The idiosyncracies of Canada’s medical schools can be both a strength and a drawback. An exchange program sponsored by the Hannah Institute hopes to bring the schools a little closer by opening up the communication lines from coast to coast.
The first exchange took place this April between the University of Western Ontario and the University of Calgary. Medical students met at Western for three days of talks and socializing.
“One of the objectives is to have each student work up a talk of ten minutes to stimulate further research,” says UWO Hannah Professor Paul Potter, who helped coordinate the exchange along with Calgary’s Dr. Peter Cruse.
Topics ranged from diseases among the Cree of Alberta to the old medical art of uroscopy.
Professor Potter says he hopes the exchange will become a regular annual affair, possibly with next year’s exchange matching Calgary with Halifax’s Dalhousie University.
I worked as Editor and Writer for the newsletter of the Hannah Institute for the History of Medicine (under the direction of the Editor-in-Chief and Hannah Executive Director Dr. J.T. H. Connor) in the early 1990s. Located close to the University of Toronto and within a neighbourhood claiming a long association with medical and scientific discovery (Sir Frederick Banting, co-developer of insulin for the treatment of diabetes, lived at 46 Bedford Road,), the goal was to better connect Canada’s medical history community of scholars and raise the profile of the funding resources available to further the study of medical history in Canada.
“… in recent years it has become a pursuit for a growing number of researchers. … Behind much of this growth has been the Hannah Institute for the History of Medicine which has encouraged writing …”.
It’s search and destroy time at Ontario’s ministry of health: search out savings and destroy inefficiency and waste. But many remain apprehensive that not all the cuts are going to be logical and fear the province’s health and well-being will be affected.
As part of the social contract deal, the Ontario Medical Association must find $20 million in cuts from the list of services covered by OHIP. The OMA and the provincial government are currently haggling over which procedures and examinations will be cut.
“We look at services that aren’t medically necessary,” says health ministry spokesperson Layne Verbeek. “Because we were wealthier in the past, we were able to cover some services. We aren’t in that position now. But I don’t see how eliminating medically unnecessary treatments will affect the population.”
The fallout of the Rae government’s attempts to reign in costs and recover lost revenues may take years to unfold, but it is already apparent that Ontarians will be paying more.
“Access to necessary treatment should not depend on a person’s ability to pay,” says health policy critic Carol Kushner. “What disturbs me about any delisting program is that virtually every medical service could be termed medially necessary. There are very few services that are an out-and-out waste of time.
“We often point to the fact that Ontario spends $200 million a year treating the common cold. Well, most of that is a waste of time. But delisting even that kind of service would be a detriment to the public’s health, because a small group of patients really do need to see a doctor when they have a cold.”
OMA spokesperson Jean Chow says it’s too early to pin down the exact cuts that will be made. “It’s a little premature to try and speculate what the final list will be.”
The newly-created Non-Tax Revenue Group is hard at work finding fees, fines and penalities the government can add or hike to boost revenue from this source from $5 billion to $10 billion a year.
The spring budget saw the first hit, with the addition of $240 million in non-tax revenue.
A radical reshaping of medicare is taking place. Private sector services – for which consumers pay directly or through insurance companies – now make up 34 per cent of Ontario’s health care funding, compared to 42 per cent in the United States, according to a recent study by the Canadian Medical Association.
Health minister Ruth Grier has also floated the idea of widespread hospital closures. Both the Toronto and Windsor district health councils (DHCs) are carrying out feasibility studies on “reconfiguration.” The ministry is remaining tight-lipped about which hospitals will get the chop.
“One suspects there’s room for efficiency – there are a lot of empty beds in a number of different places,” says ministry spokesperson Verbeek.
“All hospitals are being reviewed, with a view to closing one or two hospitals,” says health planner Lisa Paolatto, who is working on a feasibility study on “reconfiguration” for the Essex County District Health Council, along with Toronto’s DHC.
Closing hospitals could present a serious political hot potato for the government. In Britain, the Conservative government is still recovering from the bad feelings surrounding proposals to close world-renowned hospitals in the London area. The public feels great loyalty to local hospitals, a feeling that has been further fostered by hospital charities that raise millions a year from the communities’ good will.
“This is going to open up new discussions of money between doctors and patients,” says Kushner. “Seniors are a unique group in Canada because they remember what it was like before medicare – what it was like not to be able to pay for the doctor, to forgo treatment that they thought was necessary. They understand the financial hardship that could occur if they were unlucky enough to have a family member who needs expensive medical treatment.”
Ontario’s health care system is in the midst of a big change. But where are the new jobs going to be and how can health care workers prepare for the coming crunch?
“Anybody who thought they could progress through the health care system until retirement is in for a shock,” said Ruth Robinson, a national health care consultant for Peat Marwick Stevenson and Kellogg management consultants.
Radical changes are taking place in the health care system and it looks like traditionally safe occupations are in for a shake-up.
“Hospitals are being pressured to change fundamentally,” said Ms. Robinson. “The net effect is fewer jobs. A lot of people will have to think about new careers.”
In the Ministry of Health working document entitled Goals and Strategic Priorities, released in January, the fundamental shift from treatment to disease prevention and health promotion is laid out in generalities.
The goals range from health equity for aboriginals, women, children and AIDS patients to better management of costs to development of a stronger health care industry that will jump start the economy. And they range from the reorganization of professional responsibilities to promotion of services outside institutions with the goal of keeping people out of hospitals.
One thing is clear, the talk is about big changes. But talk is cheap to laid-off health care workers looking for new jobs.
The provincial government’s recently passed, but yet to be proclaimed, Regulated Health Professions Act will have serious repercusions for all health care providers.
“Traditionally, doctors have an exclusive domain over a wide area,” said Charlie Bigenwald, executive director of health human resources planning at the Ministry of Health. “Even though other people could do things, they had to be delegated by a doctor. With the legislation, we have pushed back what doctors can do. This means there will be more opportunity for a wider variety of health care workers to get into those areas.”
Midwifery is one of the benefactors of changes in regulations. The Ministry of Health is looking into having a university-based program for midwives.
Ms. Robinson predicted nurses and middle management will suffer the most in the change to community-based health care.
“Nurses will need to get a bachelor degree if they hope to compete for jobs,” she said.
As for middle managers, who often have clinical skills, they will have to reconsider staying in health care, she said. “They will disappear significantly. They can advance themselves by getting back to clinical skills or consider management positions in non-health care areas.
“There is nothing to be ashamed of about career changes these days,” she added.
In the shift towards community-based care, opportunities will arise for health care workers who can offer creative solutions to improve service delivery.
“For nurses, we currently have something called the Nursing Innovation Fund where individuals can apply for a wide variety of developmental things like attending workshops, conferences and training programs. We process 2,500 applications a year,” said Mr. Bigenwald.
The Ministry of Health hopes the future sees a health care system that adds to the province’s economy rather than drains it.
“We spend $17 billion a year on health care. We never looked at the health care system as an economic motor in the past. The question we are asking right now is ‘why can’t an Ontario firm make the carpets, beds, sutures etc?’, said Mr. Bigenwald.
Ms. Robinson said “Governments are running out of money and can’t increase funding. They will be looking for more partnerships in the private sector. In this climate, creative solutions to health care delivery have a great opportunity.”
American-style private health care is slipping across the Canadian border under the noses of three provincial NDP governments, say researchers representing an association of health care workers.
Jackie Henwood and Colleen Fuller of the 7,500-member Health Sciences Association of British Columbia charge in a recent report that a combination of free trade and tightfisted government spending is undermining the universality of medicare and ushering in the beginnings of a two-tier system.
While the health care industry created more jobs than any other sector of the economy between 1984 and 1991, they point out, things have changed dramatically since the Canada-US free trade agreement came into effect in 1989. Now much of this growth is clustering in the private sector.
And they expect that this trend will continue under the forthcoming North American free trade agreement.
“NAFTA will accelerate trends towards a privatized, nonunion and corporate dominated system of health care in Canada,” says the report.
Binding provisions
Chapter 14 of the Canada-US free trade agreement opened competition for health-care facilities management services to US companies. Certain NAFTA provisions will bind all levels of government to consider for-profit health care companies on equal footing with public providers when bidding for services, and entitles them to compensation if they can prove to an arbitration board that they’ve been wronged.
“That represents a substantial encroachment on the democratic right of local, provincial and federal governments to make decisions,” says Cathleen Connors, who chairs the Canadian Health Coalition, which includes labour activists, nurses, doctors and other health-care workers.
This, in combination with health care cutbacks – both federal and provincial – is resulting in service and job cuts, bed closures, increased drug costs and an increase in privatization, the report says.
In the area of home care, for example – visiting nurses, physiotherapists, homemakers and other services – private firms now take in close to half of all OHIP billings. Many of their clients pay out of their own pockets for services.
The Ontario ministry of health doesn’t keep statistics on the private home health care sector in the province, but the Ontario Home Health Care Providers’ Association, a trade group, estimates that private firms in the industry now employ 20,000 people.
The industry is dominated by a small number of large firms, including Paramed, Comcare and Med+Care.
“It’s a market situation,” says Henwood. “If the services aren’t available to people within the public sector, they will go outside of it.
“We’ve seen this in other countries like England, where they had a public system and now have a parallel private system. If you erode a system enough that people get pissed off, they are going to start to look for alternatives, and the people with the greatest liberty are those with money.”
Connors says that because the Canada Health Act only covers the provision of hospital and physician services, the prinicples of universality and comprehensiveness don’t extend down to community-based services like home care.
The study also found that giant US private health insurers are positioning themselves to reap profits in the fertile Canadian market.
Last week, Wisconsin-based American Medical Security Inc. announced it will begin offering American hospital insurance to Ontario residents this month, citing a demand in Canada to bypass lengthening waiting lists for medical treatment.
Giant US west-coast insurer Kaiser Permanente declared in the March 1992 issue of Fortune magazine that they have targeted Canada as the next growth market. And American Express membership now offers the privilege of health insurance.
With private health care services sprouting up like spring weeds, says Henwood, provinces are placing yearly limits on the number of private services covered under provincial health plans, thus preventing people shopping around for services, no matter what their income.
Sheila Corriveau, corporate relations coordinator at Toronto-based Dynacare, Canada’s largest full-range private health care company – which operates labs, retirement homes, homecare services and consulting services – is enthusiastic about expansion plans, and says that removing patients from hospitals into their homes has been a boon for private health-care services.
“I think the health system will benefit, because what you are really doing is off-loading the cost from the public sector and from the treasury to private enterprise,” says Harry Shapiro of Dynacare. “Private enterprise depends on its own ingenuity for survival and its own levels of efficiency.”
But advocates of the public system say the free-market option now looming is being ushered in by the very parties that Canadians have come to rely on to defend medicare.
Medicare stance
Ontario’s new health minister, Ruth Grier, however, denies her government is jeopardizing medicare.
“I want to disagree with that as profoundly as I can,” she says, fidgeting with an ashtray during a recent interview. “Our government has reaffirmed its commitment to medicare. Over the last decade, under conservative and liberal governments, health care costs have increased in double-digit figures. The system would have collapsed at that rate of growth.
“I guess I haven’t found a way of blaming free trade for failures of the health care system at this point,” she says.
But critics say in the last year alone, Ontario’s ministry of health has capped health coverage for travellers abroad, removed coverage for physical exams requested by employers, chopped hospital beds and cut back the number of drugs covered on the provincial drug plan.
Grier says that the government’s vision relies on a new view of medical care seekers as consumers who are going to take more responsibility for their own health care
“Government can’t do it all,” she says.
Now Magazine (Toronto, Canada), April 8-14, 1993.
More investigative journalism by David South for Toronto’s Now Magazine:
Now Magazine (Toronto, Canada), November 12-18, 1992.
More healthcare reporting by David South from Canada’s Today’s Seniors:
David South Consulting 
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