tag:theconversation.com,2011:/es/topics/wait-times-42506/articlesWait times – The Conversation2020-04-29T12:12:26Ztag:theconversation.com,2011:article/1363142020-04-29T12:12:26Z2020-04-29T12:12:26ZWait times remain stubbornly long in hospital emergency rooms<figure><img src="https://images.theconversation.com/files/329804/original/file-20200422-47784-16wqp2s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">How long will you wait?</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/sliding-doors-of-emergency-room-in-hospital-royalty-free-image/601797385?adppopup=true">Getty Images</a></span></figcaption></figure><p>Each year, there are well over 100 million hospital emergency department visits in the U.S. In 2017, there were about <a href="https://www.cdc.gov/nchs/fastats/emergency-department.htm">139 million</a>, or 43 visits for every 100 Americans.</p>
<p>While wait times have declined in the last decade – now averaging about 40 minutes – they remain stubbornly long. Millions of patients still wait at least two hours to see a provider – <a href="https://www.cdc.gov/nchs/data/nhamcs/web_tables/2017_ed_web_tables-508.pdf">7 million did</a> in 2017 – and that is no guarantee they won’t have to wait even longer for treatment. In California, <a href="https://www.sacbee.com/news/local/health-and-medicine/article230552184.html">hundreds of thousands of patients that same year</a> left after getting an emergency department bed but before their care was complete.</p>
<p>How long people have to wait can have a lot to do with the outcome of those visits, <a href="https://doi.org/10.1016/j.rmclc.2017.04.008">sometimes with serious consequences</a> that include longer hospital stays, increased medical errors and higher death rates. </p>
<p><a href="https://www.bu.edu/sph/profile/paul-shafer/">One of us</a> studies how people enroll in and use health insurance, including how often they go to the emergency room and why, while the <a href="https://www.bu.edu/sph/profile/alex-woodruff/">other is a policy analyst</a> who is focused on access to care for vulnerable populations, in particular those with opioid use disorder. We decided to take a deeper look at what we know about the drivers of emergency department wait times and crowding, especially as the COVID-19 pandemic shows just how important a well-functioning emergency medicine system is.</p>
<p>We studied the literature on emergency wait times and identified several reasons why they remain high. One surprise finding is that many <a href="https://journals.sagepub.com/doi/full/10.1177/1062860617700721?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed">patients likely without true emergencies are told to go</a> to the emergency room by physicians out in the community, which contributes to high emergency department volume.</p>
<h2>An obligation to treat everyone</h2>
<p>Every day, hospital emergency departments serve as the entry point into health care for Americans who don’t feel right and have nowhere else to go, or have an emergency, like a car accident. This also includes millions of patients seeking <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4156292/">routine medical care</a> that is available elsewhere: While the estimates vary widely from <a href="https://pubmed.ncbi.nlm.nih.gov/28992158/">study</a> to <a href="https://pubmed.ncbi.nlm.nih.gov/26763823">study</a>, upwards of a third of all emergency department visits could be considered “nonurgent.”</p>
<p>Emergency rooms face a Herculean task. They are asked to be prepared for anything and everything, keep wait times down and costs low. They are <a href="https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/">mandated by law</a> to treat and stabilize anyone who walks in the door regardless of their ability to pay, a burden that no other part of the health care system faces.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/330066/original/file-20200423-47841-xyv0nc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/330066/original/file-20200423-47841-xyv0nc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/330066/original/file-20200423-47841-xyv0nc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/330066/original/file-20200423-47841-xyv0nc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/330066/original/file-20200423-47841-xyv0nc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/330066/original/file-20200423-47841-xyv0nc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/330066/original/file-20200423-47841-xyv0nc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Patients forced to wait for treatment in the hallways of an Atlanta Hospital in 2006 due to lack of space and overcrowding.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/at-grady-memorial-hospital-emergency-department-where-many-news-photo/98618601?adppopup=true">Jonathan Torgovnik/Getty Images)</a></span>
</figcaption>
</figure>
<p>The average wait time to see a health care provider in the emergency department in 2017, the most recent national data available, was <a href="https://www.cdc.gov/nchs/data/nhamcs/web_tables/2017_ed_web_tables-508.pdf">37.5 minutes</a>, down from <a href="https://www.cdc.gov/nchs/products/databriefs/db102.htm">58.1 minutes</a> a decade earlier.</p>
<h2>Why the wait?</h2>
<p>An obvious driver of crowding and high wait times is how many patients show up for treatment.</p>
<p>A large number of patients who don’t <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4156292/">have what rises to the level of a true emergency</a> are referred to the emergency department by outside physicians. These referrals could be because the physician is not sure if they can provide complete care, or because their schedule is too tight to see patients quickly. One <a href="https://pubmed.ncbi.nlm.nih.gov/28693337/">study</a> found that about half of “nonemergent” patients contacted another physician first, and 70% of them were told to go to the emergency room.</p>
<p>One of us experienced this firsthand recently. Paul’s rambunctious three-year-old launched herself off the couch head first into the coffee table. There was lots of blood, crying and an immediate trip to urgent care. It was a small wound that the doctor probably could have stitched up himself, but he recommended that Paul go to the emergency room because his daughter might need a plastic surgeon. She ended up not needing stitches and was instead patched up with surgical glue. From her leap off the couch until arriving back home, we probably spent a few minutes with doctors and a couple of hours waiting.</p>
<p>Also adding to the emergency department load is that outside physicians often lack admitting privileges to hospitals. When a patient needs to be admitted as an inpatient but the provider can’t admit them directly, they send the patient to the emergency room for admission instead. <a href="https://www.acepnow.com/article/latest-data-reveal-the-eds-role-as-hospital-admission-gatekeeper/?singlepage=1&theme=print-friendly">A report from the American College of Emergency Physicians</a> suggests that 70% of hospital admissions come through the emergency room, and it is increasing.</p>
<p>For patients who choose to go on their own to the emergency room, it might be exactly the right thing to do. Chest pain can be indigestion or a sign of a heart attack. Playing Monday morning quarterback after the fact, <a href="https://epmonthly.com/article/prudent-layperson-meet-imprudent-payer/">which insurers sometimes do</a>, makes it easy to point fingers at patients for “avoidable” visits, but it is <a href="https://pubmed.ncbi.nlm.nih.gov/23512061/">unfair</a>.</p>
<h2>Solutions exist</h2>
<p>There are several options for hospitals and communities to reduce the demand for emergency department services. </p>
<p>Urgent care centers and retail clinics <a href="https://pubmed.ncbi.nlm.nih.gov/30193357/">can care for simpler cases</a> that otherwise might have showed up to the emergency room, but the evidence <a href="https://www.annemergmed.com/article/S0196-0644(16)30998-2/abstract">isn’t clear</a> on how much volume they absorb. There is some evidence that retail clinics, like CVS Minute Clinics, may actually <a href="https://www.healthaffairs.org/doi/10.1377/hlthaff.2015.0995">increase health care use and spending</a>.</p>
<p>Over half of emergency department visits (57.2%) come <a href="https://www.cdc.gov/nchs/data/nhamcs/web_tables/2017_ed_web_tables-508.pdf">outside of business hours</a>, when many retail clinics, along with more traditional options like community health centers and primary care offices, are often closed. </p>
<p>Many urgent care centers are open later and on weekends, but not everyone has easy access to one. Many lower-income neighborhoods do not have <a href="https://www.bostonglobe.com/metro/2019/01/12/urgent-care-centers-proliferate-mass-but-fewer-low-income-patients-have-access/FATkqt7OtDc0sHFupk7eSJ/story.html">access to urgent care</a>. Not surprisingly, when urgent care centers close at night, <a href="https://www.nber.org/papers/w25428">nonemergent emergency room visits increase</a>. </p>
<h2>No beds to be had</h2>
<p>No one really knows what the “right” average wait time is. It will always be too long for someone. One of the biggest challenges to reducing wait times is crowding that occurs because the emergency room has no beds available because patients are waiting to be released or moved. </p>
<p>If a patient needs to be admitted but there are no unit beds available, the emergency department often “boards” the patient for hours. The emergency physicians association calls this “<a href="https://www.acep.org/globalassets/sites/acep/media/crowding/empc_crowding-ip_092016.pdf">a primary contributor to crowding</a>” and notes that over 90% of hospitals routinely report crowded conditions in their emergency rooms.</p>
<p>The situation is even worse when it comes to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3408670/">psychiatric</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2396562/">substance use</a> patients, where limited availability of specialized treatment beds means even longer waits. Space in homeless shelters can matter too. There are many nights when it isn’t safe to send someone back out into the cold with nowhere to go.</p>
<p>Boarding and crowding are <a href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2011.0786">not new problems</a>, yet policymakers and health care leaders have struggled to find and implement solutions. Improving this system will require pushing on several levers to connect patients with the right level of care. This effort can help ensure that when true emergencies happen, people can get the care they need quickly.</p>
<p>[<em>Like what you’ve read? Want more?</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=likethis">Sign up for The Conversation’s daily newsletter</a>.]</p><img src="https://counter.theconversation.com/content/136314/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Shafer has received funding in the past three years from the Kate B. Reynolds Charitable Trust, Robert Wood Johnson Foundation, Horowitz Foundation for Social Policy, and the North Carolina Translational and Clinical Sciences Institute.</span></em></p><p class="fine-print"><em><span>Alex Woodruff does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In a well-functioning health care system, the emergency room would be able to meet the needs of all of its patients in a timely manner.Paul Shafer, Assistant Professor, Health Law, Policy and Management, Boston UniversityAlex Woodruff, Policy Analyst, Boston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1333012020-03-16T12:18:50Z2020-03-16T12:18:50ZClosing polling places is the 21st century’s version of a poll tax<figure><img src="https://images.theconversation.com/files/319986/original/file-20200311-116240-1slu37o.jpg?ixlib=rb-1.1.0&rect=103%2C8%2C2892%2C2205&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Californians wait in line to vote on Super Tuesday, March 3, 2020.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/CA-Election-2020-California-Voting/37d4681bbfce4cac95f3d2e09edbe765/14/0">AP Photo/Ringo H.W. Chiu</a></span></figcaption></figure><p>Delays and long lines at polling places during recent presidential primary elections – such as voters in <a href="https://www.washingtonpost.com/politics/long-voting-lines-in-texas-spotlight-concerns-about-access-to-the-polls/2020/03/04/e729486a-5e2e-11ea-b014-4fafa866bb81_story.html">Texas</a> experienced – represent the latest version of decades-long policies that have sought to reduce the political power of <a href="https://www.theguardian.com/us-news/2020/mar/02/texas-polling-sites-closures-voting">African Americans</a> in the U.S.</p>
<p>Following the Civil War and the extension of the vote to African Americans, state governments worked to <a href="https://theconversation.com/what-everyone-should-know-about-reconstruction-150-years-after-the-15th-amendments-ratification-122117">block</a> black people, as well as poor whites, from voting. One way they tried to accomplish this goal was through poll taxes – an amount of money each voter had to pay before being allowed to vote. </p>
<p>This practice was abolished by the passage of the <a href="https://constitutioncenter.org/interactive-constitution/amendment/amendment-xxiv">24th Amendment</a> in 1964. Further protections for nonwhite voters came with the Voting Rights Act, which closely followed the <a href="https://kinginstitute.stanford.edu/encyclopedia/selma-montgomery-march">Selma to Montgomery civil rights protest marches</a> 55 years ago, in March 1965.</p>
<p>But in recent years, new barriers have gone up that, we believe, constitute a new type of poll tax on working people and minority voters. <a href="https://scholar.google.com/citations?hl=en&user=yi48Sl4AAAAJ">We</a> <a href="https://scholar.google.com/citations?user=xoubpW0AAAAJ&hl=en&oi=ao">are</a> scholars of the American civil rights movement, including the <a href="https://www.nsf.gov/awardsearch/showAward?AWD_ID=1660274">Student Non-Violent Coordinating Committee’s voting rights efforts</a>.</p>
<p>Unlike past poll taxes, the modern poll tax isn’t paid in money, but in time – how long it takes a person to get to a polling place, and, once there, how long it takes for them to actually cast their ballot.</p>
<h2>Securing the right to vote</h2>
<p>Almost immediately after the <a href="https://www.law.cornell.edu/constitution/amendmentxv">15th Amendment</a> gave African Americans the right to vote in 1870, state governments in the South passed a series of laws seeking to limit <a href="https://www.crf-usa.org/black-history-month/race-and-voting-in-the-segregated-south">freed blacks’ voting power</a>.</p>
<p>In addition, white supremacist organizations like the <a href="https://www.washingtonpost.com/news/the-fix/wp/2016/11/02/the-long-history-of-black-voter-suppression-in-american-politics/">Ku Klux Klan</a> used violence to intimidate African Americans from casting ballots.</p>
<p>This situation remained largely unchallenged for almost a century, until the 1960s, when the years of protest by the civil rights movement bore fruit in the abolition of poll taxes and federal protection of citizens’ voting rights.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/319988/original/file-20200311-116291-175fbbv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/319988/original/file-20200311-116291-175fbbv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/319988/original/file-20200311-116291-175fbbv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=613&fit=crop&dpr=1 600w, https://images.theconversation.com/files/319988/original/file-20200311-116291-175fbbv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=613&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/319988/original/file-20200311-116291-175fbbv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=613&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/319988/original/file-20200311-116291-175fbbv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=770&fit=crop&dpr=1 754w, https://images.theconversation.com/files/319988/original/file-20200311-116291-175fbbv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=770&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/319988/original/file-20200311-116291-175fbbv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=770&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">President Lyndon Johnson signs the 24th Amendment, Feb. 4, 1964, abolishing poll taxes.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Signing_of_the_Constitutional_Amendment_on_the_Poll_Tax.jpg">Cecil W. Stoughton/Wikimedia Commons</a></span>
</figcaption>
</figure>
<h2>Creating a new poll tax</h2>
<p>Since the 1960s, there have been efforts by state and local officials to limit these hard-won victories. </p>
<p>The most recent chapter in this battle is the 2013 Supreme Court decision in <a href="https://www.oyez.org/cases/2012/12-96">Shelby County v. Holder</a>, which lifted restrictions on states that have historically blocked African Americans from voting, so state governments no longer need to seek federal approval before taking actions that might disproportionately harm black citizens’ <a href="https://www.theatlantic.com/politics/archive/2018/07/how-shelby-county-broke-america/564707/">right to vote</a>. </p>
<p>Since the Shelby County decision, local election boards and state governments have closed over <a href="https://www.motherjones.com/politics/2019/09/report-more-than-1600-polling-places-have-closed-since-the-supreme-court-gutted-the-voting-rights-act/">1,600 polling places</a>. That is approximately 8% of total voting locations within jurisdictions affected by the Shelby decision. </p>
<p>The U.S. Commission on Civil Rights, a bipartisan independent study group started in 1957, found that states claimed polling-place closures were intended to save money, centralize voting operations, and complying with Americans with Disabilities Act – but really the goal was <a href="https://www.usccr.gov/pubs/2018/Minority_Voting_Access_2018.pdf">reducing voter turnout</a>, particularly among minority voters who were historically disenfranchised. Using publicly available data, federal lawsuits brought against states and counties the report documents clear patterns of discrimination.</p>
<p>These closures, often done with little notice or public accountability, have occurred across communities of varying racial and <a href="https://civilrights.org/democracy-diverted/">demographic characteristics</a>. What unites these places are <a href="https://uknowledge.uky.edu/klj/vol104/iss4/5/">the costs they impose</a> on voting – from longer wait times to transportation obstacles – experienced disproportionately by voters of color, older voters, rural voters, voters with disabilities and poor working <a href="https://civilrights.org/democracy-diverted/">people in general</a>.</p>
<p>In the 2016 election, for instance, scholars at UCLA found that voters in black neighborhoods waited, on average, <a href="https://arxiv.org/abs/1909.00024">29% longer to vote</a> than voters in predominantly white communities. The study found, “Even within the same county, voters in a hypothetical all-black precinct would wait 15 percent longer than voters in an all-white precinct.” </p>
<p>The study found voters in majority black precincts were far more likely to <a href="https://arxiv.org/abs/1909.00024">wait longer than half an hour</a> to cast a ballot than voters in majority white precincts. A study of the 2012 election found that the voters who waited in long lines paid, collectively, over <a href="https://doi.org/10.1089/elj.2014.0292">half a billion dollars</a> in lost wages.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/320259/original/file-20200312-111232-1h18azh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/320259/original/file-20200312-111232-1h18azh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/320259/original/file-20200312-111232-1h18azh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/320259/original/file-20200312-111232-1h18azh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/320259/original/file-20200312-111232-1h18azh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/320259/original/file-20200312-111232-1h18azh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/320259/original/file-20200312-111232-1h18azh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/320259/original/file-20200312-111232-1h18azh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Voters in Houston, Texas, wait in line to vote on Super Tuesday 2020.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/voters-line-up-at-a-polling-station-to-cast-their-ballots-news-photo/1204959570">Mark Felix/AFP via Getty Images</a></span>
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<h2>Considering time</h2>
<p>We believe that polling place closures represent a modern-day version of the poll tax. </p>
<p>In our view, access to polling places is a key element of citizens’ <a href="https://www.casemine.com/judgement/us/5914b24dadd7b0493475f116">right to vote</a>. People need fair and equitable access to places to vote – and determining what that means should include time and travel costs imposed on voters. This would expand traditional understandings of access to polling places beyond narrow legal opinions and take into account the full range of racial and class barriers to being able to participate in U.S. democracy. </p>
<p>Everybody’s time is valuable. But wait times have different effects depending upon a person’s socioeconomic status. </p>
<p><a href="https://heinonline.org/HOL/Page?handle=hein.journals/tndl85&div=7&g_sent=1&casa_token=b6sHA4AGfu8AAAAA:lRaEeXP_zforinl7vSd2bTvYfwkXqH_K479KZkRxBDv2h_RFdUaRleSa3PJ2K8C_dskseFpF7Q&collection=journals">Working people calculate daily</a> how much time, if any, they can afford to be away from their hourly wage job. Interminable waits at polling places may not fit in the schedule with a second or third job. Work supervisors may not excuse a late arrival or an absence. A working person may feel pressure to leave a polling place before casting a ballot, just to get to work on time and keep the <a href="https://thehill.com/homenews/campaign/486932-sanders-calls-long-lines-at-michigan-polling-stations-an-outrage">money coming in</a>.</p>
<p>Importantly, the Supreme Court’s Shelby County ruling did not invalidate all of the Voting Rights Act. Rather, it threw out the method by which the federal government could determine <a href="https://www.justice.gov/crt/section-4-voting-rights-act">which areas of the country had policies</a> that resulted in widespread voter disenfranchisement. </p>
<p>Congress could enact new legislation detailing a new method of making that determination, which would then <a href="https://www.vox.com/2016/2/14/17619202/voting-rights-fight-explained-key-sections-rights-act">restore federal oversight</a> to states that create barriers to voting. </p>
<p>However because of our federal system where states have direct oversight of elections many of these decisions ultimately take place at the local and state level. As a result, election officials need to work in transparent ways with diverse communities to ensure that changes to voting locations do not disproportionately limit minority access. In addition, states could also ensure equal access to voting by creating, or expanding, early voting periods, and making it possible <a href="https://www.ncsl.org/research/elections-and-campaigns/early-voting-in-state-elections.aspx">to vote by mail</a>.</p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p><img src="https://counter.theconversation.com/content/133301/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The modern poll tax isn’t paid in money, but in time – how long it takes a person to get to a polling place, and, once there, how long it takes for them to actually cast their ballot.Joshua F.J. Inwood, Associate Professor of Geography Senior Research Associate in the Rock Ethics Institute, Penn StateDerek H. Alderman, Professor of Geography, University of TennesseeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1283752019-12-10T17:51:18Z2019-12-10T17:51:18ZGood governance is the missing prescription for better digital health care<figure><img src="https://images.theconversation.com/files/305519/original/file-20191205-39001-1mtgujt.jpg?ixlib=rb-1.1.0&rect=320%2C89%2C3684%2C2484&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Despite massive investments, Canada's health-care system has not reaped the benefits of digital technology like banking and retail sectors have.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Recently Ontario released its <a href="https://news.ontario.ca/mohltc/en/2019/11/ontario-expanding-digital-and-virtual-health-care.html">Digital First for Health strategy</a> — aiming to further digitize health care and end the problem of <a href="http://www.health.gov.on.ca/en/public/publications/premiers_council/default.aspx">overcrowded hospitals and “hallway medicine.”</a> </p>
<p>While applauding the government’s continuous effort to improve quality health care through digital health, one can’t help wonder about the bumpy journey this has been to date.</p>
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Read more:
<a href="https://theconversation.com/ontario-public-health-cuts-will-endanger-the-public-116502">Ontario public health cuts will endanger the public</a>
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<p>It has been a journey involving large financial investments — from the launch of <a href="https://www.infoway-inforoute.ca/en/about-us">Canada Health Infoway in 2001</a> to use technology for more efficient delivery of services, to the billion-dollar project <a href="https://www.cbc.ca/news/canada/toronto/ehealth-scandal-a-1b-waste-auditor-1.808640">eHealth Ontario in 2008</a> to create electronic health records.</p>
<p>However, despite being the <a href="https://www.fraserinstitute.org/studies/comparing-performance-of-universal-health-care-countries-2019">most expensive universal-access health-care system</a> in the Organization for Economic Co-operation and Development (OECD), the Canadian health-care system continues to grapple with chronic challenges. These include skyrocketing <a href="https://theconversation.com/we-must-rethink-health-care-to-include-social-and-environmental-costs-of-treatment-121649">health-care costs</a>, <a href="https://theconversation.com/seeing-a-family-doctor-just-got-even-harder-in-ontario-125487">unbearable wait times</a> and an <a href="https://theconversation.com/canadian-health-care-needs-agile-leaders-and-bold-visions-for-the-future-116331">aging population</a>.</p>
<p>It is puzzling that one of our most cherished Canadian institutions — our public health-care system — struggles to reap the benefits of the digital revolution, while other industries such as banking and retail have already harnessed advanced technologies to deliver fast and convenient services. </p>
<p>The reason: our health-care system lacks good governance.</p>
<h2>Software systems must work together</h2>
<p>For example, one key contributor to the hallway medicine issue is the <a href="https://orionhealth.com/media/4894/orion-health-interoperability-high-level-report-final-1.pdf">lack of system interoperability</a>. </p>
<p>In other words, multiple software systems are needed to support the transition of a patient from hospital care to community care. In Ontario, the <a href="https://hssontario.ca/News/Pages/Meet-CHRIS.aspx">Client Health and Related Information System</a> (CHRIS) helps this process and is available province-wide. </p>
<p>Unfortunately, some EMR systems are not interoperable with CHRIS and as a result, care plans are faxed, duplicated and not always synchronized when updated. The result: a long waiting time to transition a patient, which results in hallway medicine.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/305520/original/file-20191205-38984-17acbgd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/305520/original/file-20191205-38984-17acbgd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/305520/original/file-20191205-38984-17acbgd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/305520/original/file-20191205-38984-17acbgd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/305520/original/file-20191205-38984-17acbgd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/305520/original/file-20191205-38984-17acbgd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/305520/original/file-20191205-38984-17acbgd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A piecemeal approach to digitization will not prepare our health-care system for the aging population.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/canadian-health-care-needs-agile-leaders-and-bold-visions-for-the-future-116331">Canadian health care needs agile leaders and bold visions for the future</a>
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<p>There are other painful effects of our fragmented health-care systems: <a href="https://vancouversun.com/news/local-news/b-c-has-second-highest-hospital-readmission-rate-in-canada-solutions-elusive">hospital readmissions</a> and <a href="https://www.fraserinstitute.org/studies/waiting-your-turn-wait-times-for-health-care-in-canada-2018">excessive wait times</a> for medical diagnoses and treatments, to name just two. </p>
<p>What is more, the current piecemeal approach to digitization will not prepare our health-care system for the <a href="https://www.canada.ca/en/employment-social-development/programs/seniors-action-report.html">aging population</a>. This will result in an increase in elderly patients who have multiple chronic conditions and require care from multiple service providers.</p>
<h2>A change of mindset is needed</h2>
<p>Granted, significant improvements have been made in different provinces. According to the Canadian Medical Association 2017 Physician
Workforce Survey, more than <a href="https://www.cma.ca/sites/default/files/pdf/health-advocacy/activity/2018-08-15-future-technology-health-care-e.pdf">82 per cent of primary care doctors</a> used an electronic medical record system across provinces and 85 per cent of primary care doctors accessed lab results and notes electronically. </p>
<p>Hospitals and health-care agencies have also allocated <a href="https://hospitalnews.com/first-canada-epic-end-end-electronic-medical-record/">significant resources to modernize their IT systems</a> and embrace IT into their daily operations.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-future-of-psychiatry-promises-to-be-digital-from-apps-that-track-your-mood-to-smartphone-therapy-110489">The future of psychiatry promises to be digital — from apps that track your mood to smartphone therapy</a>
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<p>However, the key issue here is to change the mindset that more technologies will cure our health-care system. While it always sounds exciting to introduce new technologies in hope that they will do wonders, more systems would not fundamentally address the painful issues Canadians have been experiencing.</p>
<h2>Transparency and accountability</h2>
<p>Instead, we need a governance structure in place — to fund only IT investment initiatives that are interoperable with existing backbone systems. Better data access should be achieved <a href="https://www.theglobeandmail.com/opinion/article-why-are-fax-machines-still-the-norm-in-21st-century-health-care/">not through fax machines</a>, phone calls, post mails, printouts and emails, but through seamless integration of technologies that allow data to be communicated without losing its accuracy, completeness and timeliness.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/educating-nurses-to-support-digital-health-105777">Educating nurses to support digital health</a>
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<p>Good governance stresses transparent funding policies and accountability that links investments to outcomes. Private organizations rely on governance to reduce costs and make businesses agile and scalable. The number one component of the <a href="http://www.euro.who.int/__data/assets/pdf_file/0012/302331/From-Innovation-to-Implementation-eHealth-Report-EU.pdf">national e-health strategy recommended by the World Health Organization (WHO) is governance</a>.</p>
<p>However, governance has not yet been paid much attention to by either government officials or health-care service providers. It explains the bumpy road we have experienced in our path of health-care digitalization. </p>
<p>As technologies are deeply ingrained in our health-care system, it is critical to have better governance — in order for Canadians to enjoy world-class digital health care.</p><img src="https://counter.theconversation.com/content/128375/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Linying Dong receives funding from Mitacs and OCE.
</span></em></p>The digitization of health care in Canada has been a bumpy ride — due to lack of focus on governance, and lack of emphasis on interoperability, transparency and accountability.Linying Dong, Associate Professor, Toronto Metropolitan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/961702018-05-14T21:57:50Z2018-05-14T21:57:50ZHow to solve Canada’s wait time problem<figure><img src="https://images.theconversation.com/files/218635/original/file-20180511-34027-1r1tz5n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Nearly every Canadian family has a wait time story. This is because our system is not designed to provide optimal care for patients with multiple chronic diseases. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Canadians are <a href="https://www.theglobeandmail.com/opinion/article-bc-where-access-to-a-wait-list-is-considered-access-to-health-care/">fed up with long wait times</a> for <a href="http://www.cbc.ca/news/health/hip-knee-replacement-wait-times-1.4615531">health-care services</a>. </p>
<p>A new <a href="http://waittimes.cihi.ca">analysis from the Canadian Institute for Health Information (CIHI)</a> shows wait times for hip and knee replacements and also cataract surgeries have increased across Canada since 2015.</p>
<p>But we love our health care system. In particular, we take pride in the principle that care should be provided on the basis of need, rather than ability to pay. </p>
<p>Our system and its virtues have become part of our collective identity. We even named Tommy Douglas, the architect of medicare, “<a href="http://www.cbc.ca/archives/entry/and-the-greatest-canadian-of-all-time-is">The Greatest Canadian of all time</a>.” </p>
<p>Are long wait times simply the price we must pay in order to uphold our Canadian values of equity and fairness?</p>
<p>As a doctor of medicine and professor who has spent a career in health policy and advocacy, I disagree. Our health system — designed in the 1960s — is in dire need of an overhaul. Canadians and their health needs have changed, but the system hasn’t changed with them. Wait times are not the core problem. They are a <em>symptom</em> of the problem. </p>
<p>And, like every doctor, I would rather cure the problem than just treat the symptoms.</p>
<h2>A nation of perpetual pilot projects</h2>
<p>It can be difficult to challenge the status quo, particularly when the health system has become so iconic. </p>
<p>Critics argue, however, that our “system” is not really a system at all — our public investment is largely confined to doctors and hospitals while home and community care, drugs, rehabilitation, long term care, dentistry and many other important health services are paid for from a mixed bag of public, private and out-of-pocket sources. </p>
<p>Our federated model has created provincial and territorial silos, and our attempts at integration and reform have largely fallen flat. Monique Bégin famously said that we are a <a href="http://www.cmaj.ca/content/180/12/1185">country of perpetual pilot projects</a>, lamenting our inability to scale-up and spread new ways of doing things. </p>
<p>The highly respected Commonwealth Fund has consistently <a href="http://www.commonwealthfund.org/publications/fund-reports/2017/may/international-profiles">ranked our system either ninth or 10th out of 11 peer countries</a> for many years now. </p>
<p>On one issue in particular — wait times — we rank dead last.</p>
<h2>The ‘wait time problem’</h2>
<p>Nearly every Canadian family has a wait-time story. We wait in emergency departments. We wait to see family physicians. We wait for tests, procedures and surgeries. We wait to see specialists. We even wait to get <em>out</em> of hospital — an increasing number of Canadian seniors find themselves in acute care hospital beds not because they are sick, but because they cannot live independently and have nowhere else to go.</p>
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<img alt="" src="https://images.theconversation.com/files/218903/original/file-20180514-100722-m2s73x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/218903/original/file-20180514-100722-m2s73x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/218903/original/file-20180514-100722-m2s73x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/218903/original/file-20180514-100722-m2s73x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/218903/original/file-20180514-100722-m2s73x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/218903/original/file-20180514-100722-m2s73x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/218903/original/file-20180514-100722-m2s73x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A ‘national seniors’ strategy’ could help fix the system to reduce wait times.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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</figure>
<p>Successive provincial, territorial and federal governments have all acknowledged and addressed the wait-time problem. In 2004, Prime Minister Paul Martin announced a 10-year health accord with the provinces, touting it as the <a href="http://policyoptions.irpp.org/magazines/the-2004-federal-election/a-fix-for-a-generation/">fix for a generation</a>. </p>
<p><a href="http://www.waittimealliance.ca/">The Wait Time Alliance (WTA)</a>, a national federation of medical specialty societies and the Canadian Medical Association, developed a <a href="http://www.waittimealliance.ca/benchmarks/">list of evidence-based wait-time benchmarks</a> for nearly 1,000 health services so that progress could be measured. </p>
<p>A total of <a href="https://www.theglobeandmail.com/opinion/editorials/a-retrospective-on-the-fix-for-a-generation/article4096807/">$41.3 billion was spent by the federal government over 10 years</a>, including $5.5 billion to specifically address wait times in five key areas: Cancer, cardiac, sight restoration, medical imaging (CT and MRIs) and joint replacement.</p>
<p>Some provinces, notably Ontario, saw improvement. Annual report cards from the WTA and Canadian Institutes for Health Information (CIHI) showed modest improvements across the country. </p>
<h2>A landscape of chronic disease</h2>
<p>But now were are seeing slippage. Performance on wait times is <a href="https://www.cihi.ca/en/wait-times-for-priority-procedures-in-canada-2017">holding steady at best</a>. It’s increasingly clear that all this money bought us time, but did not fix the problem.</p>
<p>And no wonder. Because the problem is not a lack of investment. Canada has the fifth most expensive health-care system in the world. <a href="https://www.cihi.ca/en/health-spending">In 2017, we spent around 11.5 per cent of our GDP on health care</a>. </p>
<p>Spending more is not the solution. Spending smarter is.</p>
<p>The underlying problem is the system itself (or, rather, the lack of a system). The hodgepodge of bureaucracies, budgets, facilities and providers that collectively carry out the business of health care in this country are more disconnected than ever before. </p>
<p>At the same time, patients’ health-care experiences are changing. No longer is the health-care landscape dominated by acute illness — where you get sick, you get treated and then you get better. </p>
<p>Increasingly, the landscape is dominated by chronic disease. In fact, most patients with chronic disease actually have <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60240-2/fulltext"><em>multiple</em> chronic diseases</a>. </p>
<h2>How to fix the system</h2>
<p>Our system is not designed to provide optimal care for these patients and, as a result, everything slows down. Patients with complex needs who are not really acutely ill wind up in emergency departments and hospitals. </p>
<p>Emergency departments and hospitals, in turn, experience overcrowding and can’t do what they are designed to do. Surgeries and procedures get cancelled, wait times increase and everyone gets delayed care.</p>
<p>Fixing the <em>system</em> is the only way we will ever get wait times to come down. History has shown that spending more money doing the same things over and over does not work. </p>
<p>A great place to start would be to develop and implement a <a href="https://www.demandaplan.ca/">national seniors’ strategy</a>. Such a strategy would acknowledge that the new health-care landscape is one of multiple chronic diseases driven by our aging population. It would work to develop a properly integrated, transdisciplinary model of care in the community. </p>
<p>Doing so would free up hospitals to do what they are supposed to be doing — looking after acutely ill people and performing procedures and surgeries. Budgets that align with patient trajectories, wherever they are in the system, rather than with institutions or programs, will allow smarter, more efficient spending. </p>
<p>And building in incentives for better patient outcomes, shorter waits and enhanced satisfaction will help realign our primary accountability — to the patients we serve rather than to the institutions where we work.</p><img src="https://counter.theconversation.com/content/96170/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chris Simpson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>To improve wait times for surgery, Canada needs to fix its health-care system. Developing a national seniors’ strategy would be a good place to start.Chris Simpson, Acting Dean, Faculty of Health Sciences, Queen's University, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/826742017-09-24T23:12:55Z2017-09-24T23:12:55ZHow healthy is the Canadian health-care system?<figure><img src="https://images.theconversation.com/files/183665/original/file-20170828-1612-bhj9um.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Our rapidly aging society will place even greater pressure on the already expensive and mediocre Canadian health-care system.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p><em>This article is part of our global series about health systems, examining different health care systems all over the world. Read the other articles in the series <a href="https://theconversation.com/au/topics/global-health-systems-series-43434">here</a>.</em></p>
<p>Canada’s health-care system is a point of Canadian pride. We hold it up as a defining national characteristic and an example of what makes us different from Americans. The system has been supported in its current form, more or less, by parties of all political stripes — for nearly 50 years.</p>
<p>Our team at the Queen’s University School of Policy Studies <em>Health Policy Council</em> is a team of seasoned and accomplished health-care leaders in health economics, clinical practice, education, research and health policy. We study, teach and comment on <a href="http://www.queensu.ca/connect/policyblog/">health policy</a> and the health-care system from multiple perspectives.</p>
<p>While highly regarded, Canada’s health-care system is expensive and faces several challenges. These challenges will only be exacerbated by the changing health landscape in an aging society. Strong leadership is needed to propel the system forward into a sustainable health future. </p>
<h2>A national health insurance model</h2>
<p>The roots of Canada’s system lie in Saskatchewan, when then-premier Tommy Douglas’s left-leaning Co-operative Commonwealth Federation (CCF) government first established a <a href="https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/health-care-system/canada.html">provincial health insurance program</a>. This covered universal hospital (in 1947) and then doctors’ costs (in 1962). The costs were shared 50/50 with the federal government for hospitals beginning in 1957 and for doctors in 1968. </p>
<p>This new model inspired fierce opposition from physicians and insurance groups but proved extremely popular with the people of Saskatchewan and elsewhere. Throughout the 1960s, successive provincial and territorial governments adopted the “Saskatchewan model” and in 1972 the Yukon Territory was the last sub-national jurisdiction to adopt it. </p>
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<p><em><strong>Read this article in French: <a href="https://theconversation.com/systeme-de-sante-canadien-un-bilan-en-demi-teinte-83899">Système de santé canadien : un bilan en demi-teinte</a></strong></em></p>
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<p>In 1968, the National Medical Care Insurance Act was implemented, in which the federal government agreed to contribute 50 per cent toward the cost of provincial insurance plans. In 1984 the <a href="https://lop.parl.ca/content/lop/researchpublications/944-e.htm#chistoricaltxt">Canada Health Act</a> outlawed the direct billing of patients supplementary to insurance payments to physicians.</p>
<p>The <a href="https://www.med.uottawa.ca/sim/data/Canada_Health_Act.htm">five core principles</a> of the Canadian system were now established: universality (all citizens are covered), comprehensiveness (all medically essential hospital and doctors’ services), portability (among all provinces and territories), public administration (of publicly funded insurance) and accessibility. </p>
<p>For the last 50 years, Canada’s health-care system has remained essentially unchanged despite numerous pressures.</p>
<h2>Long wait times</h2>
<p>The quality of the Canadian health-care system has been called into question, however, for several consecutive years now by the U.S.-based <a href="http://www.commonwealthfund.org">Commonwealth Fund</a>. This is a highly respected, non-partisan organization that annually ranks the health-care systems of 11 nations. Canada has finished either ninth or 10th now for several years running. </p>
<p>One challenge for Canadian health care is access. Most Canadians have timely access to world-class care for urgent and emergent problems like heart attacks, strokes and cancer care. But for many less urgent problems they typically wait as long as many months or even years. </p>
<p>Patients who require hip or knee replacements, shoulder or ankle surgery, cataract surgery or a visit with a specialist for a consultation often wait <a href="http://www.waittimealliance.ca">far longer than is recommended</a>. Many seniors who are not acutely ill also wait in hospitals for assignment to a long-term care facility, for months and, on occasion, years. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/184382/original/file-20170901-27291-139epe4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/184382/original/file-20170901-27291-139epe4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=415&fit=crop&dpr=1 600w, https://images.theconversation.com/files/184382/original/file-20170901-27291-139epe4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=415&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/184382/original/file-20170901-27291-139epe4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=415&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/184382/original/file-20170901-27291-139epe4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=521&fit=crop&dpr=1 754w, https://images.theconversation.com/files/184382/original/file-20170901-27291-139epe4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=521&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/184382/original/file-20170901-27291-139epe4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=521&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Canada ranks 9th out of 11 countries in The Commonwealth Fund ‘Mirror, Mirror 2017’ report.</span>
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</figure>
<p>And it’s not just accessibility that is the problem. Against measures of effectiveness, safety, coordination, equity, efficiency and patient-centredness, the Canadian system is ranked by the Commonwealth Fund as <a href="http://www.commonwealthfund.org/publications/fund-reports/2017/jul/mirror-mirror-international-comparisons-2017">mediocre at best</a>. We have an expensive system of health care that is clearly under-performing.</p>
<h2>A landscape of chronic disease</h2>
<p>How is it that Canada has gone from a world leader to a middle- (or maybe even a bottom-) of-the-pack performer? </p>
<p>Canada and Canadians have changed, but our health-care system has not adapted. In the 1960s, health-care needs were largely for the treatment of acute disease and injuries. The hospital and doctor model was well-suited to this reality. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/183666/original/file-20170828-1542-1elm9qe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/183666/original/file-20170828-1542-1elm9qe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/183666/original/file-20170828-1542-1elm9qe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/183666/original/file-20170828-1542-1elm9qe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/183666/original/file-20170828-1542-1elm9qe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/183666/original/file-20170828-1542-1elm9qe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/183666/original/file-20170828-1542-1elm9qe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Medical care offered in homes can be more efficient and comfortable than hospital visits.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>Today, however, the health-care landscape is increasingly one of chronic disease. Diabetes, dementia, heart failure, chronic lung disease and other chronic conditions characterize the health-care profiles of many Canadian seniors.</p>
<p>Hospitals are still needed, to be sure. But increasingly, the population needs community-based solutions. We need to “de-hospitalize” the system to some degree so that we can offer care to Canadians in homes or community venues. Expensive hospitals are no place for seniors with chronic diseases.</p>
<p>Another major challenge for Canadian health care is the narrow scope of services covered by provincial insurance plans. “Comprehensiveness” of coverage, in fact, applies only to physician and hospital services. For many other important services, including dental care, out-of-hospital pharmaceuticals, long-term care, physiotherapy, some homecare services and many others, coverage is provided by a mixture of private and public insurance and out-of-pocket payments beyond the reach of many low-income Canadians. </p>
<p>And this is to say nothing of the <a href="https://www.cma.ca/En/Pages/health-equity.aspx">social determinants of health</a>, like nutrition security, housing and income. None of these have ever been considered a part of the health-care “system,” even though they are just as important to Canadians’ health as doctors and hospital services are.</p>
<h2>Aging population, increasing costs</h2>
<p>Canada’s health-care system is subject to numerous pressures. </p>
<p>First of all, successive federal governments have been effectively reducing their cash contributions since the late 1970s when tax points were transferred to the provinces and territories. Many worry that if the federal share continues to decline as projected, it will become increasingly difficult to achieve national standards. The federal government may also lose the moral authority to enforce the Canada Health Act.</p>
<p>A second challenge has been the increasing cost of universal hospital insurance. As economic growth has waxed and waned over time, governments have increased their health budgets at different rates. In 2016, total spending on health amounted to approximately <a href="https://www.cihi.ca/en/nhex2016-topic1">11.1 per cent</a> of the GDP (gross domestic product); in 1975, it was about <a href="http://evidencenetwork.ca/costs-and-spending/costs1">7 per cent</a> of GDP. </p>
<p>Overall, total spending on health care in Canada <a href="http://worthwhile.typepad.com/.a/6a00d83451688169e201b7c6fd426b970b-pi">now amounts to</a> over $6,000 (US$4,790) per citizen. Compared to comparably developed countries, Canada’s health-care system is definitely <a href="https://blogs.wsj.com/economics/2013/07/23/u-s-health-spending-one-of-these-things-not-like-others/">on the expensive side</a>. </p>
<p>Canada’s aging population will apply additional pressure to the health-care system over the next few years as the Baby Boom generation enters their senior years. In 2014, for the first time in our history, there were <a href="http://www.statcan.gc.ca/daily-quotidien/150929/cg150929b004-eng.png">more seniors than children</a> in Canada.</p>
<p>The fact that more Canadians are living longer and healthier than ever before is surely a towering achievement for our society, but it presents some economic challenges. On average, <a href="http://www.andrewweavermla.ca/wp-content/uploads/2015/01/HealthSpend.jpg">it costs more</a> to provide health care for older people. </p>
<p>In addition, some provinces (the Atlantic provinces, Quebec and British Columbia in particular) are <a href="http://www.statcan.gc.ca/daily-quotidien/150929/cg150929b004-eng.png">aging faster</a> than the others. This means that these provinces, some of which face the prospects of very modest economic growth, will be even more challenged to keep up with increasing health costs in the coming years.</p>
<h2>Actions we can take now</h2>
<p>The failure of our system to adapt to Canadians’ changing needs has left us with a very expensive health-care system that delivers mediocre results. Canadians should have a health-care system that is truly worthy of their confidence and trust. There are four clear steps that could be taken to achieve this:</p>
<h2><em>1. Integration and innovation</em></h2>
<p>Health-care stakeholders in Canada still function in silos. Hospitals, primary care, social care, home care and long-term care all function as entities unto themselves. There is poor information sharing and a general failure to serve common patients in a coordinated way. Ensuring that the patient is at the centre — regardless of where or by whom they are being served — will lead to better, safer, more effective and less expensive care. Investments in information systems will be key to the success of these efforts.</p>
<h2><em>2. Enhanced accountability</em></h2>
<p>Those who serve Canadians for their health-care needs need to transition to accountability models focused on outcomes rather than outputs. Quality and effectiveness should be rewarded rather than the amount of service provided. Alignment of professional, patient and system goals ensures that everyone is pulling their oars in the same direction.</p>
<h2><em>3. Broaden the definition of comprehensiveness</em></h2>
<p>We know many factors influence the health of Canadians in addition to doctors’ care and hospitals. So why does our “universal” health-care system limit its coverage to doctors’ and hospital services? A plan that seeks health equity would distribute its public investment across a broader range of services. A push for universal pharmacare, for example, is currently under way in Canada. Better integration of health and social services would also serve to address more effectively the social determinants of health.</p>
<h2><em>4. Bold leadership</em></h2>
<p>Bold leadership from both government and the health sector is essential to bridge the gaps and break down the barriers that have entrenched the status quo. Canadians need to accept that seeking improvements and change does not mean sacrificing the noble ideals on which our system was founded. On the contrary, we must change to honour and maintain those ideals. Our leaders should not be afraid to set aspirational goals.</p><img src="https://counter.theconversation.com/content/82674/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chris Simpson is a past president of the Canadian Medical Association and has served as their spokesperson on numerous health policy issues. He is also a member of the National Speakers' Bureau and speaks on health policy issues at meetings of NGOs, associations, societies, universities, and other organizations.</span></em></p><p class="fine-print"><em><span>David M.C. Walker, Don Drummond, Duncan Sinclair, and Ruth Wilson do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Bold leadership is needed to adapt Canada’s expensive and mediocre health-care system for an aging population struggling with chronic disease.Chris Simpson, Professor of Medicine and Vice-Dean (Clinical), School of Medicine, Queen's University, OntarioDavid M.C. Walker, Stauffer-Dunning Chair and Executive Director, Queen's School of Policy Studies, Queen's University, OntarioDon Drummond, Stauffer-Dunning Fellow in Global Public Policy and Adjunct Professor at the School of Policy Studies, Queen's University, OntarioDuncan Sinclair, Professor of Health Services and Policy Research, Queen's University, OntarioRuth Wilson, Professor of Family Medicine, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.