Back to National Health Expenditure Trends
Transcript
Chris Kuchciak
Okay, well, we’ve got the top of the hour here. Good afternoon and good morning, wherever you are. I’m delighted to welcome you to today’s session. My name is Chris Kuchciak, and I manage the National Health Expenditures program here at the Canadian Institute for Health Information. I’m coming to you from Ottawa, which is the traditional unceded and unsurrendered territory of the Algonquin Anishinaabe Peoples, and CIHI would like to collectively acknowledge the lands we all occupy, whether treaty or unsurrendered.
We’re thrilled to have over 200 people registered for today’s event, and we will be recording it and making it available on our website and YouTube.
So it seems like policy-makers are running 2 races these days. One is a sprint to provide emergency response to deal with the pandemic. The other is a marathon dealing with issues that existed long before the pandemic and will exist long after. Think of things like spending and fiscal position, population aging, health workforce and technology.
Well, joining me today is an outstanding panel of experts to discuss. We have Livio Di Matteo, who is professor of economics at Lakehead University. He’s a member of the NHEX Advisory Group and is a regular media commentator on public policy.
We have Dee-Jay King. He is the executive director of Health Economics and Funding with the government of Alberta. He leads a team that brings evidence to operational and policy decisions at Alberta Health.
Kim McGrail is professor at UBC, the School of Population and Public Health and the Centre for Health Services and Policy Research. You’ve seen her research on aging and costs and utilization of health care services and financing.
And Rebekah Young we have is the director of Fiscal and Provincial Economics with Scotiabank. Prior to joining Scotiabank, she spent many years at the federal Department of Finance.
Now we plan to make some time at the end of our session for you, the viewers, to ask some questions, so please feel at any time to drop your questions in the Q & A button at the bottom of your screen.
So let’s start our discussion today dealing with the challenge of balancing health spending needs and doing it within our budgets.
So, Livio, turning to you first, historically, we’ve seen steady increases in health spending. What is your view on the sustainability of this trend?
Livio Di Matteo
Good afternoon and good morning to everyone. Bonjour à tout le monde. Well, that’s a very good question. Sustainability is a question where the answer, I suppose, an economist would say depends on the time perspective you’re looking at. I mean, over the long run, the concern over sustainability has been because of the fact that health spending has grown both in per capita terms and as a share of GDP.
If we go back to the 1970s, you’re looking at a health expenditure–to-GDP ratio about 7%. Currently, it’s about 13%, just under 13%, and that’s fuelled concerns about sustainability, particularly because of the recent surge as a result of the response necessary to deal with the COVID-19 pandemic.
In per capita terms, over the last almost 40, 50 years, a real per capita spending, once you adjust for inflation, population, has gone up 2.5 times. So, over the long term, there has been a concern that there may not be enough resources given that the rise of health expenditure seems to be inexorable.
In the short term, the pandemic, of course, has probably renewed concerns about sustainability given there’s been this sudden surge, but the concerns about sustainability in a sense come and go, depending on the growth rate. I mean, in the late ’50s, ’60s, into the ’70s, during the start of medicare, you were looking at growth rates of provincial/territorial spending in real per capita terms of well over 10%. These then stabilized at about 3% over the course of the ’80s. There was actually a decline in the early ’90s during the period of the federal fiscal crisis. Then concerns about sustainability reignited, given that from about the late ’90s to about the Great Recession you were looking at a growth in per capita spending of about 4%.
But then it moderated, and up until the pandemic it was only growing at about 1% a year in real per capita terms. It’s been the pandemic that’s seen a surge in spending, and even there, you have to examine the surge carefully. The pandemic response has been responsible for a surge in spending, but if you filter that out, in real per capita terms, there was actually a decline in quite a few categories out of health spending.
So should we be concerned about sustainability? On the one hand, the level of sustainability is what society is willing to pay for it. If society is willing to pay for a health expenditure ratio of 13% or 14% or 12%, then that is perfectly reasonable.
The other issue when it comes to the fact that about two-thirds is provincial/territorial government is that, well, the system is as sustainable as you want it to be. And if you look at the behaviour of provincial governments over time, they’ve always dealt with expenditure concerns when necessary. The best example of that, of course, was the early ’90s.
I think sustainability is a concern, but the greater concern is value for money in terms of we seem to spend an awful lot on health, but the outcomes tend to be a bit more mixed. Of the OECD countries, we are what? 7 out of 38 in our health expenditure to GDP. We’re pretty close to the top 10 or in the top third of low per capita spending. And yet, our performance tends to be a bit more mixed on things like infant mortality, some types of survival rates for different types of cancers, et cetera. That’s on the outcomes side.
On the inputs side, despite the fact that we seem to spend an awful lot of money, our physicians per 1,000 population are ranked 30th out of 38. Hospital beds, we’re also quite down there as certainly noted during the pandemic. MRIs per million, again, we tend to be in the bottom third. So we have this odd situation where we seem to spend a lot. The outcomes are a bit more mixed.
It’s not that we have a bad health care system; we have a very good health care system. I mean, it’s easy to exaggerate these rankings given that these are all developed countries, and so the actual differences on the outcomes, in some respects, are actually quite small. But yet, there is the question of can we get a better value for money?
And that becomes a concern because in the longer term, if you think about it, the health care system does have to compete with everybody else. There’s a lot of concerns about climate change. There’s concerns about inequality, housing costs. And so these are all issues that, in a sense, are going to capture the attention of the public, policy-makers, politicians. And so I think it’s important, if you’re going to get more resources, to demonstrate value for money given that you will probably have to make more of a case as time goes on.
Over to you, Chris.
Chris Kuchciak
Thanks. Now, Dee-Jay, turning to you and thinking about provincial and territorial health spending. Before the pandemic, Alberta was on the upper end of the spectrum when it comes to per capita spending. Can you share a little bit about the process that Alberta undertook to address this issue?
Dee-Jay King
Well, good afternoon, everybody. As you note, Chris, I think we are still on the higher end of the spectrum. And as Livio noted, Canada is a pretty high spender globally on a per capita basis, and we tend to look, at least my group tends to look primarily at per capita spending because it kind of standardizes across different jurisdictions.
So, as we just talked about, Alberta continues to be one of the highest per capita spenders amongst the larger provinces in Canada, and that difference is quite significant actually. If you take a look at the NHEX reports, we’re quite a bit above some of the other larger provinces.
And so, obviously, looking that we’re high among Canada, but we’re also high globally, just it stands to reason that we’re, obviously, at the very high end of the spectrum for health care spending.
And as Livio noted, our health outcomes as Canadians just aren’t seeming to kind of align with the amount of dollars we’re spending in the space, and that, of course, mirrors in Alberta. And so, even amongst the provinces, our outcomes are not significantly different than our colleagues’.
And so what we try to do then is we try to look at what’s driving the costs. And when you start to look at that, of course, one of the first things you look at is labour, and labour tends to be about two-thirds of the system costs in Alberta. And labour is a very interesting area. And anybody who’s out there that works in the labour space, I think you’ll agree that there are so many variants and so many ways to approach labour analysis. I’m no expert for sure, but my observation is that generally when the economy is in an expansionary period, basic economics would say that you’re driving up compensation because of the extra demand in the economy. And, of course, this rising tide would impact health care as well.
But what we find though, especially in the health care space, is that wages are much stickier on the way down during economic contractions, and that’s different than other sectors where you can see significant declines in wages and benefits in those spaces.
The health care labour needs just don’t ebb and flow quite like the general economy, and that’s a bit of a challenge for provinces and other jurisdictions in order to manage that. Because once the cost’s sort of there, you kind of get stuck. And the way to do that, and Alberta went down this path a few years back, but you start to signal to your stakeholders that the belt needs to be tightened. And we heard Livio talk about the ’90s, and that was a dramatic period of time for those old enough to be part of that in the health care space, but essentially the fiscal belt, we started to signal that the fiscal belt needs to be tightened and started to take some action to do that.
And I will say that Alberta over the past several years has been able to work with its stakeholders and to, in some respects, tighten that fiscal belt. Overall, costs haven’t really went down, but on a per capita basis, it’s definitely flatlined. And, again, looking at the NHEX report, you’ll see that Alberta’s having some success flatlining the overall growth in health care expenditure while other provinces, for many different reasons, continue to grow their spending in that space. And so that difference between us and the other large provinces is starting to reduce a bit.
And again, so I’d say from that perspective, Alberta has had the success they were looking for, and we definitely use publications like National Health Expenditure to help us monitor where we’re at in our comparison with other provinces.
Hopefully, that answers your question, Chris.
Chris Kuchciak
Yes, indeed, Dee-Jay. Thank you so much. Now I’m thinking I’m going to turn over to you, Rebekah, thinking of your time at the Department of Finance. And the realities of post-pandemic budget deficits, what are some of the challenges that you see of managing budgets while juggling competing demands for funds? And since we have primarily a health system planner audience, how can we be aware of these issues when putting our budget requests together to finance?
Rebekah Young
Well, I think you capture the essence of what the Finance Department does, with that idea of competition and competition for finite resources. So the finance minister, he or she — she as it is now — is the “no” minister, typically. So, for every dollar available there are literally tens and tens of requests for that limited dollar, so the Finance Department has to trade off these competing demands and where should they be allocated.
Now the headline numbers that they allocate, so do they go with the big number or a small number? They try to calibrate that to economic conditions. So when the economy’s weak, they’ll tend to spend more; and when it’s stronger, they’ll spend less. So there’s that aspect.
And the third issue that they try to do as well is they try to think where are we going to enhance growth? And now that’s one challenge because they see things like health expenditures as just that, as an expenditure, not as a something that is going to strengthen growth.
So I would say our economic systems right now aren’t great at capturing the value of a healthy workforce, or an educated workforce for that matter. So we still see these as expenses and not as growth enhancing.
So those, in a nutshell, are a few things that the Finance Department and the finance minister are weighing off when they’re trying to decide how much and where should they allocate.
Now I would say in the current context, there are some positives and negatives in terms of allocating additional funds to health expenditures. And the first is that right now what we see is the federal government, it has this willingness or propensity to spend right now coming off the initial effects of the pandemic. So we know they had an enormous deficit last year. It was about 350 billion. A big chunk of that went to health care, and so that’s actually given provinces some breathing space because we had these large exceptional transfers to provinces to support the pandemic so far. And we know from election promises that there should be more coming for provinces, owing to some backlogs in things like surgeries and other procedures.
So there is this propensity to spend right now, and in part because, quite honestly, the pandemic exposed some major gaps in our health systems, also in our long-term care systems and, more generally, in what we might call the caring economy. So we’re in a situation of propensity to spend. Federal government are aware of the gaps in the provinces with a bit more breathing space.
Now the downsides are that there’s a sense now is it time to start reining in those expenditures? So I suspect that Ottawa will be looking at, very carefully now going ahead, how much more do they spend. But I would say pragmatically looking at recommendations for proposals that are being made, one that was mentioned already, this idea of value for money. And I would take that a step further. Not just value for money, not just focusing on inputs or the dollar value that is being sought in a proposal, but really try to shift to outcomes. So what are the — and even not in terms of hospital beds or number of procedures, but in terms of the welfare — benefits that it provides for the population? And I know that is even getting ahead of where the federal system is often in measuring outcomes as opposed to inputs, but I really do think that that’s where the system needs to go and that proposals that are able to better illustrate what money buys will get more light of day.
A second aspect I think is that focusing on gaps in the system, so where are additional or incremental dollars going to help close some of the gaps that were identified over the last 20 months?
And I guess my final point would be remember that Ottawa is looking at the system as a system of many systems across the country in health care. And so also look at ideas, proposals that have potential for economy of scale. So the request might be just for 1 specific geographical area or 1 specific discipline, but sitting in Ottawa, the perch in Ottawa, generally they’re looking for ideas that might, if successful, demonstrate scale for other regions that will bring benefits.
So those are just a few practical considerations I would flag in the context of what we’ve lived through in the last 20 months.
Chris Kuchciak
That’s great. Thank you, Rebekah.
Now I just want to shift gears and talk about population aging. This is a topic that we’ve been talking about for years. It’s a steady cost driver that existed long before the pandemic, will continue afterwards.
Kim, turning to you, the pandemic highlighted issues related to seniors’ care. How do you think health system planners should tackle this issue, especially with regards to finding the appropriate balance between long-term residential care and homecare?
Kim McGrail
Thanks, Chris, and thanks for the opportunity to be here today. And I’d just start by saying I really appreciate the way that you frame the question, because while the focus of the pandemic was and has been on long-term care, we do really need to consider the whole continuum of care, including home-based care, other community services and various forms of congregate housing, as well as long-term care.
So maybe the first point I’ll make, and perhaps this is the most important piece, is that this part of our health system really does need more investment, more funding. This is perhaps one of the gaps that Rebekah was pointing to. And this doesn’t mean that we need overall health expenditures to go up, but we’d at least need to consider some reallocation. Perhaps there’s some efficiencies in other parts of the system. If we can agree on that, the next thing to consider is how that funding could best be used.
So one way to approach this would be by reaffirming or updating the values that inform our health systems, and particularly those that relate to this sector, which really does start to cross over between health care and social services. And some of the questions we might want to ask is what do we think should be publicly funded, how does that work with other sorts of funding options, and who are the services for, and where should they be provided? And I’m sure there’s many, many other questions as well, but this really does relate to some, I would say, normative decisions that need to be made, or values-based decisions that we need to make. And ideally, we would make those with the public.
So, without question, I think we need to look beyond the current models that we have in place in this sector of the health system. For example, a lot of the existing long-term care infrastructure is old. It often uses shared rooms and is based on an institutionalization model. So the same model is used for people who have really, really different needs as well, so that’s something that we might need to rethink, or I would suggest we do need to rethink.
So, for example, people with significant physical impairments or complex underlying health conditions have the same institutional model in front of them for long-term care as do people with significant dementia but who otherwise may be well. It’s not clear at all that those people need the same supports or the same services or would even necessarily do well in spaces that are shared overall.
So perhaps, more importantly, the preference for individuals and families is for people to remain in the community as long as they possibly can, and this means needing different forms of care, whether that’s home-based services or different kinds of congregate living.
And I can put a point on what’s happening in this sector using the example of British Columbia and acknowledging that there are big variations across provinces and territories in the formation and policies in this particular part of the health care system.
But in B.C., the population of older adults about doubled between 2001 and 2021, so over the past 20 years. And the doubling was from about 500,000 people over the age of 65 to now about 1 million people in that age group. And meanwhile, the number of long-term care beds that are available increased by about 3,000 from 25,000 to 28,000. So, if you do the math, this means that we have a 60% lower supply of publicly funded long-term care beds than we did 20 years ago.
Now some of that, a small bit of it, might be compensated by other forms of care, but overall, I think we’re doing some cost shifting, but this has been done implicitly rather than based on, as I’d said earlier, discussions about values and what we really want out of this part of the system.
So in the context of COVID and the focus on long-term care, this means that they have a, I would argue, pretty invisible effect on pretty frail people who were left in the community and lost a lot of services and social connections because of the lockdowns and so on.
So, ultimately, this is really about transforming a system to be patient- and family-centred or person- and family-centred, and really with an objective I hope that we have of delivering health and social care that will support better health.
Back to you, Chris.
Chris Kuchciak
All right. Thanks, Kim. Actually, on your last point, I’d like to just double back to Rebekah for a moment then. Can you comment on Kim’s point about the objective is to deliver better health and health care? And what other factors in the broader Canadian economy should we consider?
Rebekah Young
I think Kim makes an excellent point, well many excellent points, but in particular about the need for a dialogue in that some of these decisions are value decisions or normative decisions that we as a society need to have. And so one way of looking at it is that we’re all taxpayers in the system and we’re all patients in the system. So we have a social contract with our government that, in exchange for our tax dollars, we have a certain expectation for services in our health care or education systems. And so we need to have that kind of dialogue of what do we expect for the tax dollars that we are spending.
And when we look at where some of the changes might be going, both in terms of the pressures on our systems, our health care systems, as well as the pressures on the tax base, I think that really points to a need for this type of dialogue.
And so, first of all, if we look at aging demographics, in part, I would say broad-based across the country, but particularly acute in some areas, including out East where I am right now, is that that will have an increasing cost pressure for governments with aging populations. And at the same time, aging populations, as they drop out of the workforce, they are paying less taxes, so fewer tax dollars to provide arguably a higher level of service.
But fortunately, we do have growing population right now in Canada. A big part of that is immigration, and so we’re bringing in younger, new Canadians providing higher taxes, but they’re also putting more pressure on the systems as well. So, again, just reinforcing that we need to have that discussion because there are a lot of these structural changes going on that are putting cost pressures up and could put the tax base under pressure if we don’t decide what is it that we want for a system and what sorts of outcomes do we want.
And just picking up on a second point that Kim made, which is there really isn’t any panacea or cookie-cutter approach, and I like the idea of that person-centred or patient-centric driven approach and that it’ll be a variety of solutions, not just depending on your geography or your household, but even at the stage of life that an individual might find themselves in, is that one or a different solution might be appropriate. So how do you design a national system that allows for a multitude of different solutions over time and, at the same time, still maintain proper oversight, effective funding and a focus on outcomes?
So I think, again, just reinforcing that it’s really timely that we have more of these discussions.
Chris Kuchciak
Yeah. And I think your point, Rebekah, we’re all patients and we’re all taxpayers. I think that’s a good reminder, certainly for me anyway.
And a reminder to you in the audience, you can drop your questions. We’ll have time at the end for viewer questions. You can drop those in the Q & A.
So I want to shift gears to go back to a conversation we touched on at the beginning about the caring sector of the economy and when we think of health care services that are provided by people or labour.
Livio, I want to bring you back into the conversation. The health workforce has been a key cost driver of Canada’s health system. What are some of the trends health system planners should be considering?
Livio Di Matteo
That’s a very good question, Chris. In the end, there appears to be shortages of health care professionals, whether it’s physicians or nurses or PSWs. This was something that was evident before the pandemic and it’s certainly been intensified during the pandemic, but it’s a bit of a paradox because on the one hand, we spend a lot on health and yet, there seems to be continual shortages and waiting lists, et cetera.
And so, I mean, how do you wrap your head around that? And I think if I had to sort of throw something out just off the top of my head, I would say that we seem to have a health care system that essentially has fewer health care professionals per capita compared to a lot of other systems. We pay them a lot and then we work them really hard.
I mean, on the one hand, our physician numbers or our hospital bed numbers are much lower than other countries’. On the other hand, they’re run very intensively. I mean our physician consultations per capita are sort of near the upper end. And so that, in a perverse sort of way, might be contributing to shortages because when you sort of run your system like that, there could be a lot of burnout amongst staff and physicians, et cetera. And so maybe that’s part of the problem, so that’s something to consider.
Then the other issue is, just again, along this line of shortages. I mean, the number of physicians per 100,000 in Canada stayed relatively flat from about the 1980s up until oh, the late ’90s, early 2000s. But since then, it’s actually grown. We’ve probably increased the per capita number of physicians by about 25%. And yet, at the same time, we have, in the early 2000s, about 14% to 15% of Canadians without a family physician. And today, that number really hasn’t changed much even though we’ve augmented the stock. So there’s been changes in the workforce in that we’ve added more physicians, but they are taking on fewer patients. They want more of a work–life balance. So how do you accommodate that with the remuneration necessary to attract people into the sector, whether it’s nurses or PSWs or physicians? I mean there’s an awful lot going on there in trying to sort that out.
In the end, the demographics of all these professions are aging. And so just as the population is aging, so is your health care resources, your health care workforce. So how do you plan for replacement and entry? Do you increase immigration of foreign professionals into our system? Do you boost our training? How do you plan? Planning is important, but the other thing you have to keep in mind when planning is you have to be careful. Much like generals are sometimes always fighting the last war, you have to be careful when you’re planning that you’re not planning for the last pandemic or the last health care crisis.
I mean, take the long-term care sector, for example. There’s a lot of plans now being made for investment in new beds in long-term care, new resources going into long-term care, and I think you have to think about that carefully because, during the course of the pandemic, anyone with family or relatives in long-term care sort of glimpsed what happened and well, I think a lot of us just aren’t planning to go there one way or another. I mean, there’s ways to be creative. Trust me.
And so you might be over-investing. Think of what happened in education in the ’60s and ’70s when they thought the baby boom would go on forever and they sort of overbuilt capacity in schools, and then the ’90s and the 2000s are years of school closures. You don’t want to repeat that kind of mistake. Maybe you do want to focus more on homecare options, more flexible options that allow people to stay in their homes longer. And, of course, that’s going to affect the type of staff you’re going to hire, the type of planning that you might want to do.
So, I mean, there is a lot going on there. And planning is important to augment the human resources, but I don’t think there’s going to be any type of a panacea, or as has already been noted, or a one-size-fits-all solution to how we deal even with the human resource issues here.
Chris Kuchciak
So, Dee-Jay, going back to you, because we heard from you talk about labour at the start of the event today. Can you shed some light on how some of the challenges are playing out in Alberta? And what are the issues that you’re considering?
Dee-Jay King
Yeah. You bet. So, as Livio just mentioned, many different issues around the labour space. One thing I’d like to focus on is something I mentioned before. It was the ability to claw back benefits and incentives once they’re in place because I think that fits directly with what Livio was trying to explain there.
Yeah, early in the COVID crisis, one of the things that Alberta determined was, and across the country quite frankly, that there was a problem in some of our long-term care spaces, our continuing care spaces with what I think Ontario calls PSWs. In Alberta, we call them health care aides. And they’re essentially at the lower end of the wage continuum and, funnily enough, they’re at the front line of COVID because they’re the ones that do a lot of the direct work with clients. Other providers do that as well, but the HCAs, in our case, get the lion’s share of that work. And really, obviously, with the pandemic in the middle of their work environment, it increased their exposure to COVID for sure. And what we were hearing rumours of is people were really considering whether or not they should continue to work in the space because of their own personal perspective on exposure to COVID and things of that nature.
So early on in the pandemic, Alberta provided a $2 top-up to these workers in facility-based continuing care. And it really was deemed to be required to incent folks to continue to work in the space even during a pandemic. But during the communication and what we got approval for from a budget perspective really was a temporary measure during the pandemic which, as we all know, is continuing to go on and new variants are coming out regularly, but what it showed though is that incentives or remuneration or some type of consideration of the work environment needs to happen. And so provinces are trying and attempting to do that to incent folks to be involved and continue to be involved in health care because health care can be a difficult place to work, depending on the environment.
But on the cost side, on the expense side, it is interesting in that, as I talked about before, these type of things are a bit sticky. So when we identify the incentive to both the operators as well as staff, we were very clear in Alberta that this was only during the pandemic and that the $2 incentive would go away when the pandemic is over.
Not sure when that will be or who’s going to make that call, but nonetheless, I think the stars are starting to align against clawing back that incentive. And specifically, as was mentioned by several of our speakers, we’re starting to see general labour shortages in health care, and especially staff at the lower end of the pay spectrum. They’re finding other opportunities and choosing to go that route or they’re just not entering the system, as well as we’re all hearing about rampant inflation, again, due to the pandemic. But the two of those together really start to set a framework where it will be difficult for governments to claw all or some of that incentive back.
And so take that example though, and take it out to the broader response for the pandemic, where Alberta’s invested hundreds of millions of dollars into the response for the pandemic, essentially going into the fairly inelastic labour supply, so basic economics. But you’re throwing a bunch of dollars into a system for a particular need and your labour supply’s fair inelastic, and generally that drives up wages and incentives in the system.
So it will be very interesting. The story’s yet to be told of how successful governments will be in removing these response dollars once the pandemic cycles down or ends altogether, which is, I think, the hope of most of us.
So the continuing challenge will be in our health care spaces to really retain folks, which is what the $2 incentive was about, and attracting youth into the sector. And so that’s a function of supply–demand, dollars and culture, quite frankly. So it’s a story that’s evolving before us.
Chris?
Chris Kuchciak
Thanks. So what I want to do now is look ahead to the future and future opportunities. We saw during the pandemic an uptake in the use of technology and specifically, as an example, virtual care.
Kim, considering all we’ve discussed today and the move towards virtual care during the pandemic, how can we continue to evolve in the future?
Kim McGrail
It’s a great question, and an interesting and important challenge. I would say in the case of primary care, the very quick and really complete switch during the first part of the lockdown on the pandemic to virtual care was both compelling and depressing. So it was compelling because it shows that where there’s a will, things can happen quite quickly. I found it a bit depressing because it really shouldn’t take a pandemic to make these kinds of changes within a health system, and clearly, the virtual space is one of those that we had the capability of expanding those services far more than we had prior to that.
And again, I think this is really about transforming the system to be person-centred. Virtual care in its widest sense is the way I’m meaning it. So this is about cases where you might have a nurse or some other kind of health care provider in a room that’s set up with technology in a rural location, and through that to be able to speak to a specialist in a different location, which is really about extending the reach of specialty services, but also it really means that patients and families don’t have to travel for everything that they might need a specialist for. So that’s on one side of things.
And then, of course, the primary care side, where the virtual care’s setting allows patients to receive care that doesn’t require hands-on or in-person contact with a provider. It might be for a prescription refill or a quick question, and maybe, in some cases, they would be triaged and asked to come in, but in other cases, again, you save time and travel costs and day care costs and missing work and all of those other things that if you can provide that virtual care.
Without question, virtual care can’t replace in-person care. I don’t think anybody is driving toward that. On the other hand, it would also seem unreasonable at this point to go back to the old normal. So if virtual care is here to stay, then we need the right policies and right technology and technological implementation to support its use.
So on the policy side, I think one of the major things is just to acknowledge and support the idea that this is another legitimate mode of providing care for your patient. And the acknowledgement, of course, means that there would be reimbursement for those services in a fee-for-service setting and/or allowance for that time that it takes in a non-fee-for-service setting.
And again, it’s not an either/or. We need to have both in-person, virtual, other kinds of interactions between providers and the public. And ideally, what we’re going to frame this around is ensuring that we provide the right care in the right place at the right time, with virtual just being another potential right place. So the policy environment needs to support those kinds of things, appropriateness of care and that sort of thing.
On the technology side, it really is pretty clear from the existing research that the way you implement these virtual technologies into the system really matters for their uptake and use. So, for example, in a primary care setting, it’s really important to integrate the virtual care options into an EMR so that when you’re providing virtual care, it’s an ease of access, it’s not yet another system, any kind of documentation or conversations can be easily placed in the EMR, that there’s some sort of support or training for how to do the kind of concierge services around using virtual platforms and so on.
So those kinds of things, again, they’re available to us, but we need to make sure that the policy environment and technology environment supports, as I said, something that I hope is here to stay as a permanent part of the health care’s delivery model.
Chris Kuchciak
Okay. Thank you, Kim.
I’m going to go back to you, Rebekah. Kim paints actually a very promising future in terms of future of health care. What should planners be thinking about for funding this future?
Kim McGrail
Well, I guess I totally agree. We sort of fast forwarded a couple of decades in what we saw in the delivery of virtual health care over the pandemic. And, again, I would echo Kim’s point that it was somewhat disappointing that it took a pandemic. But how do we now capitalize on what we’ve learned as a result? And how do we make sure that the best practices bubble up and the stuff that didn’t work out so well gets left behind?
I would note in the near term we still don’t know what the final price tags will be on health care over the course of the pandemic. So I mentioned that provinces, many provinces so far that have tallied their deficit spending over last year, including in health care savings, so part of it is that the federal government provided offsets, but part of it was that some procedures were just delayed or some consultations that had to take place in person, there were good chunks of last year that they weren’t happening. And so how much of the underspend last year is a backlog of stuff that couldn’t be done virtually and is pushed forward in looking ahead?
So I would say we’re not out of the woods yet to be able to say that we’ve caught up with demand for health care yet as a result of the pandemic. And what will be the cost structure? So has our pricing reflected this change? And so what might have been at one point a 30-minute consultation in person, now can often be done in a 5- or 10-minute phone consultation. So I would say that something to watch is what are the final price tags coming in over the next year or two?
But when we look beyond the next year or two, I think we may, and we should, capitalize again on this idea of disruptive technology and bending that cost curve of the delivery of health care in better outcomes for less input. And again, it’s really an unprecedented moment that we had a live experiment of trying virtual health care.
So as we look ahead and we see the math doesn’t add up in terms of burgeoning costs and a shrinking taxpayer base, we may have a lot of ideas ripe for the picking when we look back at what we’ve learned over the course of the pandemic.
So I really think that it is an area that, particularly going forward in proposals that are pitching to the government for funding, should be looking at how their ideas really capitalize on that learning. And so how can we deliver a better system with fewer inputs and leveraging the virtual learnings that we have acquired over the past 20 months?
Chris Kuchciak
So now’s the time where we will turn to the viewer questions, and I think I’m going to start this first one going back to Livio and then Dee-Jay, if you want to chime in.
One of our viewers asks that given the scarce nature of health human resources and the portability of their skills and credentials within Canada, is there the potential that we might be driving up wages or labour costs through competition across provinces? Or even within a province, competition for that scarce labour across facilities?
And I’ll start with you, Livio, and Dee-Jay, you can add if you have anything else to add.
Livio Di Matteo
Well, that’s a very good question. And it’s, in the end, really a question about federalism, if you want to think of that. Federalism is Canada’s greatest strength and its greatest weakness at the same time. On the one hand, having provincial health systems competing and innovating and coming up with new ideas that could then be shared, I think is really good. On the other hand, sometimes there are benefits to better coordination, which is not always apparent when you have competing systems.
Now, in the case of scarcity of labour and resources, the most constructive solution is to have the provinces cooperate to boost supply, whether it’s working together on immigration or on training opportunities, on recruitment. Trying to restrict competition, in the end, will involve affecting the mobility of professionals. And I think in the short run you might get some benefits out of that, but in the long run what you’re doing is creating an incentive for highly trained professionals to take advantage of international opportunities.
So, I mean, if the provinces can work together on planning initiatives to boost supply, and don’t ask me how to do that, I’ve never run a health ministry. However, if there must be some way of working together on that, I think that would be for the best. But you do have to be careful there. You don’t want to restrict opportunities of health care professionals in such a way that they might be tempted to leave.
Chris Kuchciak
Yeah. Dee-Jay, you run a health ministry, are working in policy. Anything else to add to that?
Dee-Jay King
Well, I agree. Absolutely, supply is probably a large part of the challenge, and we absolutely do compete both within province and across provinces, not just for supply of a limited resource. And it’s not just about dollars; it’s also about working environments.
So I’d go back to an example we had in the mid-’90s, where we were losing a bunch of physicians at that point in time to other jurisdictions. Funnily enough, a large number of them went to B.C. And it wasn’t for more dollars, because we were still paying more at the time, but it was for quality of life and other things that we haven’t really got our finger on yet. But those are part of the supply equation that I think we also need to look at.
So we should look broadly about what attracts folks to specific industries and what our supply–demand equation looks like and what we really need from a supply perspective.
Chris Kuchciak
Okay. And we have time for 1 more viewer question. And maybe, Kim, I’m going to look to you because you touched on primary health care in your discussion. And one of the questions comes in looking at filling gaps in the future with disciplines more broadly, thinking physician assistants and community social workers and others, and I guess that touches on scopes of practice. And maybe can you speak to that in terms of filling major gaps in the system?
Kim McGrail
Yeah. It’s a really interesting question about how to respond to some, and this is both about community need, but also about health human resource availability. And there are really interesting things going on. I’m thinking about Nova Scotia, for example, where I know that there have been some experiments in expansion of community paramedic, that kind of model where there’s certain that are trained to actually provide something that looks pretty close to primary care, at least triaging, and often leaving people in place rather than necessarily just thinking that as a paramedic what you have to do is go pick people up and transport them someplace else.
So I think there is a lot of scope for those kinds of services and changes in the scope of practice and really trying to think of it from a patient-centred lens of how do these different scopes of practice interact when we’re trying to provide more care outside of institutional settings, whether we’re talking about hospitals and getting people out of hospitals earlier or avoiding hospitalization altogether, or retaining people in community rather than admitting to long-term care facilities.
So there is a lot of opportunity there. I would say at the same time that the health economist Bob Evans used to talk about the health care feast, and it kind of references the number of different kinds of providers and the pay skills of providers that are operating in the health care system. So we really do have to be planning carefully about how we introduce new things and what that means for the supply and need for other kinds of health human resources capabilities as well.
Chris Kuchciak
Yeah. I think at this point, I would like to probably take time for a roundtable with all of our panellists before we close off. And so maybe we can all come on screen and maybe if we can close out our session and basically asking each of you, going around the table, to share your final takeaways to our audience of policy folks today.
Maybe, Livio, I’ll start with you. Any final takeaways for our audience?
Livio Di Matteo
Well, as much as I consider economics one of the helping professions, it’s really difficult to provide an all-encompassing takeaway aside from some of the effect that well, there’s an awful lot going on. There’s a lot of uncertainties, a lot of change and, to a large extent, I think decision-makers, it’s much like a card game. You are going to have to play the hand that you’re dealt as best that you can.
And so in the end, health expenditure decisions and resource allocations are going to have to be made. I mean, the decision is going to have to be made. You’re going to have to do it based on the best available information that you can pull together. And if the decisions turn out to be correct, I suppose so much the better.
I mean, that’s probably not the most reassuring takeaway, but I don’t think there’s an easy answer to a lot of what’s going on. But you don’t give up. I mean, like I said, you play the hand that you’re dealt as best that you can.
Chris Kuchciak
Great. Rebekah, maybe I’ll turn to you next. Any final thoughts?
Rebekah Young
Yeah. I mean, I’ve learned a lot on the panel myself, and one thing I think my takeaway from an economic perspective is that perhaps our models for economics don’t capture everything they need to. For example, they don’t capture the value of a healthy society, and hence we don’t value proactive measures. So we’re always waiting until the patient is sick, until the patient is no longer able to live alone. Like we’re always waiting ’til it’s too late in a way. How do you actually create a system that values that health care or the proactive approach?
Also, how do you have a system that’s flexible to innovate? So how do you have, like, hundreds and thousands of little ideas sparking — Kim mentioned, many of us mentioned, specific examples. How do you foster those ideas and have the best ones surface to the top and foster them so that they can spread to other communities? And that we learn from ones, that there’s a tolerance for ideas that are tried, and we learn from them. They don’t necessarily succeed, but we shouldn’t banish or punish failures. We should actually learn from them. So how do we create that system of innovation?
And the final point would again be back to economics, and are we correctly valuing the caring economy? And so it was mentioned labour shortages, and particularly front-line workers in the health system, and support workers in long-term care homes, is that, are we reflecting what we truly value in what they do in the wages that they are paid?
So just a couple of thoughts that sparked in my mind as we were discussing today.
Chris Kuchciak
Dee-Jay, I’ll turn to you next. Final takeaways?
Dee-Jay King
Sure. I think we’ve heard some really good thoughts today about both the opportunities and some of the challenges in health care space. I want to leave on a positive note because I do think we have really great people in the health care space that are monitoring and analyzing the system on an ongoing basis. And I suspect that there are many of those folks watching today, that are in that space where they’re giving evidence to decision-makers or they’re part of small businesses or they’re consultants or in the private space.
So I guess kind of my parting thought is let’s ensure that we’re giving great evidence and giving great innovative ideas to decision-makers so we can maximize the outcomes that we’re getting from the dollars that we’re spending. And we’ve heard that over and over again today.
Chris Kuchciak
For sure. And, Kim, you get the last word. Please, your final takeaways.
Kim McGrail
Yeah. Thanks for all of this and I will start by saying I really agree with what my co-panellists have said, so I’ll just highlight a couple other things. And just really picking up on something Livio said: I think we can expect that change is going to be constant, so we really have to figure out how the system can be a learning health system, so we take this more as a smooth kind of change process rather than this kind of stair step, all of a sudden, things are wildly different at one time.
I think that another theme that came out of the discussion today is there isn’t one-size-fits-all and there really is some benefit in variation, whether that’s across regions or across people, as long as we can learn from it, and that goes back to this idea of being a learning health system.
And then the other is that I agree with this, we need really good decision-making and we need great evidence to inform decision-making, and I would just add, I think we need inclusive decision-making. I think we really need a lot of different viewpoints and stakeholders involved because there are different perspectives and ways of thinking about problems and solutions. And if we want to address the issues that, Chris, you raised at the beginning, all these issues of equity and access and outcomes that have been with us prior to the pandemic, then we’re going to need that inclusive approach coming out of the pandemic and beyond.
Chris Kuchciak
So I think with that, I’m going to wrap things up. I think we’re going to put up a poll on your screen for viewers to fill out, and we just want to get your feedback on some of the information that you’ll be using.
With that, I want to thank our panel for their outstanding insights. I want to thank you, the viewers. We didn’t get to all your questions, but I want to thank you for your presence here today.
A recording of this event will be made available in the next few days, and please circulate it amongst your colleagues who weren’t able to make it today.
If you’re interested in hearing more about this topic and others, you can check out CIHI’s new podcast available on Spotify, Apple and Google. There’s an evaluation form in the chat. Please give us your feedback to help us make these events better. And if you have more questions, you could always reach me at our email address, nhex@cihi.ca, that’s n-h-e-x-@-c-i-h-i-dot-c-a.
Want to thank you all again. Please keep in touch and have a great rest of your day. Thank you.
Livio Di Matteo
Thank you.