Monday, October 3, 2011

A heath care experiment

Readers know that I live in Quebec -- land of socialized medicine, and that I hold relatively "right wing" market economic views.  Quebec (like all Canadian provinces) runs its own health care system, Quebec is one of the poorer states in the country, our size makes up for the average income -- we stand behind Ontario, British Columbia and Alberta, but just ahead of the Maritimes.  Yet our residents require the best health care system in the world -- but of course since private providers are prohibited by law from operating in the province (one of the most restrictive systems) it makes sense that if you prohibit the provision of private healthcare, that the government takes over this duty.

One problem has been the emergency room crowding, it is easy to wait 12 hours -- don't arrive at the emergency on a Saturday afternoon!!! However, emergencies have been expanded dramatically over the past 15 years, there has been a change in the way residents and interns deal with outpatient follow-up:  20 years ago it was "call me at home", now its "go to the emergency".  Moreover, hospital procedures have also changed.  When I was 17 I had an appendectomy -- mine was an emergency I was in and out of the hospital within a week (very fast).  I actually worked at the hospital where I had my operation -- its strange to be greeted by a nurse that until 24 hours ago was a work colleague (literally).  Moreover, that was my only experience of dealing with the emergency room:  

I waited at home all day -- feeling worse with increasing pain (and no appetite), around 5 pm I took a cab to the hospital, I was greeted by the admittance staff (I had worked at the emergency) who knew me well.  they asked me to walk in the back corridor where a young doctor looked at me (who also knew me) pressed his finger in my abdomen...20 seconds later I was on a stretcher, blood was drawn and medical history was taken by an intern.  By 8 pm I was on the table and had my appendix out, three days later I was out of the hospital, walking like a question mark.

I have always been a fan of "user fees" as a market method of discouraging "emergency room abusers", amazingly despite the long waiting time, some people will go to the emergency three or four times a week.  A regional hospital in the province decided to look at the problem of "serial abusers", and discovered startling facts, first they are young in their 50s, second the bulk have mental, respiratory cardiac problems or drug problems. These patients accounted for 25% of the emergency room walk-ins, but accounted for 75% of the emergency room resources.

In fact, all these patients have one aspect in common -- these were chronic illness problems.  So the hospital decided to "follow" these patient with a social worker and a doctor that would contact them and make sure that they medication and health was well followed -- total cost $100k per year, a drop int he bucket when you consider that an emergency room bed cost upwards of $500 per hour, and better care for the patients, who have reduced their visit to the emergency room to nothing.

Amazingly, this was not a "market solution"  these patient were not "abusing" the system but were really sick and required closer follow up (but much lower intensity).  Obviously, had these patient had a family doctor this would not have been a problem, but it is an elegant solution that meet these patients needs!  

This episode reminds me of how the U.S. is "not" dealing with its health care problem.  It is well established that the U.S. system is the world's most expensive, and yet produces poor outcome -- quality of life is poorer than in many countries that have cheaper systems.  American doctors operate more than any other doctors.  Not only is the system expensive a large percentage of the population is not covered, before the financial crisis something like 30 - 50 million were not covered.  It has to be worse today since 16% of the population in either unemployed or underemployed... and insurance costs are rising at double digit per year and have done so for a decade or more.  Yet the Americans are unable to look beyond the mantra of the "private sector solutions".  what was done here in Quebec is ground breaking it reduces wait time in emergencies for real problems, and provided adequate care to sufferers of chronic illnesses.

Read it here (in french)


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