This episode of Hub Dialogues features host Sean Speer in conversation with Dr. Adam Kassam, the past president of the Ontario Medical Association, about the strengths and weaknesses of Canada’s health-care system and the need for reform.
They discuss the problem of pandemic-induced backlogs, how the Canada Health Act is hindering innovation, and why reform needs to be done on an inter-governmental basis.
Transcripts of our podcast episodes are not fully edited for grammar or spelling.
SEAN SPEER: Welcome to Hub Dialogues, I’m your host, Sean Speer, editor-at-large at The Hub. I’m honoured to be joined today by Dr. Adam Kassam, a Toronto-based physician and the past president of the Ontario Medical Association. In these roles, Adam is a regular commentator on health policy issues from the COVID-19 pandemic, to health-care financing, and virtually everything in between. I’m grateful to speak to him today about the state of health care in Canada, and what needs to be done to aspire to better health outcomes for all Canadians.
Adam, thank you for joining us at Hub Dialogues.
ADAM KASSAM: Thanks for having me, Sean.
SEAN SPEER: Let’s start with a biographical question. How did you go from studying to be a physician to completing a Master’s in Public Health at Columbia? How, in other words, did you get interested and involved in health policy issues?
ADAM KASSAM: Yeah, so, it’s an interesting story, because I actually did my master’s between my third and fourth year of medical school. I spent 10 years in the States; I’m born and raised here in Toronto—diehard Leafs fan and so this season obviously was challenging, as it is with every season—but I spent four years at Cornell doing my undergrad in biology and then went straight into medical school thereafter at Dartmouth. And between my third and fourth year, I actually was having a bit of a crisis of confidence. I actually didn’t think that I wanted to be a doctor, believe it or not, at the end of my third year, because I didn’t really do very much that I found inspiring or really loved to do, frankly, clinically. Thankfully, as a result of finding actually the specialty that I’m now in, if it hadn’t been for that I wouldn’t probably be a practicing physician.
But between my third and fourth year, I was still struggling with figuring out what I wanted to do, which is what led me to thinking about taking some time to recalibrate my vision for the future. Really, it led me to a Public Health Policy degree at Columbia. And it was a great opportunity because at that time, this was around the 2011-12 era, the Affordable Care Act was kind of making its way through Congress in the United States and it was gripping our world, at least in medicine down in the United States, quite substantially.
So, that’s what drew me in to begin with: how do we create laws? How do we create better ones? How do we create legislation and ultimately produce, hopefully, a better health-care system as a result? And so, that’s kind of what led to that impetus for me wanting to develop a bit of a better knowledge and understanding of that policy work. That then bled into some of the work that I’ve been doing over the past handful of years, which is really tackling the challenges that we have here in Canada and specifically here in Ontario.
SEAN SPEER: That’s great, Adam, let me pick up on some of those challenges and the policy thinking that you’ve done. As OMA president, you’ve called for the need to “future-proof health-care systems in Canada.”
What does that mean? And what would a future-proof system look like in broad terms? Is it more public investment? Or is it institutional change? Rethinking the role of public versus private? Or something involving all of the above?
ADAM KASSAM: Yeah, I think all of the above is the right way to think about that. It’s a very complex problem, Sean. I think the reason why we’re thinking about future-proofing right now, in the context of perhaps coming out of, or at least through, this pandemic, I think that we recognize here in Canada that our capacity to deliver care at a high level at times of crises, such as the pandemic—so high volumes of patients very acutely ill and doing so for a sustained period of time, perhaps across the country in very different ways—is a challenge for our system. Now, I will also add though, that no system got this perfect, right? No system around the world has been able to manage the level and severity of COVID disease and burden, I would say, consistently well throughout the past two and a half years. There hasn’t been one.
So, this is obviously part of the challenge. How do you create a system that’s available to adapt in a very acute moment of crisis that maybe comes around once every 100 years? And so that’s the challenge. How do you do that for the future? But then also, what we have now is figuring out how to get through some of the carnage and the wake of the pandemic in terms of backlogs, delayed care, and access to certain types of services. How do we now get through all of that? That was a problem before, and is a significantly larger problem now,
SEAN SPEER: Let me take you up on that precise question, Adam. As you say, a major imperative here is the pandemic-induced backlogs for surgeries and diagnostic tests. This backlog from the pandemic builds upon pre-pandemic wait times in key areas such as knee and hip operations.
Tell me a bit about the integrated ambulatory centres model that you’ve championed. How would it work? And how can it help to address these significant backlogs?
ADAM KASSAM: The OMA came up with this idea around integrated ambulatory centres or IEC, some people will call it community health centres, community surgical centres, etc. But really what it is, is an independent but linked infrastructure that is able to focus on specific types of surgeries and procedures that can now be done outside of the four walls of a hospital safely, routinely, and often same-day. And so, when we think about the gamut that this might run, it includes things like same-day hip and knee replacement surgeries, it includes certain types of endoscopies, ENT procedures, it’ll include a lot of ophthalmological cataract, retinal, and other ophthalmologic procedures that are often routinely done as a same-day kind of procedure. We also have things like certain types of plastic surgery, certain types of skin cancer removal, hysterectomies, and certain types of gynecological procedures that can actually be done same-day and allow folks to go home.
We actually see this model play out extremely well in other jurisdictions around the world. So namely, Western Europe, the United States, and even parts of central Canada have adopted these kinds of standalone surgical and diagnostic centres that can actually have higher volume, be more efficient, achieve economies of scale, and ultimately get through what we are now seeing is a backlog that stands, at least here in this province, close to 21 million total health-care services. Which, approximately a million or a million and a half of that is surgical and diagnostic.
SEAN SPEER: If I can just ask a follow-up, Adam, may I ask what is the principal obstacle to moving in this direction? It seems pretty intuitive; it addresses a specific problem and the case that it enables economies of scale is pretty compelling. Why aren’t we doing it?
ADAM KASSAM: I think that we have in our health-care environments a challenge with the concept of ownership and profit. This is something that our society and our communities, and frankly our legislators, need to better understand. So, as an organization, the OMA, we take a profit-agnostic view of who should be owning the surgical centres or these diagnostic centres, whereas, I think, politically, this becomes a much more heated and charged conversation because we’re in the midst of a writ period here in Ontario where there are campaigns that are ongoing, that seek to, I would say, differentiate themselves from one another based purely on this notion of profit.
And I think that we have to maybe take a step back and really understand, what does profit mean? Who’s owning this infrastructure? How is it being supported? Where is the funding coming from? And can you have a profit versus not-for-profit? Does it even matter? Maybe that’s a better question: does profit even matter, in the context of getting care to people, if we can ensure that everyone has access, reasonable access, and is getting high-quality care with great outcomes?
SEAN SPEER: You mentioned the need to sort of step back and grapple with these questions as a matter of first principle. I think that’s right. In that vein, you’ve written in favour of what you call a “blended healthcare model.”
Let’s just start in big-picture terms. What is a blended health-care model? And what do you think it’s preferable to?
ADAM KASSAM: So, Sean, we actually have a blended model here in Canada. I think that’s sort of one thing that we have to recognize already. So, for example, I’m a physiatrist, and no one knows what that is, so I’m going to give you a bit of an education. A physiatrist is a rehabilitation doctor that takes care of folks who’ve had muscle, bone, or nerve injuries. So, I often see patients who’ve had strokes or spinal cord injuries, brain injuries, catastrophic injuries, amputations, these types of injuries. If someone comes and sees me, either in the hospital or in a clinic, often almost all the time, like almost every single encounter that I’ll have with the patient, I’ll be recommending some sort of course of physiotherapy. Whether it’s resistance training, endurance training, making sure someone is able to have the appropriate walker and be able to use that around units or at home, but it involves therapy. And therapy isn’t really is not covered through our conventional OHIP system, right? We don’t charge OHIP a service fee for a physiotherapy encounter.
And so often, that physiotherapy encounter is paid for either out of pocket by a patient or a family or it’s paid for through an insurance program that that individual might have through their work or independently. This is an example of where care is provided to an individual through a different model of care, as opposed to a health insurance program that is funded through taxes. This example can be extended right across our health-care system: occupational therapy, speech language pathology therapy, psychotherapy, we think about drug coverage.
So, we already have, in a sense, a blended model. What we have to figure out as a country, and perhaps even as jurisdictions right across the country—so province by province—what do we think is a basic level of insurance service that no one should have to pay for? And how much of it can we potentially continue to deliver at a high level, with appropriate wait times, with appropriate access? That’s the conversation. We have to define those first principles. How much of this can we actually do and do well? And how much of it do we need to then have other areas of service providers play a role?
SEAN SPEER: Let me pick up that point. As you mentioned, Adam, our Medicare model provides 100 percent first-dollar coverage for physician and hospital services, but minimal public support for non-insured services such as drugs, dental, long-term care, and many of the others you mentioned.
Does our deep yet narrow form of public insurance coverage still make sense? Should we be revisiting how we dedicate scarce public dollars to provide shallower yet perhaps broader public insurance like most other universalized health-care systems around the world?
ADAM KASSAM: Yeah Sean, I think you bring up a good point, which is to say that every single high-performing health-care system around the world has some sort of blended model. When you look at the Commonwealth Fund that ranks the OECD nations in terms of their health-care outcomes, and we think about the quadruple aim, or the quaternary aim, we in Canada haven’t been performing very, very well, for a very long time.
I think it’s helpful for us to look at other jurisdictions and other countries, and see if we can, in fact, learn from their experiences. Perhaps their pitfalls, but perhaps even some of the ways in which they’ve adapted their models over the course of the past, let’s say 10 years, but even through the pandemic perhaps, and what can we do better. I think we should always be striving to be better and deliver better care, and I think we are very much at a tipping point. We saw throughout the pandemic people just not being able to access the proper type of care at the right time. We’re seeing some of that happen right now as well as a result of the pandemic backlogs.
The question now becomes for us, what do we need to do with the scarce resources that you’re describing, Sean? How do we appropriately fund the important things that we need to? And then, ultimately, not be afraid to have tough, honest conversations with voters, with taxpayers, with citizens about what they think are the priorities. And hopefully, those two things dovetail with policymakers who are ultimately thinking about the future of health care in this country and in this province as we continue to hobble in terms of our health-care system now, and probably for the foreseeable future, if we don’t do anything substantial.
SEAN SPEER: As we think about reform, you’ve made the case that it needs to be done on an inter-governmental basis. You’ve written for instance, that “it’s naive to think that provincial governments should be trusted to improve health care delivery on their own.”
Why do you think it’s important that the federal government play a greater role in the health-care system? And how might that role manifest itself?
ADAM KASSAM: So, I think if we take it back to the origins of Medicare back in the 50s, Tommy Douglas, Saskatchewan, everyone knows the story. Everyone loves that story. We have to remember that at that time in the 50s, it was actually a hospital-based insurance program that was a 50/50 proposition between the federal government and the province. And you can imagine seventy years later, advancements in health care have been quite substantial. What I mean by that is that 75 percent of care that’s now delivered across this province here in Ontario, Sean, to patients across Ontario, happened outside the four walls of a hospital. So, they happen in a family doctor’s office or a pediatrician’s clinic. They happen perhaps at endoscopy suites, or an X-ray and ultrasound facility. So, there are so many different things that now happen outside the four walls of a hospital where the original spirit of Medicare, which was, once again, a partnership between the federal and provincial government, has now been eroded over time by all levels of government by all stripes of government.
Where we now sit, at least in Ontario, at that shared responsibility being 22 percent to the federal government and close to 80 percent by the province. And so, that mismatch, I think, is extremely challenging when provinces are starting to think about delivering care and planning for the future of care. Frankly, over the past several years, we’ve seen large investments in a number of different areas, including whether it’s obviously the pandemic relief and CERB, and now we’re talking about national defence spending, and so there is an appetite here, at least over the past five years, to have larger spends on national interests. I would argue that Canadian health care is one of them and should be one of those national spends that we focus on.
In fact, in the last election campaign, federally, I think the prime minister actually on the hustings was actually campaigning on having every single Canadian have access to the family doctor. You know, I get that that’s a political, expedient way to talk about health care. And the feds know that this is a provincial jurisdiction, the provinces know that they want some more money from the feds to make that happen, but if we think that we’re going to try and play this political hot potato after a pandemic where now people are really, really upset about not being able to have access to care that they believe that they should have access to—and frankly, they should have access to it, because they’ve been paying through their taxes for it.
I think we’re at a different stage in having that conversation about who should own health care, at least at a jurisdictional level. Let’s get rid of that notion and supplant it with, “Ok, let’s try and have a team Canada approach to health care.” And so, what that ultimately means is that the feds gotta pony up some more dough.
SEAN SPEER: In addition to additional federal dollars, which as the president of OMA, you made the case that the goal ought to be to at least to get to 35 percent of the cost deriving from federal transfers, is there anything else that the federal government ought to be doing? Is there a case, for instance, Adam, that we need to be revisiting the Canada Health Act? as aspects of the Act become an impediment to some of the types of innovations that you were talking about earlier?
ADAM KASSAM: I think that there’s probably a general consensus in the medical community, but also sort of in legal and public policy circles, that we do need a modernization of the Canada Health Act. For example, over the past five years, but really over the past two years, we’ve seen now an explosion of care now delivered virtually, so virtual care. Much of this kind of new innovation—which is great, and I will tell you that virtual care and the explosion of virtual care over the past years is probably one of the largest innovations in health care in a generation. And part of the reason why that was able to have taken place, at least in our model, is that between the provinces and the Medical Associations, broadly speaking, there were negotiations that were happening, and did happen in order to ensure that those services could be insured and paid for through OHIP or an equivalent provincial health insurance plan. Again, I have to reiterate, that is probably one of the largest innovations in a generation in terms of health, and health insurance coverage, for the broader public in 50 to 100 years.
So, we have the capacity to innovate very quickly and bring things online, but all of it as you’re describing, some of that is unfortunately hamstrung by certain aspects of the Canada Health Act, but it’s also hamstrung by the lack of new legal language to enshrine some of these services in the way that they need to. In addition, when we think about integration or data, we think about three other areas. We have to talk about integration, talk about a little bit about virtual care, but we also have to talk about security and privacy.
Here’s an example. So, about a year ago, I worked at a hospital that has a shared electronic medical record system with several hospital networks, and they were hacked. And in fact, they were hacked by some nefarious actors abroad. What that meant was at one of the hospitals they couldn’t deliver care at all. You couldn’t order Tylenol in the emergency room because it was a completely digital hospital. So, now you have a situation where these are becoming targets of nefarious proxy international agents that are seeking to do damage, not only to us, but perhaps to our peer nations.
So, this is a national defence issue. This is a federal government issue, but it also requires partnership across levels of government. This is where health care is now becoming so integrated that it needs to have that kind of cooperation at a federal, provincial, and a municipal level.
SEAN SPEER: You’ve also written and talked a lot about shortages with respect to doctors, nurses and other health-care professionals. Let me just ask about doctors, Adam. What explains these shortages? What’s wrong with the current education and residency systems? How should they change?
ADAM KASSAM: So, this is a supply and demand issue. So, the first is that we just don’t have enough doctors. We could talk about how we just didn’t plan enough early on or haven’t done so over the past 10 or 20 years to really meet the demands of, firstly, an aging population. So, all the boomers that are getting older, need care, we didn’t really plan or haven’t planned for a health human resource strategy for those folks. We’re also seeing commitments by all levels of government and across all party stripes, to grow our domestic population through immigration in order to support a growing economy, to support a growing country. And so, we now have both a growing population but also an aging population, and both are happening at a very rapid pace. Demand is outstripping supply first and foremost, in terms of health human resources.
Now, if you’re in downtown Toronto on University Avenue, you might not necessarily notice that because you have a lot of different types of physicians on University row, which are very, very well resourced environments, both academically and through tertiary or quaternary hospitals. But, you know, take 30 minutes and go up to 404, and now you’re in Markham or in Aurora and suburbs of the GTA, or west out in Brampton, they’re not the same resources, and they have larger and growing populations. So, first and foremost, we have a shortage of health-care providers, both what we would call sort of highly-trained and then sort of middle-trained.
The second is that we, unfortunately, several years ago actually took a step back by cutting residency spots instead of adding them. I think that was quite short-sighted. And then third, we have also a mismatch of region by region, meaning we might have a lot of dermatologists in downtown Toronto, but we might not have a lot of dermatologists out in Cornwall. So, matching our supply and demand is going to be, I think, a very important step forward.
And then finally, we have a very strange paradox here in this province of having underemployed surgeons and waitlists for hip and knee replacements or other types of surgeries for folks who are waiting for care. And that has to do with hospital infrastructure: not having enough operating rooms, not having enough operating staff, or the allied health staff or the nursing staff to support that kind of that scaling up. And this comes back to where ICs and having these independent facilities may actually make a dent in those types of ways.
These are complex problems. And layered on top of all of that, Sean, is we also have a number of internationally medically-trained professionals in this country who can’t get licenses, they can’t sit for their boards, and it’s kind of hard from a bureaucratic and a credentialing perspective. And that’s an area where I think that we can probably start to see some streamlining. I know that certain levels of government have made commitments to do just that.
SEAN SPEER: You’ve spoken with thousands of physicians and other health care professionals in your role as president of the OMA, to say nothing of your other activities. Do you think they’re open to serious reform at this stage? Would they put everything including, for instance, greater private delivery on the table?
ADAM KASSAM: I think that physicians—so in my role as the OMA president, I had the honour of representing 43,000 doctors across the province. There’s a joke in medicine, where you put five doctors in a room, Sean, you get six opinions. You can imagine the multiplier effect before 3000 people and it’s true. So, what I mean by that is that you have such a diversity of voice and opinion and thought in our physician community, and broadly speaking across the health sector.
I think that in a strange way, and in a profound way, the pandemic has fundamentally changed the way that we all look at our health-care system and believe that it has an opportunity to change. What that change looks like, I think, can become not only politically charged, but it can also become quite heated. But I do think there is an appetite now to start thinking about what does the next 20 years look like? What do the next 40 years look like? Hopefully, there is a safe space to be able to do that, in a way that allows for us to take the politics and the rhetoric out of that conversation and really focus in on what the real goals of our health-care system should be, which is to deliver high-quality care at the right time for the right patient in the right context.
SEAN SPEER: Just a final question. Listeners will hear in your thoughtful and passionate answers a commitment to that long-term change in long-term vision. What are your next plans? How are you going to direct your passion and your talents as you move out of the role as president of the OMA?
ADAM KASSAM: Sean, it’s a good question. I’m going to take some time this summer to do a little bit of self-care, spending time with our dog and my wife. My wife is a physician, and so we’ve been kind of going full tilt for the past two and a half years. You know, we have an election that’s ongoing right now, and I think a lot of what the public in Ontario is really looking for is at least to have that election happen, let’s figure out where we’re at, and then we can start focusing on a future that I think is still very bright.
You know, Sean, I’m a glass-half-full kind of guy. I think that we’ve come out through the pandemic learning a lot as a system, learning a lot as a profession. Hopefully, we can apply a lot of those lessons to a system that I’m going to require, that hopefully if we have kids, my kids are going to require, you and your family is going to need to be able to be high performing. So, that’s something that I’m still committed to, and I want to be able to contribute in any way that I can.
SEAN SPEER: Well, we look forward to seeing where that path takes you. Dr. Adam Kassam, thank you so much for joining us at Hub Dialogues today to share your insights and analysis. And thank you for your service over the pandemic.
ADAM KASSAM: Thank you, Sean. I appreciate being invited to speak with you.