Politicians are always banging
on about smarter use of our healthcare resources. While
this sounds great on paper, before anything can get fixed,
reformers need to get their heads around how spending
decisions are really made.
Consider this real life quandary:
a promising treatment for autism, called Lovaas or applied
behavioural analysis, is available, but there's a catch
-- it's very expensive. Should it be covered by medicare?
When faced with that very question, the government of
British Columbia answered with a resounding "No." But
a BC court begged to differ -- invoking the Charter
of Rights and Freedoms to ensure access. Now, lawyers
from the federal government and seven provinces are
at the Supreme Court of Canada trying to overturn the
BC court decision.
Courting
disaster?
There's a very good chance the BC decision will be reversed
because policymakers fear it will open the floodgates
to court challenges by any Tom, Dick or Harry who wants
public coverage of a particular treatment. "The courts
can say you have to be reasonable in your denial of
a service and consider the evidence," says Colleen Flood,
assistant professor of law at the University of Toronto,
"but they're not a very good place in which to deal
with evidence about effectiveness and healthcare outcomes."
She thinks these court challenges can easily devolve
into a battle of the 'experts.'
In the past, it's proven difficult
to get the courts to add to the medicare basket. The
last successful Supreme Court challenge was the Eldridge
case in 1997, which ordered the BC government to pay
for sign language interpreters for deaf people accessing
health services.
So, if not in the courts, where
are coverage decisions being made? Professor Flood is
trying to get to the bottom of that mystery in a three-year
study called Defining the Medicare Basket. Funded by
the Canadian Health Services Research Foundation (CHSRF)
and the Ontario Ministry of Health and Long-term Care
and conducted by U of T's Health Law and Policy Group,
the study hopes to unravel who decides which medical
goods and services get publicly funded in Ontario. What
they've discovered so far probably won't set many minds
at ease.
Too
many cooks
In Ontario, the Physician Services Committee along with
medical consultants play a big role in deciding what
gets covered under medicare. As for the other stuff
in the healthcare basket, decisions are made by many
and sundry, like the provincial formulary committees,
the new national -- save Quebec -- Common Drug Review
(CDR) process, Cancer Care Ontario, as well as the various
hospitals and regional health authorities. But the Ontario
Medical Association is the most important decision-maker
at the moment. "Their decisions determine what happens
in hospitals, they determine the drug regime that will
accompany treatment and what diagnostics will be used,"
says Professor Flood.
The system remains desperately
fragmented, with many provinces re-inventing the healthcare
wheel. "There are so many levers of decision-making,"
she says, "and within their little spheres of influence
they have enormous impact on what's in and what's out
of medicare." But while each province ultimately decides
how to stock its own medicare basket, there are some
ongoing efforts to come up with a way to share the wealth
of knowledge used to make these decisions. The CDR,
for one, streamlines the provinces' drug listing resources
by studying cost-effectiveness centrally and then letting
the provinces decide what to do with the recommendations.
Their word carries a lot of weight. "A 'yes' from the
CDR means maybe," says Professor Flood, "and a 'no'
pretty much means no."
Professor Flood sees an urgent
need to broaden out the healthcare system so it covers
more than just physician and hospital services, while
getting rid of things that either don't work or bring
only scant benefits. "For example, there's no evidence
that annual general checkups bring any actual benefit,"
she says, "but we fund them while we don't have universal
access to insulin or childhood vaccinations."
Now there's a court challenge.
Defining the Medicare Basket
will be released in 2006. For more information, please
visit the project's website: www.law.utoronto.ca/healthlaw/basket
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