In with the entrepreneurship, out with the crisis management

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McGill Reporter
April 19, 2001 - Volume 33 Number 15
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Home > McGill Reporter > Volume 33: 2000-2001 > April 19, 2001 > In with the entrepreneurship, out with the crisis management

In with the entrepreneurship, out with the crisis management

Photo Dr. Howard Bergman, a member of the Clair Commission that examined health care in Quebec

As former Saskatchewan premier Roy Romanow prepares to direct a Royal Commission that will examine the state of Canada's health care system, Dr. Howard Bergman might be thinking to himself, "Been there. Done that."

Bergman, McGill's head of geriatrics and the director of the Jewish General Hospital's geriatrics division, recently served on Quebec's Clair Commission that took stock of the province's health care system. Chances are, the Clair Commission's report is at the top of Romanow's reading list right now.

Bergman recently made a presentation about the commission's work to members of the Department of Epidemiology and Biostatistics. Although he frequently describes himself as "an ex-member of an ex-commission," the man clearly doesn't want his group's findings to gather dust.

If the Clair Commission's major recommendations are acted upon by Quebec City -- and the Ministry of Health did give the report glowing reviews when it was released to the public in January -- big changes will be in store for our health care system.

In his talk at McGill, Bergman characterized the system as "fragile and vulnerable.

"Costs are rising," he said. "Ten years ago, health care accounted for 30 per cent of the Quebec budget. Now it's 40 per cent." An aging population with a growing reliance on the medical system promises to make health care a more expensive proposition in the years to come. New medical technologies also come with a hefty price tag.

While more money may be required to get the system on steadier footing, Bergman says the public purse can only provide so much.

"What we spend on health is money taken away from something like education," he said, adding that there are also implications for deficit management and the competitiveness of [Quebec's] tax system.

One of the commission's key recommendations, and one that the government might find problematic, is that Quebec City play a less active role in the day-to-day running of the system.

"There is little separation between politics and management issues," Bergman said. "If the Shawinigan general practitioners threaten to resign, the deputy minister of health descends on Shawinigan. I'm not saying it wasn't an important issue, but it's crisis management.

"The message that comes out of that is that if you get something in the newspapers, if you can get questions asked in the National Assembly, you can get somewhere.

"We need to depoliticize the management of the health care system," Bergman declared. To address this concern, the Clair Commission proposes an arms-length agency to attend to much of the nitty-gritty work, with major actors such as regional health boards, hospitals and physicians' groups having a greater say in how medical care is parcelled out.

The Ministry of Health would step back and play a coordinating role in setting standards and monitoring the performance of the system. "They would evaluate the way things are going and make the necessary adjustments" based on how well clearly defined goals are being met, rather than on putting out political fires.

But Quebec politicians often take pride in an activist approach to government, so Bergman isn't certain if this aspect of the Clair Commission's philosophy will fly.

"Even the opposition wouldn't like it," Bergman noted in a follow-up interview with the Reporter. With health care currently attracting so much attention, if the government were to play a reduced role in its administration, "what would the opposition criticize the government about?"

Consistency of leadership is another argument for the government to take a more hands-off position.

"We spend $15 billion a year on health care and the deputy minister changes almost every year. Can you imagine a $15 billion corporation where the CEO changes every year?"

But leadership isn't necessarily good at the level of the hospital board of directors, says Bergman. "We need more people with administrative experience. Instead, [a board] has become a place where different sorts of tensions are played out [involving] all the different interest groups within hospitals."

Perhaps the most important series of recommendations revolve around the creation of a network of family medicine clinics that would offer round-the-clock medical service.

Composed of six to 10 general practitioners, working with nurse clinicians and others, these clinics would be the key ingredient in a major rethinking of how basic health care is delivered.

The way things are currently constituted, Bergman believes, it's far too easy for a patient to get lost among the different players in the system -- CLSCs, hospitals, chronic care facilities, etc. -- especially if a patient doesn't have a close connection to his own general practitioner.

"Somebody has to be responsible for the patient," Bergman argues. Someone who can keep close tabs and make a special effort to nip problems in the bud before they lead to lengthy hospital stays and expensive treatments.

But doctors are paid on a fee-per-service basis. Taking extra time to carefully track the progress of a patient with a complex medical condition isn't really rewarded right now; that's time spent away from treating easier cases which, in a fee-per-service system, brings in the money.

Under the Clair Commission's concept, the new family medicine clinics wouldn't operate that way. The new model would offer incentives for looking after patients' health needs in a more general way.

"Five years ago, physicians were prepared to impale themselves on the sword of fee per service," believing it was the fairest method of payment, says Bergman. Now they argue "it doesn't allow them to follow up on complex cases.

"The report proposes that we give these physicians the room to manoeuvre while insisting on a certain amount of accountability."

Another factor would be a greatly enhanced province-wide computer network linking clinics to hospitals and other important players to make tracking patients' progress and determining treatment options easier.

For their part, patients would be free to choose one family medicine clinic over another. Clinics that earned their patients' trust and loyalty would be rewarded.

The notion of adding a certain degree of competitiveness to the health care system is a contentious idea in some quarters; not everyone listening to Bergman's presentation was comfortable with it.

But he makes no apologies.

"We are promoting entrepreneurship in health care. You can pay a hospital a global budget or you can tie a portion of that to performance." Bergman believes the latter is fair and geared to producing better results, so long as the government makes two things abundantly clear: how much money hospitals and other players have to work with and what exactly is expected of them. Quebec City hasn't always had the best track record on either score.

This notion of greater control over your own resources and a greater degree of competitiveness can play itself out in a number of ways.

"If a region wants to ask [McGill University Health Centre executive director] Hugh Scott if the MUHC can handle their heart surgeries, Scott has to worry about his own centre going over-budget. There is no incentive, no way to influence the MUHC to do your heart surgeries.

"If we give the regions control over their budgets, then they can call up Hugh Scott and say, 'We want to pay you to do our cardiac surgeries.' Then Hugh Scott is listening.

"After three years (the proposed duration of such contracts), the region might decide, 'Maybe we want to see what CHUM (the Centre hospitalier de l'Université de Montréal) has to offer.'"

Some argue that the commission should have devoted more time to examining acute care, but Bergman believes he and his colleagues were correct in focusing on primary care.

"If we don't make strong inroads into improving the management of primary care, we won't make any inroads into improving acute care. That's the most important thing to fix." Better care earlier on results in fewer trips to the ER and fewer stays in a hospital.

So, will the commission's report result in any major changes? Bergman says the government is laying the groundwork for pilot projects aimed at testing and implementing the family medicine clinics concept. The most recent Quebec budget paid heed to upgrading computer systems.

As for Romanow, Bergman offers the following advice on looking at a provincial jurisdiction from a federal perspective.

"Quebec aside, if you look at Ontario, B.C. and the other provinces and the focus is going to be on telling the provinces what to do, I suspect he's going to meet a lot of resistance.

"The most important thing he can do, in my view, is to contribute to the process of reflecting on the kind of health care system we all want."

Bergman can also offer Romanow a sense of the work that awaits him in putting together a commission with such an ambitious task ahead of it.

"It's like doing major renovations on your house. At some point, you see the destruction going on and you think, 'Why did I ever get into this?' Then you see things coming together and you're happy with what you see. And when it's over, you vow you will never do it again in your life."

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