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Harry Rakowski: It’s time to acknowledge our health care is at a breaking point

Commentary

As a previous head of three U.S. cardiovascular organizations, I have always not just defended, but rather promoted, the quality and universality of the Canadian health-care system to my American friends. While our system is universal and generally of good quality, it is far from perfect. Access to care has always been marred by excessive wait times to see a physician, undergo imaging procedures, or have timely surgery.

COVID-19 was particularly hard on our system which already had little flexibility for increased capacity. Despite recent reassurances from government officials, we have a crumbling system that needs urgent crisis management to find both immediate and long-term solutions. We need to stabilize the current mismatch of increased demand and inadequate supply and develop structural and innovative solutions for the future. 

While the problem is obvious and needs to be honestly admitted, the solutions are not easy. Governments, used to moving “at the speed of bureaucracy” with options put through a political filter, usually prefer short-term cosmetic fixes rather than fundamental change. 

What are our short-term options?

Currently, just as with inflation we have too much demand chasing too little supply. The immediate need is to reduce demand and increase supply, particularly in the most constrained areas of care. Nowhere is this more critical than in our ER crisis. There are too many patients without an alternative to ER care, not enough ER beds, and jammed hospital wards with patients staying too long, especially as they await long-term care beds. 

Below are three immediate options to help deal with the problem. 

1. Technology. Diagnostic Robotics is an Israeli company that has redefined how individuals access health care using powerful AI algorithms, automated prediction models, and clinical assessment platforms.Most health execs expect widespread implementation of AI in the next 5 years https://www.businessinsider.com/health-it-leaders-bullish-on-ai-implementation-2020-11 They have been able to successfully reduce ER visits using this predictive technology to determine the urgency of required care and whether it should be provided by alternative options. In 2020, our federal and provincial governments rejected their free offer that I tried to broker to help us triage COVID-19 patients. We urgently need to retain them to work with us now. They can streamline the inflow of ER patients as they have proven in Israel and other countries and meet privacy needs. 

2. Increase access to non-emergent care by increased use of Telehealth manned by nurses and nurse practitioners. We also need more 24/7 out-of-hospital urgent but non-emergent care clinics to decant ERs. 

3. Adopt U.S. models of bringing urgent care teams to the patient. This has been used successfully to reduce long ER visits, improve care, and lower costs. Dispatch Health in the U.S has a care model that sends emergency care trained teams to patients’ homes with mobile blood work labs, IV fluids, nebulizers, and other ER equipment. In addition, hospital-at-home programs shorten hospital stays and unblock beds for ER patients stuck in hallways. Models such as those used by Johns Hopkins and the Mayo Clinic Acute Hospital at Home model reported in the New England Journal Acute Hospital Care at Home: The CMS Waiver Experience https://catalyst.nejm.org/doi/full/10.1056/CAT.21.0338 can be copied. This service provides 24/7 access to a care team of nurses, nurse practitioners, and physician assistants as required. There is also at-home equipment including a telephone connecting directly to your care team, a personal emergency response bracelet, as well as vital sign monitoring devices, internet connectivity, mobile imaging testing, and at-home IV services. There is no reason why we can’t work to adopt this proven, effective approach.

Increase efficiency of health care professionals

Since it takes years to train new practitioners, we need to urgently increase the efficiency of practice and reward those willing to work more. This requires the efficiency of available business models and the use of advanced technology. 

1. Increase patient-facing time and reduce clerical tasks. Hospital procedures and newer health information systems increase the amount of soul-destroying nurse and physician time spent on clerical rather than patient-facing time.  

2. Open dedicated surgical units outside of hospitals. This can follow the Kensington Opthalmology Centre model that delivers highly efficient cataract surgery as a stand-alone affiliate of the Toronto Western Hospital. We need more of these as well as dedicated orthopedic hospitals so that surgeons with unused capacity have access to more operating time without competing with hospital-based surgeries such as transplants. These dedicated specialized centres maximize surgeon efficiency within a universal care model, at lower cost and higher patient satisfaction. We need them to reduce the unacceptable wait times for low-risk surgeries that are appropriate for such centres. 

3. Incentivize care that does not increase burnout. We can do this by maintaining a payment model for appropriate virtual care and providing premium pay for nurses and doctors in high burnout jobs in our ERs and ICUs. We should also now welcome back unvaccinated health-care workersUnvaccinated health-care workers called back to work after AHS COVID vaccine mandate lifted https://www.cbc.ca/news/canada/calgary/unvaccinated-health-care-workers-called-back-to-work-after-ahs-covid-vaccine-mandate-lifted-1.6385568 as current variants are less dangerous and vaccination status is much less relevant in protecting you from infection. 

Increase the number of health care professionals. 

Ultimately we need to match increasing medical and nursing school enrolment to high-quality predictive data that defines increasing needs for an aging population and projected higher rates of retirement for nurses and physicians. In the shorter term, we can use foreign medical and nursing graduates under a supervised mentorship program while preserving reasonable regulatory college standards. Some highly trained foreign graduates can be confirmed to be suitable to fully practice within a few months. Others less trained can help out in associate roles much like nurse practitioners. 

In 2018, Elon Musk had a crisis on his hands. He had a crucial supply shortage when faced with large numbers of promised deliveries of his Tesla Model 3 that could not be accommodated in his two Fremont California factories already running at full capacity. He simply built a new third production line in a giant tent in his parking lot in two weeks using available scrap material at low cost. 

He recognized and admitted that there was a problem and creatively dealt with it in record time. We need governments, unions, medical organizations, and health-care workers to acknowledge that health care is at a breaking point and finally work collaboratively to find solutions that can also be implemented in record time. 

Steven Globerman: Costs of mandatory environmental, social and governance disclosure would likely outweigh benefits 

Commentary

The ESG movement“Environmental, social, and governance (ESG) criteria are a set of standards for a company’s behavior used by socially conscious investors to screen potential investments. Environmental criteria consider how a company safeguards the environment, including corporate policies addressing climate change, for example.” https://www.investopedia.com/terms/e/environmental-social-and-governance-esg-criteria.asp is proliferating across the Western world. 

In the United States, the Securities and Exchange Commission wants to increase disclosure requirements (with an ESG focus) for investment funds. The European Union has had disclosure mandates for public companies since 2018, tied to the UN’s Sustainable Development Goals.Do you know all 17 SDGs? https://sdgs.un.org/goals Here in Canada, under current Canadian securities legislation, there are no specific requirements mandating the disclosure of the “environmental, social and governance” practices of public companies, but the idea is gaining steam in some Canadian precincts including the Trudeau government’s latest budget

Why? According to proponents, expansive and mandatory ESG disclosure regulations will better inform investors about the ESG practices of public companies (their carbon usage, for example) and thus more investment capital will flow to ESG-intensive companies and less will flow to companies lagging in ESG initiatives.

But in reality, an expansive government-mandated ESG reporting regime in Canada will likely have social costs that outweigh any social benefits. 

Consider this. If investors are willing to pay more to own stocks and bonds of a company that follows “best practice” ESG activities, that company surely has a strong incentive to inform the investment community about its ESG activities because it would help lower its financing costs, which, from an investor’s perspective, are mirror images of the values of that company’s equity and debt-financing instruments. As such, if companies voluntarily disclose to investors their favourable ESG-related activities, those companies should enjoy a lower cost of financing and a competitive advantage.

So if voluntary ESG disclosure will likely benefit companies, why would government need to impose an ESG disclosure mandate? True, in an environment where ESG disclosures are not mandated and thus less regulated by government, some companies may make false or exaggerated claims about their ESG practices (sometimes known as greenwashing“Greenwashing is the process of conveying a false impression or providing misleading information about how a company’s products are more environmentally sound. Greenwashing is considered an unsubstantiated claim to deceive consumers into believing that a company’s products are environmentally friendly.” https://www.investopedia.com/terms/g/greenwashing.asp). But these same companies would suffer permanent reputational and financial damage if investors identified this greenwashing. That’s likely a risk few companies would take.

Moreover, some argue that ESG disclosure rules, backed by regulatory penalties against violators, would produce more useful ESG information for investors than a regime of voluntary disclosure. But in reality, it’s unlikely that any standardized ESG disclosure rules would remain relevant across different companies carrying out a wide range of production activities in our modern economy. For example, why mandate the same carbon disclosure rules for petroleum refineries and software developers?

Also, rating companies based on ESG performance remains a subjective exercise. Indeed, different ESG rating services, which sell their corporate rankings to investors, often disagree in their rankings of the same companies. And individual rating services change their rankings of the same companies over short periods of time, sometimes dramatically. In this context, requiring investors to rely on standardized disclosure information consolidated and distributed by rating agencies might actually deprive investors of relevant ESG information that does not fit into the government-mandated disclosure format.

Finally, this debate should include empirical evidence about whether mandating more expansive and standardized ESG disclosures would benefit investors. But unfortunately, methodological and measurement problems plague the empirical tests on that question. Nevertheless, a new study published by the Fraser Institute, which evaluates the available empirical evidence on the financial returns to ESG-themed investment strategies, finds no consistent evidence supporting the claim that highly-ranked (by ESG rating agencies) companies are rewarded with lower costs of capital.

This finding further calls into question whether a more expansive and standardized ESG reporting regime—mandated by government in Ottawa or elsewhere—will produce social benefits. Although there’s no doubt it will impose onerous new costs of doing business, particularly on small and medium-sized enterprises.