Sunday, November 24, 2002
Why Roy Romanow is part of the problem, not the solution
By Brian Lee Crowley
Roy Romanow, the head of the federal commission into the future of health care, has assiduously prepared the public for what his forthcoming report will recommend. That’s a pity, because what he’s made clear is that he has no intention of even acknowledging the fundamental conflict of interest that is at the root of the system’s difficulties.
The problem’s not money; indeed more money will put off real reform to another day, at a great cost in poor quality care, frustrated consumers, loss of personnel and angry voters.
The private sector is subject to government regulation where competition alone may not be sufficient to guarantee high quality goods and services, or where consumers may lack the knowledge to make informed choices.
For example, governments regulate many aspects of the production, quality and safety of food. They set minimum standards on hygiene, freshness and quality of raw materials, working conditions, use of therapeutic agents, pesticides and more. They require manufacturers to disclose ingredients, best-before dates and, in some cases, when the products were packaged.
But when the government regulates itself and its provision of health care services, the picture is radically different. Government health authorities, for instance, don’t even set official standards for appropriate waiting times. No one knows how long the health care system thinks people should wait for particular treatments, so no one can be held accountable for failing to meet the standard.
Governments’ conflict of interest as both the insurers and providers of health care is best summed up by the different ways in which the provinces regulate private providers of other kinds of insurance (auto, life, home) and the way that they regulate themselves as the monopoly provider of health insurance. The provinces would never permit a private sector insurer to behave in the cavalier way that they themselves behave as insurers of our health.
Is our system a monopoly? Of course. Provincial governments not only pay for necessary care, but also govern, administer and evaluate the services they themselves provide. They define what constitutes “medically necessary services,” pay for virtually all of them, and forbid private insurance for these services. They negotiate payment schedules with the powerful provider groups. They often set the budgets for nominally private health care institutions, appoint many of their board members, and have the explicit or implicit power to override management decisions.
In health care, like any enterprise, a constant flow of information is needed to determine whether the organization’s goals are being met. Only then can the people administering the organization be held accountable. Successes can be rewarded, failures overcome, and health care consumers and citizens can make informed personal and political choices.
Like other forms of monopoly, however, the Canadian health-care system cuts itself off from vital information, such as who waited too long for care, and who got better, who got worse, and who was left unaffected by their contacts with the health system. This is because useful information about our health care system’s performance will be used to assess the performance of those responsible for the system, so it is not in their interests to collect it. They are in a conflict of interest.
It’s also because, in a competitive environment, consumers “vote with their feet.” Over the years, they have preferred calculators to slide rules, natural gas and oil to coal, and faxes and e-mail to “snail mail,” even though in most cases the old dominant industry was powerful, rich, and well-connected.
But in a monopoly, even a regulated one, the relative power of consumers and suppliers is reversed. Before the advent of competition in the telephone industry, dissatisfied customers faced the massive indifference of a bureaucracy that literally could take their business for granted.
Administrators of our health-care system likewise suffer no direct consequences from poor customer service. They aren’t even answerable to a demanding regulatory agency, other than the vague federal power to withhold funding for violations of the equally vague principles of the Canada Health Act. Other than notoriously ineffective channels of complaints to politicians, letters to the editor, and calls to open-line shows, dissatisfied consumers have little power to influence the system.
This translates into excessive waiting times, error tolerance, and the growing use of health services outside “official” channels. Roy Romanow thinks this unresponsive monopoly is just fine and only needs more money – a lot more. That’s why he’s part of the problem, not the solution.
Brian Lee Crowley is the President of the Atlantic Institute for Market Studies, a public policy think tank based in Halifax; and co-author of the forthcoming Definitely Not the Romanow Report: Achieving Equity, Sustainability, Accountability and Consumer Empowerment in Canadian Health Care. firstname.lastname@example.org.