Health care: what we get for our money, Part II - Macleans.ca
 

Health care: what we get for our money, Part II


 

Assessing the performance of an entire national health system—if “system” is the word for any country’s amalgam doctors’ offices, walk-in clinics, imaging labs, hospitals and more—is notoriously difficult.

If you just look at how long people live or what illnesses they’re susceptible to, the big variables are what sort of food they eat, whether they exercise much, if they smoke, and how rich they are. Examining outcomes alone doesn’t reveal much about the narrow contribution of the health system.

If, on the other hand, if you simply tally up the number of medical procedures performed, you’re probably not going to discover much about what you’re really getting for your health care dollar. It would be like crediting your mechanic for the frequency with which he replaces car parts, rather than his success in actually keeping the vehicle on the road.

These are the sorts of tricky considerations I waded into yesterday with a post critical of the Fraser Institute’s recent report Value for Money from Health Insurance Systems in Canada and the OECD.

To rehash a bit, that report looks at 18 diagnostic and surgical procedures, relying on OECD data for how often they are performed in Canada relative to other developed nations. Canada scored above the OECD average for only a third of the 18 indicators, despite ranking sixth on health spending. The report’s authors, Brett Skinner and Mark Rovere, conclude that this shows Canadians aren’t getting good value for their health insurance dollars.

But I don’t think these indicators indicate any such thing. They show, for example, that in Canada doctors perform fewer caesareans, tonsillectomies and appendectomies per capita than the OECD average. Why should this be counted as underperforming? If anything, these numbers suggest that Canadian physicians exercise proper discretion before cutting.

The Fraser Institute’s list of 18 indicators also shows that Canada has fewer MRI and CT scanners than the OECD average. But what is the cost-effective number of scanners? The OECD says: “Many studies have attempted to assess tangible medical benefits of the substantial increase in CT and MRI examinations in the United States but found no conclusive evidence suggesting such benefits.”  Maybe having fewer machines means Canada is getting better value for its health dollars, not worse.

Among the indicators used by the Fraser Institute, several are inarguably important, especially the numbers of physicians and hospital beds—two key categories in which Canada lags. But taken as a bundle, it’s hard to see how the data from this very mixed bag tells a coherent story.

In my posting yesterday, I pointed to a readily available alternative. In Health at a Glance 2009, in a chapter entitled “Quality of Care,” the OECD provides 11 relevant statistics. These range from your chances of surviving a heart attack or stroke in hospital, to how well your doctor manages your diabetes, to whether you’re likely to be screened for cervical and breast cancer. Canada performs better the OECD average on eight of these carefully selected measures, worse on just one, and posts mixed data on two.

The Fraser Institute’s Skinner, in a comment on my blog post, said that by citing the OECD “Quality of Care” numbers, I was displaying my failure to grasp the difference between “the outputs of ‘health insurance’ and the outputs of ‘medical treatment’.”

If I’m following him, he’s saying that looking at the numbers of various procedures performed (as his study does) tells us what we’re getting from health insurance, whereas the outcomes the OECD looks at as “Quality of Care” indicators show what we’re getting from medical treatment. Skinner also says he “used all available data from the OECD for medical goods and services—the things that health insurance buys.”

But health insurance doesn’t just buy MRI scans and appendectomies, and all those other surgeries and procedures listed in the Fraser Institute study. Health insurance also buys emergency care when you’ve had a heart attack, and long-term care when you’re suffering from diabetes, and screening for cancer, and treatment for mental disorders. And how well these sorts of services are provided is captured, in part, by the OECD “Quality of Care” data.

Don’t get me wrong—I’m not arguing that the OECD figures somehow put to rest the debate over Canadian health care. Many Canadians are rightly unhappy about how many hours a moderately sick individual is likely to languish in an overcrowded emergency room before seeing a doc, how many weeks it often takes to see a specialist, and how many months to find a family physician willing to take on new patients.

Against this backdrop of justified discontent, though, it’s important to recognize that Canada’s health system performs well compared to other rich countries when you look at reasonable indicators, such as the OECD’s “Quality of Care” numbers. There’s no evidence that the public insurance model for delivering those key services is broken by international standards.

What’s wrong then? That’s a huge question. But just to get the ball rolling, if our main complaint is that we’re waiting too long to see a doctor, isn’t the underlying problem probably too few doctors? Similarly, if we’re annoyed at long waits in backed-up ERs, isn’t the problem almost certainly too few hospital beds to take the patients who came in before us?

 

 


 

Health care: what we get for our money, Part II

  1. So, if I have surgery to revove a part of a cancerous colon, that's a medical good or service they'll count, but the $6 stool sample mail-in card that can detect the colon cancer and prevent the surgery isn't measured?

    I may not be a statistician, but even I know which leads to a happier (and cheaper) outcome…

  2. So, if I have surgery to revove a part of a cancerous colon, that's a medical good or service they'll count, but the $6 stool sample mail-in card that can detect the colon cancer and prevent the surgery isn't measured?

    I may not be a statistician, but even I know which leads to a happier (and cheaper) outcome…

  3. "Maybe having fewer machines means Canada is getting better value for its health dollars, not worse."

    " … isn't the underlying problem probably too few doctors …. almost certainly too few hospital beds …"

    It is one or the other. Technocrats like to spout twaddle like fewer machine equals better value. But people with heart problems don't want to hear nonsense about how they have to wait weeks for mri and isn't rationing just wonderful.

    Of course the underlying problem is too few doctors/nurses/beds/meds/technology – that's a feature, not a bug, according to fans of our health care system. We all get equally crappy service and treatment.

  4. "Maybe having fewer machines means Canada is getting better value for its health dollars, not worse."

    " … isn't the underlying problem probably too few doctors …. almost certainly too few hospital beds …"

    It is one or the other. Technocrats like to spout twaddle like fewer machine equals better value. But people with heart problems don't want to hear nonsense about how they have to wait weeks for mri and isn't rationing just wonderful.

    Of course the underlying problem is too few doctors/nurses/beds/meds/technology – that's a feature, not a bug, according to fans of our health care system. We all get equally crappy service and treatment.

    • No, it can be both. If the machines aren't as efficient uses of money as doctors and hospital beds, then having fewer machines means we're getting better value for that, but having fewer doctors means we're getting worse value for that.

      And where on earth did you get your ideas about technocrats? Typically they're the ones who are on about how we always need the absolute latest and greatest machine (like F-35s), not saying that we don't need any more.

      And yes, we all get equal service. You may call it crappy, but the argument is that the alternative would make it a helluva lot worse for those without money. It'd still average out to the same overall level of crappiness. But it would concentrate that among those who could least afford it.

  5. "…according to fans of our health care system. We all get equally crappy service and treatment"

    No, according to HC's critics of our…

  6. "…according to fans of our health care system. We all get equally crappy service and treatment"

    No, according to HC's critics of our…

  7. Interesting post, John. Adds to my view that Maclean's Canada Blog is the place to start reading every morning.

    Very minor point … the HUGEST variables in health are (1) public-health measures that are now just part of our background, starting with clean drinking water; and (2) antibiotics. Cholera & its ilk were huge killers 100 years ago (and still are where clean drinking water isn't available, viz Haiti), and sepsis was a huge killer even in our grandparents' day.

    All the best.

  8. Interesting post, John. Adds to my view that Maclean's Canada Blog is the place to start reading every morning.

    Very minor point … the HUGEST variables in health are (1) public-health measures that are now just part of our background, starting with clean drinking water; and (2) antibiotics. Cholera & its ilk were huge killers 100 years ago (and still are where clean drinking water isn't available, viz Haiti), and sepsis was a huge killer even in our grandparents' day.

    All the best.

  9. I think you're arguing two seemingly opposed positions that may not be as exclusive as you imply. The Fraser Institute's report is looking at 'value' not 'quality'. It's great that less procedures are needed in Canada, but then why are we paying more for it than other nations? There may be a perfectly good reason for this, but a closer look is needed. What portion of health care costs are contained in specifically procedures-done? Is the reason that we have less procedures but higher total spending because we spend more on preventative care or is it additional administrative costs or higher labor costs or maybe even geographical because we need so many hospitals spread out over a sparsely populated nation? How much more capacity for procedures is available without further infrastructure investments? What increases in capacity are going to be needed for an aging population and in what areas and what will those cost?

  10. I think you're arguing two seemingly opposed positions that may not be as exclusive as you imply. The Fraser Institute's report is looking at 'value' not 'quality'. It's great that less procedures are needed in Canada, but then why are we paying more for it than other nations? There may be a perfectly good reason for this, but a closer look is needed. What portion of health care costs are contained in specifically procedures-done? Is the reason that we have less procedures but higher total spending because we spend more on preventative care or is it additional administrative costs or higher labor costs or maybe even geographical because we need so many hospitals spread out over a sparsely populated nation? How much more capacity for procedures is available without further infrastructure investments? What increases in capacity are going to be needed for an aging population and in what areas and what will those cost?

  11. They show, for example, that in Canada doctors perform fewer caesareans

    Using caesareans as a metric in a world where there is increasing pressure to either bypass the natural birthing process out of fear of pain or for… shall we say… vanity reasons seems almost as counterproductive to legitimate discussion of the issues as breaking out breast implantation numbers. Like those, it's become a procedure whose use is as much cosmetic/personal choice as medically necessary on occasion.

  12. They show, for example, that in Canada doctors perform fewer caesareans

    Using caesareans as a metric in a world where there is increasing pressure to either bypass the natural birthing process out of fear of pain or for… shall we say… vanity reasons seems almost as counterproductive to legitimate discussion of the issues as breaking out breast implantation numbers. Like those, it's become a procedure whose use is as much cosmetic/personal choice as medically necessary on occasion.

    • It would be interesting to see how many c-sections are done on Fridays.
      It is an observed phenomenon at the hospital I'm most familiar with …
      staff is available …. don't have to be called in the weekend. And it reduces
      the uncertainty factor in physicians' weekends off.

    • Not sure what obstetricians you’ve worked with, but I’ve never seen or heard of a C-section being performed for vanity or fear of pain. If the surgery went south, it’d be pretty hard to defend in front of a regulatory body if your reason for C-section wasn’t medically indicated.

  13. It would be interesting to see how many c-sections are done on Fridays.
    It is an observed phenomenon at the hospital I'm most familiar with …
    staff is available …. don't have to be called in the weekend. And it reduces
    the uncertainty factor in physicians' weekends off.

  14. No, it can be both. If the machines aren't as efficient uses of money as doctors and hospital beds, then having fewer machines means we're getting better value for that, but having fewer doctors means we're getting worse value for that.

    And where on earth did you get your ideas about technocrats? Typically they're the ones who are on about how we always need the absolute latest and greatest machine (like F-35s), not saying that we don't need any more.

    And yes, we all get equal service. You may call it crappy, but the argument is that the alternative would make it a helluva lot worse for those without money. It'd still average out to the same overall level of crappiness. But it would concentrate that among those who could least afford it.

  15. Don't know if anyone is still following this post or not, but here are a couple of
    graphs that might say something by way of international comparison …. or …

    http://voices.washingtonpost.com/ezra-klein/2010/

  16. Don't know if anyone is still following this post or not, but here are a couple of
    graphs that might say something by way of international comparison …. or …

    http://voices.washingtonpost.com/ezra-klein/2010/

  17. Not sure what obstetricians you’ve worked with, but I’ve never seen or heard of a C-section being performed for vanity or fear of pain. If the surgery went south, it’d be pretty hard to defend in front of a regulatory body if your reason for C-section wasn’t medically indicated.