Some thoughts on ecology, evolution and economics

Caring for Canadians

Four years ago, I highlighted Jeffrey Simpson’s five recommendations for improving the value of  medical care in Canada.  These addressed some of the natural weaknesses of a single payer system, which frequently lead to long wait times.  One of these recommendations, investment in home care, has been seized upon by the Trudeau government as a way to make medical care more human and possibly more efficient.  The efficiency argument is harder to make, even though hospital beds are clearly more expensive than home care and they are critical to reducing wait times and overcrowding in emergency rooms.  I am concerned that this investment in home care will be easily absorbed by the pent-up demand without having a major effect on overcrowding in hospitals.

In individual deals with the provinces and territories (except Manitoba*), the federal government has effectively committed to maintaining the previous 6% annual increase in the Canada Health Transfer with a 3% increase in general funds and the remaining increase earmarked for home care and mental health.

The Canadian Institute for Health Information has been tracking home care in Canada since 2011. Though the data is primarily from two populous provinces (Ontario and BC) it describes a system with mostly older patients (around 85% are 65 or older) receiving help with bathing and house cleaning (70%).  Less than half (42%) receive visits from nurses or therapists and only a quarter get specialized treatments, such as oxygen or injected medicine.  The complexity of cases being handled in a home setting increased in Canada from 2011-2015.  On a scale from 0-5, with 5 representing a high risk of mortality and 0 representing stable patients, the average patient assessment went from 1.28 in 2011 to 1.46 in 2015.  At the same time, there was a rising tide of  exhaustion and anger among family and friends caring for these patients as part of home care, going from 24% to 32% of patients with signs of caregiver stress in just 5 years.  This could represent a system that is expanding its reach to more complex cases or one that is struggling to meet increasing demand. Success for  the federal initiative would include reduced waiting times in emergency rooms, increased complexity of care at home and, hopefully, reduced caregiver stress.

Another argument for home care is that much more can  be done with modern communications and electronic records.  It is feasible that hospitals will become communication hubs where paramedic and nursing staff across a large region can respond to concerns raised by physicians using the latest equipment to monitor patients at home. However, getting the technology right will have to go hand in hand with getting the medicine right. Putting the wrong person a 10 minute drive away from help could be fatal.

The demographic forces at play cannot be forgotten either.  Though an aging Canadian population is currently  a modest cost factor – increasing spending by 1% per year, this will likely change in 2026 when the first baby boomers turn 80, an age when per-person medical costs quickly double. Caring for the boomers will run its course by the middle of the century but the Canadian health care system will be transformed by the experience.

* Manitoba signed a deal with the Federal government in August 2017.