Monday, September 26, 2011

Preventative Health Care in Ontario: All Lips, no Hips

Preventative health care sounds groovy, like a gorgeous, different-tasting brownie -- if only we had some, we’d all feel better. But GPs don’t want to educate themselves, medical schools don’t teach it, the government doesn’t want to pay, and judging by my GP’s and other medical pros’ reactions, most people exercise a collective yawn in the face of diet and exercise suggestions.

The problem with preventative health care begins in medical school where lip service is paid to nutrition and exercise. It reminds me of what I learnt in psychology: psychology teaches you about healthy minds, not just unhealthy, so you can recognize good health and help those with poor mental health. Psychiatry looks only at unhealthy.

Governments refuse to pay GPs for the time required to look after those of us with chronic illnesses. The Ontario government figures twenty bucks ought to cover the hour needed to discuss the multiplicity of problems, test results, emotional fallout, and how to continue on. And so many GPs don’t spend the time, and patients suffer. And as much as the government doesn’t support chronic care, they definitely don’t pay GPs for the time needed to explain and persuade people why they need to stop smoking, eat better, exercise, stop drinking, or get help for drug addiction, to name a few preventative steps. Five minutes comprising “lose weight and come back in six months” or “sorry, you’ll have to wait a year to get help for that drug addiction problem” don’t cut it.

Governments don’t seem to like paying upfront for these sorts of things though. It’s hard on the bottom line and because the payoff isn’t easily quantified in the ledger -- eg, $100 for GP to explain cholesterol test results and teach diet, exercise, and drug solutions, then $100 back in work no longer being lost, 100 hours extra time spent volunteering or playing with kids, $1000 saved in not spending future taxes on cardiac care (these numbers are purely representative) -- it’s easier for short-term thinking governments not to program for long-term savings.

But just paying GPs properly is insufficient. You still have the whole issue of GP education and people being able to afford healthy food, never mind taking courses on how to cook better or learning how to exercise. Then there’s the conundrum of how do you motivate and keep people motivated?

Neil Seeman has an intriguing idea. Heathy living vouchers.

We know that in this age of cheap, plentiful food, one way of reducing obesity is to strip away personal responsibility entirely. The only country that publicly boasts a total absence of obesity among the general population is North Korea, likely the result of gross malnutrition under the stranglehold of dictatorship and communism. Those sentenced to controlled environments — long prison terms, for instance — tend to lose weight, too. But that’s obviously not a path down which freedom-loving Canadians likely want to go.” (Neil Seeman, Director of The Health Strategy Innovation Cell at Massey College, University of Toronto in The National Post, 27 January 2011)

Yet the way governments and people go about it here in the free world, there is a sort of finger-waggish, there’s only one way to do it feeling about it. There’s little acknowledgement of the individual obstacles people face. Sometimes it’s emotional eating, and so the person needs mental health care first. Sometimes it’s a slow metabolism, so they need much encouragement to exercise a lot. And sometimes, like with me, brain injury created exercise intolerance and so that has to be managed at the very least and improved upon before any weight loss strategy will work.

An HLV is an annual sum of money for every person 16 years and older — probably about $5,000 in Canada — to spend on healthy-living options that are agreed to by the person and his or her primary care provider. The money comes from a 2-4% slice off the provincial budget. The money can be applied only to options approved by a self-governing (non-state) regulatory college representing all members of qualified health professionals.

To use the voucher, the patient would need to satisfy certain conditions, including close co-operation with a primary care provider to make sure the HLV is working. Through specialized billing codes, the primary care provider (in a public, private, or semi-private funding system) would be rewarded for participating in healthy-living counselling. Through online and face-to-face interactions, the patient is held accountable; otherwise he or she loses the voucher.

Vouchers can be highly varied in their offerings, including private nutrition counsellors, or personal digital assistants for diabetes self-monitoring. This is very different from small-scale tax credits that can only be narrowly applied for things such as sports activities
.” (Neil Seeman, The National Post, 27 January 2011, the full article is worth reading)


Innovative approaches with much thought and research behind it are what the four parties ought to be looking at in this election. There’s lots of talk about the importance of health care from them but nothing that’s going to change Ontario and Canada’s obesity epidemic. So we shall all truck along as before with the very wealthy buying their preventative health care and the very poor buying their only affordable food: Big Macs.

No comments: