Health care costs: putting our worries in context

Why there’s no need to panic about the quality of care in Canada

Worry about the cost of Canadian health care is growing among those who pay attention to how governments pay for programs, which is a good thing. But I think we should get straight on the strengths of the system before we start arguing in earnest about how to reform it.

The Organization for Economic Co-operation and Development set a grave tone earlier this fall by warning that Canada’s public health spending is unsustainable; among those who took note was former prime minister Brian Mulroney. But the Paris-based OECD was only echoing earlier pleas from the likes of former B.C. finance minister Carole Taylor and former Bank of Canada governor David Dodge, who have both called for a candid, national conversation about containing the rising costs of care.

Indeed, that debate must begin soon if serious ideas are to be hammered out in time for a new agreement between Ottawa and the provinces on health transfers when their current deal runs out in 2014.

My own inclination is to view the public insurance model as basically sound. Still, I can see that the provinces are struggling to pay for care that often falls short of what we’d like. So, in a bid to jar myself into the more open mindset Taylor and Dodge encourage, I figured I should consider the arguments coming from those with the opposite bias.

Fortunately, the Fraser Institute seems to offer up the very thing: a report published just last month called Value for Money from Health Insurance Systems in Canada and the OECD, by Brett Skinner and Mark Rovere. As you’d expect from the right-leaning institute, their report presents a challenge to those of us who think well of the Canada Health Act and all it has wrought.

“Despite being ranked as the sixth most expensive health insurance system in the world in 2007,” Skinner and Rovere write, “Canada ranked below the majority of the other 27 OECD countries in almost every indicator of medical resource availability and the ouput of medical services for which comparable data were available.”

That’s a pretty disturbing overview—very expensive, lousy outcomes. But look a little closer. Skinner and Rovere list 18 indicators based on OECD data, all concerning diagnostic or surgical procedures, ranging from the number of MRIs per million people to the number of appendectomies per 100,000.

In fact, Canada performed better than the OECD majority on seven of those statistics, including the number of knee replacements and the number of bypass surgeries. To me, scoring below average in 11 of the 18 categories doesn’t back up the claim that Canada fell short “in almost every indicator.”

More important, though, is what these indicators actually indicate. It’s probably significant, for example, that Canada has fewer curative care beds per capita than most OECD countries (although we have more than the usually well-regarded Swedes and Finns), but should we really worry about performing fewer tonsillectomies than the OECD average?

To me, the grab bag of procedures listed by the Fraser Institute as indicators of value for money seem a strange mixture of the evidently significant and the seemingly irrelevant. I was surprised that the OECD would choose this particular list of benchmarks for the quality of health systems.

But then I found out the OECD does no such thing. I looked up the OECD’s own report Health At A Glance 2009, and turned to the chapter conveniently titled “Quality of Care.” The chapter expressly sets out to provide some guidance when it comes to answering this question: “Which areas of the health care system are providing value-for-money and which show opportunities for performance improvement?”

Unlike the Fraser Institute in its “value for money” assessment, the OECD’s “Quality of Care” chapter does not put much stock in procedures-per-capita numbers. Instead, it looks at 11 indicators, focusing on factors like avoidable deaths in hospital and delivery of preventive measures.

Canada scores better than the OECD average on eight of the 11 indicators. On two indicators, the Canadian outcome is mixed. On just one, Canada scores worse than the OECD average. It doesn’t take long to look at the tables, but here’s a brief summary.

— The sole category where Canada clearly does worse than the OECD average is in-hospital fatalities after strokes.

— The story is mixed for Canada on diabetes: slightly higher than average acute diabetes complication rates, but lower than average rates of amputations caused by diabetes. As well, on early childhood vaccination rates, Canada’s story is split: better than the average on measles, but worse on hepatitis B.

— Canada performs better than the OECD average in avoidable admissions for asthmas and bronchitis; on avoidable admissions for heart failure and high blood pressure; on deaths from heart attacks in hospitals; on unplanned hospital readmissions for mental disorders; on screening for cervical cancer; on mammography; on survival rates for cervical cancer and colorectal cancer; and on getting senior citizens their flu shots.

It would be foolish, of course, to argue that we should all relax just because Canada scores so well compared to similar advanced nations according to nearly all of the OECD’s quality-of-care indicators. Provinces nonetheless face escalating costs that are likely to worsen as the population ages. Individuals still feel justifiably annoyed when they have trouble finding a family doctor or wait for hours in an emergency room.

But let’s not go into this complex debate in an ill-informed panic over the basic standard of health service Canadian are now getting for their tax dollars. Based on the reasonable indicators chosen by the OECD for the purpose of making international comparisons, care here is better than average pretty much across the board.

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