May 30, 2017

It takes two hats to properly assess if our healthcare system is performing as it should

At HSCN, economist Colin Busby weighs in with the good, the bad and the possible

If economist Colin Busby is correct, Canadians are looking at a far different future than they’re used to. His news may not be cause for celebration, but the energetic Associate Director, Research at the C.D. Howe Institute says there’s still time to reset and recalibrate.

Right off the top Busby admits he’s coming at it from a different perspective. After spending the early part of his career advising Ministers of Finance, he has moved into healthcare and is finding convenient intersections between the two fields. The obvious linkages and synergies between healthcare and economics, the self-professed ‘two-hatted’ scholar says don’t get talked about enough. Speaking before an audience of cost-conscious and data-driven healthcare procurement specialists at HSCN (Healthcare Supply Chain Network) 2017, Busby is doing all he can to change that.

Busby was introduced by Cynthia Valaitis, HealthPRO’s President and CEO, following a short video that celebrated Canada at 150 and reflected with pride on a healthcare system that is foundational to what makes us great. “The ability to access care no matter your geography or economic status is a hallmark of Canada,” she said. “It is only by continuing to work together collectively that we will ensure its sustainability.”

No system-wide solutions

Not just maintaining but innovating and improving our healthcare system is something Busby says we’ve been doing for years but in a scattered and incoherent way. “There are big variations in how we deliver care not just between Canada and other countries but between provinces,” he said. “Canada has never done anything system-wide to address our problems.”

The problems that Busby sees on the horizon, namely a slow growth economy, the threats of digital technology on healthcare, and the massive transition created by our aging population, will draw heavily on our ability to change and adapt. “Aging is a good thing but it’s not an easy thing to adjust to and is going to profoundly change the way we organize and deliver care,” he says. “I’m a not confident that we have done enough to prepare for that. Spending has not been at the right time or the right place.”

Canada’s cyclical economy has experienced its share of ups and downs, but Busby says the shifts he’s seeing now could last for a long time. Precipitated by changing demographics, we’re entering a period of slow economic growth. “For many years, the 18-64 year olds were a significant contributor to the growth of our economy,” he says. “Those ages are dropping off and in some areas we’re looking at no growth in the labour force.”

It’s the proverbial economic spin-off effect – fewer people working and contributing, leading to lower tax revenues, and a focus by governments on fiscal prudence rather than program investment. This isn’t news to hospitals that have been living under the dark and ever-darkening cloud of cost restraint since the early 90s. Most industries benefitted when the economy surged in the mid-late 90s – except of course hospitals, that have never really come out of their own uniquely painful and extended period of slow growth.

Don’t discount the disruptive effects of technology

And don’t count on technology to save us. It’s been instrumental in dramatic changes in healthcare but Busby also sees technology’s disruptive effects. “Technology does lead to improved productivity and growth when you’re talking machine to machine, but in this new landscape of everything being automated, where will the new jobs be?” He sees this as a threat – even in healthcare where many jobs require high cognitive capacity – that is not well understood.

Casting aside its impact on jobs, technology has had a significant impact on our life and health expectancy. The impact is such that we use the data of longevity to justify increasing our investments in those technologies. But are these investments really leading to better and safer care? The question is often asked and Busby is not pleased with the answer. “In Commonwealth surveys on care and safety data in 11 countries, Canada ranks low on all metrics,” he says.

Busby explained the reasons for these low scores – a lot of waste; as many as 30% of our interventions are unnecessary; and we could do be doing a lot more to improve the productivity of our system.

“We know Canadians spend a lot more time than they should waiting for health services,” he says. This crisis in cost, care and productivity he puts squarely at the feet of misaligned priorities. “Right now the costs are being born by third parties, i.e., by individuals and their families, and so our healthcare providers have little incentive to look for ways to reduce the costs of waiting outside the system,” he says. We’re keeping stats but are they on the right things? He gives the example of knee operations. “We know exactly how many are done, but do we know how many of those lead to improvements in mobility?”

Making providers accountable for costs

What providers should be looking at – which Busby sees happening all over Europe – is value-based care, when you shift your approach to creating linkages between treatments, efficiencies and cost. “Efforts to improve efficiencies in healthcare are not going to happen until providers have to be more accountable for the costs involved,” he says.

While there’s much to be concerned about, Busby is encouraged by the move to empowering patients and engaging with them in meaningful ways. Ultimately, it will be the patients who he sees exerting pressure for reform on the healthcare providers and the system. The cost pressures of an aging population will definitely take their toll, but for his final piece of advice – undoubtedly with both hats on – Busby seemed determined to find an upside. “Canada is well positioned to create a response and what better time to do it than in a climate of political uncertainly and slow economic growth.”

And in case anyone got lost in Busby’s economic forecasts and prescription for change, as she stepped on stage to thank him Valaitis summed it up perfectly – “Stay healthy, don’t retire and keep paying your taxes!”