Monday, November 8, 2010

A health care rant

Much of this is taken from a Facebook conversation, but has been added to and tweaked. So if you are one of the 3 people that read it there, and you know who you are, you still need to read it again.

Language has become a problem in the health care debate, with one side taking the Canada Health Act as a sacred trust, and the other as a sacred cow. As in, ready to have holes poked in it to join the ones already there. The whole sound bite thing has made it very difficult to even discuss the issue because as soon as you say "privatize" people assume you mean going to the American system when that might not be the case at all.

We already have lots of people making a profit out of health care. Every General Practice doctor, and every dentist just for a start. So anybody that objects to privatizing of health care because somebody is going to make a profit needs to get with the program.

The problem with health care as a commodity is that demand is essentially unlimited. Who wouldn't go for that second test just to be sure, or another round of imaging to get the best possible picture of where to cut? Yet there are limited resources to meet that demand. Limited equipment, limited numbers of people to run that equipment, and most critical of all, limited numbers of people to interpret the results and decide what should be done, then do it. Plus we have idiots who have no idea what the proper use of an emergency ward is, or how to effectively access the system, then wonder why they are sitting in the emergency ward for 24 hours with a minor injury.

What we have now is a sick care system. I want a health system that keeps people from getting sick in the first place. I want to see people much like Registered Nurses set up in strip malls like 7-11's are. People register with their nearest one, and go in regularly, I'm thinking monthly, or every couple moths. Check weight, blood pressure, look in various orifices, prod sensitive bits of anatomy, and keep data so that when a problem comes up everybody knows what the baseline is, and have an understanding of what normal is. This would catch problems like diabetes much earlier.

Once it's determined that further treatment is necessary, the nurse feeds them into the system. They see the appropriate specialists, get tests ect. Then they get treatment. If some doctor figures he can fill the demand for xyz procedure better and faster because that's all she's going to do, then the system works out a price, and sends the people. Whatever gets the job done most efficiently is what floats my boat.

Now, should people with more money jump the queue? Let's make sure we understand the question. Lets look at some procedure, call it x. Doesn't matter what it is, really. In a year the Canadian medical system can do only so many of them. Some are routine, some are emergencies, some are done by a specialist that can't do anything else, and some are done by a generalist who, to some extent, can choose to one of many procedures. Trying to optimize the time of the medical professionals, and the associated equipment while meeting the needs of patients is an extremely difficult problem.

If there are more people who want or need procedure x than the system can process, then we have a problem. Most of the time, it's the worst case that gets treated. By making that person wait, their case is probably much worse than it would have been if they had been treated right away, and they've likely developed further complications. The medical system has been working on a triage basis. Mostly. If that's what it is, then people understand. But when the rich and powerful go to the front of the line, it causes social unrest, it does. Yet it's clear that the medical system needs some way of rationing the available services.

I don't particularly object to some doctor working outside the system and charging a fee for his patients. After all, the doctor has valuable skills, and one can't blame them for trading those skills for as much money as possible. But is money the only rationing system? I'm not sure. It's just the one we use most. The fear is that the rich will get good, immediate care, and the poor will get inadequate, long delayed care. After all, the medical professionals are going to want to work in the system that compensates them the best. Providing skills at a discount to serve a social need is all well and good, but doesn't put food on the table.

I also object to the insurance companies telling us what procedures we can have, because that's what they're willing to pay for, even if the doctor and the patient want something else. That is a repellant system that I want no part of.

To sum up, privatization is not a dirty word. It just needs to be carefully handled.

Now lets look at the people in the system. I want each person to get a statement at the end of the year that details how much they and their families cost the system. Not in the sense that it's a bill, it's just a statement. To balance it off, it also lists what they paid into the system in terms of taxes, special fees, and anything else. It would be interesting to include figures like the max cost for one individual, the mean, mode, average, and minimum cost for a person.

There are lots of times where a person might have a very expensive year due to an accident or the onset of some expensive medical condition. The hope is that when the entire Canadian public is considered the risk pool, all these things average out.

Yet there are some people who cost more than others, consistently, year in and year out. Way more. We should be looking for the consistently most expensive people in the system. Most people think that costs for each person are about the same, on average. For most people that's true. But for a small segment the costs are much higher. Some of the homeless are into the emergency wards weekly. Drug users. Drunks. The sick elderly. The handicapped.

I'd like to identify those high risk people, and start addressing their specific issues to drive down their costs. In the book "What the Dog Saw" by Malcolm Gladwell, there is a chapter talking about homelessness. The costs of these homeless people on the medical system is staggering. When you look at what gets spent, and the people resources they tie up in the process, it become much easier to justify a custom solution. Like giving them an apartment and their own social worker. Sounds bad, but it saves big dollars.

I'm a pragmatic person. I don't have ideological labels on me. I want solutions that make the best use of our taxpayer dollar, and that are as fair as possible. That might mean that people have to start taking better care of themselves, and if they don't, they should get billed. If that means that a few people get "special treatment" because that special treatment costs half of what treating them like everybody else costs, then I'm all for it. And no, I don't think the appropriate treatment for the sick elderly involves an ice floe and polar bears. Still, they have specific issues that can drive down the costs of treating them. For example, doctors and nurses making regular house calls on them sounds expensive, until you consider the alternative of having them in a bed in a hospital.

Smokers are one of my hobby horses. Smokers are making themselves sick, and are helping make those around them sick. Cigarette smoke is horrible stuff, and there is no redeeming social value from it. At least auto exhaust (which has got much cleaner over the years) is balanced off by the transportation provided. Smokers should pay higher health care premiums. Much higher. Like twice or three times or more. They should routinely be denied expensive medical services like heart or lung transplants because they aren't interested in their health. If they were, they'd quit smoking. Naturally, I think the services that help people quit should be widely available, and should be tax deductable. We should be doing anything possible to prevent people from becoming smokers in the first place. Cigarettes should not be available in a corner store. Only at licensed tobacconist shops that don't sell anything but tobacco products. And yes, they should be allowed to sell pot too. I confess I'm not sure how these people should be identified so we know to charge them higher taxes.

All that said, I'm not sure I want to go down the road of charging everybody a different health care tax based on their bad habits such as smoking, drinking, eating fatty foods, not getting exercise, and who knows what else. I don't like the idea of turning Canada into some namby-pamby nanny state where people wear helmets on a day to day basis because, gosh, they might fall down and injure themselves. Even though I've done just that and know of others who have too.

As for high risk activities my thinking is that many of these are common things that are part of the risk pool. Hockey is a part of Canadian culture, and most people play hockey at some time in their lives, and yet there are a lot of injuries from it, some quite serious. Any activity has the risk of injuries, and hence, putting a demand on the health care system. Hell, just being old is a risk all by itself. Where do you draw the line between high and medium risk?

I look at how people prepare for the activity. Do they wear the appropriate personal protective gear? Have they made themselves aware of the hazards of the activity and taken the appropriate steps to mitigate them? Are they in reasonable physical shape for that activity? Do they practice it at the appropriate level (pickup, recreational, league, professional, ect)? Do they have the appropriate first aid equipment on hand? Is there booze involved? The exact response to each of these varies by the activity. A game of pickup baseball at a family picnic will generate entirely different answers than someone going back country cross country skiing. And different again from woodworking, parachuting, scuba diving, climbing mountains, and well, everything that humans do for fun.

Some people make the argument that too much exercise is bad for you as well, driving up the need for knee and hip replacements, or injuries. Look at the medical resources needed at, for example, Ironman, to give IV fluids to people who pushed too hard on the day. Some might say those medical resources might be more effectively used elsewhere, and we shouldn't allow people to do medically risky things such as Ironman. Or we might realize the superb conditioning levels of Ironmen drives down the cost of the system overall because of the lower incidence of heart and lung disease, and on that basis, offer people that complete an Ironman a 10% break on their taxes.

But when we talk about dangerous activities, we need to talk about the elephant in the room. The 800 pound gorilla. Right now the single most dangerous thing that a North American does is be in a car. Yup. Driving. There are things like heart and lung disease that kill more people, but as an activity in itself, being in a car is extremely dangerous. If we want to cut health care costs, I say, I YELL,

 There Is No Such Thing As A Car ACCIDENT! 

Every one of them has a cause, and in almost every time the cause is driver error. The cost of these "car accidents" is horrendous. It took about 10 seconds to find these figures from 2007 for Alberta alone.

458 people killed, and 24,530 injured in 153,901 reported traffic collisions. 

Go back and read that again. I'm not kidding, and I'm not making it up. Alberta's population is only 3 million or so. WTF!!!!!! Why do we put up with this? I'd love to see how much that costs our health care, and how many hospital beds would be freed up if those victims were dropped out of the system. There are entire industries  built around repairing the people, cars, and infrastructure damaged by these collisions. Imagine what more productive use they could be put to.

We should start investigating these "accidents" the same way we investigate plane crashes. There is no reason in the world why driving shouldn't be as safe as flying as a mode of transportation. It's our idiot drivers that make the roads so dangerous. Cars themselves are pretty safe these days, and in fact they're so safe they are starting to promote riskier driving behaviours. Let's start weeding out the idiots, and upgrading driving skills. Here's some ideas, in no particular order:

  • Name and shame people that caused a collision. Put their name and photo in the paper, and on a government web site for the purpose. Give their car some equivalent of a dunce hat.
  • Double, or triple the insurance rates of those demonstrating incompetence at driving. 
  • The first driving impaired offense should be an educational whap upside the head with a wet cod because it is only just barely possible the person might genuinely believe themselves to be ok. I'm talking hundreds of hours of community service dealing with the aftermath of drunk drivers. I'm talking passing a driving skills course that makes the current road tests look like kindergarten. I'm talking a fine of say, 10% of your gross income from all sources. This should be enough to get the person's attention that driving impaired is a major no-no. For a second offense I think a suitable punishment is to have all their organs harvested and distributed to the people on waiting lists for organ transplants. You only think I'm kidding.
  • People who no longer have the required driving skills need to be removed from the road. Everybody should have mandatory road tests every 5 years, which includes a refresher on driving skills. At 60 it should go to every 2 years, and at 70 every year. These road tests should be much tougher than they are now. They should include dusk and night driving, a skid test, and dealing with vehicles such as cyclists, oversized loads, and construction or farm equipment.
  • There should be a much greater use of simulator technology used for driver training. Right now it's common to see driving and flying games. But we should be creating driving simulators similar to airplane simulators. These are so accurate that pilots are rated to fly the airplane with passengers for the first time after such training. I'd like to see the driving simulator so accurate, and so tough that the cocky teenagers come out with wet pants and ringing ears. 
  • Rather than ban the use of cell phones while driving; if a collision investigation shows the driver was using a cell phone or similar device, then the insurance company need not cover the costs of that collision. That forces people to take responsibility for their actions. 
  • The so-called 'single vehicle accidents', where a driver winds up in the ditch are evidence of driver incompetence. Regardless of when their license renews, it should expire immediately to force them through a renewal exam and refresher. Maybe their insurance rates should go up. It should be noted there are times when ending up in the ditch *is* the correct course of action.
  • I'd like to get rid of about 90% of the signs on the road, including traffic control signs and devices. Did you read about the experiments in Europe to do away with traffic signs? Very interesting. By making the roads more unsafe, it forces the drivers to pay more attention and interact with the other people on the road.
  • Public transit needs to be made drastically more effective. Calgary's system only qualifies if you live near an LRT station and only want to go downtown.
Really, that's two rants in one, health care and driving. Stay tuned for a rant on zero tolerance rules.


  1. You are being far too practical an impractical world.

    It could be much could be stuck in the American Healthcare system (oh, didn't anyone tell you it's the "best in the world"...GAH! and WHATEVER!)

    Seriously though, you should run for office :-)

  2. BTW...can't wait for the zero tolerance rules :-)

  3. Good food for thought! I agree with many, if not all of your points.

    Maybe you should be the next Health Minister...


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