“The World Is Not the Way They Tell You it Is”*

1. “The World Is Not the Way They Tell You it Is”* Robert G. Evans Centre for Health Services and Policy Research, UBC April 4, 2008 The Money Game “Adam Smth” (George Goodman) 1966

2. This is a story about: • Myth and Reality • Identity, • Anxiety, and • Money. (Ibid.)

3. For Example: • CANADA NEEDS MORE DOCTORS!!! • (The CMA)

5. And is about to get them, in spades. • Policies ten years ago have determined our future for the next decade, at least • Increased training places now would only add to the surplus twenty years from now.

6. But what about the terrible shortage TODAY! • Has anyone checked the trends in medical services use (or at least in physician billings)? • Expenditures per capita, adjusting for inflation, have been rising rapidly for a decade now.

8. Growth in Expenditures per capita, B.C.1997$, p.a., alternative deflators BCMA CIHI • 1978-2005 2.45% 1.61% • 1978-1991 2.90% 2.02% • 1991-2005 2.04% 1.22% • 1991-1996 0.05% -0.32% • 1996-2005 3.17% 2.04% • 2005-2007 -- 2.44%

11. Growth in Expenditures per Physician, B.C.1997$, p.a., alternative deflators BCMA CIHI • 1978-2005 1.79% 0.96% • 1978-1991 1.68% 0.82% • 1991-2005 1.90% 1.08% • 1991-1996 0.38% 0.01% • 1996-2005 2.76% 1.68%

12. Is Physician Productivity Really Rising That Fast? • If yes, why do we need more doctors? • If no, what are they billing for?

13. But How Many Doctors Are There? • The number of doctors per capita has hardly changed in twenty years • In 1990, this ratio was called a surplus. • True, the population have aged, but in itself this makes little difference (0.3% -0.5% per year)

16. Yet Doctors Are Working Less • Decline in Self-Reported Weekly Hours of Work, Canadian GP/FPs • Watson et al. (1993-2003) 8.5% • Crossley et al. (1982-2003) 15.6%

17. So: Widespread perceptions (and loud claims) of shortage • Same number of doctors, • Each (on average) working fewer hours, and • Providing or at least billing for more and more services, • Large increase in doctor supply on the immediate horizon

18. But Other Countries Have More Doctors!!! • Indeed they do, but there is no relation between doctor numbers and health status • For that matter, there is no relation between health spending and health status either, at least not in high income countries.

20. Why Does the CMA Want More Doctors? At CMA, defending and promoting the interests of Canada’s doctors is central to our mission. Advancing the medical community’s financial interests is an important element of that commitment.” -- Victor Dirnfeld, former president, CMA

21. “To every complex question there is a simple answer: Neat, Plausible, and Wrong.” H.L. Mencken

22. Another Example: Underfunded and Fiscally Unsustainable? • Canada’s health care system is not fiscally unsustainable • In international terms it is well-financed • There are still many opportunities for improved efficiency • But the twin propositions above boil down to an argument for cost-shifting from public to private budgets, and cost expansion

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26. Health spending did significantly increase its share of provincial government spending – but NOT or revenue, and this expenditure trend ended several years ago. • “Apocalyptic demography” is also a myth. The aging population will require increases in health spending, but will not strain a growing economy.

30. So Why Tell Lies? Myths obscure the real objectives of: • Transferring costs from the healthy and wealthy to the unhealthy and unwealthy, • Improving access for the wealthy and unhealthy, and • Expanding income opportunities for strategically placed providers.

31. REFORM: Improve, make better, eliminate accumulated inefficiencies and abuses • RE-FORM: Change the structure, for better or for worse • REACTION: Restore past practices or structures, remove innovations

32. GENERAL BENEFITS: A shared objective of more effective, efficient, timely, humane, health care. (Rousseau’s General Will) • REDISTRIBUTION: Inherent conflict over the balance of benefits and burdens among the members of the population. (Resulting in Rousseau’s Will of All)

34. WHO PAYS?How is the total bill divided among the population? WHO GETS? Are access, quality, timeliness based on need or ability/willingness to pay? WHO GETS PAID? How much are providers paid, and how much is taken out in administrative overheads?

35. Yet Another Example: B.C.’s Fair Pharmacare Redistribution of income from drug users to taxpayers, i.e. from unhealthy and unwealthy to healthy and wealthy • Partial mitigation through income-related subsidies

36. Effect on access unclear, drug use apparently unchanged. • Longer-term increase in expenditures due to reduced purchaser bargaining power. Income transfer from drug users and taxpayers to drug manufacturers

37. Genuine Reform Might Address: • Efficiency and Effectiveness of care provided • -- Micro, the hospital porter story • -- macro, the clinical variations stories

38. Large Variations in patterns of care among: • 1) Regions • 2) Hospitals • 3) Individual Clinicians • Unrelated to patient needs, characteristics, or outcomes

40. American studies of regional variations: Higher utilization and costs associated with: • Poorer quality, • Higher mortality • No greater patient satisfaction, • But more physicians (specialists) and hospital capacity

41. Better Health? • Greater Effectiveness and Efficiency? • Or Just More Activity and Higher Cost?

42. Well…. • Expenditure Equals Income