¦¦
.'.,..:.:.'¦"
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Another positive step forward for community health By J.D. Wallace, MD It has for years been obvious that if we are to have any hope of controlling the rate at which health costs in Canada are
escalating,
we
must
wean
public
and health professionals away from the habit of using high-cost, active-treatment general hospitals as the primary point of contact with the health system. Except for major urgent health prob¬ lems, the primary contact for both pre¬ ventive and curative medicine should be community- rather than hospitalbased. Every effort should be made to keep the person who does not need a general hospital level of care out of the "golden bed" in the first place. In the past,. much of our time and effort has been spent in getting him out of it once he has gotten in through either convenience or necessity. The hospital habit of both citizen and health professional primarily has evolved through a the physician conveni¬ variety of circumstances .
.
overbuilding (or overbedding as they now call it), educational conditioning and, most of all, questionable plan¬ ning and control. Let's take the last one first, because it is the most signi¬ ence,
ficant. As a "what if"
question to put your on course what would have happened had the federal government in the mid-fifties reversed its priorities and brought into being universal medical care insurance 10 years before introducing hospital in¬ surance? That would, in effect, have told the public it would have been completely covered for professional preventive and treatment health serv¬ but the moment one were to ices climb into a "golden bed" it would have cost him or his private insurer X dollars a day until he climbed or was lifted out again. Surely that would have provided the public, and in turn its doctors, with an incentive to stay out in the first place if admission was not really necessary. thought
processes
978 CMA JOURNAL/NOVEMBER 22,
It
would,
as
feels it is unfairly being the villain by the poli¬ ticians and senior public servants that set up the bass-ackards arrangement in the first place. It's as though we, rather than they, had planned the scheme which is now back-firing financially. Ideologies and strong (but frag¬ mented) empires built up over the past 25 years have to be either modified by persuasion and regulation (the usual Canadian way) or torn down and rebuilt. The public and the health pro¬ fessionals that serve it must be reeducated or at least reoriented. The pres¬
well, have stemmed the fession
political pressure that resulted in the overbuilding of acute general hospitals in this country. The funds thus saved could well have provided incentives to develop the better community health service system we are now seeking under adverse circumstances. It would as well have stimulated nonprofit agencies, such as Blue Cross, besides private insurance companies, to come up with good, competitive, hospital in¬ surance programs that would un¬ doubtedly have been less costly than the national/ provincial governmentfinanced system we have developed. However, for whatever political reason, the government of the day did not select that priority. Instead, it in¬ troduced legislation and invoked regu¬ lations that said in effect to the public: "If you can get into an active-treatment hospital bed, we'll pay the shot, otherwise you're on your own." Not even the costs of outpatient services at the patient a hospital were included
now as
portrayed
ent
community-based, primary-contact
health-care agencies and facilities must be coordinated and supplemented where necessary. Financial and status incentives must be provided to com¬ munity-based health services and those who work in them. Our potential to achieve these ob¬ jectives was given a considerable boost last July. With little fanfare, two ma¬ jor health education and research facil¬ the health sciences centre and had to be admitted to get his or her ities the school of hygiene at the University insurance benefits. were merged. These had One does not have to be an econom- of Toronto for in relative isola¬ functioned years re¬ ist or sociologist to understand the tion one from the other. What used to action of the public and the doctors to that sort of an insurance program. be the school of hygiene is now the of community health, faculty The get-in-get-them-out habitual hos¬ division of medicine, University of Toronto. pitalization syndrome was off to a roar- From that organizational vantage point start. ing it can, if permitted to do so, have a The provincial medical associations direct, positive input into the under¬ found themselves in the position of graduate and graduate education pro¬ having to organize nonprofit medical grams of the medical school and other the PSIs, health professional faculties. care insurance programs that eventually MSIs and wotnot Traditional interprofessional barriers covered about 80% of the population are hard to break down. It is best to in most provinces. Their expertise be¬ prevent them from being built up in came the basis of federal/ provincial the first place. That can only be acmedicare 10 years later. complished by a better coordination of Having considered both alternatives the various education programs in our from which the government had to health sciences centres. This merger at choose, and remembering the positive U of T could do a lot in the right reaction by medical associations to se¬ direction if all concerned give it an at least that's lection of what proved to be the wrong opportunity to work and most costly one, the medical pro¬ the way I see it... ¦ 1975/VOL. 113 .
.'.,..:.:.'¦"
¦¦¦=¦'*
¦¦¦¦
.¦
Another positive step forward for community health By J.D. Wallace, MD It has for years been obvious that if we are to have any hope of controlling the rate at which health costs in Canada are
escalating,
we
must
wean
public
and health professionals away from the habit of using high-cost, active-treatment general hospitals as the primary point of contact with the health system. Except for major urgent health prob¬ lems, the primary contact for both pre¬ ventive and curative medicine should be community- rather than hospitalbased. Every effort should be made to keep the person who does not need a general hospital level of care out of the "golden bed" in the first place. In the past,. much of our time and effort has been spent in getting him out of it once he has gotten in through either convenience or necessity. The hospital habit of both citizen and health professional primarily has evolved through a the physician conveni¬ variety of circumstances .
.
overbuilding (or overbedding as they now call it), educational conditioning and, most of all, questionable plan¬ ning and control. Let's take the last one first, because it is the most signi¬ ence,
ficant. As a "what if"
question to put your on course what would have happened had the federal government in the mid-fifties reversed its priorities and brought into being universal medical care insurance 10 years before introducing hospital in¬ surance? That would, in effect, have told the public it would have been completely covered for professional preventive and treatment health serv¬ but the moment one were to ices climb into a "golden bed" it would have cost him or his private insurer X dollars a day until he climbed or was lifted out again. Surely that would have provided the public, and in turn its doctors, with an incentive to stay out in the first place if admission was not really necessary. thought
processes
978 CMA JOURNAL/NOVEMBER 22,
It
would,
as
feels it is unfairly being the villain by the poli¬ ticians and senior public servants that set up the bass-ackards arrangement in the first place. It's as though we, rather than they, had planned the scheme which is now back-firing financially. Ideologies and strong (but frag¬ mented) empires built up over the past 25 years have to be either modified by persuasion and regulation (the usual Canadian way) or torn down and rebuilt. The public and the health pro¬ fessionals that serve it must be reeducated or at least reoriented. The pres¬
well, have stemmed the fession
political pressure that resulted in the overbuilding of acute general hospitals in this country. The funds thus saved could well have provided incentives to develop the better community health service system we are now seeking under adverse circumstances. It would as well have stimulated nonprofit agencies, such as Blue Cross, besides private insurance companies, to come up with good, competitive, hospital in¬ surance programs that would un¬ doubtedly have been less costly than the national/ provincial governmentfinanced system we have developed. However, for whatever political reason, the government of the day did not select that priority. Instead, it in¬ troduced legislation and invoked regu¬ lations that said in effect to the public: "If you can get into an active-treatment hospital bed, we'll pay the shot, otherwise you're on your own." Not even the costs of outpatient services at the patient a hospital were included
now as
portrayed
ent
community-based, primary-contact
health-care agencies and facilities must be coordinated and supplemented where necessary. Financial and status incentives must be provided to com¬ munity-based health services and those who work in them. Our potential to achieve these ob¬ jectives was given a considerable boost last July. With little fanfare, two ma¬ jor health education and research facil¬ the health sciences centre and had to be admitted to get his or her ities the school of hygiene at the University insurance benefits. were merged. These had One does not have to be an econom- of Toronto for in relative isola¬ functioned years re¬ ist or sociologist to understand the tion one from the other. What used to action of the public and the doctors to that sort of an insurance program. be the school of hygiene is now the of community health, faculty The get-in-get-them-out habitual hos¬ division of medicine, University of Toronto. pitalization syndrome was off to a roar- From that organizational vantage point start. ing it can, if permitted to do so, have a The provincial medical associations direct, positive input into the under¬ found themselves in the position of graduate and graduate education pro¬ having to organize nonprofit medical grams of the medical school and other the PSIs, health professional faculties. care insurance programs that eventually MSIs and wotnot Traditional interprofessional barriers covered about 80% of the population are hard to break down. It is best to in most provinces. Their expertise be¬ prevent them from being built up in came the basis of federal/ provincial the first place. That can only be acmedicare 10 years later. complished by a better coordination of Having considered both alternatives the various education programs in our from which the government had to health sciences centres. This merger at choose, and remembering the positive U of T could do a lot in the right reaction by medical associations to se¬ direction if all concerned give it an at least that's lection of what proved to be the wrong opportunity to work and most costly one, the medical pro¬ the way I see it... ¦ 1975/VOL. 113 .
