BC Health Care

1
BC Health Care

• The Romanow Report and
• the state of Provincial health care
• Tom Koch
• adj. prof. Gerontology, Simon Fraser University
  (SFU).
• adj. prof. Geography (medical), UBC.
• bioethicist, Canadian Down syndrome Society
• (resource council).
• assoc. David Lam Center for Int.
  Communications, SFU.
• dir. Information Outreach, Ltd.

http//kochworks.com
2
Federal and Provincial perspectives
Within the next year, federal and provincial
elections will be fought in large part over the
issue of healthcare and responsibility for
it. And while there is a robust federal debate
over healthcarefunding and scopethere has been
no debate over provincial health initiatives
since the current governments election.
3
Debate
Debate

• The lack of debate can be traced to
• Lack of a strong legislative opposition.
• Lack of an educated and watchful press.
• Lack of public venues for debate and
• citizen participation.
• LHA amalgamation (Vancouver Coastal as an
  example).
• The desire to preach to the choir.

4
The Result
The most extensive contraction of health service
in the provinces history, and the most
expensive, has occurred without debate, with a
minimum of discussion and a maximum of rancor.
5
Summary History
6
The Provincial Perspective
The current government was elected in 2000 on
the promise of an open, inclusive, consultative,
transparent service that would not cut health
services but would cut costs, providing
healthcare more efficiently and less expensively.
7
Public Support
During the campaign, both the public and health
professionals agreed on the need for change, that
the system needed fixing, or at least would
benefit from improvements. If we could have more
for less . . . Why not?
8
The history
In April, 2002 the BC government announced major
changes to the infrastructure of the provincial
health care system.
9
Rationale
One goal was to restore public faith in
provincial health care BC. We can never
again let the system run down to the point where
people lose confidence in health care.
H. McLeod, Vancouver-Costal Health
Authority interim CEO. Province
Newspaper, 24 April, 2002, A4.
10
To Build the system . . .

• Financial To decrease cost by at least 550
  million without a loss of service.
• This required
• Increased efficiency,
• Economic sustainability,
• Increased user confidence,
• Health worker support.

11
B.C. demographics
The promise of more for less was made with full
knowledge of BCs population trends. Increases in
most jurisdictions meant more service would be
required in all parts of the province, and
especially in its most populated, southern
districts.
12
The provincial reality
Courtesy CHSPR BC Health Atlas, 2002.
13
The Provincial Result
The result has been less for more . . . less
service at a greater cost during a period of
rapid population growth. There is less public
confidence and worse relations between the
government and the health professionals who
provide bedside service.
14
Service Summary
B.C. hospital service capacities have decreased
by between 8 and 12 percent overall. The
closure of hospitals, ERs, and nursing homes has
increased pressure on remaining institutions.
Closures may have increased both systemic
costs (Lin, 2001).
15
budget cuts
16
Changes Resulting

• Removed from the BC system by 2004
• gt862 acute care beds.
• 9 to 12 ERs.
• gt10-12 hospitals.
• gt1,890 long-term and extended care beds.
• One or more rehabilitation centers.

The restructuring has been a wholesale
contraction.
17
Results in patient days.
     Put another way, in the language of patient
days service, this is at least 11.4 of patient
days at full capacity. At 85 capacity the
reduction is approximately 10 percent. This is
well below OECD median levels.
18
Hurrah! Opps
Great Less persons in hospital is more people at
home with lessened noscomic illness. . . . if
decreased patient days was accompanied by
increased homecare services and support. It would
be good if it did not also represent persons sent
home from hospital who needed to be hospitalized,
if all those who needed hospitalization received
it.
19
Communities most affected
Communities with hospitals that have been
closed/downgraded Ashcroft Castlegar Clearwate
r Delta Enderby Ft. St. James Kaslo Kimberly
Mission Summerland Sanich Victoria New
Westminister
Vancouver
20
Effect of hospital closures

• Increases pressure costs for remaining
  institutions.
• Downloads costs of travel on patients, patient
  families.
• Likely increased length of patient stay at
  referral
• hospitals (Lin, 2002).
• Decreased chances of survival in some health
• situations.
• Loss of staff to BC health system.
• Decreased income/livability in local/regional
• communities.
• Decreased long-term desirability of a region.

21
Vancouver-Coastal Effect
VGH Status 2000-2001
662 patient days per 1000 pop. age adjusted.
1.8 bed per 1000 pop. age-adjusted.
2.1 beds per 1000 pop. age adjusted
_at_ 85 percent capacity
2003 587 patient days per 1000 pop.
age adjusted. 1.6 beds per 1000
pop. age adjusted.      1.9 beds per 1000
pop age adjusted _at_ 85 percent
capacity. -      
22
Effective results Wait lists/wait time

• Wait lists for essential, non-critical
• surgical procedures (hip replacement,
• for ex.) have at least doubled.
• Wait times for beds have increased.
• Wait times in many Emergency rooms
• have increased.
• Wait time for diagnostic procedures and
  specialist referrals has increased.

23
Changes Emergency Rooms
Communities with ERs that have been eliminated
or downgraded Chemainus Delta Enderby Hope Cas
tlegar Kaslo Mission Richmond Summerland Port
Moody Greater Vancouver
24
Effect on ER Service

• Increased travel time may decrease survival
• rates and increase length of stay.
• Travel costs downloaded on patient.
• Emergency service response time decreases as
• distance from nearest ER increases.
• Pressure on remaining ERs increases.
• ER waiting times increase.
• Decreased response capability in cases of
• disaster or epidemic.

25
The flaw The Inelasticity of demand
Demand is relatively inelastic. 93 percent of
all hospitalizations are unavoidable (Lin et
al. 2002). They are required if patient life
and life quality is to be maintained. Delay may
result in longer hospitalization in the end.
All changes occur within the context of this
relative inelasticity.
26
Networks and the domino effect
Because demand is relatively inelastic, and
service therefore mandated, closure of one
institution places pressure on those remaining,
and on other parts of the system. Money saved in
one place must be spent in another, or downloaded
to the patient. Savings are thus typically
illusory.
27
Referral Centres

Impact is greatest on referral centres that
receive the most complex cases and serve
simultaneously as local and district hospitals.
VGH, for example, serves (a) Vancouver (b)
Greater Vancouver (c) Vancouver Coastal and (c )
the province at large. Fewer hospitals in
outlying areas increases pressure on VGH.
Downgrade of services (emergency and acute) at
distant hospitals increases pressure at tertiary
and higher level centres.
28
Specialty Centers
Similar problems can be seen at other provincial
referral centres. For Example G. F. Strong
Spinal Cord Injury
neurological traumatic
brain injury Closure of Skeleen Village, a
TBA rehabilitation
facility.
29
Sick patients travel further
B.C. standards in this area do not compare
favorably with even those in the U.S. 1-hour
travel time to Emergency care for BC
citizens. 2-hour travel time to Acute care
service. Changes have increased distance to
service in most areas, urban and rural.
30
Hidden Costs
The necessity of sending some patients to Alberta
or U.S. medical institutions for urgent treatment
is a hidden cost of the B.C. system
contractions. Stories abound but no analysis of
the system costor life costhas been reported.
31
Management and style
The B.C. government has approached the business
of health care by transforming healthcare into
just another business. It isnt, neither
economically nor socially.
32
Business/health models
Just in time manufacturing modes do not
serve in public service. Health care
requires slack and redundancy if emergencies
(epidemics, major accidents) are to be handled).
Short-term cost-benefit accountancy is costly,
and may result in diminished service.
33
The B.C. Government argument

• The B.C. Government has blamed health care cost
  increases on
• the federal government and its failure to
• adequately fund health care and
• Increasing labour costs for care providers

the continued escalation of health care costs is
not sustainable, Ministry web site.
34
Spending has Increased
In BC, we're spending over 42 per cent of the
total provincial budget on health care, with 2
billion in new funding added over the past three
years. B.C. Ministry of Health web site
accessed 8 May 2004. http//www.healthservices.gov
.bc.ca/bchealthcare/pressure.html
35
Federal Monies
BUT federal monies for provincial health systems
have increased, in part as a result of the
Romanow Commission and its debates. This has been
a boon unacknowledged by B.C.s government in
public or on its website.
36
Labour Costs
The government has blamed rising costs/declining
services on patient-related employees
We now spend 10.7 billion a year on health
care. Of those dollars, almost 70 per cent goes
to compensation for health care providers and
support workers . . .the continued escalation of
health care costs is not sustainable.
B.C. Ministry of Health web site accessed 8 May
2004. http//www.health services.gov.bc.ca/bchealt
hcare/pressure.html
37
Increasing cost structures

• But among the most significant areas of
• cost increase have been
• restructuring itself.
• management salaries.
• non-patient care salaries.
• advertising.

38
Non-labor costs restructuring.
VCHA financial statements peg the cost of the
restructuring in 2002-2003 at 20.2 million for
VCHA alone. Similar costs presumably occurred in
other Health Authorities.
Restructuring costs In the current year,
management has recorded an expense of for
restructuring costs in the amount of 20.2
million. The restructuring costs consist of
severance and related costs that are anticipated
to result from the restructuring of the VCHA.
From 2002/03 VCH financial statements
39
Increased Management Costs

The number of employees earning more than 75,000
a year at VCHA alone rose from 2002 to 2003 by
about 47 percent. The cost was about 55
million.
From 2002/03 VCHA financial statements
40
Non-patient care costs
These are not cooks, dietitians, electricians,
laundry workers, lab technicians, floor nurses,
etc. They are financial analysts, risk assessment
supervisors, managers, PR personnel, etc. The
promise of money going directly to the patient
is unmet.
41
Severancenon-patient care personnel
In addition, there were 34 severance agreements
made between Vancouver Coastal and its
non-unionized managers in 2002-3 for between 1
and 18 months compensation. An unknown but
significant number of managers were on paid
stress leave as well.
42
Long-term costs

• Hidden as well are unconsidered but real long
  term costs of the restructuring to the BC
  economy
• Loss of jobs to economy.
• Loss of secondary revenues.
• Loss of trained, stable, local population.
• Increased costs elsewhere in system.
• Loss of individuals to work force.

43
Lack of Consultation

Promises of openness and consultation have been
unmet. The changes, while fundamental, have
occurred without public debate, discussion, or
citizen discussion. There is, however, a
carefully constructed, provincial health services
web page on the Internet.
44
Public Advertising
Instead, the government has used paid advertising
as its principal medium for discourse. In two
separate campaigns the health ministry has spent
over 900 million on advertising promoting its
restructuring. This does not include the cost
of branding of LHAs, web page design, etc.
45
Branding healthcare
The result is precisely that of a private
corporation (Phillip Morris, perhaps)
repositioning a product it wants to sell to the
public. It appears to be a U.S. model of private
health and private business transposed into a
Canadian provincial setting.
46
Health care overhead U.S.
The U.S. experience in private health care
suggests a management overhead of at least 20
of total cost of service. It is a minimum
inevitable with privatization . . . and
apparently with the B.C. governments business
model.
47
Timing

Timing of changes has been rapid and without
thought to human consequences or long-term
planning necessities. As one minister said,
patient problems are the sawdust that
accompanies any renovation. Clearly, changes
have been rushed and therefore implemented
without adequate safeguards.
48
Assisted Living

As SFUs Charmain Spencer notes To date,
consumer input and influence have been noticeably
absent from the development of the assisted
living mode. Perhaps not surprisingly, the
resulting health, safety, and tenancy safeguards
. . . have been minimal. Spencer, C. 2004.
49
Summation

• Promised but unfulfilled by the current
• restructuring are the following goals
• Less expensive health system.
• More comprehensive health system.
• Shorter wait times for elective surgeries.
• Better labour relations.
• Restored public confidence.
• Public transparency.

50
Outcomes

• The results to date have been
• Waiting lists for common procedures
• have doubled or trebled.
• Service has decreased in many regions.
• Labour strife has increased.
• Costs have increased.
• Public confidence is diminished.

51
Underlying assumption . . .

• Scarcity of resources is a limiting reality.
• It must be met by
• rationing of services.
• decrease of services.
• increased efficiency of existing (remaining)
• services.

52
Scarcity is an outcome
Scarcity is typically a condition we create, an
outcome and not an Inherent limit. Current
policies have created scarcity, or increased it.
53
Tom Koch http//kochworks.com
Book Titles 1990-2004 The Wreck of the
William Brown A True Tale of Overcrowded
Lifeboats and Murder
at Sea (Douglas McIntyre, 2003 McGraw-Hill,
2004). Scarce Goods Justice,
Fairness, and Organ Transplantation (Praeger Pub
2001) Age Speaks for
Itself Silent Voices of the Elderly (Praeger
Pub 2000) The Limits of
Principle Deciding Who Lives and What Dies
(Praeger Pub 1998)          Second
Chances Crisis and Renewal in Our Everyday Lives
(Turnerbooks 1998)          The Message is
the Medium Online Data and Public Information
(Praeger Pub 1996)         
Watersheds Stories of Crises and Renewal in
Everyday Life (Lester Pub. 1994)         
A Place in Time Care Givers for Their Elderly
(Praeger Pub 1993)          Mirrored
Lives Aging Children and Elderly Parents
(Praeger Pub 1990)          The News as
Myth Fact and Context in Journalism (Greenwood
Press 1990)          Journalism for the
21st Century Electronic Libraries, Databases
and the News (Praeger Pub
1991)         Creating a Cycle Efficient
Toronto (Toronto City Cycling Committee) 1992
Six Islands on Two Wheels A
Cycling Guide to Hawaii (Bess Press 1990).
54
Selected references

• Cohen, L. A. Manski, R. J. Magder, L. S.
  Mullen,s, D. Dental visits to hospital emergency
  departments by adults receiving Medicaid. J. of
  the American Dental Assoc. 133, 715-724.
• Koch, T. 2001. Scarce Goods Justice, Fairness,
  and Organ Transplantation. Westport, CT and
  London, UK Praeger Books.
• Lin, G. Allan, D. E. and Penning, M. J. 2002.
  Examining distance effects on hospitalizations
  using GIS A study of three health regions in
  British Columbia, Canada. Environment and
  Planning A 34, 2037-2063.
• Lowe, J. M. and Sen, A. 1996. Gravity Model
  Applications in health Planning Analysis of an
  urban hospital Market. Journal of Regional
  Science 363, 437-461.
• Mahew, L. D. Ribberd, R. W. and Hall, H. 1996.
  Predicting Patient flows and hospital case-mix.
  Environment and Planning A 18, 619-639.
• Morrill, R. 1974. Efficiency and Equity of of
  Optimum Location Networks, Antipode 6141-46.
• Moscovice, Ira. 1999. Quality of Care Challenges
  for Rural Health. Minneapolis, MN U. Minn.
  Rural Health Research Center, 7.
• Shudd, S. 1996. The Impact of Travel on Patient
  Outcomes. Dissertation Yale University.
• Spencer, C. 2004. Seniors Housing Update 131.
  Simon Fraser University Gerontology Research
  Center.