Health reform: We can't wait
Second in a series of expert analysis articles on important issues in the N.B. election
He was the president of the College of Physicians and Surgeons of New Brunswick from 1985 to 1986 and president of the New Brunswick Medical Society from 1988 to 1989.
He is the author of: Medicare Myths: 50 Myths We've Endured About the Canadian Health Care System (2004).
Furlong served as the minister of health and wellness from 1999 to 2001 and minister of education from 2001 to 2003.
He recently served as the chairperson of the federal inquiry into the use of Agent Orange at CFB Gagetown and he was the chairman of the New Brunswick Trauma System Advisory Committee.
New Brunswickers will be heading to the ballot box in a month and in the coming weeks citizens and politicians need to have a frank and honest discussion on the future of our health-care system. There are many pressures facing our cherished health system. We cannot afford to wait any longer to start making the reforms.
The New Brunswick health system is on track to eat up 50 per cent of the provincial budget by 2015. That should cause voters to ask some very tough questions of their politicians — and themselves — about how to create a sustainable system during this election period.
The financial stress being inflicted by the health system on New Brunswickers is not a situation being felt only in this province. There are considerable pressures on the 13 ministries of health in Canada and also on the federal government. These issues may preclude the Canadian health-care system as we know it today and knew it for the last 40 years.
Politicians must now land somewhere between financial "pressure versus public demand."
Society must start talking seriously about how we use our health system. We have to make sure that what we are doing in our health-care system is necessary and that procedures and treatments that are not needed are no longer funded.
What many people do not realize is we are doing so much in the "illness-care system" that doesn't need to be done and doesn't make any difference in people's health.
The New Brunswick health-care system faces a series of pressures as it fights for sustainability. Once those pressures are realized, there are political choices that must be made if the system, which is a source of great pride to many Canadians, is to be sustained for future generations.
Cost pressures
The cost of health care is increasing at alarming rates that are not sustainable. We have approximately a $1-billion increase each month in Canada, $20 million per month in New Brunswick.
The budget for the Department of Health and Wellness in my first year as minister was $1.5 billion. Now compare that to the most recent budget that forecasted health spending at $2.46 billion in 2010-11.
The fact the health department's budget expanded by $1 billion in a decade reinforces how we have no choice but to address the financial crisis in the system.
If we believe otherwise then we are deluding ourselves because incremental cost increases of seven or eight per cent in a budget that already represents almost 50 per cent of the province's overall budget cannot be continued considering the province's revenues have grown closer to one per cent in recent years.
New Brunswick, such as many other provinces, is running a deficit as it grapples with the global economic downturn. The health department eats up the largest share of the provincial budget annually.
As we run more deficits, which is made up largely by payments to our health-care system, we are adding more money to our debt. Payments on the provincial debt are the fourth largest component of the budget at $625 million, behind health, education and central government. If we get an increase in interest rates, the interest of our debt could go over $1 billion and soon that could be third biggest expenditure.
Simply put, if we don't control health-care costs we won't be able to control provincial solvency.
Frivolous utilization
The health-care system is excellent but unnecessary utilization is rampant and increasing. A simple example, someone who misses a day of work at the provincial government often needs to produce a note from a doctor in order to be paid for that day. That person is forced to walk down to a doctor's office or an emergency room in order to see a physician. This visit is frivolous but it adds costs the system.
There must be a way of dealing with these types of costs, as well as find ways to end the duplication or even quadruplication of things we do in the system.
Society has some tough choices to make. For example, we have to rethink doing sophisticated technological investigations on people in their 90s who are in palliative care. Do those procedures make any difference in that person living or dying? No they don't, but they surely increase costs.
I estimate that at least 15 per cent of the health-care utilization is useless. And that useless utilization adds up to $40 billion annually across the country.
Demographics
Demographics are not on our side in the next 25 years. By 2015, we will have more people over 65 years of age as we do under 20 years of age. That is exacerbating the financial problems facing the health system.
Baby boomers are bringing with them diseases — such as the obesity epidemic and diabetes — that will add massive costs to the system.
The real need of the system is increasing, as already noted, thanks to changing demographics. When baby boomers age that will mean more utilization of the health-care system.
We are not ready for this looming challenge. But we have no choice and we have to manage it.
Many hospital admissions will have to be taken care of at home through extra-mural services because we cannot afford to build 500 hospital beds to get the baby boomers through the system. Instead, we need to expand extra-mural considerably over the next two to three decades.
As baby boomers age, senior care will have to be home or community based, not institutional for reasons of numbers and cost. Some European countries are de-institutionalizing senior care.
Increasing diagnostic technology
Modern illness care now demands more and more sophisticated technology. Both utilization and cost of purchase and operation are increasing very rapidly.
We need to figure out how to more efficiently use the technology that is available. Nobody gets a coronary bypass without needing it and there is no wait time or misuse of severe emergencies.
But inside the system — and most of the older part of our population will confirm this — there is significant ineffective use of health services. I call this useless utilization. If we don't get at that problem then we won't have the services when we truly need them.
Increasing drug coverage
Medications are becoming more costly and therefore less accessible. The costs of some drugs are out of the range of 90 per cent of the population.
We should be looking at culling out medications that are useless and put the emphasis on where it needs to be.
The solution is to use these expensive therapeutic and pharmacologic technologies only when you have to and like other parts of the health system, end frivolous use.
Electronic health records
E-health records that are user friendly and shared with hospitals, doctor's offices, pharmacies, extra mural program and possibly WorkSafeNB is needed.
The Department of Health is moving in this direction when it announced a series of steps toward implementing a one-patient one-record system in 2007.
When the system is implemented the idea is that doctors offices will be linked and important health information can be shared in a way that will save money and help in better decision making.
Rural versus urban inequalities
New Brunswick is still largely a rural province but the health system in rural areas is under added stress.
About 20 per cent of Canada lives in rural areas but statistics from the Canadian Medical Association show only 10 per cent of doctors live in rural areas.
It is harder to get physicians to work in rural areas and keep them there once they start.
Many physicians starting their careers resist and refuse to work longer hours. This compounds the problem in areas already struggling with a shortage of doctors.
In spite of these challenges, governments have an obligation to keep quality rural public services. It is absolutely necessary that rural areas have access to primary care services. As for hospital services, rural areas must have general surgery and anesthesia to deal with local casualties.
Patient participation
People will have to take part of the costs of the system soon, governments cannot afford what is happening now, let alone the future.
Primary-care access
We must end useless utilization of expensive emergency rooms by expanding access to primary-care facilities.
The system must be reformed so citizens have access to primary care at least 18 hours a day.
If you look at primary care, most doctors' offices are open Monday to Friday, five or six hours a day or about 35 hours a week. But the other 125 hours in the week that aren't covered by primary care.
During those 125 hours, the primary care is going to an emergency room, where the specialists are trained for high-intensity, low-volume work. Instead, they are dealing with high-volume, low-intensity work.
We cannot take our whole primary-care system and have it operate between 9 a.m. and 4:30 p.m. and tell people that outside of those hours it's up to them.
We need to stretch primary care to cover at least 18 hours a day and take the pressure off emergency rooms.
Politics
Once the pressures are understood it's up to people to deal with the politics. Politicians must now commit to cost controls with astute initiatives on the demand side to preserve the system.
The politics of promotion of more money supply for health must now be controlled.
More spending on illness has not resulted in more population wellness over the last 20 years.
This requires a shift in thinking about how we approach health care.
Wellness of our population is an education issue not just a health system issue. It is most effective if you begin delivering the message of wellness in the formative years of young people and not waiting until they are decades older and in a doctor's office.
Young people need to told about the importance of not smoking and eating healthy at an early age or they will begin those unhealthy habits. Those habits will have long-term impacts on their health and the health-care system.
And when wellness issues are discussed with young people, it must be done in a way that is "cool." Young people are not going to absorb the message if it is delivered in a sterile doctor's office during a five-minute visit.
This is the generation we must target our scarce health-care dollars on. We cannot justify the massive amount of money spent on the last five years of life compared to the small amount spent on the first five years of life. This spending difference is a social inequity.
The political platform of deficit and debt control must now supersede the politics of giving more and more of our grandchildren's resources today.
"Reeling in" of the expectations of a wanting population will be a political reality and challenge. Our health-care system must be one we can afford for the "needs" of our population, not the "wants" of our population.
Health-care reform must be discussed as the Sept. 27 election nears because it is our number one social program. Many of us take it for granted that our health system will always be there. But with the current and looming costs, it may not always be with us.
So the question will be how to make it sustainable. There has been suggestion that spending growth in future years should be capped to one per cent. The answer is not that simplistic.
This tactic of capping spending growth was tried in the past by people who didn't understand the system. It didn't work.
Health-care funding is like a large ocean freighter that's moving in its own direction and it will be tough to turn around. This one won't be slowed down in five to 10 years and that's why we have to start now. It won't stop growth in health in one budget but we must begin to bend the cost curve.
So in the next month, when citizens speak with politicians and the debate turns to health care, the fundamental conversation must shift. We can no longer simply say we want more health care. That has to change to: how can we keep the health care that we have.
I can assure you the way we are going now, we can't sustain it. We need to stop hearing promises of more spending. We need to start hearing politicians say, "Vote for me I will make sure health-care is sustained by not overfeeding it with money."