^{Posted on March 18, 2009}

The real health care lessons from Europe

By Irfan Dhalla and Chris Mackie
Ottawa Citizen
March 17, 2009

In Belgium, there are four doctors for every 1,000 residents compared to 2.1 per 1,000 in Canada.

In the United Kingdom, the government has established an independent agency to evaluate new technologies before paying for expensive treatments that do not provide significant benefit.

In Denmark, local governments play a role in deciding where family doctors will establish their practices and more than 80 per cent of health care is paid for publicly, compared with about 70 per cent in Canada.

Yet instead of returning from his recent European sojourn trumpeting these facts and all the ways we might innovate within medicare, Canadian Medical Association president Dr. Robert Ouellet has decided that what makes health care work in Europe is that they make better use of the private sector (as favourably reported in the Citizen editorial “Medical improvement,” March 7).

If our goal is merely to convince Canadians that privatization can improve health care, selectively citing some European examples is a pretty good strategy.

But if we truly want to bring the lessons of European health care to Canada, we should realize that privatization has never been the European prescription.

In fact, in almost all European countries, privatization has played only a cameo role.

Some of the lessons of Europe can already be found in Canada.

Across our own country, small-scale solutions are being implemented that are making our system safer, more effective, and more efficient.

Electronic prescribing, integrated home care, centralized waiting lists, better health technology assessment, and increased team-based care are just a few.

But instead of suggesting how we might improve medicare, Dr. Ouellet argues not only for increased private funding, which would mean user fees and a greater role for private insurance companies, but also for increased private delivery within the publicly funded system.

If he examined the evidence, including that produced by the organization he leads, Dr. Ouellet would know that the debates about user fees and private insurance are essentially dead.

Economists have repeatedly demonstrated that user fees reduce health care consumption and short-term costs. But the same research also shows that user fees reduce both necessary and unnecessary health care. Patients often don’t know whether they need to see a doctor or not.

Ignoring a nagging cough that’s been hanging on for a week is unlikely to cause harm. But ignoring a painless lump under the armpit might delay a diagnosis of cancer.

So we should continue to encourage people to seek care early by keeping doctor visits free.

Similarly, private insurance has repeatedly been demonstrated to be both inefficient and unfair. Insurance companies don’t want to insure people who are likely to need health care. Even when they do provide insurance, they use every tool at their disposal to avoid paying out on claims.

Using the private sector to provide publicly funded health care admittedly has some intuitive appeal. At least it used to back in the good old days when we all believed in the supremacy of the market.

But if the economic crisis has taught us anything it should be that we need to be wary of those who answer “privatization” regardless of the question.

Market-based competition in health care might look good on paper, but it doesn’t always work in practice. Many towns need only a single hospital, which makes competition impossible. And even in urban areas, hospitals that are forced to compete rather than co-operate tend to end up fighting over the least complicated and most profitable patients, leaving fewer options for those with complex illnesses who are in greatest need of care.

We should all be wary of selective comparisons to European countries that are devoid of context.

Most European countries are geographically tiny, which makes their health care systems easier to organize. Their social safety nets are more tightly woven, income taxes are higher, and health care professionals are usually paid significantly less — in part because they cannot easily emigrate to the United States.

Is Dr. Ouellet arguing for higher income taxes and lower pay for Canadian doctors?

Although there is much to learn from Europe, and even from the United States, we have a long list of worthwhile innovations right here in Canada that we know will improve our health care system if they are implemented more widely.

What ordinary doctors and Canadians want to see is a movement for change in health care that draws on those aspects of European systems that are based on evidence and consistent with our values.

Dr. Irfan Dhalla is a general internist at St. Michael’s Hospital in Toronto. Dr. Chris Mackie is a public health physician in Hamilton. Both sit on the board of Canadian Doctors for Medicare.