UBC Faculty Research and Publications

Waiting for health care in Canada : problems and prospects Barer, Morris Lionel, 1951-; Lewis, Steven May 31, 2000

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata


52383-Barer_ML_et_al_Waiting.pdf [ 1.07MB ]
JSON: 52383-1.0048419.json
JSON-LD: 52383-1.0048419-ld.json
RDF/XML (Pretty): 52383-1.0048419-rdf.xml
RDF/JSON: 52383-1.0048419-rdf.json
Turtle: 52383-1.0048419-turtle.txt
N-Triples: 52383-1.0048419-rdf-ntriples.txt
Original Record: 52383-1.0048419-source.json
Full Text

Full Text

Centre for Health Servicesand Policy ResearchWaiting for Health Carein Canada:Problems and ProspectsMorris L. BarerSteven LewisHPRU 2000:9D May, 2000\;Health Policy Research UnitDiscussion Paper SeriesTHE UNIVERSITY OF BRITISH COLUMBIAWaiting for Health Carein Canada:Problems and ProspectsMorris L. BarerSteven LewisHPRU2000:9D May 2000Paper prepared for the Atkinson Foundation; all errors and opinions are the responsibilityof the authors. This paper draws extensively on background work for a report to HealthCanada in 1998. We are grateful to our collaborators on that report, Paul McDonald,Claudia Sanmartin, Sam Shortt, and Sam Sheps, on whose contributions we have drawnunashamedly for this paper.Centre for Health Services and Policy ResearchUniversity of British Columbia429 - 2194 Health SciencesMallUniversity of British ColumbiaVancouver,BCV6T 123The Centre for Health Services and Policy Research was established by the Board ofGovernors ofthe University ofBritish Columbia in December 1990. It was officiallyopened in July 1991. The Centre's primary objective is to co-ordinate, facilitate, andundertake multidisciplinary research in the areas ofhealth policy, health servicesresearch, population health, and health human resources. It brings together researchers ina variety of disciplines who are committed to a multidisciplinary approach to research,and to promoting wide dissemination and discussion of research results, in these areas.The Centre aims to contribute to the improvement ofpopulation health by beingresponsive to the research needs of those responsible for health policy. To this end, itprovides a research resource for graduate students; develops and facilitates access tohealth and health care databases; sponsors seminars, workshops, conferences and policyconsultations; and distributes Discussion Papers, Research Reports and publicationreprints resulting from the research programs ofCentre faculty.The Centre's Health Policy Research Unit Discussion Paper series provides a vehicle forthe circulation of (pre-publication) work ofCentre faculty, staff and associates. It isintended to promote discussion and to elicit comments and suggestions that might beincorporated within revised versions of these papers. The analyses and interpretations,and any errors in the papers, are those of the listed authors. The Centre does not reviewor edit the papers before they are released.A complete list of available Health Policy Research Unit Discussion Papers and Reprints,along with an address to which requests for copies should be sent, appears at the back ofeach paper.A. Getting our Terms Right1. What is a Waiting List?A "waiting list" for health care is a list of patients awaiting a service such as surgery or anappointment with a cardiologist. But this doesn't tell us whether everyone who waits fora service is actually on a list, or how patients get on lists, or whether they all need to bethere, or who manages the lists. It is also silent on whether physicians share lists so thatpatients get service through the shortest or fastest moving list.So when the Winnipeg Free Press reports that the wait list for cataract surgery inWinnipeg has 2000 patients on it, what does this tell us? Everyone can probably agreewith the basic definition of a wait list. But that's about all we'll find agreement on in thiscontentious area. It is no wonder that we end up with a confusing public discussion abouthow long the lists are for different types of care in Canada.2. Does Everyone Who Waits End Up On A List?No. Take the case ofMr. Ross, who has seen his family doctor and will eventually bereferred for an MRI. Before he finally gets his MRI, he may end up on half a dozen, ormore, different wait 'lists' (for other specialty examinations; lab tests; x-rays; otherdiagnostic work-Up; outpatient clinic; etc.). But he may also have waited a few days tosee his general practitioner. Was he on a "waiting list" during that time? Well, no, or atleast not a 'formal' one. The office appointment calendar is the wait list. No one inCanada keeps track of how many patients wait for appointments with their g.p.s (is anappointment the same afternoon a wait?), or how long they wait.3. What do people mean when they talk about "wait times"?A "wait time" is the amount of time a patient is on a "wait list" before receiving theintended service or procedure. Even this simple notion gets complicated in somecircumstances.Let's return to Mr. Ross awaiting the MRI. Ifhe waits for four different physicians orservices on his way to the MRI, at what point in that process should we start the wait timeclock for the MRI? "Wait time" can mean the time Mr. Ross actually waited for theMRI, the time his internist told him he should expect to wait, the average or median timethat all of that internist's patients waited, or are likely to wait, and so on. Unfortunately"wait time" means different things to different people, can be calculated in many differentways, and is used for different reasons, often depending on the point being made.Wait times can be either "forward looking" (prospective), or "backward looking"(retrospective). Each type of information will be useful to different people. It may be ofsome interest for Mrs. Fogg to know that her friend Mrs. Goodeye recently waited 4months to have her cataract removed by an ophthalmologist in Regina. But it is moreimportant for her to know that this ophthalmologist's new cataract patients can now1expect to wait 6 months. If she could get the same information for all Reginaophthalmologists offering cataract removal services, she could make some importantdecisions. For those responsible for planning cataract facilities and services in Regina, itmight also be useful to have the same sort of information 011 other cities in Saskatchewan,and indeed elsewhere in the country.B. What's in a Wait?4. How and when do patients get onto wait lists?A typical process will probably look something like this: Mrs. Jones will see her gp, whowill examine her and send her to a specialist (an appointment for which she may wait,even if she is not placed on a "wait list"). The specialist may decide (s)he thinks a CTscan is necessary to confirm a diagnosis, and will place Mrs. Jones on a wait list for thescan. Or he may decide that surgery may be necessary, and refer her to a surgeon whomight, in tum, place her on a wait list for the surgery. That wait list will 'belong' to thesurgeon.Your doctor's decisions about when to put you on a wait list will depend on how urgentshe thinks your situation is and how long the waits are for patients, already on the lists.Consider Mrs. Fogg's cataract situation. Suppose that in her city, there is a relativelyshort wait time for cataract removal- say, 3 months. She sees her surgeon in February1998. He notes that her visual acuity remains good, but a cataract is forming, and in ayear or so it may warrant removal. Ultimately he puts her on the list in February 1999and she has the operation in May 1999. Now suppose her twin sister has an identicalvisual situation, but where she lives, the expected wait time is 15 months. Her surgeonputs her on the waiting list in February 1998 in anticipation that she will get her cataractremoved about May 1999. So both patients end up getting the cataract removed at aboutthe same time, and end up waiting about the same time, but the "official" wait time willbe 3 months for Mrs. Fogg, 15 months for her sister. This will be duly reflected in waittime statistics!!Patients may end up on lists without knowing, or wanting, or needing to be there. Incountries such as the UK, some wait lists are independently audited. Audits finding 20%,30%, 50% and more ofpatients who should not be, and often should never have been, onthe lists have been reported. Could the same be true in Canada? Embarrassingly, wedon't know. Wait lists here are rarely (perhaps never) audited.In short, patients get on wait lists in Canada through a poorly understood, haphazard,unaudited, entirely private process largely controlled by individual physicians. Do theneeds ofpatients playa role? Absolutely. Is this the only thing that counts? We simplydon't know. And at the moment we have no way of finding out whether two patientsseeing different physicians for the same condition would end up on a list at the same time.25. How are wait times measured?"Wait time" is simply the interval between the point when a patient is placed on a list, andthe point where she is taken off the list, either due to a change in her circumstances,death, or getting the service for which she was waiting. So ifwe take the average of thewait times for everyone who came off a list last month, we will have a meaningfulstatistic on which everyone can agree. Right? Well, perhaps ... but remember Mrs. Foggand her twin sister. There are many different lists, many different points in a care'episode' when patients might be put onto various lists, and many different decision rulesused by physicians in choosing whether and when to place their patients on particularlists.To complicate matters further, there are different ways ofmeasuring wait times. Eachanswers a slightly different question:• how long did patients recently treated have to wait for their service or procedure(retrospective);• how long have patients currently on a list had to wait (cross-sectional);• how long did patients placed on a list in January 1998 have to wait for their service orprocedure (prospective).There is no reason that these different methods will produce the same "wait times".What's worse, none of them provides a precise answer to the question most frequentlyasked by patients: "How long will I have to wait?" Using each of these three methods toprovide an approximate answer to this question can, and often does, create a bewilderingrange of answers.But even this is not the end of the story. The more statistically inclined will have noticedthat we have been deliberately vague about wait time "statistics". But here, too, there arechoices. Which "statistic" the Winnipeg Free Press chooses to use can affect the impactof its message. Wait times tend to be, in statistical jargon, highly skewed. This meansthat very long waits are the exception. A few long waits can have the same misleadingeffect on wait time statistics as a few palatial mansions on average housing prices. If 11patients have waiting times of 10, 15,20, 15, 12, 8,25,60,200, 15, 10 days, then themean (average) wait time for this group ofpatients will be 390/11 = 35Y2 days. Yet 9 ofthese 11 patients waited 25 days or less, and 7 of the 11 waited 15 days or less. When apatient asks that question, "How long will I have to wait?", her physician is unlikely tosay 35 days. Yet average wait times are often found in official wait list reports. Readerbeware.Only one of these cases is a candidate for a media story: the 200 day wait. We've allseen the headlines: OR backed up for 7 months. Ifwe know nothing else about this case,we do know that such a wait is highly unusuaL But in the world of selling papers and tvadvertising spots, the exception often makes the story. This gets an unassuming publicunderstandably concerned, playing nicely into the hands of those seeking to get moremoney into the system.3Is there a better way? In fact there are a number ofmore meaningful statistics. Themedian would be the wait of the middle, in this case 6th, patient, if the patients areordered by wait time - 8, 10, 10, 12, 15,15, 15,20,25,60, and 200 days. Some reportsuse what we might call "range" statistics -- ~ ofpatients waited 10 days or less; 2/3 ofpatients waited 15 days or less, 1 in 11 patients waited more than 100 days, and so on.As if issues ofwhen, how and why patients end up on lists were not problem enough,there are other sources ofvariation behind wait time statistics. It is little wonder thatmuch public confusion results.6. Why do people disagree about wait times for the same set of patients?Disagreement is a direct result of the many sources ofvariation noted above. Becausechoices can be made about when a wait begins (e.g. when Mr. Ross first sees his generalpractitioner, vs. when a specialist refers him for an MRI), how waits are measured, andwhat statistics are used to report wait times, it is inevitable that there will be disagreementabout "true" "wait times".There are no agreed 'scientific' rules for when Mr. Ross or Mrs. Jones should be placedon a list. There is no 'science' that will tell us whether to use the retrospective orprospective method ofmeasuring wait times. And while scientists may disagree about themerits of different statistics, all of them will be used at different times because differentchoices support different arguments. If you want to portray wait times as very long, youmight argue that the wait begins with the point of first contact with a gpo This willprovide a dramatically different picture than, say, using the time when a patient wasbooked for surgery. If you want to downplay the seriousness of the waiting game, youwill cite typical waits and ignore the very long ones. Conversely, if you want to"demonstrate" that the system is falling apart, you will refer mainly to the few patientswho wait a very long time, find an angry one, and parade him before the media.7. Are patients on wait lists monitored and re-evaluated for changes incondition?We don't know. No doubt some patients are periodically reassessed. We have notedabove that there is no requirement in Canada for wait lists to be independently audited todetermine whether everyone on a list needs to be there. If even this minimal qualitycontrol is rare, systematic monitoring of the condition ofpatients on waiting lists-particularly for elective procedures - is likely also to be the exception. Remember thatindividual physicians - not hospitals or regional health authorities - create andmaintain most waiting lists in Canada. Shared, coordinated wait lists managed by groupsofphysicians or hospitals are very rare. We know ofno public information that could tellus whether, or when, the order ofpatients on lists is monitored and changed as a result ofchanging clinical circumstances.48. What makes a waiting list fair or unfair for the public?A core principle underpinning Canadians' faith in, and expectations of, their health caresystem is "to each according to his/her need." The expectation is that equal needs will betreated equally, and unequal needs differently. A wait list or wait list system that fails toensure that patients get care roughly in order of relative need or urgency, would likely beviewed by most Canadians as inherently unfair. At least part of the current controversyaround workplace injury victims receiving care faster than other patients awaiting thesame services is based on a sense that this is unfair (although it may make perfect sense toa Workers' Compensation Board and to employers).9. What makes a waiting list fair or unfair for providers?Health care providers are also directly affected by when and whether their patients getonto lists, and how long they have to wait. Let's assume that cataract operating roomtime is assigned to ophthalmologists on the basis ofhow many procedures they did lastyear, or the length of their wait list. Is this fair to providers, to their patients, to thepublic more broadly?As potential or actual patients, we have an interest in ensuring that all physicians aresufficiently busy to maintain their skills, that new doctors have the opportunities toperfect and maintain those skills, and that our access to care is not jeopardized by thedeparture or retirement of a few providers. It would be unacceptable to interfere with thepublic's freedom to choose their doctors, but it is impractical, and undesirable, for allpatients to be seen by the doctor with the biggest reputation. Providing the public andreferring general practitioners with information about the track record of all providers(procedural report cards, for example) and differences in waiting times might lead todifferent choices and, quite possibly, shorter waits for at least some patients. Fairness toproviders requires a careful balancing of the interests of all providers, not just those whoargue that their long lists are a reflection of superior quality. This, in tum, begs forcomprehensive and accessible information on wait times and on outcomes.10. Who is responsible for the accuracy of wait lists?In two words, "individual physicians". With the exception of some cancer registries andcardiac care networks, there is very little coordination or sharing ofwait list informationamong physicians. Physicians own the lists, and only they are in a position to beresponsible for the accuracy of the lists.But what makes a list "accurate"? Decisions about when it is appropriate to place apatient on a list are largely the decisions of individual physicians. If physician A placesMr. Ross on his list before physician B would have, does that make physician A's list"inaccurate"? physician B's? If an independent audit would find that Mr. Ross isinappropriately placed on a list, does this make the list "inaccurate"? There can be noanswer to these questions unless there is widespread agreement on the "right" criteria forplacing a patient on a list.5There are also other less contentious sources of inaccuracy. Ifpatients end up on listswithout their knowledge, and do not wish to be there, those lists are inaccurate.Similarly, if you have received your MRI but remain on a list, or you are on more thanone list for the same procedure simultaneously, these are clearly sources of inaccuracy.Since wait lists in Canada are not audited, no one, including physicians themselves, hasany idea how accurate Canadian wait lists are.11. Why do some people seem to wait forever for service while others hardly wait atall?There are many reasons why wait times vary. Some regions have fewer physicians ordiagnostic machines per capita than others; if needs are the same, waits will tend to belonger in those regions. Some physicians "list early" in anticipation of long waits -recall Mrs. Fogg's sister. Some patients insist on being served by Dr. Longwait eventhough the services ofDr. Quick are available in half the time. And because most waitlists aren't managed in the true sense ofthe term, some unfortunate patients languish onlists because no one is paying attention and they are unassertive about getting somethingdone.But it's not always "the system" that makes people wait. British studies have shown thatmany patients refuse offered slots, choosing to wait longer. In Saskatchewan largenumbers ofpeople were found to have cancelled their own scheduled cataract surgery forreasons ofpersonal convenience. "Waiting forever" (which usually means a year or two)is actually what some people want.Patients awaiting different types of services are also likely to wait different lengths oftime. Where a variety of surgical procedures all use the same operating rooms, some ofthose procedures (e.g. hernia operations) may be considered more elective than others.This will mean that hernia patients may wait longer than patients awaiting otherprocedures.12. How can patients find out if other physicians have shorter wait lists?Although this seems like the sort of information that patients would want to have readilyavailable, in fact there are very few places in Canada that provide it. The availableoptions are not great. Patients can:• ask either their gp or specialist. But most ofus would not do either, for fear ofseeming to be questioning the physician's judgement, or because we want a particularphysician to provide the service. In most situations the physician would not have theinformation anyway.• check an internet or telephone-based wait list registry such as those in BC andQuebec. This has considerable potential. At the moment, however, there areconcerns regarding the timeliness, accuracy and completeness of such sources. Forexample, they may not include all hospitals, or all services/procedures. In addition,6most patients are unaware of their existence. Even if a patient does consult such a list,and finds a physician with a shorter list, at the moment the only way the patient canget other information on that physician is to ask his/her own physician; see above.• in isolated situations, count on a well-managed registry such as the cardiac carenetwork in Ontario, in which case they may not need to find out. One of the keypurposes of such networks is to attempt to get patients to surgery roughly in order ofurgency. Sometimes this means moving patients to the next available convenientsource of care if their local system is backlogged. But even that network reportssome variation in wait times across participating sites and providers.In summary, at the moment it is virtually impossible, or at least highly impractical, formost patients in Canada to get this information.13. Are Wait Lists or Times too long in Canada? How would we know?The number ofpatients on a wait list is not meaningful, if it is not accompanied byinformation on how long they have been on the list. "Health care wait list 10,000 andgrowing" might make for great newspaper headlines. But ifwe are given additionalinformation that the list is for patients with a non-life-threatening condition, and that theusual wait is 10 weeks, the situation takes on a different complexion.We can't say ifpatients wait too long unless we define what "too long" means. This intum requires a) consistent methods for deciding when patients should be placed on lists;b) that patients on the lists be ordered according to relative priority; c) periodic re-evaluation of their conditions; and d) mechanisms to move people up or down the listsdepending on their changing conditions. Other than for some life-threatening conditions,the great Canadian wait lists tragedy is that we do not have the management orinformation systems to know, or to be able to find out whether, and where, wait times are"too long". What we have, instead, is a virtually endless litany ofclaims about direcircumstances. Where there are genuinely dire circumstances we can't determine whetherthey arise because of too few resources, poor coordination or list management, suddenunpredictable changes in clinical condition, or any other reason.14. Don't people get sicker, and even die, while on wait lists in Canada?Patients on wait lists can be in pain, have reduced mobility, and suffer anxiety. Theircondition may deteriorate, sometimes to the point ofmaking it impossible to have theintended procedure. Some patients on wait lists will die, just as sick patients not on waitlists die. Do patients die because they are on lists for too long? Are they more likely todie because ofwaiting than from undergoing the services/procedures? Does "thesystem" make too many people endure an "unreasonable" amount of suffering or risk?It would obviously be desirable to have "suffering thresholds" below which we wouldexpect people never to fall as a result ofwaiting. To eliminate all suffering due to waitingwould require wait times of zero, the achievement ofwhich would increase costsenormously. The challenge is to balance the quite understandable concerns ofpatients7awaiting care and their families, with the broader vi):He(;lnlf;; mterest in ensuring thatresources are used wisely and fairly.Some recent Canadian research has found that not are unhappy about waiting.Very few patients who felt waits were "too long" to seeadditional public fundsused to reduce wait times (although this may related to procedures they werewaiting for and may also now be changing, as Canadians seem increasingly concernedabout access to care). Fewer still seemed interested in shelling out extra moneypersonally to reduce their wait time.Claims about patients dying because of waiting too k,ng cannot be confirmed or deniedfrom current research and information. This a part ofthe state ofwait listinformation in Canada. Even simple statistics such as deathsfrom differentprocedures,or deaths ofpatients on different lists, are simply not avauame,15. Is Waiting always Worse than Not Waiting?In a word, no. Some physicians put patients on wait lists knowing that the patient mayneed the service/procedure eventually, but where providing immediate service would beinappropriate. In some cases an alternative approach may improve the patient'scondition, in which case being put on a waiting list is a type of insurance policy. Waitingcan also provide time for the patient and his/her family to seek other opinions, time forthe body to have another chance to work its own magic. Indeed, the extensive auditresearch from the United Kingdom reveals many wait list patients who said they nolonger wished to be on a list because their condition had improved.C. Doing Something about Wait Lists in Canada16. Why do we have waiting lists anyway? How come the United States does not?Wait lists are a necessary part ofmanaging a largely publicly funded health care system.Ifno one ever waited, key parts of the system (people, facilities, equipment) would sitidle for long periods of time because the system would have to be able to deal with 'peakload'demands. Or, worse, those 'excess' resources might be used to provide services ofmarginal, or no, benefit. The costs of this sort of over-investment can be immense,because we are preventing "real resources" (people, buildings, not money) from beingused in other, more productive ways.Wait lists (if appropriately constructed, monitored, audited, and coordinated) can be veryuseful management tools. As we have seen above, they are tools to get patients toresources in order of urgency/priority, give patients time for sober second-thought, andensure that people, equipment and facilities are used efficiently.We hear virtually nothing about wait lists in the United States because investment andtraining decisions are uncoordinated, and often private. The United States has ended up8with much more capacity as a result. They have built, not by design but by accident, forpeak load and more. Even public facilities are forced to compete with private; to do sothey often buy equipment they do not really need, in order to "keep up with the Joneses".The United States could be described as suffering from the side-effects of a medicalequipment arms race.But this doesn't mean that patients in the United States never wait. The dirty littlescandal there is that (approximately) 15% of the population has no insurance coverage.Many others have inadequate coverage, cannot get immediate access, and cannot movefreely between jobs because ofhealth care conditions. If you are sick in the United Statesand have either no or inadequate insurance coverage, you would probably consider beingin Canada on a wait list a remarkable luxury. Such patients wait for care because theycannot afford it. They are not on anyone's wait list, except their own.17. What do other countries do to manage wait times?The most common approach to reducing wait times has been to provide funding foradditional resources (e.g. skilled personnel, operating suite time). But in country aftercountry, research has demonstrated that additional funding has seldom permanentlyreduced wait lists or times. Indeed, sometimes more funding leads to more procedures,but longer waits. This "feedback" effect occurs because referring physicians increasereferrals to specialists if they think wait times are going to fall. The implicit "threshold ofneed" for when to put a patient on a list falls.Presumably because of the rather dismal record on reducing wait times by addingresources, some countries have paid more attention to the 'demand' side. One approachnoted above is routine audits of lists. This has been shown to reduce substantially thenumber ofpatients on lists, but so far as we know has not, anywhere, become amainstream, regular part of a wait list management system. Reducing the number ofpatients on lists could reduce wait times if some of those removed would otherwise havereceived the service inappropriately. Regular periodic reassessments ofpatients on listshas also been used effectively in the UK to reduce last minute cancellations.Some policies have focused on getting care to the patients who have been on lists thelongest. One approach has been to arrange priority access for patients who have waitedlonger than a specified time. Another approach is to offer a "guaranteed maximum wait"time. Under this latter program, if the maximum wait time for an MRI is 3 months, andMr. Ross has been waiting 80 days, he will be given higher priority than someone whohas only been on the list for one month. Without additional resources to increasethroughput, the logic of these programs is to deliver service to patients with less urgentneeds (but who have been waiting longer) at the expense ofpatients with more urgentneeds who have not been waiting as long. In contrast, the recently-developed NewZealand system ranks all patients on a list according to relative "urgency" and ensuresthat those at the top of the lists get care fastest.A crucial point is that coordinated (or better, consolidated) wait lists have been found tobe most responsive to the relative priority ofpatients. Some progress is possible even9where individual specialists maintain their own lists ifwait times are available to thereferring gps, and they are encouraged to refer to specialists with the shorter wait times.Some jurisdictions have gone further, replacing waiting lists with a system ofpre-arranged admission/service dates. Rather than being placed on a list and waiting until shereaches the top, under this system Mrs. Fogg would be given a firm date for her cataractoperation. This has reduced the number ofpatients not showing up when called, and thenumber admitted through emergency departments.18. What is being done in Canada to reduce wait times, and with what effect?Canada has followed the international trend - the most common approach has been tothrow money at the problems. But in some areas Canada has been among the leaders indeveloping coordinated list management approaches, an example being the Cardiac CareNetwork in Ontario. Such initiatives have, however, been the exception, not the rule. Byand large, money has been used to paper over cracks, with little effort to find theunderlying structural problems that created the cracks in the first place.Other documents detail the approaches of individual provinces. Here we provide only themost cursory of summaries. Provinces have taken three general approaches: morefunding; information enhancement (wait list registries); and coordination/priority-settinginitiatives.More FundingMost provincial and territorial Ministries ofHealth have had to address perceived waitlist/time crises at one time or another over the past five years. Targeted new funding hasbeen the policy of choice. It is almost impossible to determine whether any of theseinjections has had long-lasting effects on the wait lists to which it was directed.Ministry reports in British Columbia claim that additional funding has reduced waits forsome types of care. But any such effects are likely to be transitory, if internationalexperience can be taken as a guide. Some provinces have developed contractualarrangements with care-providers in the United States, as a temporary mea-sureto reducepressure on in-province waits. These, too, have a mixed record of success.Information EnhancementBritish Columbia and Quebec appear to be the most advanced in terms of attempting todevelop systems to provide timely information to referring physicians and their patients.Since 1993, the B.C. Ministry ofHealth has maintained a registry to track waiting listsand waiting times for many surgical procedures, covering about 30 hospitals and over1,000 physicians. These data now feed a web site that can be accessed by anyoneinterested in wait times for different surgeons and procedures. Quebec has also recentlyestablished a similar web-based resource. Nova Scotia has recently provided acomprehensive report on wait lists and wait times and has plans to develop an ongoingwait list/time monitoring system.10Coordination/Prioritization InitiativesCanadian initiatives to develop systems that co-ordinate the lists of individual physiciansare few and far between. The leading example has been the development of the CardiacCare Network (CCN) in Ontario. Twelve surgical centres participate in the CCN. Eachcentre has a nurse co-ordinator responsible for .iata collection and for locating a suitableand willing surgeon or interventiona1 cardiologist who then communicates directly withthe referring physician. IfMrs. Card is sent to one of these centres, she will be assessedand assigned a priority based on an "urgency rating score". The CCN will then determinewhich site is able to provide her surgery in the most timely way. Similar patientprioritization systems are being developed and implemented in Ontario for orthopaedicprocedures such as hip and knee replacements. There are other similar systems in pocketsacross the country, in cancer and eye care, largely because of the vision and commitmentof individual or small groups ofpractitioners.More recently, 19 partners in the four western provinces have teamed up in the WesternCanada Waitlists Project. The intent of this project is to develop and field test patientpriority ranking systems for five clinical areas - MRI, cataract, orthopaedic procedures,paediatric mental health, and general surgery.To date, only the CCN has produced any information on "effects". Research has shownthat the priority rating schemes have been accepted by the physicians affiliated with theCCN, that patients with higher urgency scores tend to have shorter waits, that fewsurgeries get cancelled or delayed, that there are very few adverse events when patientsare appropriately prioritized, and that waiting times are reduced ifpatients do not insist ona particular cardiologist. In this case, additional resources were also found to have led toa decrease in waiting times.There appears to be growing interest in the further development ofprioritization/coordination initiatives. Without them, in our view, there is little hope thatCanadian provinces will be able to get beyond the endless crisis-cash-crisis... cycle.19. Wouldn't putting more public funding into health care reduce wait times?Not necessarily. Ifwe don't have the information we need to determine where our realpriorities lie, then simply adding funding for health care comes with no guarantee, or evenlikelihood, that the funding will get to where it is needed most. Should we put the fundinginto procedural cardiologists, or operating suites, or surgical beds, or cardiacperfusionists, or intensive care nurses, or a program of flu vaccines for nursing homeresidents? If funding is handed out to those who make the most convincing sales pitchesunsubstantiated by real data and analysis, then the public should quite appropriately beskeptical.But even ifwe found the right targets, we would need to ensure that new funding gottranslated into additional "real resources". Money doesn't treat patients, nor does itinevitably buy increased capacity. IfMinistries ofHealth add $100 million to the systemand it all goes for increased salaries for nurses (perhaps a good thing for other reasons),11the money buys not a single additional procedure. If the cost of a drug doubles, doublingthat drug's budget will not make it possible to serve even one additional patient.So should we ever add funding in response to apparent crises? Additional funding forhealth care is but one choice among many competing worthy aims, like preservation ofparkland; salmon enhancement programs; better housing for inner cities; reduced classsizes, and so on. The first thing we should do is establish whether the apparent crisis isreal, and what priority it should have, relative to others both outside, and inside, healthcare. Then we might well add money, carefully targeted. When we do decide to commitnew funds to health care, we should not forget that we have many choices -- morepaediatric mental health, or more cataract removals, or more flu vaccines, or moreexpensive drugs, or more hip replacements? Again, it will help to have information onexpected costs and benefits since it will never to be possible to do everything.Part of keeping our eye on the ball is never forgetting the lessons ofhistory. It does notmatter how much public funding is made available to health care. There will still beclaims that it is not enough, that there are crises here, wait lists there, physician shortageshere, nursing shortages there. The claims have been with us at all times, and all levels offunding.20. Why can't I simply pay to get faster access? Wouldn't the private fundingreduce the waits in the public sector?An elected official with half a million dollars in the bank complains about not wanting todie on a wait list. Advocates pressuring provinces to allow private hospitals claim thatthese will reduce wait times in the public sector. Such complaints and claims have beenwith us as long as those general claims that the system is "under-funded". And they dotend to find a responsive audience, among the public and the media. But these tum out tobe more common than sense, and seldom do real consequences, or real agendas, getexposed.What does "paying for faster access" mean, and how would it work? One option wouldbe to allow people to "buy their way to the top" of queues in the public system by payinguser fees. No one is actually proposing this system in Canada because it so transparentlyviolates a central premise ofMedicare: ability to pay shall not affect access to neededmedical services.Another option is to allow private facilities to operate entirely outside Medicare, withindividuals (or third party insurance) paying the entire cost ofprocedures. This option,the argument goes, would take well-to-do people out of the public queue, thereby movingeveryone else up and reducing wait times. And we would still have the tax dollars ofthose who opted out to fund public services, just as we get tax dollars to support publicschools from those who pay handsomely to send their children to private schools.At first blush, this seems to solve a lot ofproblems. Unfortunately the blush fadesquickly. Even "full cost" is not, in practice, full cost. For example, people now canpurchase laser eye surgery from a variety ofprivate vendors. But in those (admittedly12rare) instances when something goes wrong, the public system bears the costs of'mopping up', which can sometimes be substantial and long-term. While this example isof a service not covered by provincial health plans, the scenario would be the same for hipsurgery as for laser eye surgery. If Canadians could purchase hip replacements or herniarepairs in Canada privately, the public system, under current arrangements, would pick upthe costs ofprivate procedures gone wrong. Those who speak of "full cost" NEVERmean that these additional costs should be included. So even the "full cost" option endsup being public subsidy ofprivate decisions in ways that the public might not support.Certainly they have never been asked!Furthermore, creating a "full cost" private payment option still requires those "realresources" - people, places and things. How would we create those private resources?One option would be for health care personnel to work partly for.the public sector, partlyfor private patients. Where this arrangement exists, research from Manitoba, Alberta,and the UK reveals that public patients ofphysicians who work for both public andprivate clients wait longer than patients ofphysicians who provide care only in the publicsector.Another option might be to require health care providers to make a choice between publicand private care. Just how having some of our surgeons abandon the public sector for theprivate could possibly shorten public sector waits is not immediately obvious, particularlyif, as many of those making the argument claim, there is already a shortage ofphysicians,nurses, etc., in the public sector.Could we not simply increase enrolment in health science educational programs toproduce enough personnel to serve both the public and the private parallel systems? Yes,we could, but at what cost, and who would pay? All post-secondary education in Canadais highly subsidized by taxpayers. Would Canadians really support paying higher taxes toproduce graduates who would serve only the well-to-do? Alternatively, suppose we wereto charge students destined for the private system full fare (on the order of $40,000annually for medical students, probably $15,000 for nursing students). Should we openthis option to the not-so-talented children of the wealthy while better qualified Canadiansare denied entry to training programs? And would this mean that students graduatingfrom the public post-secondary system would be barred from practising privately?Such approaches would begin to move us away from "service on the basis of need;payment on the basis of ability to pay (through taxation)" to "service on the basis ofability to pay; payment on the basis ofneed". This is more than simply rearrangingwords on the page. It strikes at the very heart of the funding principles on which the lastthree decades ofhealth care in Canada have rested.21. Are there other things we can do to improve information and reduce wait times?The first order ofbusiness is to create good information systems, based on standardizedconcepts and terms that provide real-time intelligence for decision-makers and the public.They must identify people at risk because ofpotentially excessive waits; ensure thatpatients are reassessed when their circumstances change; and remove those whose clinical13condition improves, who have decided to forego the' who die, who move out ofjurisdiction, and so on. They should get patients to care roughly in order ofurgency.They should also follow patients after service OJ procedure, so that we developinformation on how different patients do after receivingcare, For most procedures, thecurrent Canadian "non-system" ofphysician-controlled not only makes it impossiblefor managers to manage, but also "puts patientsWhile it makes sense to begin sorting out the system m a areas in order to establishsome basic principles and to test the process ofprioritizing patients (as the WesternCanada Waitlist Proj ect is attempting to do), ultimately road must be traveled by theentire system. Accessibility and prioritization are crucial to every type ofhealth careservice; piecemeal 'solutions' may compromise overall system integrity, continuity andfairness.Improving information and reducing wait times a systematic and sustainable mannerwill require movement on a number of fronts, including significant investment in waitlists information, the coordination of lists with patient interests as the guiding priority, thedevelopment and application ofvalidated patient prioritization systems, and theimplementation of independent random audits. In our view, all of these elements must bepresent ifwe are to see permanent gains and restored confidence among Canadians inaccess to care. As it is, the waiting list non-system in Canada is a classic case study offorced decision-making in an information vacuum. We have become hostage to our ownfailure to invest in the necessary intelligence-gathering.14


Citation Scheme:


Citations by CSL (citeproc-js)

Usage Statistics



Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            async >
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:


Related Items