Technology and the future of public health care

A couple years ago I put out a report for the CCPA that crunched the numbers on health care sustainability. The main finding was that public health care was basically sustainable in that it could handle projected increases in population, aging and inflation as long as GDP continued to grow at a reasonable rate (consistent with what we have seen over the past quarter century, anyway).

The real challenge facing health care is not a “silver tsunami” but has to do with health care technology, and a system that accommodates the introduction of new technologies that are tantamount to an increase in the total amount of health care services in the public basket. That is,  after population growth, aging and inflation have been stripped out, we see rising real health spending per capita over the past decade that can only be explained by increases in new technological capabilities, since we are not seeing an increase in long-term care facilities, home care services or other non-doc-and-hospital services that were part of the expansion of public health insurance coverage in the 1970s and 1980s.

I pointed to four areas that challenge health care going forward: new surgical techniques, including knee and hip replacements, that have grown far beyond the rate that would arise from population growth or aging alone; new diagnostic techniques, such as MRIs and PET scans; pharmaceutical drugs; and highly technologized end-of-life care. In these areas, we need to have a public system that determines what gets covered by the public system and what the evidence is to support inclusion. At its worst, these new technologies crowd out existing services, such as pressures on hospitals to close beds.

That’s all a long-winded summary as a set up to a great article in November’s Literary Review of Canada by Charles Wright. Wright is a surgeon-come-healthcare-consultant and he nicely adds many examples of the above problem based on his own experience in the system (as opposed to me, who dropped biology after Grade 10). Wright reviews evidence on costs and benefits of certain drugs and procedures in the context of the public system, but also dives into the “over-medicalization” of our society and the expectations that have been created about what is normal. He concludes:

In summary, elimination of inappropriate current services and control of expenditure on ineffective new services or technologies are two of the most crucial measures to ensure sustainability of our healthcare system. Unfortunately, most of these options are not greeted with wild enthusiasm by politicians for two powerful reasons: the public’s reaction to the perception that services, whether appropriate or not, are being restricted and the predictable organized resistance to change by many vested interests within this huge industry. Unlike in the U.S., we at least do not have to deal with the hysterical behaviour of a private health insurance industry terrified at the prospect of losing the 4 percent of the GDP it currently enjoys.

There is certainly much that can and should be done to limit inappropriate medical care. Canada’s population is generally literate and well educated. There is a crying need for massive, eye-catching, sustained public education programs to disseminate accurate and balanced information based on evidence, rather than on the marketing biases of big pharma. This communications initiative should be designed and presented by advertising professionals who can match the medical industry’s techniques, but with the close collaboration of independent experts who understand the evidence. Don’t ask your doctor if you need [the latest miracle drug being pushed on television]; ask your doctor to explain why you really need each of your prescriptions and what the side effects are. The same approach would help the public to understand the sound reasons for not insuring every new technology and drug that comes along. The “informed consent” currently given by many patients for medical procedures is perfunctory. People need to be fully informed about the balance of potential benefit and harm that is inherent in any medical intervention. Is the 55-year-old man getting a PSA test aware that it carries a much higher risk of leading to incontinence and impotence than offering any benefit? Is the woman about to have her breasts compressed onto an X-ray plate aware that she has a much greater chance of harm than benefit resulting from the test?

All of these measures stay within the principle of equitable access to medically necessary care regardless of financial means that is the most defining characteristic of Canadian health care. We have to recognize the paradox that increasing healthcare interventions can cause more harm than benefit, and take an intelligent, evidence-based approach to setting limits not only to funding but also to what is in the best interests of people’s health.