The Commonwealth Fund’s 2021 report comparing the healthcare systems of 11 developed countries ranked Canada in 10th place, ahead of the United States, which was at the very bottom. Finishing ahead of the U.S. is nothing to be proud of, contends Dr. Paul Woods, a former president and CEO of London Health Sciences Centre.
“Because Canada finishes ahead of the United States, people say ‘ha, we’re better than the Americans,’ but we’re second last out of 11 countries. That is not acceptable, so taking this Commonwealth Fund report, removing the U.S. and recognizing that we’re dead last would be a great thing to do.”
The Commonwealth Fund is a U.S.-based private foundation with a mission “to promote a high-performing healthcare system that achieves better access, improved quality and greater efficiency, particularly for society’s most vulnerable.”
The 2021 report, released in August, compares 11 high income countries – Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States – using 71 performance measures across five domains, including access to care, care process, administrative efficiency, equity and health outcomes.
The data used in the report comes from Commonwealth Fund surveys conducted in each country, as well as from the Organization for Economic Co-operation and Development, and the World Health Organization.
Canada placed 10th in equity and healthcare outcomes, ninth in access to care, seventh in administrative efficiency and fourth in care process.
Dr. Woods, who describes himself as a “policy wonk” with an interest in health policy and system transformation, wasn’t surprised about Canada’s poor ranking in access to care, which reflects wait times and affordability.
“When I was at London Health Sciences Centre, I was shocked and dismayed to find how long it would take patients to obtain total hip and knee surgeries. It was an average of a year and in some cases just short of two years. Since the pandemic, I suspect it’s now even worse.”
Canada also scores poorly in access to primary care. “The Netherlands, which ranked first in access to care, has an incredible primary care model, where if you have a need, you can pick up the phone and have that need satisfied immediately, whether it’s a telehealth visit or after hours,” noted Dr. Woods. “The standard Canadian answer to a need at 2 am is to go to Emergency, which is a terrible answer.”
In the Netherlands, general practitioners are required to provide at least 50 hours of service between 5 pm and 8 am annually in order to maintain their professional licences, according to the Commonwealth Fund report.
Only 34.7 percent of Canadians reported they could get an appointment with a doctor or nurse either the same day or the next day, compared with 61.5 percent of respondents in the Netherlands.
According to Dr. Karim Keshavjee, who trained as a family doctor and now works for the University of Toronto’s Dalla Lana School of Public Health, the biggest problem with primary care in Canada is that we don’t do enough to care for people who are at highest risk of poor outcomes – the working poor, who are scraping by on the minimum wage, working two jobs with no health benefits, struggling to pay their rent and surviving on junk food.
“We need to change how doctors practice,” he said. “We still wait for these patients to come to us, but health is the last priority for someone working two jobs.”
Too many Canadians – especially the working poor – don’t even have family doctors, he complained. Instead, “we’ve taken the shortcut to healthcare access, which is walk-in clinics and emergency departments. But that’s not access to good healthcare.”
Despite having universal healthcare, Canada also scores poorly on affordability, especially for psychotherapy and pharmacare. Ontario, for example, doesn’t pay for psychotherapy unless it’s performed by an MD or a nurse practitioner. Psychologists and social workers, who are among the best qualified to provide counselling, aren’t covered by the Ontario Health Insurance Plan, complained Dr. Woods.
Prescription drugs are covered in Ontario for those over 65 or under 24, low income earners who qualify for the Trillium Drug Program and employees enrolled in employer sponsored insurance plans, but that still leaves many Ontarians paying out of pocket.
Canada’s demographics contribute to its poor ranking in healthcare equity.
Citing the example of the federal government’s COVID Alert cellphone app, Dr. Woods questioned the extent to which marginalized Canadians, including the homeless, new immigrants and Indigenous people, took advantage of it. “We deploy these programs for white, affluent people and end up worsening health disparities,” he complained. “It’s very easy to get care to white, affluent people because they watch CBC News and use the Internet.”
Poor rankings in access to care and equity are inextricably linked to poor health outcomes measured by preventable mortality. New immigrants, for example, access primary care less often for chronic disease management and are at greater risk for poor outcomes.
Canada’s vast geography also impacts on equity, notes Dr. Woods. “If you live in Ignace, Ontario (245 kilometres northwest of Thunder Bay), or in Toronto, you should have the same ability to access primary care, but we have a maldistribution of healthcare resources in Canada. If you look at healthcare outcomes in these small, rural areas, they’re way worse than they are in urban centres like London, Toronto and Ottawa. Geography does determine whether you live or die, particularly for Indigenous people.”
Another problem with Canada’s primary care model, according to Dr. Woods, is that physician payment is not aligned with health system goals. “Physicians are paid for doing a transaction, not for obtaining some sort of global health outcome. If you come in with a sore knee, we could take your knee out and put in a titanium and plastic one, but if you’re 300 pounds, the best thing for you to do would be to lose 100 pounds. But surgeons don’t get paid for you to exercise and lose 100 pounds.”
“In Canada’s primary care model, we prescribe medication for patients with high blood pressure, but we don’t do a very good job making sure they take it, following up in a timely manner, making sure their blood pressure is controlled, managing side effects and being available to answer questions,” said Dr. Woods.
Dr. Keshavjee cites the example of a patient on dialysis who is costing the healthcare system $100,000 a year. “This patient’s kidneys didn’t miraculously fail overnight,” he said. “It happened over a decade. We need to pay more attention to these patients upfront.”
In some countries, a diabetic who hasn’t had his feet checked in six months will get a knock on his door from someone asking, ‘Can I have a look at your feet, sir?’” We don’t do that in Canada.
Investments in social services can reduce pressure on the healthcare system, but as president and CEO of London Health Sciences Centre, Dr. Woods had zero flexibility in allocating dollars to worthy programs in the community.
“The way healthcare is organized in Ontario is so antiquated because it’s by entity instead of by population. I had no breathing room to invest outside my sphere. In downtown London, for example, there’s a program called Youth Opportunities Unlimited serving homeless youth and teenage mothers. I would have loved to put a half million dollars into that, but I had no room for it. With adequate support, those kids would be less likely to show up in ER and admitted to hospital.”
Canada ranked fourth in the Commonwealth Fund’s care process domain, which encompasses screening and vaccinations, medical errors, care planning that reflects patient preferences, and IT-enabled information sharing for co-ordinated care. The report doesn’t reveal Canada’s ranking in the latter sub-category, but Dr. Woods claims there is room for considerable improvement.
“Canada has no discernable health technology strategy. We have a lot of small “s” strategies and jurisdictional squabbles with Canada Health Infoway, Ontario MD and others all fighting for funding. That’s not a health IT strategy. If it were up to me, I’d take all that funding, thank everybody for their time and start from scratch.
“When you have self-contained systems, you have to start creating ways for them to talk to each other, but they don’t and it’s expensive.”
Government should require electronic health record vendors to be able to “API data into a health information exchange,” he urged.
An ideal health IT system should allow us to find out how many diabetics living in Oxford County accessed care or how many patients in Middlesex County have their blood pressure controlled, said Dr. Woods. “That’s entry-level stuff. That’s something we should be able to do. We can’t generate standardized reports to cohort patients by disorder, by multiple disorders, by postal code, by census tract, or by ethnicity.”
With a health information exchange, effective data governance and interoperability, healthcare professionals would be better able to share information and proactively address healthcare issues.
Dr. Keshavjee, who has a special interest in enterprise healthcare architecture, agrees that excellent technology and data are necessary for identifying high-risk patients, but questions the efficacy of health information exchanges. “Canada Health Infoway recommended health information exchanges back in 2003, but it didn’t work,” he remarked.
It turns out that it doesn’t matter if a family doctor gets a discharge summary in two days, instead of two hours because the likelihood of a patient being readmitted to hospital in that period of time is very remote, “so what problem are we solving by spending all that money on exchanging this data?” he asks.
The Commonwealth Fund report concludes that the top-performing countries provide universal coverage to remove cost barriers. They invest in primary care models to ensure high-value services are equitably available. They reduce administrative burdens and they invest in social services that increase equitable access to nutrition, education, child care, housing and transportation.
Does Canada need to spend more than the 10.8 percent of GDP it currently spends on healthcare?
Perhaps, but not necessarily, according to Dr. Woods. Norway, the United Kingdom, the Netherlands, Australia and New Zealand all spend less than Canada as a percentage of GDP, while the U.S., which ranked 11th, spends a whopping 16.8 percent of GDP despite being the only country in the study lacking universal healthcare.
“Maybe we do need to spend more, but we definitely need to spend it differently,” he said.
