Castonguay has some good ideas for fixing medicare

Government should take a careful look at health-care recommendations

Commission Castonguay

The report of Claude Castonguay's working group on health-care financing was released last week to a great hue and cry across Quebec. In the rush to sink the report like a stone, we might be overlooking the fact that a good portion of it actually addresses the organizational aspects of the health-care system. Regardless of where they stand on the issue of health-care privatization, most Quebecers would agree that organizational reform is very much needed.
Take the reaction of Health Minister Philippe Couillard. While he immediately distanced the government from the more controversial aspects of health- care financing - both the imposition of user fees and the widening of private markets in health care - Couillard did agree that the system could better maximize productivity and improve its performance. Even Michel Venne, the PQ appointee to the working group who refused to endorse the call for private health care, stood behind these organizational recommendations that went beyond the working group's mandate on financing.
How could the Castonguay report help in this regard?

First would be the recommendations on information technology. The working group was unanimous in suggesting that new information technologies for patients and administrators constitute an "essential tool" for improving productivity and efficiency in the health-care system. Even though Quebec has relatively lower administrative costs than, say, the U.S., the amount of paper that has to be pushed to find out about a person's medical history, the number of diagnostic tests that have to be performed and often repeated, and the lack of a system to collect and collate essential health data, are all jeopardizing the organization and delivery of care. This adds unnecessary costs, overtaxes available resources,and increases risks to the population's health.
Health-care systems around the world are recognizing this essential challenge, but it comes at enormous cost. The British, for example, have poured billions of pounds into information technology over the past few years. Castonguay's recommendations for pilot projects are arguably a good way to address the issue.
The report also suggests better continuity of care and more investment in primary care and home care. If these sound familiar, it is because they have been talked about in health-care circles for years. Even though Castonguay himself roundly castigated Roy Romanow's 2002 report as "demagogy and foolish comment," the emphasis on the need for better access points into the health care system and for more support for care outside the hospital setting - more precisely, in the home - were central points of the Romanow report.
The concern over continuity of care is at the heart of primary health-care reform in Quebec and across the other provinces as well. Even though the Quebec health-care system was supposed to be based on a vision of integrated care, in practice, we have come to rely far too much on specialists, walk-in clinics and emergency rooms for the kind of care that could be provided much more cost-effectively in other settings. The reason we all need a primary-care doctor is because any efficient health-care system needs a reliable point of access to ensure appropriate treatment and continuity of care.
Then there are the matters of governance and the allocation of resources in the health-care system. Even though the Castonguay report emphasizes the need for "national" objectives, it also suggests that the top-down and overly bureaucratized approach to health-care organization needs to change.
While every health-care provider and administrator in Quebec might be cringing at the thought of yet more prescriptives for reorganization, Castonguay's suggestions for rationalizing regional agencies and allowing for more autonomy in their functioning are important points to consider.
More problematic, perhaps, is how to put into practice this reallocation of resources. Again borrowing from recent British reforms, the report suggests that money should "follow the patient" through the system instead of being allocated to health-care establishments on the basis of rote budgeting. This means that performance of different health-care settings - hospitals, clinics and the like - would matter as money would flow where patients choose to go.

There is already a measure of this in our fee-for-service system, as patients choose (if they can) a health-care provider and are then referred to others or to a hospital setting. But Castonguay is suggesting that even hospitals be financed along performance criteria, and be allowed to have more leeway in purchasing services, thus injecting new measures of competitiveness into the health-care system.
Castonguay himself emphasized the financing aspects of his recommendations and it is clear that he really believes in increasing the scope of private markets in health care. Still, the other recommendations in the report show that there is plenty of scope - and hope - for reform of the public system without dismantling it altogether.
Ironically, the lasting legacy of the report of the working group on health- care financing might not be about new sources of private funding but rather about innovative ways to reorganize the existing public system.
Antonia Maioni is visiting scholar at the McGill Institute for Health and Social Policy.

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