PLATFORMI* TRIBUNE
PLATFORM * TRIBUNE
Down
the Oregon trail
The way for
Canada?
Harry E. Emson, MD, FRCPC A 11 systems of publicly financed health care face a common problem: the cost of human ingenuity applied to health care exceeds the capacity to pay for it. The effects of this disparity are unpleasant. One is that not everyone receives all the health care from which they might benefit; there will be suffering and death that could have been avoided or postponed. Another is that choices must be made, and these will be based on an assessment of relative values - of different forms of health care and of the people who will receive or be denied such care. The hard word is rationing. Who determines the values on which rationing is based, and how do they do this? Some people maintain that redistribution of resources within the health care system, allocation to it of a greater share of community resources and increased efficiency would obviate the need for rationing. Although such arguments may be cogent this view is not generally held, and the problems of health care rationing occupy an increasing amount of space in professional and lay journals. Attempts to come to terms with these problems in Oregon have drawn attention. The system there is very different from ours. The state's population is about 2.7 million, of which 450 000 (about 17%) have no health care insurance. The majority are covered to some extent by Medicare and Medicaid programs or by private plans, which may or may not be employer-funded. It is a patchwork quilt of care. Those who are uninsured might have been described 150 years ago as the "deserving poor": poor not by reason of indolence or dissipation and deserving the assistance of the more fortunate in society. It is toward insured coverage of this minority group that present plans are directed. However, there is a distinct possibility that what is decided for this group may become a precedent for the rest of the population.
Health care in the United States is rationed on the basis of who is covered as well as what is covered. When Oregon moves toward the situation we now have in Canada, in which everyone is covered by health care that is partly publicly financed, the question of what types of services will be insured will become inescapable. We already know that to fund all kinds is impossible, because it would be too expensive: given the open-ended nature of health care it would be like writing a blank cheque. The ways in which Oregon has tried to solve this problem are therefore significant to Canadians. The Oregon approach has been to devise a list of health care priorities based on three principles: equity for those not now insured, explicit choice (fairer than hidden rationing) and a combination of expert analysis and community values. One strategy - the scientific - is to rank services according to quality of well-being and a cost-benefit measure. Another, more innovative method is to go to the public for ideas through community meetings and a telephone survey, a procedure made mandatory by the state legislation. (The values obtained through this second method are interesting; of high priority were quality of life, prevention, ability to function, cost-effectiveness and equity.') The results are melded into a list of groups of illnesses, conditions and procedures and within them a more detailed list. The level of funding determined by the state legislature will determine the cut-off point in the list: conditions and procedures above the line will be insured by the state and those below will not. The cut-off point could move up or down over time, depending upon the availability of funds. The whole process is under the control of an appointed commission that is independent of politics. The ways of determining priorities have been criticized. The community meetings, though open to
Dr. Emson is professor ofpathology at the Royal University Hospital, Saskatoon, Sask.
Reprint requests to: Dr. Harry E. Emson, Department ofPathology, Royal University Hospital, Saskatoon, SK S7N OXO DECEMBER 1, 1991
CAN MED ASSOC J 199 1; 145 (1 11
1441
.M
all, were allegedly attended largely by health care workers and others in the system; those actually affected by the scheme were less well represented. Was this, in fact, the payer setting limits for the deserving poor in an excess of cautious paternalism? Perhaps the poor will bear the burden of the plan, and decisions will be made by the "haves" for the "have-nots." Any attempt to rank health care omits variation in individual response. The relation between community values and those defined by larger democratic groups or by scientific or moral analysis is uncertain. The scientific analyses in Oregon originally produced some very bizarre rankings of priority, which were eliminated by the application of common sense and by reference to priority scales determined by other methods. One of the most publicized decisions was not to fund organ transplantation (although kidney transplantation is covered by Medicaid at present), a decision taken on strictly utilitarian grounds and deliberately balanced by a complementary decision to insure preventive antenatal procedures. Whether all this will, in fact, come to pass depends on legislative will and the negotiations between state and federal governments over the financial details. If it does, the world will eagerly watch the results. In the meantime, are there any signposts for Canada on the Oregon trail? We are way ahead, in that we have jumped the huge hurdle of who is covered, by the principle of universality embedded in the foundation of Canadian medicare, and this should take care of most of the issues under the equity principle. We have quite conspicuously not substituted explicit choice for hidden rationing. We possibly rely to some extent on expert technical data and obviously very little on community values. Perhaps Canadians are different from Oregonians and should not move along the same road. However, we are faced with the same decisions, simplified considerably by our principle of universal coverage and by our very small second tier of health care (e.g., the National Defence Medical Centre, which serves our federal politicians and senior civil servants). We are perhaps fortunate, perhaps supported in national hypocrisy, in not having to make most decisions on a two-tier or multitier system; in the United States the extra tiers are eagerly supplied by and easily accessible as commercial health care.2 Decisions on health care rationing are made in Canada all the time but not by explicit public choice. Some are made by politicians, and political value systems riddle the process, for example in decisions about where hospitals should be sited and how they should be equipped. The value systems of individual politicians, too, influence events: the minister of health for Saskatchewan decided not to permit the 1442
CAN MED ASSOC J 199 1; 145 (11)
establishment of abortion clinics, thus overruling a decision of the College of Physicians and Surgeons of Saskatchewan. In other provinces politicians have suggested exclusion of procedures such as vasectomy from medicare coverage (Saskatoon Star-Phoenix, Mar 28, 1991: C10). Decisions are made to establish mammographic screening programs. Some provinces have commissions to evaluate health care technology, and they consult with commission members in making decisions about technology,3 but more have chosen not to establish them. Health care decisions may be driven by the law, as in the province-wide introduction of nonionic radiographic contrast media in Ontario4 or more diffusely as doctors move away from forms of practice (e.g., anesthesia and rural obstetrics5) perceived as bearing a high risk for a negligence lawsuit. In all health care systems that combine political and bureaucratic components values of cost and quality are inextricably and uneasily intertwined. Nowhere in Canada do we have any system that continually samples public opinion and community values about priorities in health care. Most politicians would say that the processes of democratic election supply this information, but rarely does it amount to anything more than strident statements that "medicare is safe in our hands." A number of surveys attempt to sample public opinion. Alberta's Rainbow Report6 is one of the more slickly printed and highly coloured and, like others, is full of generalities and lacking in detail. From its accounts of community meetings it seems that the same values were expressed as in Oregon. However, the provinces are not legally required to use such a sampling process in setting priorities, let alone be bound by its results. As yet, no province has delegated the setting of priorities in health care to an independent, nonpolitical body and limited legislative decisions to the overall level of funding. These ideas seem to me to have merit for Canada. In a democratic society those to whom something is done should have the right to determine its nature and extent. First, in setting priorities in health care we need both scientific analyses and community values suitably reconciled and combined. Community values should be established not by surveys and glossy reports but, rather, by continual, valid methods of evaluation. Second, the process should be an open one whereby procedures and results are made public and not suppressed by those with conflicting interests. Explicit choice is fairer than hidden rationing. Third, priority setting should be separated from politics by the establishment of adequately funded, publicly accountable bodies of guaranteed independence - perhaps no one who has ever held elected office or a civil service position should be eligible for membership! LE Ier DECEMBRE 1991
The final step is the questionable one: whether a cut-off point moves inexorably up the scale. The Canadian legislative body would be willing to dele- Oregon trail may look increasingly inviting. gate power to such a process by funding only the overall amount to be spent on health care and References leaving priority setting and cut-off points to another body. In the present political climate this seems rather dubious; too much power and too large a pork 1. Garland MJ, Hasnain R: Health care in common: setting priorities in Oregon. Hastings Cent Rep 1990; 20 (5): 16-18 barrel are at stake. Whether Canadians would wel2. Korcok M: US cash registers humming as Canadian patients come such a radical concept is, again, dubious, flock south. Can Med Assoc J 1991; 144: 745-747 although there are precedents. However, the time 3. Screening for Breast Cancer in Quebec: Estimates of Health may be ripening. When decisions on health care were Effects and of Costs, Conseil d'evaulation des technologies de la sante du Qu6bec, Montreal, 1990 seen as the distribution of largess there was certainly 4. Goel V, Deber RB, Detsky AS: Nonionic contrast media: an impulse to have them centrally and politically economic analysis and health policy development. Can Med made, with the full panoply of publicity. Now that Assoc J 1989; 140: 389-395 decisions are hard, bitter ones about who gets and 5. Woodward CA, Rosser W: Effect of medicolegal liability on patterns of general and family practice in Canada. Can Med who does not get what there is a tendency to Assoc J 1989; 141: 291-299 peripheralize them. Giving the responsibility to oth- 6. Premier's Commission on Future Health Care for Albertans: ers of setting priorities within the constraints of a The Rainbow Report: Our Vision for Health, Govt of Alberta, global sum of money becomes more attractive as the Edmonton, 1989
Conferences continued from page 1440 Jan. 30-Feb. 1, 1992: International Joint Conference on Stroke and Cerebral Circulation Phoenix, Ariz. Scientific and Corporate Meetings, American Heart Association, 7320 Greenville Ave., Dallas, TX 75231; (214) 706-1253
Feb. 1-8, 1992: International Symposium on Current Trends in Infectious Diseases Grindewald, Switzerland Office of Continuing Medical Education, University of California - San Francisco School of Medicine, 521 Parnassus Ave., San Francisco, CA 94143; (415) 476-5208 Feb. 2-6, 1992: Golden Jubilee Conference of All India
Ophthalmological Society Ashok Hotel, New Delhi Dr. C. Roy, president, Physicians Interested in South Asia (PISA Canada), 1417-750 W Broadway, Vancouver, BC V5Z 1J4; (604) 872-8719 Feb. 6-8, 1992: National Forum on Health Care Ethics Decision Making that Values Differences Westin Hotel, Ottawa Freda Fraser, director of communications, Catholic Health Association of Canada, 1247 Kilborn P1., Ottawa, ON K1H 6K9; (613) 731-7148 Feb. 6-10, 1992: International Conference of Dermatology and Venerology Cairo Meetings coordinator, Jefferson Center for International Dermatology, 1020 Locust St., Philadelphia, PA 19107; (215) 955-5785 DECEMBER 1, 1991
Feb. 9-16, 1992: Congress of the International Society of
Gynecological Endocrinology Madonna di Campiglio, Italy Prof. A.R. Genazzini, Universita di Modena, via dei Pozzo 71, 41100 Modena, Italy
Feb. 10-16, 1992: Sudden Infant Death Syndrome International Conference Sydney K. Fitzgerald, Sudden Infant Death Research Foundation Inc., 1227 Malvern Rd., Malvern, VIC 3144, Australia Feb. 11-14, 1992: Asia-Pacific Burns Conference Singapore Secretariat, Academy of Medicine, 16 College Rd., 01-01 College of Medicine Building, Singapore 0316 Feb. 11-14, 1992: 2nd International Conference on Recent Advances in Crisis Intervention and Community Mental Health Krishna Oberoi Hotel, Hyderabad, India International Conference Secretariat, 63 Nabcroft Lane, Crosland Moor, Huddersfield HD4 5DU, England; telephone 011-44-0484-658054, fax 011-44-0484654777
Feb. 14-16, 1992: Asian Congress of Plastic Surgery
Singapore Secretariat, Academy of Medicine, 16 College Rd., 01-01 College of Medicine Building, Singapore 0316 Feb. 16-20, 1992: International Congress on Cardiovascular Research Antwerp, Belgium Sr. S. De Nollin, Te Boelaerlei 23, 2140 Borgerhout, Belgium
continued on page 1473 CAN MED ASSOC J 1991; 145 (I1)
1443
PLATFORM * TRIBUNE
Down
the Oregon trail
The way for
Canada?
Harry E. Emson, MD, FRCPC A 11 systems of publicly financed health care face a common problem: the cost of human ingenuity applied to health care exceeds the capacity to pay for it. The effects of this disparity are unpleasant. One is that not everyone receives all the health care from which they might benefit; there will be suffering and death that could have been avoided or postponed. Another is that choices must be made, and these will be based on an assessment of relative values - of different forms of health care and of the people who will receive or be denied such care. The hard word is rationing. Who determines the values on which rationing is based, and how do they do this? Some people maintain that redistribution of resources within the health care system, allocation to it of a greater share of community resources and increased efficiency would obviate the need for rationing. Although such arguments may be cogent this view is not generally held, and the problems of health care rationing occupy an increasing amount of space in professional and lay journals. Attempts to come to terms with these problems in Oregon have drawn attention. The system there is very different from ours. The state's population is about 2.7 million, of which 450 000 (about 17%) have no health care insurance. The majority are covered to some extent by Medicare and Medicaid programs or by private plans, which may or may not be employer-funded. It is a patchwork quilt of care. Those who are uninsured might have been described 150 years ago as the "deserving poor": poor not by reason of indolence or dissipation and deserving the assistance of the more fortunate in society. It is toward insured coverage of this minority group that present plans are directed. However, there is a distinct possibility that what is decided for this group may become a precedent for the rest of the population.
Health care in the United States is rationed on the basis of who is covered as well as what is covered. When Oregon moves toward the situation we now have in Canada, in which everyone is covered by health care that is partly publicly financed, the question of what types of services will be insured will become inescapable. We already know that to fund all kinds is impossible, because it would be too expensive: given the open-ended nature of health care it would be like writing a blank cheque. The ways in which Oregon has tried to solve this problem are therefore significant to Canadians. The Oregon approach has been to devise a list of health care priorities based on three principles: equity for those not now insured, explicit choice (fairer than hidden rationing) and a combination of expert analysis and community values. One strategy - the scientific - is to rank services according to quality of well-being and a cost-benefit measure. Another, more innovative method is to go to the public for ideas through community meetings and a telephone survey, a procedure made mandatory by the state legislation. (The values obtained through this second method are interesting; of high priority were quality of life, prevention, ability to function, cost-effectiveness and equity.') The results are melded into a list of groups of illnesses, conditions and procedures and within them a more detailed list. The level of funding determined by the state legislature will determine the cut-off point in the list: conditions and procedures above the line will be insured by the state and those below will not. The cut-off point could move up or down over time, depending upon the availability of funds. The whole process is under the control of an appointed commission that is independent of politics. The ways of determining priorities have been criticized. The community meetings, though open to
Dr. Emson is professor ofpathology at the Royal University Hospital, Saskatoon, Sask.
Reprint requests to: Dr. Harry E. Emson, Department ofPathology, Royal University Hospital, Saskatoon, SK S7N OXO DECEMBER 1, 1991
CAN MED ASSOC J 199 1; 145 (1 11
1441
.M
all, were allegedly attended largely by health care workers and others in the system; those actually affected by the scheme were less well represented. Was this, in fact, the payer setting limits for the deserving poor in an excess of cautious paternalism? Perhaps the poor will bear the burden of the plan, and decisions will be made by the "haves" for the "have-nots." Any attempt to rank health care omits variation in individual response. The relation between community values and those defined by larger democratic groups or by scientific or moral analysis is uncertain. The scientific analyses in Oregon originally produced some very bizarre rankings of priority, which were eliminated by the application of common sense and by reference to priority scales determined by other methods. One of the most publicized decisions was not to fund organ transplantation (although kidney transplantation is covered by Medicaid at present), a decision taken on strictly utilitarian grounds and deliberately balanced by a complementary decision to insure preventive antenatal procedures. Whether all this will, in fact, come to pass depends on legislative will and the negotiations between state and federal governments over the financial details. If it does, the world will eagerly watch the results. In the meantime, are there any signposts for Canada on the Oregon trail? We are way ahead, in that we have jumped the huge hurdle of who is covered, by the principle of universality embedded in the foundation of Canadian medicare, and this should take care of most of the issues under the equity principle. We have quite conspicuously not substituted explicit choice for hidden rationing. We possibly rely to some extent on expert technical data and obviously very little on community values. Perhaps Canadians are different from Oregonians and should not move along the same road. However, we are faced with the same decisions, simplified considerably by our principle of universal coverage and by our very small second tier of health care (e.g., the National Defence Medical Centre, which serves our federal politicians and senior civil servants). We are perhaps fortunate, perhaps supported in national hypocrisy, in not having to make most decisions on a two-tier or multitier system; in the United States the extra tiers are eagerly supplied by and easily accessible as commercial health care.2 Decisions on health care rationing are made in Canada all the time but not by explicit public choice. Some are made by politicians, and political value systems riddle the process, for example in decisions about where hospitals should be sited and how they should be equipped. The value systems of individual politicians, too, influence events: the minister of health for Saskatchewan decided not to permit the 1442
CAN MED ASSOC J 199 1; 145 (11)
establishment of abortion clinics, thus overruling a decision of the College of Physicians and Surgeons of Saskatchewan. In other provinces politicians have suggested exclusion of procedures such as vasectomy from medicare coverage (Saskatoon Star-Phoenix, Mar 28, 1991: C10). Decisions are made to establish mammographic screening programs. Some provinces have commissions to evaluate health care technology, and they consult with commission members in making decisions about technology,3 but more have chosen not to establish them. Health care decisions may be driven by the law, as in the province-wide introduction of nonionic radiographic contrast media in Ontario4 or more diffusely as doctors move away from forms of practice (e.g., anesthesia and rural obstetrics5) perceived as bearing a high risk for a negligence lawsuit. In all health care systems that combine political and bureaucratic components values of cost and quality are inextricably and uneasily intertwined. Nowhere in Canada do we have any system that continually samples public opinion and community values about priorities in health care. Most politicians would say that the processes of democratic election supply this information, but rarely does it amount to anything more than strident statements that "medicare is safe in our hands." A number of surveys attempt to sample public opinion. Alberta's Rainbow Report6 is one of the more slickly printed and highly coloured and, like others, is full of generalities and lacking in detail. From its accounts of community meetings it seems that the same values were expressed as in Oregon. However, the provinces are not legally required to use such a sampling process in setting priorities, let alone be bound by its results. As yet, no province has delegated the setting of priorities in health care to an independent, nonpolitical body and limited legislative decisions to the overall level of funding. These ideas seem to me to have merit for Canada. In a democratic society those to whom something is done should have the right to determine its nature and extent. First, in setting priorities in health care we need both scientific analyses and community values suitably reconciled and combined. Community values should be established not by surveys and glossy reports but, rather, by continual, valid methods of evaluation. Second, the process should be an open one whereby procedures and results are made public and not suppressed by those with conflicting interests. Explicit choice is fairer than hidden rationing. Third, priority setting should be separated from politics by the establishment of adequately funded, publicly accountable bodies of guaranteed independence - perhaps no one who has ever held elected office or a civil service position should be eligible for membership! LE Ier DECEMBRE 1991
The final step is the questionable one: whether a cut-off point moves inexorably up the scale. The Canadian legislative body would be willing to dele- Oregon trail may look increasingly inviting. gate power to such a process by funding only the overall amount to be spent on health care and References leaving priority setting and cut-off points to another body. In the present political climate this seems rather dubious; too much power and too large a pork 1. Garland MJ, Hasnain R: Health care in common: setting priorities in Oregon. Hastings Cent Rep 1990; 20 (5): 16-18 barrel are at stake. Whether Canadians would wel2. Korcok M: US cash registers humming as Canadian patients come such a radical concept is, again, dubious, flock south. Can Med Assoc J 1991; 144: 745-747 although there are precedents. However, the time 3. Screening for Breast Cancer in Quebec: Estimates of Health may be ripening. When decisions on health care were Effects and of Costs, Conseil d'evaulation des technologies de la sante du Qu6bec, Montreal, 1990 seen as the distribution of largess there was certainly 4. Goel V, Deber RB, Detsky AS: Nonionic contrast media: an impulse to have them centrally and politically economic analysis and health policy development. Can Med made, with the full panoply of publicity. Now that Assoc J 1989; 140: 389-395 decisions are hard, bitter ones about who gets and 5. Woodward CA, Rosser W: Effect of medicolegal liability on patterns of general and family practice in Canada. Can Med who does not get what there is a tendency to Assoc J 1989; 141: 291-299 peripheralize them. Giving the responsibility to oth- 6. Premier's Commission on Future Health Care for Albertans: ers of setting priorities within the constraints of a The Rainbow Report: Our Vision for Health, Govt of Alberta, global sum of money becomes more attractive as the Edmonton, 1989
Conferences continued from page 1440 Jan. 30-Feb. 1, 1992: International Joint Conference on Stroke and Cerebral Circulation Phoenix, Ariz. Scientific and Corporate Meetings, American Heart Association, 7320 Greenville Ave., Dallas, TX 75231; (214) 706-1253
Feb. 1-8, 1992: International Symposium on Current Trends in Infectious Diseases Grindewald, Switzerland Office of Continuing Medical Education, University of California - San Francisco School of Medicine, 521 Parnassus Ave., San Francisco, CA 94143; (415) 476-5208 Feb. 2-6, 1992: Golden Jubilee Conference of All India
Ophthalmological Society Ashok Hotel, New Delhi Dr. C. Roy, president, Physicians Interested in South Asia (PISA Canada), 1417-750 W Broadway, Vancouver, BC V5Z 1J4; (604) 872-8719 Feb. 6-8, 1992: National Forum on Health Care Ethics Decision Making that Values Differences Westin Hotel, Ottawa Freda Fraser, director of communications, Catholic Health Association of Canada, 1247 Kilborn P1., Ottawa, ON K1H 6K9; (613) 731-7148 Feb. 6-10, 1992: International Conference of Dermatology and Venerology Cairo Meetings coordinator, Jefferson Center for International Dermatology, 1020 Locust St., Philadelphia, PA 19107; (215) 955-5785 DECEMBER 1, 1991
Feb. 9-16, 1992: Congress of the International Society of
Gynecological Endocrinology Madonna di Campiglio, Italy Prof. A.R. Genazzini, Universita di Modena, via dei Pozzo 71, 41100 Modena, Italy
Feb. 10-16, 1992: Sudden Infant Death Syndrome International Conference Sydney K. Fitzgerald, Sudden Infant Death Research Foundation Inc., 1227 Malvern Rd., Malvern, VIC 3144, Australia Feb. 11-14, 1992: Asia-Pacific Burns Conference Singapore Secretariat, Academy of Medicine, 16 College Rd., 01-01 College of Medicine Building, Singapore 0316 Feb. 11-14, 1992: 2nd International Conference on Recent Advances in Crisis Intervention and Community Mental Health Krishna Oberoi Hotel, Hyderabad, India International Conference Secretariat, 63 Nabcroft Lane, Crosland Moor, Huddersfield HD4 5DU, England; telephone 011-44-0484-658054, fax 011-44-0484654777
Feb. 14-16, 1992: Asian Congress of Plastic Surgery
Singapore Secretariat, Academy of Medicine, 16 College Rd., 01-01 College of Medicine Building, Singapore 0316 Feb. 16-20, 1992: International Congress on Cardiovascular Research Antwerp, Belgium Sr. S. De Nollin, Te Boelaerlei 23, 2140 Borgerhout, Belgium
continued on page 1473 CAN MED ASSOC J 1991; 145 (I1)
1443
