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The Alberta Association on Gerontology is pleased to be able to respond to the report, “A Framework for Reform” as well as the implementation plan of the Alberta Government as outlined in “Alberta: Health First – Building a Better Public Health Care System”.  There are some good suggestions in this report, which we support, but there are also some suggestions about which we have some concerns in terms of how they would affect older adults in the province.  One of the stated reasons for this committee’s work was the aging of the population and thus we feel it is critical that older adults’ needs be taken into consideration as the impact of the report’s recommendations is assessed.  We have chosen to structure our response around the ten specific sections of the reform document.

1.    Staying healthy.

We strongly support health promotion and health prevention strategies.  For some time there has been much information about maintaining health and preventing poor health, but few funds have been allocated for developing any real strategies supporting this purpose.  The strategies mentioned in the report are certainly worthwhile.

We would like to ensure that the government is aware of effective health promotion strategies that can be directed toward the aging in the population.  To cite just one example, Type 2 diabetes is becoming an increasing health care problem for older people.  A recent study from the National Institutes of Health has indicated that diet, exercise and weight loss can be very effective in reducing the incidence of diabetes.  This is particularly effective for those over age 60.  Although we believe that rising costs in health care have many causes, one of the concerns always mentioned in discussing rising costs is the aging of the population.  In view of this, we strongly suggest that older people in the population not be ignored as a target group that can benefit from many health promotion and prevention strategies if funds are allocated to this purpose.

2.    Putting the “customer” first.

We commend the report for recognizing the fact that the person who is ill should be the primary focus of the health care system.  However, it is important to remember that “customers” requiring health care differ from the customer who is looking for a car.  There is not a “Consumers Report” available to help people find the best procedure or the best personnel to provide a needed service.  Generally, when a person needs the services of a specialist, they do not have the time or the knowledge to be able to go out and choose their own specialist, or to direct their own treatment.

We believe that putting a limit on the waiting period to receive treatment is also a

good idea.  The waiting period of 90 days would of course not be suitable for all conditions.  Mention is made of certain selected health services, but how are the selections to be made?  There are conditions which are sufficiently severe that 90 days would be too long.  For other conditions, 90 days might not be necessary.  We propose that standards be determined for the appropriate waiting period that would be acceptable based on the individual’s condition.  These kinds of standards would need to be developed for both chronic and acute conditions.

The idea of a medical savings account for each individual in the province sounds like it would require an excessive amount of funds just to administer, without any evidence as to its effectiveness.  A few years ago, the Health Care Insurance Plan stopped sending people an account of expenditures made on their behalf because it was too expensive.  This concept seems to us to be equally as costly or more so.  Along with that is the fact that while people make decisions as to when they wish to buy a car, people do not choose to be ill, so we have little ability to control such things.  If we did get seriously ill under this system, we would soon be in debt to the health care system.  Those with low incomes would not be able to afford their illnesses, while others would be able to have unnecessary procedures such as cosmetic surgery.  We believe this would lead to much inequity in the system.  Would it still be within the tenets of the Canada Health Act?  It would seem to us that it could limit the accessibility of health care.

3.  Redefining Comprehensive.

This recommendation is difficult to carry out without affecting the accessibility of health care.  Great care needs to be taken in considering which services not to cover.  It is important not to lose services that help maintain health, including services that might not be considered strictly medically necessary.  These are services that are preventive and rehabilitative, and that help to promote continuing independence.

We are specifically concerned that home care be retained as a part of the system (including the non professional services) and that it be adequately funded.  The Broda report on continuing care recommends a policy of “aging in place”, and we support this suggestion, but we cannot see how this policy can be implemented without adequate support for home care.  Home care is a major factor in helping people with disabilities or frailties to maintain independence.  Maintaining independence will save money in the long run, as it will mean that people do not need a lot of expensive care in a facility.  Health maintenance services are important throughout the life course, but are particularly so among older adults.

We strongly recommend that the expert panel which will make decisions on which services are publicly funded include public representation, and that the target population for any service being reviewed have significant input to the panel.  These people have collective experiential knowledge which is not always within the scope of technical experts.  They are in fact experts themselves, but in the impact of the condition on their lives.

4.  Investing in Technology.

We need to determine what data now exist, and then to set up systems to analyze that data.    Ensuring a database is consistent throughout the health care system is necessary, but we must also make certain that the database provides information in such a way that accountability for the cost and quality of health care can be assessed.  This must apply to services delivered through both public and private systems.  When developing a database which can be used to measure quality of care and cost effectiveness, the privacy of patients must be of paramount concern.

A centralized booking system would indeed be helpful in reducing wait lists. It would also give potential patients a greater opportunity to exercise control in relation to their health care, but we must realize that this will only be useful to the technologically knowledgeable.  At present, this is only 20% of the senior population.  Other types of communication will always need to be considered for those who do not have the ability to access this information electronically.

While we fully support the use of technology as a diagnostic tool, we would like to see some effort made to ensure that it is used in an appropriate and effective manner.  Technology as a diagnostic tool is critical and necessary in certain conditions, but it is an expensive and unnecessary approach to diagnosis in other situations.

5.  Re-configuring the health system to encourage more choice, more competition and more accountability.

As stipulated in the Auditor General’s 2000/2001 report (page 113), “The Department and health authorities need better methods for understanding and forecasting health needs and costs, comparing these to what is affordable and sustainable, and articulating the impacts of any difference on the population and the health system”.  Health authorities need stable budgets to facilitate planning, and those budgets should also be approved at the beginning of the fiscal year, not when more than half of the fiscal year is over.  It is important that if health authorities are expected to stay within their budgets, then the budget must be an accurate reflection of the real needs and costs of the health care system.

We believe that choice in procedures needs to be available as long as it does not result in expensive duplication of services.  It is important to remember that, as mentioned previously, health care is not the same as buying a car.  Choice is limited in most instances because the treatment of health conditions generally is based on whatever is accepted as responsible and effective treatment for any one condition.  It would not support cost effective planning to generate many facilities all competing for clients for the same service.  This would result in costly advertising and promotion.  Options can be encouraged, but they should be evidence based.

While the development of specialized services can be more efficient and cost effective, and can also improve quality of care, there is no evidence that competition is needed to develop specialized services.  Already there are specialized services for children in both Edmonton and Calgary, and there is a specialized eye clinic at the Royal Alexandra Hospital in Edmonton, and specialized heart services at the University Hospital.  We have a specialty seniors’ clinic at the University Hospital in Edmonton, and a geriatric assessment unit at the Glenrose Hospital.  Specialized services have been developed in our present system, and will continue to develop with appropriate needs assessment and resource allocation.

A private health care service does not mean that it is more innovative.  The Capital Health Authority has the reputation across Canada for innovation, and the innovation in the system is not a result of private competition.  Management that encourages innovation is what is required.  Privately funded systems do not necessarily have an incentive to develop innovations that contribute to the quality of health care.  Private for-profit systems must, first of all, increase profits for shareholders, and they may be driven in a direction that will not increase quality, but may increase costs.  Research evidence does not demonstrate that private for-profit systems improve either quality or cost efficiency.

We support efforts to reform primary health care.  Providing services to older people is often more time consuming because health problems are frequently multi-faceted.  Vision and hearing problems as well as frailty can increase the time required.  A multidisciplinary approach is the most effective for treating the health conditions of all people, and certainly of older persons.  Also community health centres available on a 24 hour basis could result in less use of hospital emergency departments.

6.  Diversify the Revenue Stream.

The report states that “without fundamental changes in how we pay for health services, the current health system is not sustainable”. We are concerned about shifting payment for health care away from the tax-supported public insurance system, in which we all share the risks according to our ability to pay, to individuals.  This will result in penalizing lower income people and those who have high medical/health problems.  Although the “Framework for Reform” does not support a special tax, we believe that once accountability is achieved, any need for increased revenue may be achieved more effectively and fairly by having a special health surtax levied through the income tax system.  This would not be as costly to administer as some of the other revenue options, and would not put unfair strain on people in the lower middle income levels.

The report appears to target money as the main source of health care system  problems.  We believe that more money does not necessarily make a system better and certainly not more efficient, although an adequate level of resources is, of course, required.  We need to focus first on restructuring the system, on improving the processes by which quality can be measured, and developing greater accountability.

One of the major factors in increasing costs at present is the rising cost of drugs.  Controlling the cost of drugs would appear to be an important factor in reducing costs to the system.  This is a critical area of importance to seniors since they use a greater proportion of drugs.  Drug related complications among seniors are an additional significant cost driver that could be lowered with better drug monitoring/dispensing plans.  We understand that joint efforts are already underway by some of the provinces to look at ways of reducing the cost of drugs. We encourage these efforts.

Encouraging cooperation between the health care authorities is positive, as it will improve service to areas where the population is sparse, and will avoid unnecessary duplication.  Efforts to do this are already being made by some of the health authorities.  This should certainly be encouraged if not actually required by the Government.

The money to pay for the health care system already comes out of the pockets of the public.  We cannot see that diversifying the sources of revenue in the form of higher premiums, user fees, medical savings accounts and such approaches will make the system any more affordable.  It is still a fact that the money is coming from the pockets of individual Albertans.  This approach could even increase the costs of the health care system, because the administration of a program to collect costs from a variety of sources will be more expensive.

Recommendations to increase the use of insurance to cover additional services are of real concern to older people, since insurance companies tend to be reluctant to provide coverage to this group.  They are regarded as a greater risk, and coverage may be denied for certain age groups among the older population.  As in current situation relating to health coverage when traveling, older people are required to pay a premium that increases with age, and coverage may be excluded for certain conditions.  Insurance coverage is not considered by older persons to be a desirable approach to assuring them accessible, affordable quality care.  Furthermore, this would increase the overall cost of health care, because insurance companies have to make profits for their shareholders.

Since 40% of the senior population in Alberta receives at least partial supplement payments from the federal and provincial government, we do not believe that increases in premiums for seniors will increase government revenues to any appreciable extent. It will certainly increase financial pressures for those in the lower middle income brackets.  We need to be aware of the cumulative effects of fees, premiums and insurance payments for people in this income level as well as having concern about sheltering those with low incomes.

We do not support the idea of using health care facilities for revenue generation such as allowing individual health authorities to increase nursing home rates without a provincially set standard.  This could result in widely varying rates for nursing home care throughout the province.    Raising fees charged to better reflect actual expenditures for certain facilities might be appropriate, if within reason, but raising revenue for the system in this manner is not acceptable because of the inequities in access it could cause.

7.  Attracting, retaining and making the best use of health care providers.

There are some good suggestions in this section, but caution must be used.  We need to encourage teamwork using all professions effectively.  Capitation can cause discrimination toward the conditions and ages of patients that medical groups will accept under this arrangement.  Persons with costly or time consuming conditions, or persons in an advanced age group, may have difficulty finding anyone to provide care for them.  Very careful monitoring of actual costs is needed, again regardless of whether the service is delivered by a publicly or privately owned provider.

Developing multidisciplinary systems of caring for people is recommended.  We need more centres like the northeast health centre in Edmonton.  This type of centre encourages using specialties effectively, using a holistic approach which should improve the quality of care in a cost effective manner.

8.  Setting Standards, Measuring Results and Holding People Accountable.

We are not sure to what extent the health care system uses evidence based information, or accurate information on cost effectiveness that would enable anyone to make decisions about what services should be covered in the present system.  According to the 2000/2001 Auditor General’s report (Page 114), considerable effort needs to be made in reporting and measuring performance in the system.  Strategies, methods and systems to produce information for costing outputs or services are needed.  Better reporting is needed to ensure accountability in the health care system.

On page 116 of the Auditor General’s 2000/2001 report, two very specific recommendations are made regarding measures to strengthen accountability for “highly specialized medical interventions which are generally complex, highly technical, and costly.”  It is suggested that the Province collect information that “compares expected results with actual costs and explains significant variances, and that we establish relevant and reliable measurements of outcomes.”  The Alberta Heritage Foundation for Medical Research and the Institute of Health Economics have health technology units doing evidence-based  research, but the Auditor General’s report indicates that much more work needs to be done in determining quality of care in relation to costs of procedures.  A method for measuring all contributing factors must be developed throughout the system prior to trying to determine which services should be funded.

We need to direct more resources to support research units like these.

There is time to take the above suggested steps in developing a system which encourages greater accountability in health care.  The actual effects of an aging population is not expected to significantly impact the system until around the year 2011, and will not reach its peak until the year 2030 (“Apocalypse No:  Population Aging and the Future of Health Care Systems”, a research document produced by the Social and Economic Dimensions of an Aging Population research program).  We need to set up an evidence based, cost accounting system so that more accurate and effective planning can be done by those responsible.

We support developing a coordinated database.  This will be difficult in such a complex system as health care, and the difficulties will be increased in a system which in the future may encourage many privately funded and operated services.

Establishing an Outcomes Commission is desirable, but in order to be effective and free from conflict of interest, decisions made by this Commission should be evidence based, and the Commission should have public representation.   We doubt it can operate effectively and fairly until some of the above suggestions have been put in place.

We commend the recognition given to the Alberta Heritage Foundation for Medical Research and the universities in Alberta for stimulating much needed research.  We are pleased to see some recognition of the importance of research in maintaining good quality health care.

We would like to suggest that the Government of Alberta consider a proposal which has recently been submitted to Alberta Seniors to establish a funded Centre for Gerontology at the University for Alberta.  Such centres improve and stimulate the amount of helpful research that is needed to maintain and improve quality of care for older people.  In the long run such research can help to decrease costs to the system by determining care that is most effective.  Since a concern at present is funding a health care system for the aging population, we believe that establishing a strong Centre for Gerontology would be a worthwhile venture.  Centres for Gerontology promote good research as well as providing excellent educational resources.

9.  Recognizing and promoting Alberta’s Health Care Sector.

We have already mentioned throughout this paper the need for establishing accountability, and promoting research and education.  We support the concept of promoting Alberta as a leading centre of health care research.  We believe most of the suggestions in this section will happen naturally if we can develop an effective, cost efficient, comprehensive health care system that is accountable to the public and that provides good quality health care.

Developing partnerships can be a very effective way of avoiding duplication and of reducing costs.  Caution is needed to ensure there is no conflict of interest, and that the benefit of the patient is the most important factor.

10.  Establishing a transition plan.

We believe there are good suggestions in this section for developing a strong and effective system.  We are concerned, however, that there is no indication in this report of the need for public input and participation in all of these endeavours.  This is, after all, a health care system developed to provide care to the people of Alberta and it is supported by Albertans’ money.  They should be involved in implementing change, considering options and monitoring the impact of the system.