Health Care Reform: Transforming Rationed Care
Governments around the world are grappling with aging populations and shrinking working-age cohorts that put at risk the productivity necessary to deliver on health and social-care commitments.
Canada’s rationed health care system needs transformation that can meet the volume of services required but in the context of a relatively shrinking pool of talent domestically and internationally. However, there are solutions if governments across Canada can be forward-looking and provide the conditions that encourage freedom to innovate and promote new ideas in health care provision.
In my book, A Physician in the Political Arena, I have called on politicians to be brave enough to enter discussions about health care reform, publicly debate the options available, and to commit to funding the reforms. (See pages 157-160.)
We must begin to think beyond the current rationed system and consider how we can move beyond tinkering with the status quo. There are more questions than answers when grappling with this matter. For example, in considering the decision-making process…
Are the current mechanisms working for physicians and other health professionals to engage and contribute effectively to the dialogue surrounding health care reform solutions?
Is the current health care environment sufficiently welcoming of the critical thinking necessary for new ideas to be put forward and developed?
What role has government and ministerial bureaucracy had in creating obstacles to physician productivity rather than much needed enhancement of productivity?
I suggest that not enough attention is given to health care providers. Government must value the people who provide the care and in a world with a shrinking pool of available health care workers, it is imperative that government has a realistic plan to address the health care crisis rather than trying to create an illusion of progress. Too often, reforms are focussed on “things” instead of the people that provide the care. Government must refocus to better understand the repercussions of losing the health providers that make the system work.
The deficiencies in the government’s decision-making process also need to be addressed if we are to achieve meaningful health care reform. First, we need politicians who are committed to working towards real solutions instead of those who promote the same old recycled ideas that have already failed to improve access. Putting off the difficult decisions to a later date while waiting for federal money to appear is not effective planning. Too often the federal dollars are attached to government’s need to demonstrate it can react rather than demonstrating it can create sustainability and stability in health care. Too often provincial dollars flow to the latest promoted fix that has been framed by health care and hospital lobbyists.
Recall that electronic medical records and team-based care were touted as solutions to finding efficiency and sustainability almost a generation ago. The reality is they have not succeeded to any significant degree in improving overall productivity, access to care, or reduction in health care costs. This does not mean that EMRs and team-based care are not useful, but simply that there are major costs associated and that unintended consequences of new technologies and administrative efforts are frequently underappreciated.
Digitalization and artificial intelligence are being presented as solutions to big problems in health care such as administrative costs. There is no doubt that they have the potential to transform health care but the likelihood of driving up health care costs is very real. And if costs are driven up in a rationed, closed system where do the dollars to attract and retain the health care providers come from?
This is an important question as the demographic hit that is intensifying isn’t just related to how quickly countries age but also to what people expect from the state.
According to The Economist article from May 2024, “Shrinking populations mean less growth and a more fractious world—Politicians must act now to avert the worst”: “…every big economy will collide with a demographic wall. The bill from pensions and hospitals will pile on fiscal pressure. Sapped of workers and ideas, economic growth could collapse while public debt balloons”. Research shows that aging populations tend to be less productive and shrinking populations could be even worse. The economy requires the constant generation of new ideas to keep its growth moving and living standards stable.
In Canada, increasing immigration has been one way for government to address our aging population and dropping fertility rate. However, over the coming decades there will be many fewer migrants to attract, and forecasts indicate that globally by 2064 fewer babies will be born than people die globally. There is and will be growing competition for people who can work.
Many believe emerging technologies will provide the solution. The growth of robotics and automation may be seen to be addressing a shrinking workforce but there will need to be a redistribution towards hands-on care including in long-term care, community care and acute care.
Digitalization and AI will require talent and strong processes to allow technology to adapt to complex clinical scenarios. Acknowledging and valuing the people behind the technologies is as necessary as measuring the effectiveness of the technology itself.
It is estimated that rich countries will need to spend 21% of GDP a year on their elderly by 2050 and while it is possible that AI advances can help cut costs, it is more likely that costs will be driven up.
Across Canada, it is imperative to build a health human resource strategy that can be adapted quickly to address the productivity needed without absorbing more and more workers to provide the same level of service. What role could AI have in this process?
The IMF blog from June 25, 2024, “Mapping the World’s Readiness for Artificial Intelligence Shows Prospects Diverge” reports that a new AI Preparedness Index Dashboard tracks 174 economies based on their digital infrastructure, human capital, labor policies, innovation, integration and regulation and has some important messages for policy makers. AI has potential to enhance productivity of existing jobs and to create new industries but investments in training workers and prioritizing AI integration will be needed. AI is poised to reshape economies around the world but could also endanger 33% of jobs in advanced economies.
It is estimated that 30% of jobs could benefit from AI integration and those workers who can harness AI could see pay gains or greater productivity.
While poorly considered bureaucratic thinking could result in concluding for example that highly trained family physicians could be replaced with other providers using AI, this would be a serious mistake. The better approach to integrating AI would be to apply it to maximizing the productivity of physicians, especially considering the labour shortage of all providers, something that is expected to get worse and not better over the coming years.
Given the importance of AI in health care, the University of Waterloo has launched “WatSPEED—Leveraging AI to Improve Health Care in Canada,” starting this past May with a focus group in Ottawa with leaders in health care and health data from both the public and private sector. The integration of AI is an opportunity to improve health care delivery to the benefit of Canadians but must be combined with the underpinnings of strong ethical considerations as stated by Dr. John Hirdes, program director, School of Public Health Sciences, University of Waterloo:
“The rapid introduction of AI-based technologies will touch every aspect of Canadian and international health care systems. AI will change direct patient care, health system management, policy development and research”
“The impact of these changes will be rapid, complex and profound.”
While the effects of AI in health care have the potential to be dramatic, it is important that governments across Canada be pro-active and forward-thinking, understanding that there has been no previous transformation in Canadian health care that has managed to reduce overall costs.
It is possible that the transformation brought on by AI will foster greater autonomy and choice for both patients and providers as health care expands to expedite disease detection, personalized medicine, and the productivity needed for our aging population.
New technologies, robotics, and AI are all promising but are not likely to address the growing demand for hands on care in a single payer system. It is urgent that governments across Canada take tangible action to reward productivity rather than attempting to create an illusion of access to care with recycled efforts that have previously failed and undervalued health care providers.
As veteran Canadian news columnist John Robson noted on X: “Every new 1st minister federally & provincially for 50 years have thought they knew better, without having thought much about health. None have succeeded and all have resorted to maintaining the illusion of progress. Our system is unworkable, the one thought none dare grasp”.
Sadly, the current ministers of health have little to zero knowledge of what it means to provide direct patient care. It is time that physicians and other health care providers have meaningful input with greater professional autonomy to improve productivity.
Dr. Merrilee Fullerton is the former Ontario Minister of Long-Term Care. This piece was originally published on her substack.