The Cost of Caring for Canada’s Health Systems — Helen Angus and Kim McGrail

Alex Maheux

Hi, welcome to the CHIP, the Canadian Health Information Podcast. I’m your host, Alex Maheux. In this show from the Canadian Institute for Health Information, we will give you an in-depth look at Canada’s health systems and talk to patients and experts you can trust. Join me as I go beyond the data to find out more about the work being done to keep us all healthy. 

CIHI has released the very first pan-Canadian look at health spending during the COVID-19 pandemic. We’re anticipated to cross the $300 billion mark this year, a new record in health spending. To help us make more sense of how this is spent, how we might be able to spend better and what this actually means for the health of people in Canada, we have 2 special guests. We’ve got Kim McGrail, Associate Professor at UBC in the School of Population and Public Health and the Centre for Health Services and Policy Research, and Helen Angus, former Deputy Minister at the Ontario Ministry of Health, who led the health response to COVID-19. 

Kim, Helen, welcome to the CHIP.

Kim McGrail

Thank you.

Helen Angus

Thank you.

Alex Maheux

I have to say, I’m really excited to have you both here today. On this podcast, we’ve talked a lot about the impact of COVID-19, the burden it has had on our health and our well-being, but something we haven’t talked about as much is the strain that it has had on the economy and government budgets, which I’m hoping is something both of you could help enlighten us a little bit about. I know it’s been pretty difficult to plan for the long term when things have been changing at such a rapid pace with new demands coming up every day, if not every minute. 

Kim, I’ll start with you. You’re a professor, a researcher, scientific director. What are some of the biggest challenges you’ve faced during the pandemic, and has it changed the way you do or the way that you view your work?

Kim McGrail

Really interesting question. There were many challenges during the pandemic that did affect, just even as a starting point, not being able to be in the same place as colleagues and staff and students was clearly a really big challenge just to make sure that people felt supported, that we had ways of continuing communication and so on. I will say that the kind of research I do uses data, so we were able to carry on with that. But from a research perspective, it was also pretty clear that COVID was going to change the nature of the questions we need to ask. It shone a spotlight on a lot of things that were existing problems but perhaps became more — but certainly became more apparent, and that has to do with issues in long-term care, issues of equity and all of those other things that I think have become pretty common conversations. 

So, I think it does mean that we have an opportunity to think about how we come out of the pandemic and the policy choices that we want to make, and to address some of the things that we really probably needed to address before but weren’t so apparent to us prior to the pandemic.

Alex Maheux

Mm-hmm. Well, you’ve set the stage nicely for Helen. Helen, you lived this; you were the Deputy Minister of Health in Ontario at the beginning of the pandemic. First of all, I’m super curious, what was that actually like and how much of your mind was focused on solving the day’s problems versus the impact the pandemic was having on human lives?

Helen Angus

Well, I guess they’re almost one and the same. We were pretty busy at the Ministry of Health from the get-go. You know, we made it a reportable — COVID — a reportable disease in January of 2020, first case on January 25. And from then on, really, the ministry moved into a command structure to largely focus on the pandemic and making sure that we were supporting the important work on the front lines both in public health as well as in health services, hospitals, physicians, nurses, PSWs, long-term care and others. And it was pretty close to a 24/7 job for almost 20 months. 

So, I would say it turned our world pretty much almost upside down so that we were very, very focused on COVID. There were usual things in government that you have to do, like prepare budgets and show up at public accounts and things like that, but COVID was really the prime directive and where we spent most of our time.

Alex Maheux

Well, let’s get into the details. CIHI released the first pan-Canadian report looking at health spending during the pandemic, which showed that there was a 12% increase in health spending during 2020, which is 3 times the usual amount. And obviously a large part of that is because of COVID, and it’s clear that the provinces and federal government had to massively increase spending to deal with the crisis and ensure that people in Canada had access to the care they needed. But I do wonder at some point what that means for the future of health care spending. 

Helen, we’ll start with you. I wonder if you can kind of help give us an idea of what the spending trends have looked like in the last 2 years, and what you anticipate seeing in the next 2 years. 

Helen Angus

Yes. So I think that those numbers that you’ve just quoted for the country probably play out in Ontario quite similarly. And obviously, a 12% increase is not sustainable, there’s going to have to be some return to a different kind of spending pattern, probably closer to what we had before. But there’s a fair bit of unknown still ahead of us, right. We’re talking here 21 months into a pandemic and it’s not over yet. So there’s lots of variables, I think, that would still impact whether we were closer to 12% or down around 4% or so, and that includes third shots for the vaccine, the ongoing challenges to the health care system, the numbers of cases, numbers of hospitalizations, but also the whole catch-up and the health care gaps that have been created. I’m sure Kim will have some comments on that. But it isn’t just surgical procedures, although those are relatively easy to forecast compared to usual. It’s also, you know, people who will have forgone preventive care and will show up with later-stage disease or advancing disease. And, of course, mental health as well. 

So, what that means for spending, I think the governments are going to have to grapple with in the months and years ahead.

Alex Maheux

I saw that Kim was nodding vigorously when you were talking about catch-up for the system. Kim, what’s your take on this?

Kim McGrail

I would just add a couple of things, and just to emphasize one thing that Helen already said, which is that this is not just about making up the surgical backlog, it is about the fact that people did miss some care, they might have stopped taking medication. We can expect that people might have gotten worse with their chronic conditions. And, of course, there were new things that have come up because of the pandemic or coincident with the pandemic, not least of which is mental health issues. And those will take a long time to address. So, it is going to be a really big challenge.

I think the only other thing I would add in particular, spending pattern and trend pieces that in addition to the 12% increase, we saw a very significant increase in the proportion of total spending that’s public. It’s been hovering around 70% public, 30% private for probably the last, I don’t know, 30 years or so, and the projection is that it will be 75% public spending in 2021, I believe. And that obviously reflects the probably 1-time increase that will also itself go back down again because of the influx of federal spending and the additional things that needed to be done in the context of the pandemic. But it is an interesting kind of phenomenon.

Helen Angus

Yeah. I think even within the spending, there’s been an increase, obviously, in public health spending and other things. And, you know, there’s probably some kind of reflection that needs to be done at the end of this about what kind of public health capacity do we need to have going forward? You talked about some of the sort of longstanding issues in the health care system, and I think about some of the inequities and some of the disparities that have been shown through the pandemic in terms of the burden of disease and willingness to take up the vaccine and other things. And so, to me it’s just not the amount of spending, it’s the buckets that the spending occurs in, and I think that can’t help but be informed by this incredibly profound experience we’ve had.

Kim McGrail

I guess there’s just one more thing I would add, is that it’s going to be incumbent on us to find the things that have hidden during the experience of the pandemic. And I’m thinking in particular about older adults who have been at home who haven’t received the services that they might have because it was significantly difficult to provide in-person care. Certainly, the informal care in the voluntary care sector really took a hit in this because they could not go to homes and do the family visiting and the helping and that sort of thing. So, I think that there’s probably quite a lot of people who have suffered in ways that we just haven’t really made very visible yet.

Alex Maheux

I think you’re both hitting on something that I’ve heard many times, which is the fact that the years leading up to the pandemic and the pandemic itself has created kind of a perfect storm for Canada’s health systems, composed of many things. But first of all, aging population, health workforce depletion. Of course, this is all underlined by COVID. It’s a lot to process and to discuss. I’m hoping we can start off talking about the aging population, as Kim you just mentioned that. I actually read, in fact, that the population of those 75 and older is expected to grow at a rate 6 times faster than the working age population. And these are people who require more care, more complex care. Kim, you’re an expert in end-of-life care and supporting aging populations. It seems that a lot of the focus we have in the health care system on supporting seniors is focused towards acute care. I’m wondering if you think we need to re-evaluate where we focus our efforts and our spending to both improve the care and the health of seniors, but also spending efficiencies when it comes to that population?

Kim McGrail

You know, one of the phenomena of our health care system is that we have these things called alternate level of care days, which means that people are in an acute care bed even though they don’t actually need to be there. What they need is some kind of support and services, but they’re in an acute care bed until that can be arranged, and that might be additional home supports so they can go home safely. Often, it’s that they’re waiting to get into a long-term care facility. 

So our ALC, alternate level of care, bed days account for something like 12 or 13% of total acute care days in the years prior to COVID, and I think that changed quite dramatically. There was a very significant effort to move people out of the acute care sector who didn’t really need to be there, particularly at the start of the first wave of COVID. But that really sort of is a signal that there’s a problem in the system in the distribution of services in the system. So we need either to — I personally think we need to really completely rethink what long-term care in the whole continuum of care looks like. Our facilities for nursing homes are aging, they’re based on very, very old models of care. People would prefer to stay at home if they can. But in the background of all of this, of course, we have an enormous demographic shift. I mean, part of which you’ve already talked about, which is the population is aging. But we’re also talking about changes in families where there’s fewer children who might be available to care for older adults, and those children are often not living in the same place as their aging parents. So we’ve got this incredible demographic change, with multiple strands of it happening at the same time. 

I keep thinking that part of what we need to go back and have a conversation about is our fundamental values and what it is that we think we want to provide or owe to our older adults and how we go about doing that in a way that isn’t about housing or warehousing in decrepit long-term care facilities and the kinds of things that really just became quite apparent during the pandemic. But as you’ve already said, were long-standing issues prior.

Helen Angus

Yeah, I think if you look at Europe, you probably — you know, I find some of the sort of naturally occurring retirement communities, supportive housing, I think there are other models that will, I think, be more suitable for the aging population and probably produce better outcomes and be, you know, more acceptable to those individuals and build on natural communities. You know, I don’t know that they’re as widespread as they could or should be, but those for me have great interest as an alternative to long-term care and sort of aging in place. But I think you’re absolutely right, we’ve got a lot of work to do.

Kim McGrail

I absolutely agree with what you said, there’s lots of models out there. And I think, you know, one of the challenges and just in the continuum of care has been the challenge around capital, because it’s very expensive to build these facilities. Not as much as hospitals, but it’s still expensive to build these facilities. But I don’t think that they’re the facilities we want. So maybe we can actually solve the capital issue by thinking differently about what it is, the organization, what this looks like, congregate housing. Even things like city planners changing zoning so that it would be more open to things like co-housing where you have groups of people who have chosen to share a space because in part that means that you have a built-in community to help, but you also have if a group of people need services, it’s actually easier for the health care system to provide services to groups rather than individual home-based visits and so on.

So there’s lots of things that could be done, but it’s going to take a lot of creativity and it certainly extends beyond the health care sector.

Alex Maheux

A big part of the concern of an aging population is the depletion of health care workers due to a combination of factors. One we’ve already talked about it, is the increasing age in population, which means many of them would be retiring. Also, burnout caused by the pandemic has been a huge area of focus and concern. And ultimately, the concern is that we’re not going to have enough people in the field to care for our older population and our population at large. What types of changes do we need to see in the health care profession that’s not just going to attract but also retain health care workers?

Helen Angus

It’s interesting, I was just reading this morning some articles on this issue because it feels like that is probably one of the most critical areas of need coming out of the pandemic, and that’s been made more challenging because of the factors you just suggested. Obviously, there is training, there’s job opportunities, opportunities for immigration and access to professions and trades for people who have been trained elsewhere. But for retention, it has to be interesting work, career path. And, you know, if you listen to the nursing unions, they’re saying, you know, permanent jobs but with benefits, as opposed to piece work. 

So there’s probably something in all of those that will help us get there, but there’s a fair bit of innovation required. You know, we actually trained some laypeople to go in and do tasks in long-term care homes and elsewhere. You know, I think there’s scope of practice issues, there’s career laddering, there’s an awful lot that has been done but obviously it needs a whole lot more.

Kim McGrail

A hundred percent to everything that Helen said. And maybe what I would just emphasize is I think we need to spend quite a lot of time making sure that the work environment itself is conducive to helping people think about staying. The career laddering is part of that, but it is not the only piece of it. I just keep hearing stories, I haven’t seen this documented in any kind of rigorous way, but just the stories of how difficult these workplaces can be. 

Maybe the best example of that from British Columbia is that very early on in the pandemic, there was an order for people to only work at 1 long-term care location. But you have to think about the reason that people were working in multiple locations is because they are on casual jobs and they have to stitch 2 or 3 jobs together to try to make things work. Well, so that’s something that’s completely within our ability to change. But I think that the environment itself and what the workday looks like and how supported people feel and then think about the home care workers who are going to individual homes and how do we actually create an environment where they still feel that they are connected to a broader team and feel safe in the things that they are doing. These are all things that we need to address. And probably pay as well.

Alex Maheux

So what I’m hearing is that in order to kind of help solve this problem there’s many things that we do. But ultimately, make sure that we’re thinking of these health care workers as people and what they need to succeed that will help greatly in helping our health care system succeed.

Another thing that has come up quite a bit during the pandemic, and maybe this is another solution or part of the solution to improving access to health care workers and systems, is virtual care. And actually, I was talking to our VP of Western Canada the other day, who said that she had, in her conversations with a lot of the provinces and territories, heard that they feel that virtual care has advanced 10 to 15 years of where it would be if it wasn’t for COVID. 

Obviously, there’s some big initial investments to make into virtual care to solidify its place, to make it more efficient, but ultimately does that lead to cost savings down the road and efficiencies when it comes to our health care budget? 

Helen Angus

Yeah, that’s an interesting question. I think virtual care has been a lifesaver in many ways during COVID. And some of it is just more work on the phone, some of it is using video conferencing and some of it is using dedicated systems. I think in general the virtual care compensation is about the same as an in-person visit. Now, I’m not sure I would expect a whole lot of savings from virtual care, but I think it actually provides a service that, you know, many people want. We have achieved levels of virtual care that we’d probably only dreamed of 2 years ago.

On the other hand, I think there are many good reasons for in-person visits. And the example that I would give would be, you know, PAP tests, not possible to do virtually. And so, it is important that physicians, nurse practitioners and others are actually in the office at least some of the time in order to be able to provide some of that in-person care that is necessary. So I think one of the public policy issues for us going forward will be, you know, what’s the right balance? You know, we certainly were driving towards more for many years, and I think now the conversation needs to be what is the right balance? And I know in Ontario, the College of Physicians and Surgeons has sent letters out to the family doctors saying, you know, you really need to spend a minimal amount of time per week in the office. And I think that’s appropriate.

Alex Maheux

Kim, what’s your take on virtual care?

Kim McGrail

I would probably come at the virtual care conversation as it being a way to provide more patient-centred care than as a way to provide an opportunity to have cost savings within the system. So it still achieves part of our quadruple aim of the experience of care and appropriateness of setting and so on. But it’s pretty clear that virtual care is a huge cost/time/effort savings to patients where it’s an appropriate tool. But I would also say that virtual care has many different forms, and some of it is about being able to provide specialty services through a virtual link to rural and remote people, which helps to avoid travel. And in some cases, that virtual care can be with a health professional on-site, like maybe a nurse-practitioner, something like that, with the patient, but access to a specialist over the virtual connection. That’s the more expensive infrastructure that you’re talking about.

There’s also virtual care, which is what we really, really experienced a big, big, huge uptick in the primary care setting, and that’s been possible, and not, honestly, that expensive to institute for quite some time. But we’ve not actually been able to embed it within the workflow and the system of care. Because really, this should be — we should be thinking about virtual options as just being another mode of contact between primary care practitioners and people who need that care. And I think we need them to be thinking about adjusting fees as well. 

So if we’re going to allow a virtual care appointment for somebody to renew an existing medication, that’s probably a very quick thing and maybe there needs to be discussion about where physicians are being paid fee for service, what is the appropriate compensation for that? So there’s lots of sort of attendant policy things around this, but I think, you know, going back to what I said before about we really want to take a patient-centred approach to care delivery. This has to be something that we find a way — we need to make the workflows easy for people.

Alex Maheux

We’ve put a lot on the table in this last 20 minutes or so. A lot of opportunities to improve health care systems in Canada, but I’m sure what a lot of people are wondering is that’s a lot of money we’re talking about. Let’s talk about how sustainable this is. Helen, with the rates of increased spending we’ve seen over the last 40 years or so, what are the types of conversations happening to ensure the sustainability of health care in Canada?

Helen Angus

I mean, there’s no doubt that providing health care to Canadians and to an aging population and as we understand the cost drivers of, you know, technology and everything else is expensive. So I still think there are things that we can do to make sure that we actually have a health care system for our children and grandchildren, and that many jurisdictions and certainly in Ontario, we looked at better coordinating care around the people who use the health care system the most. And if you start to look at some of those patterns for those patients, they’re spending a lot of time interacting with the health care system largely because they’re not getting what they need rather than they are getting what they need. And if you think of somebody who has 16 different doctors and multiple prescriptions and everything else, they’re going to the emergency department a lot, that’s really a pattern that says there’s some basic need that isn’t being met by the health care system and that we probably need to do a better job for those individuals.

And so, I think coordinating care for those who have complexity makes a lot of sense, working with patients and their families; collaborating across sectors; working together to make sure that everybody is working around the needs of patients, I think can really put it nicely, and your last comment about really making sure this is truly patient-centred. You know, there’s no doubt that there are cost drivers in the system, but I guess I remain optimistic that there are ways to achieve sustainability without dismantling what is a core Canadian value and, you know, the principles of the Canada Health Act. 

Alex Maheux

I couldn’t help but notice that Kim smiled when you talked about positivity and having hope for the sustainability of our health care system. Kim, what are your thoughts?

Kim McGrail

So I would just start by saying that the kind of discussion about sustainability of health care is peculiarly Canadian. If you look around, most other places don’t talk about that. I think that’s just simply because can you imagine a world where there isn’t a health care system? Of course, there’s going to be a health care system. I think that the bigger piece that we don’t explicitly talk about quite so much is the debates are going to be around how much is public and how much is private, how much we expect people to pay out of their pockets, as opposed to the grand vision that we’ve had for the last 50 years with Medicare, which is that we want to treat people on equal terms and conditions. Meaning that we separate the payment for services from the delivery of those services at least in the hospital and physician sectors. 

But, of course, that was always supposed to be the start of a broader system that would cover other things as well, and our individual provinces and territories have extended coverage to pharmaceuticals and long-term care and home-based services, but that’s much more on a patchwork, that’s not under the broad Canada Health Act framework across the country.

I completely agree with Helen, there is lots of ways we could be improving the system to make things more seamless, to connect silos, to be more patient-centred, to not have duplicate tests, to make sure that people’s care is coordinated appropriately. And that will all save money. There is at the same time enormous cost drivers like with new medications and expensive drugs for rare conditions and a driving need for additional technology to be used in the health system and so on. So I think there’s going to be a lot of need for, frankly, some probably pretty tough conversations about whether we want to reaffirm the values that underpin our current health system, which I hope that we do, or if we’re moving to something else. But I do think that an open conversation, including the public, and really kind of acknowledging what is my opinion that the health care system is emblematic of how we think about society and our connections to each other and what we believe we can do together better than we can do separately. So, I think there’s a lot of value in actually having these conversations and making probably what will be some tough decisions, but I agree with Helen’s general positivity and optimism that we can actually do it.

Helen Angus

Yeah. I think the pandemic’s been interesting for that when I think about when we saw some of our hotspots. Really, you know, the health and the ability to open up and in some parts of, and I’ll give Ontario as an example, really required that we actually get the COVID numbers down. I’ve just kind of come away from the pandemic with kind of new understanding of how we’re all connected and a better understanding given some of the data, you know, some of the data that we were able to collect and create during the pandemic, of some of the depth of deprivation in some of our communities that are not very far away, right. And I think that may be one of the legacies of COVID as well.

Alex Maheux

I’ll steal something that Kim said, that there’s a lot of tough but important conversations that are probably headed our way. You both have a tremendous amount of experience, you’re very seasoned in this field and I’m sure you’ve seen some ups and downs in health care in your careers. If you were to give 1 piece of advice to the decision-makers right now, what would it be?

Kim McGrail

I think mine would be to open up the conversation, include the public and don’t be afraid of bringing the tough decisions and questions forward.

Helen Angus

I think that’s great advice. I would include in that, you know, the people in the front line and help them to, you know, heal from this process and use their experience to help inform the next conversation and the next iteration of health care in Canada.

Alex Maheux

There’s certainly a lot of healing to do. Thank you both for being with us today. You’ve certainly given us a lot to think about but also a lot to be hopeful for. We’re looking forward to chatting with both of you again soon.

Kim McGrail

Thank you.

Helen Angus

Thank you very much.

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Alex Maheux

Thanks for listening. Check in next time when we bring you more valuable health care topics and perspectives.

If you want to learn more about CIHI, visit our website: cihi.ca. That’s C-I-H-I-dot-C-A. And if you like what you heard, subscribe where you find your podcasts and give us a follow on social media.

This episode was produced by Angela Baker and Stephanie Bright, and our Senior Producer is Jonathan Kuehlein. 

I’m Alex Maheux, talk to you next time.

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