|
BP-350E
THE HEALTH CARE
SYSTEM IN CANADA:
EFFECTIVENESS AND EFFICIENCY
Prepared by Odette Madore
Economics Division
October 1993
TABLE
OF CONTENTS
INTRODUCTION
EFFECTIVENESS
AND EFFICIENCY: CONCEPTS AND DEFINITIONS
THE SITUATION:
INFORMATION AVAILABLE
CONCLUSION
SELECTED BIBLIOGRAPHY
THE HEALTH CARE
SYSTEM IN CANADA:
EFFECTIVENESS AND EFFICIENCY
INTRODUCTION
Controlling health care
expenditures has for several years been a political objective in Canada.
The provincial governments already allocate a considerable portion (approximately
one-third) of their budgets to health care. The difficult economic situation,
combined with the freeze on federal Established Program Financing (EPF)
transfer payments, has tightened the financial restraints on provincial
governments. In fact, public health care expenditures have reached a threshold
that, politically, seems difficult to cross.
From this perspective, many
authors have addressed the so-called funding crisis in Canada's health
insurance system and the fact that it may become impossible to preserve
national health care principles such as universality and free access.
More and more, the way that health care costs are shared between the public
and private sectors is being called into question. Indeed, some observers
claim that the list of services now considered medically necessary and
covered by the public systems must be reviewed, or user fees imposed.
On the other hand, others
maintain that controlling health care costs does not require increased
private-sector participation in funding health care but, rather, a more
effective and efficient health care system. They argue that the delivery
of appropriate and clinically and economically effective health care services
contributes to the efficiency, or performance, of the health care system.
Effective care in an efficient system makes it possible, first, to make
optimum use of available financial resources and, second, to deliver universal,
high-quality services.
In this paper, we discuss
some theoretical and practical aspects of effectiveness and efficiency
in health care. After defining those concepts, we go on to list some health
services that, in practice, are considered ineffective, and to examine
the solutions being considered to remedy the situation.
EFFECTIVENESS
AND EFFICIENCY: CONCEPTS AND DEFINITIONS
Effectiveness and efficiency
are two concepts that add an economic dimension to health care. Applying
economic theory to health care is an effort to address the issues of allocating
physical, human and financial resources and setting priorities in the
budget decision-making process. The first issue, related to the concept
of efficiency, is to determine the optimum amount to be allocated to health
care; this depends on the extent of resources to be allocated to meeting
society's other needs. In addressing this issue, we must make a choice:
what portion of the budget is to go to health care and what portion to
other, equally important, public investments such as education, job creation,
and research and development? The second issue, also related to efficiency,
is how to allocate resources among the various components of health care,
for example, preventive care, curative care and medical research. The
third issue is to identify activities considered effective and for which
funding assistance is to be provided, taking into consideration the limitations
determined and priorities set in addressing the two preceding issues.
Before assessing the system's efficiency from a macroeconomic point of
view, we should identify the activities that are effective from a microeconomic
perspective.
Effectiveness
is the relationship between the level of resources invested and the level
of results, or improvements in health. Assessing effectiveness consists
of measuring the effects of medical practices and techniques -- therapeutic,
diagnostic, surgical and pharmacological -- on individuals' health and
wellbeing. This must take into consideration not only observed improvements
in health but also negative impacts, such as side effects and iatrogenic
effects.(1)
In its pure form, assessing
effectiveness compares two things that have the same effect or the same
purpose. If two drugs are each used to treat a particular illness, the
more effective drug will be the one that treats the illness more quickly
with fewer side effects; it is called the more clinically effective drug.
The economic dimension of
effectiveness introduces the concept of cost, and thus refers to cost-effectiveness
and cost reduction. For example, if two drugs have the same effects in
all respects (the same duration of treatment and the same side effects),
the more economically effective drug is the one that costs less.
Broadly applied, effectiveness
combines both the clinical and economic aspects of health care. Assessing
effectiveness makes it possible to determine the medical practices and
techniques that, first, actually help improve health and, second, make
good use of resources. Since resources allocated to health care are limited,
only effective practices and techniques should be used.
As a corollary, the clinical
and economic assessment of health care allows us to determine which services
are ineffective or inappropriate. A service is considered clinically ineffective
if it does not have the desired effect, such as treating or detecting
illness or improving health. A service is considered economically ineffective
if it produces only a minimal improvement in health for its cost. A medical
procedure is considered inappropriate if it has no beneficial effects,
or even has undesirable effects, on the patient's health. Health care
expenditures can be controlled better when we stop funding inappropriate
or ineffective services.
Assessing effectiveness
is not limited to comparing two similar things, such as two drugs or two
diagnostic tests; it can also be applied to different fields. For example,
we can compare the cost of prevention with the cost of using drugs,(2)
home care with hospital care,(3)
care by a physician with care by another health professional,(4)
or a new technique with existing medical practices.(5)
Assessing effectiveness
is sometimes easy and sometimes difficult. For example, the choice between
an expensive drug and a low-cost drug is fairly clear when the effects
are expected to be essentially the same. The choice is more complicated,
however, when a lower-cost drug entails longer treatment or has more side
effects. Such a choice cannot be made on economic criteria alone. That
is why clinical and economic assessment must both be applied in assessing
effectiveness. Effectiveness in the health care system continues to have
two elements: the greatest possible improvement in health at the best
possible cost.
Efficiency,
a much broader concept, is the relationship between the level of resources
invested in the health care system and the volume of services, or, what
amounts to the same thing, improvements in health achieved.(6)
The purpose of efficiency is to maximize results effectively, or services
delivered, given a particular budget. According to this concept, each
service must be delivered at the lowest possible cost, have benefits of
value equal to or greater than its cost, and make optimum use of the resources
invested. Efficiency is distinct from effectiveness in that it considers
costs in relation to benefits.
Assessing the efficiency
of medical treatments and techniques makes it possible to set priorities
when allocating resources. For example, let us assume that the government
has a budget of $1 million to purchase drugs proven to be effective
against fatal illnesses.(7) Let us also assume that, in the opinion of
experts, 50 lives could be saved if this entire budget were spent on drug A,
but 100 deaths could be prevented if it were spent on drug B. Which drug
should the government purchase? According to efficiency criteria, the
government should spend its budget to purchase drug B, whose benefits
-- the number of lives saved -- are higher. Although in this example we
are comparing costs in dollars and benefits in numbers of human lives,
benefits are often quantified in monetary terms.(8)
Assessing efficiency is
not limited to clear-cut benefits, however; in fact, we must take marginal
benefits into consideration. Let us return to the example of drug A and
drug B, assuming this time that the government has a budget of only
$500,000. In the opinion of experts, 40 lives could be saved if this entire
budget were spent on drug A, but 80 lives could be saved if it were spent
on drug B. Here again, the government should give priority to drug B.
However, in light of this most recent information and from the perspective
of efficiency, if the government's budget were increased to $1 million,
would it be better to spend the entire budget to purchase drug B and prevent
100 deaths, as initially proposed in the first example? Obviously not.
If the government purchased only drug B, the additional $500,000 would
save only 20 additional lives. If the government used the additional $500,000
to purchase drug A, however, it could save 40 additional lives. Overall,
then, it would be more efficient to allocate the budget equally between
drug A and drug B. By doing so, the government would prevent a total of
120 (40 + 80) deaths, while by purchasing only drug B, it would save only
100 lives; by adopting the former solution, the government would maximize
results.
Assessing efficiency helps
us when choices must be made from various medical practices and treatments.
Marginal benefits must always be taken into consideration. Is the marginal
efficiency of treatment A greater or less than that of treatment B? Or
must a choice be made between the present and the future? For example,
is it better to allocate more money to treatment of an illness or to research
to find a complete cure for it? Assessing efficiency is an effort to compare
the costs and benefits for society as a whole and to highlight the economic
effects of public expenditure options so that governments can ascertain
which additional investments maximize net benefits.
We must also accept the
fact that efficient allocation of resources grows out of a choice that
will always have moral and societal dimensions. Should money be invested
in equipment to treat rare cases, or in preventive programs that benefit
thousands of people? What priority should be given to services that do
nothing to alter the course of an illness but improve the quality of life?
Should priority be given to services for children, or services for senior
citizens; to physical, or mental problems? Why are some individuals rather
than others selected to receive a particular treatment? Answering these
questions will always be difficult. Along with clinical and economic concerns,
ethical considerations should be part of the budget decision-making process.
Efficiency could also be
assessed from a macroeconomic perspective in an effort to determine the
proportion of resources to be allocated to health care. In this case,
however, it is obviously easier to define a theoretical criterion of macroeconomic
efficiency in health care than to demonstrate what is or is not, in current
practice, optimum allocation of health care resources at a cost considered
acceptable for society. No one has yet determined the optimum proportion
of resources or the ideal percentage of the Gross Domestic Product (GDP)
that governments should allocate to health care expenditures. There seems
to be no standard, as is shown by the variation in proportions of GDP
allocated to health care, and the importance of the public health care
sector, in various countries. Which country has the ideal system? There
is no real answer to this question. According to Evans, "There is
... no basis, in the international experience, for concluding that one
form of organization or finance has `worked' and shown a conclusive superiority
over the others."(9) In Evans's opinion, countries have not paid
enough attention to effectiveness or responsibility in health care funding;
he therefore concludes that "despite their diversity, health care
systems have all evolved without mechanisms to assure accountability for
the effectiveness, efficiency and appropriateness of care provided."(10)
THE SITUATION: INFORMATION
AVAILABLE
It is anticipated that Canada,
like several other countries, will pay more attention in future to effectiveness
and efficiency in order to streamline its health care system. According
to a study published by the Organisation for Economic Co-operation and
Development (OECD):
We are entering an age,
therefore, where questioning will be axiomatic in health care provision.
New techniques will no longer be universally implemented without evaluating
value versus costs. Even common procedures will come under more intense
scrutiny as the need for justification increases.(11)
This trend toward more systematic
assessment of effectiveness and efficiency is justified from four points
of view. First, greater effectiveness and efficiency alleviate some funding
problems of public health insurance systems; second, more effective delivery
of services directly improves their quality; third, more effective health
care directly contributes to improvements in health; fourth, effectively
delivered health care makes the system more efficient.
However, there are some
barriers to systematic assessment of the effectiveness and efficiency
of health care. Although economic theory offers some useful tools, Canada
does not always have enough information to carry out such assessments.
The scarcity of indicators for measuring improvements in health and the
shortage of information on the effects of medical treatments make it difficult
at present to assess the effectiveness of care and the overall performance
of the health care system.
First, there are few ways
to measure improvement in health following medical treatment, so the effects
of the health care system are still often unknown. One reason is that
it is not always easy to dissociate the effect of the treatment itself
from the effects of other influences. Indeed, health depends on a great
many interrelated factors, and we are not able to ascertain unequivocally
the specific influence of health care on health.(12) Another reason is that we have no bank of
information on patients who have received treatment. For example, it is
often impossible to assess the effectiveness of hospital care because
there is no follow-up after the patient leaves the hospital. Some writers
even suggest that is impossible to measure the cost-effectiveness of hospital
care:
[...] the accounting approach
now used in funding nearly all [hospital] operations, does not let us
know how effectively the resources invested in hospitals contribute
to results in terms of health and wellbeing. It is pointless to produce
effectively something useless or something that could be produced under
different conditions. Although present information systems give us partial
information about the services produced, they say nothing about results.
[translation](13)
Second, we still know little
about the effectiveness of medicine and even less about the cost-effectiveness
of many treatments. According to former Minister of Health and Welfare
Benoît Bouchard, the cost-effectiveness of 70% of new medical techniques
has not been assessed.(14)
Despite the lack of data,
there is some information on the ineffectiveness of certain drugs, diagnostic
tests and surgical operations, which we summarize below.
A number of studies call
into question the clinical and economic effectiveness of drugs. Rheault
states that nearly half the drugs now on the market in Canada have never
been assessed: "of the 3,500 types of drugs now available in Canada,
1,500 were put on the market before 1963, before systematic assessments
began" [translation].(15)
Worldwide, some 100,000 different drugs exist, of which the World Health
Organization (WHO) considers only 270 to be essential.(16)
Some observers are also
concerned about certain prescription drugs. For example, international
comparisons show that for patients with throat and ear infections, Canadian
physicians prescribe antibiotics more often than do their counterparts
in various European countries. It seems, however, that the treatment period
is approximately the same, with or without antibiotics. Similarly, Canadian
physicians tend to prescribe drugs for patients with colds, although such
drugs are unnecessary. It seems that physicians seek to respond to the
demands of their patients, who insist on these drugs. Ontario spends approximately
$200 million in physicians' fees each year to treat patients with
colds.(17)
Some diagnostic tests and
medical examinations are also being called into question. For example,
Gibson considers that cholesterol-level tests and treatments for high
levels of cholesterol are out of control in North America. In his opinion,
the benefits of these tests and treatments are minimal and sometimes unproven.
He also claims that ultrasound tests during normal and low-risk pregnancies
are probably of no benefit; in Ontario, however, an average of two ultrasound
tests are performed during each pregnancy. Gibson recognizes that women
patients often demand these tests and that ultrasound is now recognized
as a routine medical practice.(18) The annual estimated cost
of ultrasound tests in Ontario is some $25 million.(19)
Gibson also thinks that too many X rays of minor injuries and too many
mammograms are being performed. He also considers that medical examinations
of healthy babies could be performed more economically by nurses adequately
trained in this field. Lastly, he states that several procedures forming
part of the traditional annual medical examination have no proven benefits.(20)
Finally, other observers
consider that the rate of certain surgical operations in Canada is too
high in comparison with that in other countries. Rheault notes: "It
is interesting to note that the WHO considers a Caesarian section rate
of between 10 and 12% acceptable. The rate in Quebec is 19%. Let us add
that the episiotomy rate considered acceptable by the WHO is 20%, while
the rate in Quebec is 64.7%" [translation].(21)
In Rheault's opinion, some medical practices have proven to be completely
ineffective and very expensive:
In Manitoba, a team of
researchers studied 2,000 patients who had had their gall bladders removed.
The study showed that more deaths resulted from gall bladder removal
than from not having this operation performed. In 1983, 50,000 gall
bladder removal operations were performed in Canada at a cost of between
$75 million and $100 million. If lost working days and deaths resulting
from the negative effects of these operations are included, annual costs
amount to $200 million. [translation](22)
Similarly, an article indicates
that 40% of back operations are of no use, since the problems could be
solved without surgery. This article also points out that some surgical
operations such as hysterectomies, coronary artery bypasses and cataract
operations are not always necessary.(23)
Examples of ineffective
health care are not limited to strictly medical treatments. There is also
ineffectiveness in management of the public health insurance system. For
example, according to a report prepared by the Ontario Ministry of Health,
nearly $1 billion is paid out on health care as a result of fraud.(24)
According to this report, there are several forms of health care fraud:
some persons use health insurance cards illegally; over 100,000 persons
have two health insurance cards; nearly 500,000 health insurance card
users are not eligible for the public health care system; some patients
use the health insurance cards of deceased persons; and some social assistance
beneficiaries evidently profit from the drug insurance system by reselling
their drugs on the black market.
Overall, experts agree that
making Canada's health care system more effective requires participation
by patients, physicians and governments. Gibson, for example, argues as
follows:
Physicians, patients and
government must all share the blame for what's wrong with Canadian health
care. Much of what is being done is wasteful and/or useless -- many
"treatments" have never been properly studied to know whether
they are effective or harmful.(25)
Various solutions have been
suggested for making health care and the health care system more effective.
Patients must be clearly informed which services are effective, so that
they do not exert inappropriate pressure on physicians to give them a
service or drug that will not improve their health. It also seems that
physicians should be given better information about the clinical and economic
effectiveness of medical treatments, without calling into question their
hard work in improving health and saving lives. It is generally acknowledged
that decisions about effectiveness should not rest on the shoulders of
individual physicians but, instead, be made by a monitoring and follow-up
organization. Lastly, governments have an important role to play in disseminating
information to patients and physicians.
In this regard, some provincial
governments have found innovative solutions to problems of ineffectiveness
and inefficiency. For example, the Manitoba Medical Review Committee has
been responsible for reviewing methods of medical practice for several
years in order to prevent and control "inappropriate service delivery"
(defined as being a volume of services higher than the provincial average).
This Committee asks physicians who seem to be delivering superfluous services
to reduce the volume of the services they deliver. The physicians' methods
of practice are then reviewed for several years in order to ensure that
they are following the Committee's guidelines. It seems that the Committee
has been effective in reducing excessive use of full or partial examinations,
diagnostic tests, special calls and house calls. Indeed, a study carried
out between 1984 and 1988 reported a decrease in the number of services
delivered, a decrease that was not offset by increases in other services
or in the number of patients. It is estimated that reviewing methods of
practice has saved more than $2 million over a four-year period.(26)
Similarly, Saskatchewan's
Health Services Utilization and Research Commission publishes guidelines
for medical personnel. Last year the Commission studied the cost-effectiveness
of thyroid tests and then published guidelines limiting excessive use
of such tests.(27) In its
report, the Commission indicates that the number of thyroid tests decreased
by approximately 30% after the guidelines were published.(28) It is estimated that this reduction in the
number of thyroid tests has saved some $1 million.(29)
In British Columbia, the
government and representatives of the medical profession have reached
an agreement in principle that should save $370 million in health care
costs over a five-year period. The purpose of this agreement is to limit
abuse of the system and make care more effective. Physicians are to participate
in an education program to inform and encourage the public not to make
excessive use of the health care system. It is the patient who demands
a test that the physician considers unnecessary, rather than the public
health insurance system, that must pay for the test. Secondly, physicians
are to help set up a process to review methods of practice and thus identify
excesses. Physicians not complying with the guidelines are to bear the
costs themselves.(30)
At their 1993 annual meeting,
the federal, provincial and territorial Ministers of Health agreed to
consider the possibility of establishing national guidelines on methods
of medical practice.(31)
CONCLUSION
In this paper, we have theoretically
defined the concepts of effectiveness and efficiency in health care and
suggested that effectively delivered services make the system more efficient.
In practical terms, we have seen that greater effectiveness and efficiency
require proper use of resources, appropriate delivery of care and sound
management of public health care funds. Since greater effectiveness and
efficiency encourage proper use of financial, physical, and human resources,
they help control health care costs. It seems difficult, if not impossible,
to determine the optimum level of expenditures that should be allocated
to health care; however, by using economic analysis, we can ensure that
the budget is allocated to the most effective components of the system.
Some provinces have already begun to meet the challenge of funding their
health care systems by making them more effective and efficient. We must
encourage the other provinces to do likewise.
SELECTED BIBLIOGRAPHY
Associated Press. "Study
Finds Routine Ultrasound Unnecessary for Most Pregnancies." The
Gazette (Montreal), 16 September 1993, p. B-1.
Bouchard, Benoît. Speech.
Hamilton Spectator, 14 May 1993, p. A-9.
"Campaign Launched
Against Harmful, Ineffective Drugs." Toronto Star, 18 September
1993, p. F-8.
Contandriopoulos, André-Pierre,
Anne Lemay and Geneviève Tessier. "Les coûts et le financement du
système socio-sanitaire." Programme de recherche: recueil de résumés.
Gouvernement du Québec, Commission d'enquête sur les services de santé
et les services sociaux, 1988, p. 372-373.
Culyer, Anthony J. Health
Care Expenditures in Canada: Myth and Reality; Past and Future. Canadian
Tax Paper No. 82, Canadian Tax Foundation, 1988.
Evans, Robert G. "Health
Care Reform: The Issue from Hell." Policy Options, Vol. 14,
No. 6, July-August 1993, p. 35-41.
Feeny, D., Gordon Guyatt
and Peter Tugwell (eds.). Health Care Technology: Effectiveness, Efficiency
and Public Policy. Canadian Medical Association and Institut de recherches
politiques, Montreal, 1986.
Francis, Diane. "Ontario
Health System Open to $980 M in Fraud." Financial Post (Toronto),
6 August 1993, p. 4.
Füller, A., V. Schumann
and U. Laaser. "Attitude and Behaviour of Stuttgart's Primary Care
Physicians with Regard to the Pharmacological and Non-Pharmacological
Treatment of Mild Hypertension." Costs and Benefits in Health
Care and Prevention: An International Approach to Priorities in Medicine.
Conference on Cost-Benefit Analysis in Health Care. Berlin, Heidelberg,
Springer-Verlag, 1990, p. 41-50.
Gibson, Dr. Gary. "Doctors
Must Choose the Way to Go." Globe and Mail (Toronto), 18 June
1993, p. A-17.
Government of Saskatchewan,
Health Services Utilization and Research Commission. Follow-Up Report:
Thyroid Testing Guidelines. August 1993.
Heller, Linda. "When
to Say No to Surgery." Chatelaine, October 1993, p. 99-100.
McPherson, Klim. "International
Differences in Medical Care Practices." Health Care Systems in
Transition: The Search for Efficiency, Social Policy Studies, No. 7,
OECD, 1990, p. 17-29.
Mickleborough, Rod. "$1
Million to be Saved by Cuts in Thyroid Tests." Globe and Mail
(Toronto), 31 August 1993, p. A-1 and A-2.
Modan, M., Z. Fuchs and
J.B. Rosenfeld. "Evaluation of Cost-Effectiveness of Physician-Nurse
Teams as Compared to Physicians Working Alone in Primary Care Practices
in Community Control of Hypertension." Costs and Benefits in Health
Care and Prevention: An International Approach to Priorities in Medicine.
Conference on Cost-Benefit Analysis in Health Care. Berlin, Heidelberg,
Springer-Verlag, 1990, p. 57-71.
Rheault, Sylvie. Financement
des services de santé: Défis pour les années 90. Conseil des affaires
sociales, Quebec, 1990.
Shapiro, Evelyn. "There's
No Place Like Home." Restructuring Canada's Health Services System:
How Do We Get There From Here? Fourth Canadian Conference on Health
Economics, Canadian Association for Research on Health Economics, University
of Toronto Press, Toronto, 1992, p. 99-104.
Wahn, Dr. Michael. "Controlling
Overservicing by Physicians: Review of Office Practices in Manitoba."
Canadian Medical Association Journal, Vol. 146, No. 5,
1 March 1992, p. 723-728.
Walker, Robert. "Physician
Resource Plan Seen as Priority: Guidelines to be Shared by Other Provinces."
Medical Post, 28 September 1993, p. 1 and 37.
Weissert, William G. "Cost-Effectiveness
of Home Care." Restructuring Canada's Health Services System:
How Do We Get There From Here? Fourth Canadian Conference on Health
Economics, Canadian Association for Research on Health Economics, University
of Toronto Press, Toronto, 1992, p. 89-98.
Wilson, Deborah. "BC
Pact on Health Care Counts on Major Savings." Globe and Mail
(Toronto), 1 September 1993, p. A-5.
Working Party on Testing
Strategies on Thyroid Disease. Report Presented to the Task Force on
the Use and Provision of Medical Services. January 1992.
(1) Sylvie Rheault, Financement des services
de santé: Défis pour les années 90, Conseil des affaires sociales,
Government of Quebec, 1990, p. 104.
(2) A. Füller, V. Schumann and U. Laaser, "Attitude
and Behaviour of Stuttgart's Primary Care Physicians with Regard to the
Pharmacological and Non-Pharmacological Treatment of Mild Hypertension,"
Costs and Benefits in Health Care and Prevention: An International
Approach to Priorities in Medicine, Conference on Cost-Benefit Analysis
in Health Care, Berlin, Heidelberg, Springer-Verlag, 1990, p. 41-50.
(3) Readers may consult William G. Weissert,
"Cost-Effectiveness of Home Care," a summary of 27 American
studies, p. 89-98, or Evelyn Shapiro, "There's No Place Like
Home," a Manitoba study, p. 99-104, in Restructuring Canada's
Health Services System: How Do We Get There From Here? Fourth Canadian
Conference on Health Economics, Raisa B. Deber and Gail G. Thompson
(eds.), Canadian Association for Research on Health Economics, Toronto,
University of Toronto Press, 1992.
(4) For example, see M. Modan, Z. Fuchs and
J.B. Rosenfeld, "Evaluation of Cost-Effectiveness of Physician-Nurse
Teams as Compared to Physicians Working Alone in Primary Care Practices
in Community Control of Hypertension," Costs and Benefits in Health
Care and Prevention: An International Approach to Priorities in Medicine,
Conference on Cost-Benefit Analysis in Health Care, Berlin, Heidelberg,
Springer-Verlag, 1990, p. 57-71.
(5) D. Feeny, Gordon Guyatt and Peter Tugwell
(eds.), Health Care Technology: Effectiveness, Efficiency and Public
Policy, Canadian Medical Association and Institut de recherches politiques,
Montreal, 1986.
(6) Rheault (1990), p. 2.
(7) Other interesting examples are given in:
Conference on Cost-Benefit Analysis in Health Care, Costs and Benefits
in Health Care and Prevention: An International Approach to Priorities
in Medicine, Berlin, Heidelberg, Springer-Verlag, 1990; Anthony J.
Culyer, Health Care Expenditures in Canada: Myth and Reality; Past
and Future, Canadian Tax Paper No. 82, Canadian Tax Foundation,
1988, Chapter 5.
(8) In a given budget, when both costs and benefits
are measured in monetary terms, priority must be given to projects or
activities with higher unit cost-benefit ratios.
(9) Robert G. Evans, "Health Care Reform:
The Issue from Hell," Policy Options, Vol. 14, No. 6,
July-August 1993, p. 36.
(10) Ibid., p. 39.
(11) Klim McPherson, "International Differences
in Medical Care Practices," Health Care Systems in Transition:
The Search for Efficiency, Social Policy Studies, No. 7, OECD,
1990, p. 17.
(12) André-Pierre Contandriopoulos, quoted
in Sylvie Rheault (1990), p. 104.
(13) André-Pierre Contandriopoulos, Anne Lemay
and Geneviève Tessier, "Les couts et le financement du système socio-sanitaire,"
Programme de recherche: recueil de résumés, Commission d'enquête
sur les services de santé et les services sociaux, Government of Quebec,
1987, p. 372-373.
(14) Benoît Bouchard, Speech, Hamilton Spectator,
14 May 1993, p. A-9.
(15) Rheault (1990), p. 108.
(16) "Campaign Launched Against Harmful,
Ineffective Drugs," Toronto Star, 18 September 1993,
p. F-8.
(17) Dr. Gary Gibson, "Doctors Must Choose
the Way to Go," Globe and Mail (Toronto), 18 June 1993,
p. A-17.
(18) Ibid.
(19) According to a study carried out in the
United States, ultrasound is often unnecessary, since 80% of pregnant
women have low-risk pregnancies. See: Associated Press, "Study Finds
Routine Ultrasound Unnecessary for Most Pregnancies," The Gazette
(Montreal), 16 September 1993, p. B-1.
(20) Gibson (1993).
(21) Rheault (1990), p. 110.
(22) Ibid.
(23) Linda Heller, "When to Say No to
Surgery," Chatelaine, October 1993, p. 99.
(24) Diane Francis, "Ontario Health System
Open to $980 M in Fraud," Financial Post (Toronto), 6 August
1993, p. 4.
(25) Gibson (1993).
(26) Dr. Michael Wahn, "Controlling Overservicing
by Physicians: Review of Office Practices in Manitoba," Canadian
Medical Association Journal, Vol. 146, No. 5, 1 March
1992, p. 723-728.
(27) Similar guidelines have been recommended
in Ontario. For more details, see: Working Party on Testing Strategies
on Thyroid Disease, Report Presented to the Task Force on the Use and
Provision of Medical Services, January 1992.
(28) Government of Saskatchewan, Health Services
Utilization and Research Commission, Follow-Up Report: Thyroid Testing
Guidelines, August 1993.
(29) Rod Mickleborough, "$1 Million to
be Saved by Cuts in Thyroid Tests," Globe and Mail (Toronto),
31 August 1993, p. A-1 and A-2.
(30) Deborah Wilson, "BC Pact on Health
Care Counts on Major Savings," Globe and Mail (Toronto), 1 September
1993, p. A-5.
(31) Robert Walker, "Physician Resource
Plan Seen as Priority: Guidelines to be Shared by Other Provinces,"
Medical Post, 28 September 1993, p. 1 and 37.
|
|