abortion has been, since then, a relative non-issue in Canada. Nobody has really brought a substantive case against abortion rights, and we don’t have nutjobs running doctors out of town (at least not any that make the news – if I’m wrong someone please tell me). However, the religious right – emboldened by a recently-elected majority government – have decided that if it’s fixed, break it: [Read more...]

Another victory of evidence over ‘common sense’ in Canada

There are few terms so intellectually offensive to me as ‘common sense‘. Every time someone invokes ‘common sense’ in an argument, I immediately stop listening to them. What they invariably mean is “I have no evidence to support my position, so I will substitute what I think is obvious”. The problem is that there is very little that is ‘common’ between people with different perspectives, and it very rarely makes any kind of ‘sense’. If you have an argument built from logical first principles, I will be happy to hear it; however, if it’s just based on your own particular handful of prejudices, please don’t waste my time.

It’s incredibly gratifying to see that even in this day and age where ‘common sense’ has become a mantra in our political and social life, we still see examples where evidence and reason win out:

Vancouver’s controversial Insite clinic can stay open, the Supreme Court said Friday in a landmark ruling. In a unanimous decision, the court ruled that not allowing the clinic to operate under an exemption from drug laws would be a violation of the Charter of Rights and Freedoms. The court ordered the federal minister of health to grant an immediate exemption to allow Insite to operate. “Insite saves lives. Its benefits have been proven. There has been no discernible negative impact on the public safety and health objectives of Canada during its eight years of operation,” the ruling said, written by Chief Justice Beverley McLachlin.

American liberals – our chief justice is a lady. U jelly?

A brief backgrounder – Vancouver is home to an unreal level of addiction and drug use. [Read more...]

Rationing, policy, and woo

I am a passionate believer in publicly-provided health care. Despite the narrative that seems to be fairly widespread among the Americans I speak to, public health care delivery is a much better model than for-profit care. Like any human system, it has its flaws that should be examined and improved upon. However, as both a method of caring for sick people and a method of controlling health care costs, public systems are the way to go.

The ‘dirty’ little ‘secret’ of health care is that demand will always outstrip supply. There are a nearly-infinite number of things that could qualify as ‘health care’, and we want all of them. As a result, we have to find where the limits are – where we are comfortable saying “if you want this, you’re on your own”. In the fights over health care reform in the U.S., this process got a dirty name for itself: rationing. Sounds scary, right? Your grandma needs a hip replacement, and some government fat-cat comes in and says “nope, sorry, all you are covered for is euthanasia!” Grandma gets wheeled into the back room against her will, and is put down like a stray dog. THANKS, OBAMA!

Of course the reality is that rationing happens in any health care system, including the American one. The difference is in how we ration. [Read more...]

News blast: police edition

Once again, because of time constraints and my lack of willingness to let things simply slip through the cracks and into my delete bin, I am giving you abstracted versions of news items that I think should have been developed into full-length blog posts, but for the lack of time. Sometimes my trouble as a blogger is finding enough material to get me going – this week I have the opposite problem. Here’s some stories about police, law, and justice.

‘Occupy Wall Street’ protest draws police brutality

The peaceful Occupy Wall Street protest march turned violent as the NYPD corralled and pepper sprayed the participants. Mass arrests were made and loaded onto a NYC bus further locking traffic. The protest march took a route from Zuccotti Park to Union Square on East 14th Street. The protesters were marching back to Zuccotti Park when the NYPD turned violent. Hitting, arresting and forcing protesters into a small area. At that point a NYPD supervisor yelled shut up to one of the protesters and shot pepper spray into her eyes point blank range and hitting a half dozen protesters (including 3 police officers) when they had nowhere to go. The same supervising officer was seen (photographed) laughing after the arrests while looking at his text messages. The peaceful protest march started as 300 participants but rose to over 1,000 as the event stopped traffic in lower Manhattan. People spontaneously joined the march over a 2 hour period.

I usually like to source these kinds of things from major media outlets, but sadly the trial of Michael Jackson’s doctor and Amanda Knox seem to be far more interesting to even outlets like the BBC. Maybe you hadn’t heard, but this vicious gang of thugs has destroyed billions (perhaps trillions) in wealth by manipulating markets and selling bad loans. Instead of being punished, incidentally, they were rewarded through concerted lobbying in the halls of power. If you’re pissed off, you can join a few hundred of your fellow citizens to demand that something be done about the surreal level of irresponsibility and fraud being perpetrated against the people of the world by a small group of elite jerkoffs. But don’t protest too hard, or you’ll get pepper-sprayed in the face.

Luckily the asshole who committed this assault is being named and shamed. Even if the police don’t prosecute him (and they won’t, because they circle the wagons around their own like the Catholic Church every time one of their officers breaks the law), he has been tried in the court of public opinion. Click on the link above to see some pretty graphic images of what happened that day.

Sixty percent of Toronto police arrests result in strip searches

More than 60 per cent of people arrested by Toronto police last year were forced to undergo a strip search, according to police statistics. But a police accountability group says routine searches are against the law and alleges Toronto police are using the practice to humiliate and intimidate people. Police figures show that 31,072 people were strip-searched in 2010, up from 29,789 the previous year. John Sewell of the Toronto Police Accountability Coalition (TPAC) said that means about 60 per cent of those arrested in Toronto were subjected to a strip search.

“Silly Crommunist”, you are probably saying while shaking your head and smiling indulgently “that’s an American story! Up here in our glorious north our police are respectful and kind! They’d never do that.” Yeah… seems not to be the case. Toronto cops, by their own statistics, have revealed themselves to be just as brutal, unforgiving and short-sighted as their American counterparts. Strip searches may be necessary in a small minority of cases, but unless Toronto criminals are in the habit of keeping dangerous goods taped flat to their bodies, a thorough search could be just as easily accomplished by a pat-down. This isn’t just my opinion, either – it happens to be the opinion of an Ontario superior court judge. If their goal is to humiliate and intimidate (which it seems to be), then I have no more sympathy for the Toronto police than I do for the fuckwads in New York.

Vancouver street cops still de facto mental health workers

Vancouver ‘street cops’ are still filling the gaps in B.C.’s flawed mental health system, despite recommendations in a powerful 2008 report on policing the city’s mentally ill, an updated report finds. The 2008 report, titled Lost in Transition: How a Lack of Capacity in the Mental Health System is Failing Vancouver’s Mentally Ill and Draining Police Resources, detailed flaws in B.C.’s mental health system and their effects on policing. The problems included the lack of available long-term care, lack of hospital space and difficulties in getting people assessed.

Because I opine on politics a lot, people have asked me what I would do if I had unlimited political power. Well, the first thing I would do is create some limits, because no one person should have that kind of power, but the second thing I would do is drastically increase the level and scope of mental health care we provide to our citizens. We spend an unbelievable amount of money on health care problems that should be handled through therapy rather than hospitalization. I’d certainly have the Vancouver police on my side, I’d bet. While they are not qualified as mental health workers, they are the ones who provide that service (at a level of pay far below what an actual mental health worker receives, and far below what such a person deserves). To get an idea of how serious the problems are here, take a gander at the blog written by one Vancouver beat patrol officer:

1515 hrs – Exit the courthouse in desperate need of coffee and breakfast. I’m supposed to be working one-man tonight, so I make plans with my old partner, Tyler, to visit Save-on-Meats for their all-day brekkie. But first we’ve got to deal with the shirt-less guy flipping out across the street. He’s flailing around, delivering spinning karate-kicks at phantom opponents and doing the kind of back-bends that would make even Bikram Coudhuryshudder. His behaviour, the track marks on his arms, and the needle and crack pipe in his pocket, give us a pretty good idea of what he’s been up to. We call for EHS, and 36 minutes later our friend is heading to St. Paul’s Hospital with the ambulance crew for some Narcan.

Not a glamorous lifestyle, to say the least.

So while I can sympathize with a police force that is overworked and whose positive contributions often go unrewarded, that is not enough to persuade me from my blanket condemnation of the insular, self-righteous environment that police forces in our country and others operate within. I treat police in the same way I do stray dogs – while they might look friendly, all it takes is one bad one for me to be in serious trouble.

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Ageing, health care, and sustainability – memes vs. evidence

One of the frequently-raised buzzwords in discussions of the Canadian health care system is the idea of ‘sustainability’. It is a bogeyman argument that crops up every now and then, particularly as a way of softening the rhetorical ground for increased private-sector involvement in health care. The argument often invokes the spectre of a meme called the ‘Grey Tsunami’. The argument goes something like this:

  • Canada’s population is aging
  • Health care costs are increasing faster than GDP
  • Older people use more health care resources than younger peopleTherefore, there is a rapidly approaching point when the expansion of health care costs, due to increased usage by older people, will become too large to sustain and will collapse the health case system.

The implication is usually that the only way to control health care costs is to increase privatization (which doesn’t work) or to introduce a parallel public option (which also doesn’t work). Since the premises are all true, people nod sagely and cluck their tongues and say ‘what a shame’, as though the conclusion followed logically. It’s entirely possible that the conclusion might follow logically from those premises, but it’s not necessarily the case. What would strengthen the argument is some actual evidence.

Luckily, such evidence is recently forthcoming:

To shed new empirical light on this old debate, we used population-based administrative data to quantify recent trends and determinants of expenditure on hospital, medical and pharmaceutical care in British Columbia. We modelled changes in inflation-adjusted expenditure per capita between 1996 and 2006 as a function of two demographic factors (population aging and changes in age-specific mortality rates) and three non-demographic factors (age-specific rates of use of care, quantities of care per user and inflation-adjusted costs per unit of care).

We therefore conclude that population aging has exerted, and will continue to exert, only modest pressures on medical, hospital and pharmaceutical costs in Canada. As indicated by the specific non-demographic cost drivers computed in our study, the critical determinants of expenditure on healthcare stem from non-demographic factors over which practitioners, policy makers and patients have discretion.

This is a particularly cleverly-designed study done by some colleagues of mine at the University of British Columbia. They used a statistical procedure to model the relative contributions of population age, age-specific mortality, cost of dying, and cost of surviving (within a given age range). Their analysis also included variables to account for resource utilization and cost that are separate from age. British Columbia keeps excellent electronic records for all provincial residents, meaning that they were able to apply this model to a cohort of over 3 million people, using actual real-world expenditure rather than relying on evidence from clinical trials.

Their analysis found that aging has contributed only minimally (1%) to total medical expenditures between 1996 and 2006. Using forecasts from the provincial ministry of health, they estimate that these expenditures will return to current levels beyond 2026. The major factors for health care system expenditure increase had more to do with policy decisions and the purchase cost of equipment, drugs and other technology than it did with a ‘grey tsunami’.

Another article in the same issue says the same thing, albeit a bit differently:

Conventional wisdom holds that Canada suffers from a physician shortage, yet expenditures for physicians’ services continue to increase rapidly. We address this apparent paradox, analyzing fee-for-service payments to physicians in British Columbia in 1996/97 and 2005/06. Age-specific per capita expenditures (adjusted for fee changes) rose 1% per year over this period, adding $174 million to 2005/06 expenditures. We partition these increases into changes in the proportion of the population seeing a physician; the number of unique physicians seen; the number of visits per physician; and the average expenditure per visit. Expenditures on laboratory and imaging services, particularly for the elderly and very elderly, have increased dramatically. By contrast, primary care services for the non-elderly appear to have declined. The causes and health consequences of these large changes deserve serious attention.

Using a similar data set and a different method of analysis, McGrail and colleagues found that, like overall spending, physician-specific spending was increasing. However, there has not been a corresponding increase in those users of the health care system who are not older adults. Even given this increase, the percentage of health care expenditure that is attributable to aging is small.

Given what we know about health care costs – namely, that the increase in price is due largely to the cost of innovation, we have powerful policy levers we can use to make appropriate changes that will preserve the ‘sustainability’ of the system for years to come. Our growing paranoia about the effect of the aging population does not seem to be supported by evidence from actual increases in health care expenditure. While we will undoubtedly have to change the way we think about and practice health care in light of an aging population, it does not follow that we will have to necessarily abandon the way the system is currently structured.

Above and beyond this direct message, I want to take the time to point out that health services and policy research is an important avenue of inquiry. We should make our policy decisions – health or otherwise – based on what is evident, not what is obvious. Whatever our endeavour, we should be constantly asking ourselves questions and measuring our level of success or failure honestly. The authors of this paper, rather than accepting what has been more or less ‘orthodoxy’ when it comes to the health care system, have found ways of directly testing the ‘grey tsunami’ hypothesis. This is a good thing – we should always be challenging our entrenched ideas. Failing to do so will result in us tilting at imaginary windmills, chasing ghosts and false ideas to the point where our efforts are legitimately unsustainable.

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