What can YOU do about health care costs? What can a physician do about controlling health care costs? This is a question that is being vigorously debated today and will likely be even more vigorously debated tomorrow. There are many aspects to the queslion - for instance, do physicians really generate health costs or do they merely respond to the need of their patients? This aspect has been examined in detail in an article by CMAJ staff member Claire Lalonde in this section. Are patients overmedicated?
According to one of the most authorative views available, that of Dr. Ian Henderson, Canadians as a whole may actually be undermedicated. Are health costs really climbing to an unpredictable and unsupportable level? According to Dr. Marc Baltzan, they are not. And we have articles discussing the optimal use of hospital beds and laboratory facilities by Drs. Ian Tough, J.R. Hoey, W.O. Spitzer and Stanley Sinclair. A major contribution to this debate
is a look at cost control mechanisms by economist Dr. CJ. Hindle. What do the men think who have the fiscal end of the responsibility for providing health care to Canadians? CMAJ has asked Canadian Health Minister Marc Lalonde to give his views on what might be done to reduce health costs. And, representing the provinces, we have British Columbia Health Minister Robert McClelland. This special medical economics report begins with Mr Lalonde ...
The physician and health promotion MARC LALONDE During the past quarter century in
Canada, the federal government has developed health policies directed toward two basic goals: first, individual development and wellbeing; second, accessibility to high quality health care. Motivated by a real sense of urgency, governments at all levels have pursued these two goals in developing a commendable patient-care system. As a result, Canada's public health insurance schemes today virtually assure the Canadian people of accessibility to quality health care regardless of financial means. However, despite the injection of immense resources and the almost universal availability of modern, sophisticated forms of therapy, ill-health "thrives" amongst the Canadian population. A decrease in the incidence of some communicable diseases has been accompanied by increases in such illnesses as cardiovascular disease and cancer. Many health professionals recognize that accidents and suicides, together with cardiovascular disease, lung canThe spinoff into health costs cer and other respiratory diseases, are largely the product of a faulty lifestyle - one often associated with the abuse for a new emphasis and a redirection of addicting drugs like alcohol and of our talents and energies. tobacco. Indeed the four causes I menAs research shows, the failure to tion account for about 60% of pre- wear seatbelts, excessive speed and the mature mortality in Canada. Thus it is abuse of alcohol all contribute to the imperative that we recognize a need incidence and seriousness of motor ye1040 CMA JOURNAL/MAY 7, 1977/VOL. 116
hide accidents, just as lack of physical exercise, heavy smoking or an inappropriate diet contribute to the incidence of heart disease. Similarly, excessive drinking, negligence in the home and on the job, tension and possibly chemical additives to food and the plethora of therapeutic drugs currently used in medicine all contribute to a continuing state of il[health in the community. An increase in numbers of physicians and hospital beds, or increased accessibility to these kinds of services, will do little to alleviate these conditions. There is no simple administrative decision that will correct this situation, for our personal lifestyles are vitally integrated into our social and physical environment. Those of you in the front lines of the health field already recognize the inherent difficulties of trying to change social systems or environments beyond our direct control. Governments too recognize this difficulty and rely on information and discussion rather than coercion or manipulation to bring about change. The conclusion seems clear enough. We must collaborate with those in other professions and occupations, so that we might honestly design a coordinated strategy for change, based on the widest possible consent of the Canadian people. Perhaps the most effective strategy we can follow is one that may be re-
ferred to as health promotion - a the work place has been limited by lifestyle of people around him. process aimed at fostering awareness inadequate resources and commitment. There is another way, too, in which and influencing attitudes, both of the Despite some few innovative programs, doctors can influence behaviour change individual and society at large, toward Canada needs a greater cooperative amongst Canadian people. Through achieving and maintaining optimum effort and better strategy in promotion professional associations, they may press for or against governmental aclevels of health and social wellbeing. of better health. Many Canadian doctors have func- tivities with a health component. At The federal government's intention to emphasize health promotion was sig- tioned as health promoters in a posi- all government levels, the professional nalled in the working document "A tive and rewarding way. To develop associations can participate in such New Perspective on the Health of a cliche, they have been not only add- issues as fluoridation or accident preCanadians", where two major goals ing years to the life of their patients, vention. The doctor, through his prowere defined as improvement of the but as well, life to the years of their fessional organization, has a legitimate right, and perhaps responsibility, to social and physical environment and patients. The doctor meets the patient one-to- influence policies he cannot directly modification of certain living habits that influence levels of health and one where the patient is seeking advice. control, but does care about. Doctors, individually and as a group, This is the teachable moment. It refitness. presents a prime opportunity to make have already made a significant conHealth promotion, then, is delivered by many. It is predicated on the fact the patient more aware of how his or tribution to the prevention of ill-health that informed individuals, aware of her lifestyle contributes to a particular amongst Canadian people. However, the consequences of their actions, may illness. The doctor may go a step the health challenges of tomorrow refurther by practising what he teaches quire concerted action from many initiate social change. - his very appearance, for example, parties and many perspectives. While While many organizations and in- with local fitness groups may do more governments address themselves to the dividuals may be involved in this pro- than a myriad of lectures and prescrip- political, social and economic forces cess, I would like here to focus on the tions. which influence the health of the namedical profession, not only because Similarly, doctors might make great- tion, I hope the network of health of its eminent position in delivery of er use of literature available from professionals will renew its vital role health care, but especially because of agencies and governments throughout in health promotion. the changing social environment in the country. Simply putting teaching All of us recognize the ramifications Canada today. The traditional health kits and informational materials in their of unemployment, poor housing, inapromotional role of the family and the offices, along with the usual array of dequate nutrition and pollution, as they community has been weakened by magazines, would add an educative affect the physical and mental wellfamily breakdown and the mobility of dimension to their practitioner role. being of the Canadian population. The today's nuclear family. Urbanization Most governments have a group of interrelated nature of all these proband isolation predispose toward phy- health education specialists only a lems means that we need an integrated sical and mental illness. One result is phone call away. Doctors can also con- approach in our health policies of the that now, more than ever, the medical tribute personally to a healthier en- future - a committed approach which practitioner has responsibility to treat vironment - just by attempting health will support the activities of those more than just illness or injury; he or hazard appraisals they might curtail concerned about healthier lifestyles and she must deal with the whole person. the potential for accidents, not to men- environments. Through real dialogue This is not to suggest that health tion the spinoff into health care costs. we can act, so that individuals, families promotion has been absent from medThe doctor as well has a prominent and groups of people in this country ical practice in recent years. There is position as a citizen. He can bring his will have the opportunity to develop in fact a long tradition of health pro- expertise into the streets. He should their potential, to improve their health motion in the philosophy of western not feel restricted to committees and status and to enjoy a real choice in medicine, although it has existed large- boards of health; his knowledge and the pursuit of better health. ly within the framework of health experience should be shared through As Victor Fuchs concludes in his education or "prevention before cost". talk-shows, round-table discussions and book "Who Shall Live", "by changing Unfortunately, the results of these ac- citizens' action groups. By lending his institutions and creating new programs, tivities, as demonstrated by the high support to voluntary agencies - safety we can make medical care more acceslevels of noncompliance by patients, societies, recreational groups or parent- sible and deliver it more efficiently; have been, for the most part, rather teacher associations - the doctor takes but the greatest potential for improvpoor. Part of the problem may be that health education out of the office and ing health lies in what we do and don't active health promotion in hospital set- makes the lessons an expression of his do, for and to ourselves. The choice is tings or doctors' offices, schools or in lifestyle, consequently affecting the ours."
A provincial government point of view R.H. MCCLELLAND
One important area in which physicians can help control cost of health care is laboratory tests. I think we must accept that some laboratory investigations are not useful to the outcome of a patient's problem. Often, the physician seems unaware of the exact cost/benefit Mr. McClclland is minister of health in the government of British Columbia.
ratio when some investigations are undertaken. I suspect that investigations are sometimes ordered because of a physician's curiosity or academic interest. Yet the results play no role in making decisions to solve the patient's problem, let alone cure his illness. In some cases, the tests are ordered because of physician insecurity
- which is being accentuated by the increasing threat of malpractice litigation. One way to control this expenditure is to have handwritten laboratory requisitions, as preprinted forms often make it easier to order unnecessary laboratory investigations, again without concern about cost. If preprinted re-
CMA JOURNAL/MAY 7, 1977/VOL. 116 1045
According to one of the most authorative views available, that of Dr. Ian Henderson, Canadians as a whole may actually be undermedicated. Are health costs really climbing to an unpredictable and unsupportable level? According to Dr. Marc Baltzan, they are not. And we have articles discussing the optimal use of hospital beds and laboratory facilities by Drs. Ian Tough, J.R. Hoey, W.O. Spitzer and Stanley Sinclair. A major contribution to this debate
is a look at cost control mechanisms by economist Dr. CJ. Hindle. What do the men think who have the fiscal end of the responsibility for providing health care to Canadians? CMAJ has asked Canadian Health Minister Marc Lalonde to give his views on what might be done to reduce health costs. And, representing the provinces, we have British Columbia Health Minister Robert McClelland. This special medical economics report begins with Mr Lalonde ...
The physician and health promotion MARC LALONDE During the past quarter century in
Canada, the federal government has developed health policies directed toward two basic goals: first, individual development and wellbeing; second, accessibility to high quality health care. Motivated by a real sense of urgency, governments at all levels have pursued these two goals in developing a commendable patient-care system. As a result, Canada's public health insurance schemes today virtually assure the Canadian people of accessibility to quality health care regardless of financial means. However, despite the injection of immense resources and the almost universal availability of modern, sophisticated forms of therapy, ill-health "thrives" amongst the Canadian population. A decrease in the incidence of some communicable diseases has been accompanied by increases in such illnesses as cardiovascular disease and cancer. Many health professionals recognize that accidents and suicides, together with cardiovascular disease, lung canThe spinoff into health costs cer and other respiratory diseases, are largely the product of a faulty lifestyle - one often associated with the abuse for a new emphasis and a redirection of addicting drugs like alcohol and of our talents and energies. tobacco. Indeed the four causes I menAs research shows, the failure to tion account for about 60% of pre- wear seatbelts, excessive speed and the mature mortality in Canada. Thus it is abuse of alcohol all contribute to the imperative that we recognize a need incidence and seriousness of motor ye1040 CMA JOURNAL/MAY 7, 1977/VOL. 116
hide accidents, just as lack of physical exercise, heavy smoking or an inappropriate diet contribute to the incidence of heart disease. Similarly, excessive drinking, negligence in the home and on the job, tension and possibly chemical additives to food and the plethora of therapeutic drugs currently used in medicine all contribute to a continuing state of il[health in the community. An increase in numbers of physicians and hospital beds, or increased accessibility to these kinds of services, will do little to alleviate these conditions. There is no simple administrative decision that will correct this situation, for our personal lifestyles are vitally integrated into our social and physical environment. Those of you in the front lines of the health field already recognize the inherent difficulties of trying to change social systems or environments beyond our direct control. Governments too recognize this difficulty and rely on information and discussion rather than coercion or manipulation to bring about change. The conclusion seems clear enough. We must collaborate with those in other professions and occupations, so that we might honestly design a coordinated strategy for change, based on the widest possible consent of the Canadian people. Perhaps the most effective strategy we can follow is one that may be re-
ferred to as health promotion - a the work place has been limited by lifestyle of people around him. process aimed at fostering awareness inadequate resources and commitment. There is another way, too, in which and influencing attitudes, both of the Despite some few innovative programs, doctors can influence behaviour change individual and society at large, toward Canada needs a greater cooperative amongst Canadian people. Through achieving and maintaining optimum effort and better strategy in promotion professional associations, they may press for or against governmental aclevels of health and social wellbeing. of better health. Many Canadian doctors have func- tivities with a health component. At The federal government's intention to emphasize health promotion was sig- tioned as health promoters in a posi- all government levels, the professional nalled in the working document "A tive and rewarding way. To develop associations can participate in such New Perspective on the Health of a cliche, they have been not only add- issues as fluoridation or accident preCanadians", where two major goals ing years to the life of their patients, vention. The doctor, through his prowere defined as improvement of the but as well, life to the years of their fessional organization, has a legitimate right, and perhaps responsibility, to social and physical environment and patients. The doctor meets the patient one-to- influence policies he cannot directly modification of certain living habits that influence levels of health and one where the patient is seeking advice. control, but does care about. Doctors, individually and as a group, This is the teachable moment. It refitness. presents a prime opportunity to make have already made a significant conHealth promotion, then, is delivered by many. It is predicated on the fact the patient more aware of how his or tribution to the prevention of ill-health that informed individuals, aware of her lifestyle contributes to a particular amongst Canadian people. However, the consequences of their actions, may illness. The doctor may go a step the health challenges of tomorrow refurther by practising what he teaches quire concerted action from many initiate social change. - his very appearance, for example, parties and many perspectives. While While many organizations and in- with local fitness groups may do more governments address themselves to the dividuals may be involved in this pro- than a myriad of lectures and prescrip- political, social and economic forces cess, I would like here to focus on the tions. which influence the health of the namedical profession, not only because Similarly, doctors might make great- tion, I hope the network of health of its eminent position in delivery of er use of literature available from professionals will renew its vital role health care, but especially because of agencies and governments throughout in health promotion. the changing social environment in the country. Simply putting teaching All of us recognize the ramifications Canada today. The traditional health kits and informational materials in their of unemployment, poor housing, inapromotional role of the family and the offices, along with the usual array of dequate nutrition and pollution, as they community has been weakened by magazines, would add an educative affect the physical and mental wellfamily breakdown and the mobility of dimension to their practitioner role. being of the Canadian population. The today's nuclear family. Urbanization Most governments have a group of interrelated nature of all these proband isolation predispose toward phy- health education specialists only a lems means that we need an integrated sical and mental illness. One result is phone call away. Doctors can also con- approach in our health policies of the that now, more than ever, the medical tribute personally to a healthier en- future - a committed approach which practitioner has responsibility to treat vironment - just by attempting health will support the activities of those more than just illness or injury; he or hazard appraisals they might curtail concerned about healthier lifestyles and she must deal with the whole person. the potential for accidents, not to men- environments. Through real dialogue This is not to suggest that health tion the spinoff into health care costs. we can act, so that individuals, families promotion has been absent from medThe doctor as well has a prominent and groups of people in this country ical practice in recent years. There is position as a citizen. He can bring his will have the opportunity to develop in fact a long tradition of health pro- expertise into the streets. He should their potential, to improve their health motion in the philosophy of western not feel restricted to committees and status and to enjoy a real choice in medicine, although it has existed large- boards of health; his knowledge and the pursuit of better health. ly within the framework of health experience should be shared through As Victor Fuchs concludes in his education or "prevention before cost". talk-shows, round-table discussions and book "Who Shall Live", "by changing Unfortunately, the results of these ac- citizens' action groups. By lending his institutions and creating new programs, tivities, as demonstrated by the high support to voluntary agencies - safety we can make medical care more acceslevels of noncompliance by patients, societies, recreational groups or parent- sible and deliver it more efficiently; have been, for the most part, rather teacher associations - the doctor takes but the greatest potential for improvpoor. Part of the problem may be that health education out of the office and ing health lies in what we do and don't active health promotion in hospital set- makes the lessons an expression of his do, for and to ourselves. The choice is tings or doctors' offices, schools or in lifestyle, consequently affecting the ours."
A provincial government point of view R.H. MCCLELLAND
One important area in which physicians can help control cost of health care is laboratory tests. I think we must accept that some laboratory investigations are not useful to the outcome of a patient's problem. Often, the physician seems unaware of the exact cost/benefit Mr. McClclland is minister of health in the government of British Columbia.
ratio when some investigations are undertaken. I suspect that investigations are sometimes ordered because of a physician's curiosity or academic interest. Yet the results play no role in making decisions to solve the patient's problem, let alone cure his illness. In some cases, the tests are ordered because of physician insecurity
- which is being accentuated by the increasing threat of malpractice litigation. One way to control this expenditure is to have handwritten laboratory requisitions, as preprinted forms often make it easier to order unnecessary laboratory investigations, again without concern about cost. If preprinted re-
CMA JOURNAL/MAY 7, 1977/VOL. 116 1045
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