Stinky health care spending

The stink surrounding questionable executive expenditures at the IWK is growing.

The details are laid out here:

http://www.cbc.ca/news/canada/nova-scotia/iwk-tracy-kitch-auditor-general-stephen-darcy-1.4555146

The details seem to be adding up to a type of abuse that most of us have felt was unbelievable in a small place like Nova Scotia where everyone knows everyone.

Coming on the heels of this expanding questionable expense scandal are the legal costs incurred by Capital Health and the Nova Scotia Health Authority to defend themselves against a legal action by Dr. Gabrielle Horne.

Jim Vibert, writing in The Chronicle Herald, says legal experts believe the health authorities spent $10 million of taxpayer money on their defence!!

http://thechronicleherald.ca/opinion/1550008-vibert-justice-demands-full-accounting-for-dr.-horne’s-ordeal

This gobsmacking number is unacceptable. It is too great an expenditure to not be publicized and questioned. Who authorized this? And how is it acceptable to piss away so much money on such a questionable case? The health authority managed to have the monetary award for Dr. Horne reduced, but they were still found guilty. They were wrong. And we, their employers, are left holding the bag while they spend unlimited amounts to protect their reputation and income.

Dr. Horne spend $1.3 million to defend her reputation, so with the $800,000 award granted by the appeals court, she is out money, and patients were deprived of her skill and research. Where is the penalty for the people who failed in their obligations, who were judged in the wrong by the court? What penalty or suffering or inconvenience did they endure?

The Horne case should inspire a provincial cap on how much a government agency, board, commission and minister can spend on legal fees. Allowing public officials and executives to treat the public purse as a bottomless resource for them to hide behind and cover their failures is wrong and immoral and, in this case, doesn’t contribute to better medicine in Nova Scotia. We need fixed limits on legal budgets. The NSHA won’t like it, but tough, it may be the only way to make this super secret authority truly accountable.

The questionable expenses and outrageous legal bills stink to high heaven.

When someone in the public employ behaves badly, does something illegal and/or actionable, they, not the taxpayer, should pay. It is unacceptable that the public health care system is left to pay for these wrong, and perhaps illegal, actions.

Many times a case like this would have been settled privately without the necessity of going to court. It’s ironic that a body as secretive as the NSHA would do something so publicly, which raises the question: was this action about an issue or vanity and vengeance?

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How much does this saving cost?

Halifax cardiologist Dr. Gabrielle Horne has had a $1.4 million damage award downgraded to $800,000.

In 2002, Dr. Horne, who was a rising medical star, had her hospital privileges reduced after a dispute with a hospital director of the former Capital District Health Authority.

Fourteen years later, in July 2016, after a 33-day trial into administrative bad faith a jury awarded her $1.4 million. It was the largest such award in Canada for damages to reputation and career.

The health authority appealed the award. So did Dr. Horne.

The health authority may feel they saved $600,000 with the decision of the Nova Scotia Court of Appeal, but at what cost? How much more was spent on lawyers for this appeal? How much staff and executive time was eaten up by this? And more critically, how much has this cost Nova Scotia and the Nova Scotia Health Authority’s reputation?

As we try to recruit new doctors what does the appeal say to prospective physicians about how we value and respect medical professionals?

Dr. Horne has still prevailed. It took her 14 years of fighting an unsympathetic system and she won. Two years later, she may have less money coming from the NSHA, but the court hasn’t questioned the facts: she was wronged!

The message is simple: this is a health regime that doesn’t value doctors. Of all the places in the world to practice medicine, why would a doctor choose to come to work among an executive class who won’t admit a wrong and will use the weight of the public purse against them? The only hope to salvaging the province’s and NSHA’s reputation is for a change at the top.

How much as this saving cost us?

 

A Post Script: This article in The Chronicle Herald tells us how much the lawsuit cost Dr. Horne.

http://thechronicleherald.ca/novascotia/1549558-dr.-gabrielle-hornes-14-year-legal-battle-cost-a-staggering-1.3-million

It’s a safe bet that the corporate costs for Capital Health and NSHA were far greater. Thinking about the higher costs of government actions, it wouldn’t be surprising if the NSHA/Capital Health legal costs were between $2-$3 million. Put another way, that could buy several mid-range or one top-of-the-line MRI machine. Or it could have paid the salary of a family physician for eight-to-12 years.

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Still no national drug program after 15 years of hearings, studies and agreements

One of the universal areas of agreement in Canada is the benefit of a national pharmaceutical program.

Everyone agrees a national pharmaceutical program would save money through bulk purchases of drugs. Canada has the second highest drug costs in the western world. If we had a bulk purchasing program we could use the weight of our buying power to reduce costs and it would ensure we avoided shortages of certain drugs, which have and do happen. It would also be a benefit to pharmaceutical companies because it would help them adjust their sales efforts, production and distribution so they could make more money on lower per product prices.

No one disagrees this is a good idea. In fact, in February 2003 all of Canada’s health ministers – federal, territorial and federal – agreed to a national drug policy. It was part of the foundation for the 2004 Health Accord. A national drug policy was such a good idea the health ministers agreed two more times to institute it.

A royal commission first recommended this in 1964. In 1967 and 2002 there were a national forum and another royal commission. Then, in 2003 it looked like we might act. But we didn’t. Why?

Governments agreed to it 15 years ago. No one has spoken against it, yet successive governments of all political stripes have failed to institute one.

The idea is so popular that it’s virtually spurred an industry producing annual or semi-annual schemes for a national policy.

In 2004 in support of the new National Health Accord the Romanow Commission studied it.

In June 2006 a Federal/Provincial/Territorial Ministerial Task Force on the National Pharmaceuticals Strategy said, “…Prescription drugs also constitute the fastest growing and second largest category of health care expenditure in Canada. Like governments around the world, Canada is faced with the challenge of optimizing the benefits of prescription drugs for Canadians while managing the risks and complexities associated with this rapidly evolving sector.”

“After hospital care, Canada spends more on drugs than any other major category of the health care system. Since 2000, the total public and private expenditure on prescription drugs has grown by approximately 12 per cent annually. This rapid escalation in drug costs threatens the sustainability of public drug programs.

“To ensure that Canadians continue to benefit from robust public drug coverage, public dollars must be used efficiently. By collaborating on drug price and purchasing issues, Canada’s public drug plans can encourage greater competition, increase transparency and reduce market fragmentation to ensure Canadians get the best possible prices for pharmaceuticals.”

Two of that report’s nine recommendations were:

— Establish a common National Drug Formulary for participating jurisdictions based on safety and cost effectiveness;

— Pursue purchasing strategies to obtain best prices for Canadians for drugs and vaccines;

More information is here: https://www.theglobeandmail.com/news/national/with-universal-drug-coverage-canadians-could-save-billions-study/article34141670/

In February 2017 a study in the Canadian Medical Association Journal said if the government provided universal coverage for 117 essential medicines, which accounted for 44 per cent of the prescriptions filled in Canada we would save nearly $4.3-billion.

In June 2017 a paper A Better Prescription: Advice for a National Strategy on Pharmaceutical Policy in Canada said, “Canada needs a national strategy to fulfill its obligation to ensure universal access to necessary healthcare, including prescription drugs. A 2004 attempt at a national strategy for pharmaceutical policy failed because it lacked clear vision, logical planning and commitment from federal and provincial governments. The result of uncoordinated pharmaceutical policies in Canada has been more than a decade of poor system performance.”

The Better Prescription paper, found here: http://www.longwoods.com/content/25160 says “Since 2010, provinces have been voluntarily collaborating on prescription drug pricing through a Pan-Canadian Pharmaceutical Alliance; and some provinces, most notably Ontario, have been calling for federal-provincial collaboration to establish a universal pharmacare program to make medicines more accessible to all Canadians. At the federal level, the Liberals’ 2015 election platform included promises to negotiate a new health accord and to work to make prescription drugs more affordable in Canada, promises that ended up in the new health minister’s mandate letter after the Liberals formed government in late 2015. Perhaps not surprisingly then, in January 2016, when the federal, provincial and territorial health ministers met for the first time in many years, they created a working group to explore pharmaceutical policies aimed at reducing prices, at improving prescribing and the appropriate use of drugs, and at improving coverage and access to medicines for Canadians.”

This paper tells us that in 2016 Canadians spent $30 billion on prescription drugs and $5 billion of the private spending was wasted! Further, it says that over $400 million is spent on unnecessary drugs for people over 65 and estimated that “one in six hospitalizations in Canada could be prevented if prescription drugs were prescribed and used more appropriately.“

Another paper, National Pharmacare in Canada: 2019 or bust? https://www.policyschool.ca/wp-content/uploads/2017/03/National-Pharmacare-Adams-Smith.pdf begins by saying, “It is the Canadian public policy issue that rears its head with regularity, never achieving much more than discussion, and yet never going away entirely. The issue is pharmacare, and once again it is back for discussion among academics and policy-makers, and once again it looks like the discussions will not go anywhere anytime soon. The proposal for a publicly funded pharmaceutical- coverage plan is frequently on the table in Canada, but it still is not in the cards.”

A second February 2017 paper, the Estimated effects of adding universal public coverage of an essential medicines list to existing public drug plans in Canada http://www.cmaj.ca/content/189/8/E295 “could address most of Canadians’ pharmaceutical needs and save up” to $5.83 billion annually if we covered 117 of the most prescribed drugs.

From 2006 to 2017 we have had study after study, paper and presentation after another on the benefits of universal drug coverage. Here are links to a few:

https://open.library.ubc.ca/cIRcle/collections/ubccommunityandpartnerspublicati/52387/items/1.0048260

https://www.ourcommons.ca/Content/Committee/421/HESA/Brief/BR8289787/br-external/CanadianNursesAssociation-e.pdf

http://www.pdci.ca/wp-content/uploads/2016/01/Pharmacare-Preliminary-Report-PDCI-January-2016.pdf

https://www.collectionscanada.gc.ca/eppp-archive/100/201/300/cdn_medical_association/cmaj/vol-162/issue-4/0523.htm

https://dspace.library.uvic.ca/bitstream/handle/1828/8612/Derksen_Cameron_MPA_2017.pdf?sequence=1

https://www.cma.ca/Assets/assets-library/document/en/advocacy/PD10-02-e.pdf

http://www.aims.ca/site/media/aims/Final%20-%20The%20Effectiveness%20of%20the%20Common%20Drug%20Review%20in%20Canada%27s%20National%20Drug%20Strategy.pdf

https://nursesunions.ca/wp-content/uploads/2017/07/universal-pharmacare-report-e.pdf

In 15 years we have produced at least 15 major studies on the benefits of a national drug policy. We have studied this topic to death. The benefits to people, patients and the system are clearly identified. The money to relieve the stress on the health care system is in the savings. In Nova Scotia’s case this 15 years of inaction has cost us in excess of $805 million in over-payments for prescriptions. That’s roughly half the projected cost of a replacement VG. What more do politicians, health ministers and governments need before they act?

 

 

 

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Looking south to successful new disruptors

Two of the world’s richest men may launch the biggest, positive disruption to health care in several generations.

Warren Buffet and Jeff Bezos are teaming with JP Morgan Bank to create a company to help US employees find quality care “at a reasonable cost” and tackle the “hungry tapeworm on the American economy”.

https://www.theguardian.com/technology/2018/jan/30/amazon-warren-buffett-jp-morgan-healthcare?utm_source=esp&utm_medium=Email&utm_campaign=GU+Today+main+NEW+H+categories&utm_term=262367&subid=12294947&CMP=EMCNEWEML6619I2

They’re operating in the for-profit American system, but have realized that soaring health care costs are a threat to both people and the economy.

Buffet brings a benign practicality to business. Bezos understands scale. Both understand efficiency and the need to produce results.

Their collaboration and new vision could shake up the comfortable, semi-incestuous clique of like-minded, like-educated, like-back-grounded people who manage health care. We might see a new type of results-oriented executive class introduced to health care management. And that might provide Canadian politicians with the fortitude to think outside the box when hiring executives. So instead of hiring another executive clone responding to a job description written with their particular curriculum vitae in mind, health ministers seek people with a real history of success or, failing that, demand our executives meet performance targets. Remember, in seven years Halifax hospitals have failed to meet the province’s standard for off-loading ambulance patients within 20 minutes. NS health executives have not managed to bring capital projects in on time or on budget. They have failed to recruit doctors in sufficient numbers to meet the Physician Resource Plan. They have failed to retain doctors. They have impeded doctors in taking over established practices or opening new ones. They have a history of higher-than-average administration costs, and, and, and …

Buffet and Bezos present a truly positive disruptive opportunity for western health care.

 

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The hidden costs of the doctor shortage

More and more doctors, specialists, surgeons are speaking out about the hidden costs of the shortage of family physicians in the province.

On the first work day of 2018 vascular surgeon Dr. Gerry MacKean said a complaint at a meeting of specialists was how all were being asked to step outside their medical specialties to supply the basic care normally provided by family physicians. This included writing prescriptions. Dr. MacKean knows his specialty, but he isn’t a general practitioner, isn’t up on certain pharmacology and is uncomfortable with some of the care requests being made of him. His colleagues feel the same. It’s also an expensive stop-gap measure that diverts him from more urgent cases that need his specialized knowledge.

Then Dr. Kirk Magee, interim head of emergency medicine at the Queen Elizabeth II Health Sciences Centre, added his observation about the impact of the shortage of family physicians. The shortage is driving more people to treat ERs as a type of walk-in clinic.

According to Dr. Magee 14 percent of patients visiting the Halifax Infirmary ER are orphaned patients seeking basic medical care. As many as half of the people using the ER are seeking a prescription top up.

According to the Nova Scotia Health Authority’s website, 561,516 people visited provincial ERs in the previous year. An earlier report said that 48 percent of ER visits were not medical emergencies, they were people seeking walk-in care that normally would be provided by a family physician. That means 269,527 visits were not an emergency.

This is a waste of resources, a great waste of individual’s time and a massive financial hit. The Legislature’s Public Accounts committee have been told it costs approximately $200 per ER patient. Provincial doctors say that $200 figure doesn’t include the supporting costs: like nurses or operating the facility.

Using the $200 figure means that the 269,527 non-emergency ER visits cost $53,905,400. If those patients were seen by a doctor in his or her office, the doctors would have billed an average of $31 per appointment or $8,355,337. In short, the system is wasting $45,550,063 delivering care in this format. Furthermore, since writing prescriptions isn’t a billable fee for family physicians in private practice, writing ER prescriptions is an additional $3.5 million payout. I’ve said it before, it’s not a matter of money, it’s management. If we had more family physicians the pressure would be off ERs and specialists, and the population would be healthier.

This is reminiscent of the telephone changes made in the provincial civil service in the 1990s. Efficiency experts decided a new system would cut connection charges and reduce the need for support staff across the civil service. As a result, people in the $25,000-a-year range were eased out and positions eliminated. The result was that senior executives found themselves performing the work of people paid a third or a quarter of their pay and the work they were hired to perform was impeded. Sounds a lot like health care today.

 

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Who to trust?

The Nova Scotia Health Authority has trouble communicating what they’re doing. Auditor General Michael Pickup made that point in the fall. It’s worth remembering that in 2011 former Auditor General Jacques Lapointe, having studied the problems with the cost overruns of the Truro hospital, recommended “The Department of Health and Wellness should put a process in place to ensure only complete and accurate information is presented to Cabinet.”

The former AG determined that inaccurate information was presented to justify the construction of a new hospital. And here we are almost a decade later and we’re still questioning the veracity of health executives.

It seems that after each appearance by an NSHA representative before the Legislature’s Public Accounts Committee their testimony is questioned.

For example, in April 2017 Dr. Bob Martel, a palliative care doctor from Richmond County, took issue with a statement from NSHA CEO Janet Knox that paramedics can offer in-home palliative care to 1,000 patients who have signed up for the service. Martel wrote, “On the surface, this statement is factually correct, but is misleading in that it leaves the impression with political officials interviewing Ms Knox that these paramedics are offering palliative care services to 1,000 patients. The number refers to the patient population registered as special palliative patients with Emergency Health Services over the last two years. What it really means is that EHS will respond to calls from these patients and their families in a different way: no lights and sirens, more sensitivity around issues of resuscitation and on occasion, administer bridging pain and symptom relief to patients who do not have access to their regular physician or palliative care practitioner. … This program is neither meant to provide primary palliative care nor is it qualified to assess or administer comprehensive palliative care. … It is too bad that Ms Knox was not challenged on this point as it appears that she successfully conveyed that all is well in palliative care …”

http://thechronicleherald.ca/editorials/1457478-opinion-paramedic-program-is-not-true-palliative-care

Now Herald columnist Jim Vibert questioned the information provided by – or left unsaid – by Rick Gibson, NSHA’s senior medical director, who appeared before the Public Accounts Committee in December. Vibert writes, “Gibson told MLAs the authority now has what it needs to plan for future doctor requirements across the province … But even as he was speaking, the NSHA was issuing a tender “for a more robust data system to better track and report on physician information, including credentialing, privileging and recruitment”.”

Vibert continues, “No mention was made of the tender at the committee, and members could be excused for coming away with a sense that at least the NSHA is working from good information, when it is in fact just going about the process of buying better data.”

It was, as Vibert says, not a complete picture. I am reminded of the line from A Few Good Men, where an angry Jack Nicholson screams, “You can’t handle the truth!” Is that what the NSHA executive feel about the right of the public and politicians to know about the state of our health care system?

Are Nova Scotia health executives too cute with details or uncomfortable with facts? As Vibert says, “Say what you will about the health authority – and I have – they are good at teaching us who to trust.”

http://thechronicleherald.ca/opinion/1536671-vibert-haruspicy-isn’t-revealing-the-fate-of-health-care

 

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Replace the NSHA leadership

It has come to this. James Moir, a former president of Maritime Medical Care and former chairman of the QEII Health Sciences Centre, has called for the government to fire the leadership of the Nova Scotia Health Authority.

The delivery of health care in Nova Scotia has reached a point where we are moving from insider conversations, measured statements, calls for study and other platitudes to putting our names to public calls to fix the system by firing of those who failed to deliver.

Read Moir’s comments here:

http://thechronicleherald.ca/opinion/1535593-opinion-fire-health-care-kingpins-they’ve-failed-miserably

The government was bold enough to change the system, and now we need that same boldness to fix the remaining impediment to success.

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