As Darrell Dexter and our provincial government plead for more federal dollars for health care, Amanda Whitewood, a VP at Capital Health, courageously tells us the province and district have no real idea how best to spend your money (“More to health care costs than meets the eye,” Feb. 4 opinion piece). Neither the health districts nor the provincial government are able to measure the costs of care or the benefits you get when the Department of Health spends your health dollars.
Capital Health and its predecessor organizations have been toying, unsuccessfully for years, with efforts to capture information about costs and health outcomes. Earlier initiatives to measure nursing workload started at least 30 years ago with the GRASP workload measurement system, still used in Canada. Case costing efforts have been on the radar of the Canadian Institute for Health Information for at least 20 years, and still there is little knowledge of how much a case costs, or even what constitutes a case.
Academics everywhere, and many health administrators elsewhere, know how to measure and report on the costs and outcomes of care.
Measuring results and costs may not be as difficult it seems. Interested readers who visit the site of the Pennsylvania Health Care Cost Containment Council (www.phc4.org) will be able to learn about the severity-adjusted outcomes and costs for numerous procedures for almost all health organizations in Pennsylvania. Capital Health was once a Canadian leader in outcomes measurement and participated in early studies using methods similar to those adopted, many years ago, by the Pennsylvanian Health Care Cost Containment Council, but Capital Health curtailed these initiatives.
It should matter to ordinary Nova Scotians that the provincial government is spending your health care dollars in a haphazard way. Some of the money government spends may be for services that have no beneficial effect or might even be harmful (think of how long pregnant women used thalidomide before learning about the harmful effects).
All of us, including governments, academics and health services administrators, are faced every day with hard choices. We have to know the impact of these choices on our health (and on our pocketbook) so that we can make the best choice possible or a better choice the next time.
Should your money, for example, be spent on a media campaign promoting Better Care Sooner (but not now) or on house calls for those who need them? Today, the amount your insurer (the provincial government) pays for a house call is insufficient to induce most family doctors to provide house calls. A doctor who took a taxi to a neighbouring long-term care facility would usually earn less for the trip than would the driver of the taxi.
Should government spend about $60 per telephone call so that you can call a strange nurse for advice? Or should the Health Department compensate your own family doctor to be able to speak with you over the telephone, or communicate electronically?
Should your money be spent on beds in hospital so that sick patients requiring hospital care don’t have to wait in the Capital Health emergency department for hours or days for admission, or should government pay for new clinics in rural areas?
Should Nova Scotians tolerate the two-tier system, generated by government, where some patients have doctors who are paid salary by government, and whose practices also have information systems and nursing support paid for by government; while other patients must see a doctor who receives about $30 per visit and uses some of the $30 to pay for the overhead of an office? According to Capital Health, a mere 20 per cent of patients have access to multidisciplinary primary health care teams; 80 per cent of you do not. So much for single-tier health care.
Should Nova Scotians be permitted or encouraged to pay for nursing and other services so they may receive the same comprehensive high-quality services as their neighbours who attend alternately funded, multidisciplinary clinics?
Should your money be spent on advertising and delivery of flu vaccine, when no one in Nova Scotia bothers to follow patients to learn whether those who received flu shots are overall healthier or sicker compared with their neighbours who don’t get flu vaccines? We estimate that about half of Nova Scotia health workers won’t get a flu shot this year. In the long run, are the accepters or rejecters better off?
Is the money now being spent on consultants and nursing workload systems better spent on supporting nursing care and improving the morale of nurses? Do the nurses who are participating in the current version of nursing workload measurement believe that capturing the recommended information is a good use of their time or are other methods to better understand work and results preferable?
The province recently asked Capital Health to take $30 million from its budget — a loss of 600 or more skilled jobs, while Nova Scotia suffers from serious unemployment and in the face of unprecedented demand for health care.
Which jobs should be cut? How is it possible to know whom to fire, without information about the cost of health services and which services benefit patients, which harm patients and which are merely wasteful?
A loss of 600 government jobs would not be so serious if Nova Scotians were allowed to pay for the vital health services that government rations. According to Capital Health, regardless of your ability or willingness to pay, you might be harmed by unacceptable wait times for a variety of important diagnostic tests and treatments, even while government slashes spending willy-nilly and health workers lose their jobs.
Without information to manage, does it matter whether Nova Scotia has one, five or 10 health districts?
Are we paying the CEO of Capital Health about $400,000 per year to decide that Carpedia is the best of the bunch of expensive management consultants, or do we expect the management team to develop operational efficiencies because they were hired for their knowledge, skills and experience? Without worthwhile information about access and results, how will the business consultants hired by districts do a better job than the people we are already paying to administer health care in Nova Scotia?
David Zitner, a family physician, is Health Policy Fellow with the Atlantic Institute for Market Studies and a professor in the Dalhousie Faculty of Medicine.