Eat badly, smoke and lose your right to health care

VICTORIA - Down in the U.S. companies are getting ready to fire smokers.
Over in England, overweight people are being told they won't get knee or hip replacements.
And here in B.C., the province's chief medical health officer has just warned that diabetes - largely preventable - is already a $1-billion annual cost to the health care system. Within a decade, that will double unless we change our ways.
All three stories point to the need to start a debate on just how we're going to handle self-inflicted illness and injury when it comes to allocating scarce treatment resources.
Provincial health officer Dr. Perry Kendall focused on diabetes in his annual report. About 220,000 British Columbians have been diagnosed with the disease, and the number is expected to reach 390,000 within 10 years. Its complications can be cruel - heart and kidney disease, amputations and death.
And the problems are, Kendall reported, largely preventable. About 90 per cent of the cases are Type 2 diabetes, and people can slash their risk - and the cost to us all - if they eat healthier diets, exercise and keep their weight down.
Which raises a question about individual responsibility and the how we allocate finite health care resources.
U.S. companies, facing a health cost crisis far greater than anything we've seen in Canada, have started to make choices, with smokers the first target. Some are increasing health care premiums for smokers, or offering incentives and support for people who quit.
And some are firing people who fail tests for tobacco use. Scotts Miracle-Gro has told its 5,400 employees they have until next fall to quit, or they'll get the chop. (About 30 states have laws protecting people from being fired for smoking.)
It's not a moral judgment that smokers are flawed. The decision is based on economics. Smokers cost too much.
The British National Institute for Health and Clinical Excellence has just reported on the right of people with self-inflicted medical problems to treatment, and taken a similar approach The influential institute looked at the hard practical questions. Is it right to make a child needing a liver transplant wait in the queue behind a person whose illness is caused by years of alcohol abuse?
It's a tough question. Alcoholism is a disease too.
The institute took a cautious approach. Patients shouldn't be penalized for making themselves sick, it said. But if their behaviour reduces the chance of a successful outcome, then treatment can legitimately be delayed or denied. Why spend scarce resources on a liver transplant for someone like alcoholic former footballer George Best, who kept drinking and died within three years?
In reality health care providers have made those kinds of decisions. British National Health Managers in East Suffolk needed to save money this year, and so have stopped doing knee and hip replacements for anyone with a Body Mass Index over 30. If you're five foot nine inches and weigh 205 lbs, for example, no replacement. The surgery is riskier, outcomes poorer and artificial joints don't last as long. Joint replacements for overweight people are an inefficient use of scarce dollars.
A similar approach is take by some doctors in B.C, openly or not.
It's a difficult issue, theoretically and practically.
Type 2 diabetes, for example, is not always linked to diet and exercise. And people do not always have control over their circumstances. B.C.'s welfare rates, according to a new study from the Dietitians of Canada, don't allow a nutritious diet. Children from families on welfare are at increased risk of diabetes, and most people wouldn't argue they should be denied treatment.
But we shouldn't dodge the questions. We're already rationing surgery, often in arbitrary and unreasonable ways.
Demand and treatment options are increasing, while resources are finite. Finding the fairest, most efficient way of allocating those resources means looking at all the factors - even ones that make people uncomfortable.
Footnote: The other obvious issue is prevention. Kendall says a 25-per-cent reduction in the diabetes rate would produce annual savings of $200 million. That justifies a large upfront investment to expand existing programs aimed at increasing our health, and reducing the risk of diabetes and other illness.

STV referendum plan, electoral boundary commission both need work

VICTORIA - Things are looking rocky for the Electoral Boundaries Commission, the panel with a lot to say about how democracy works in B.C.
So rocky - and expensive - that it's time to rethink the path ahead.
The commission is important. It will decide how the province is carved up into ridings for the next election, a process that's complicated and politically sensitive. Rural areas will lose seats, growing urban areas will gain and boundaries will be bent.
And this time the commission has to come up with riding boundaries both for the current system and the proposed single transferable vote proportional representation option. That's part of the preparation for another referendum on STV to be held along with the municipal elections in the fall of 2008.
Premier Gordon Campbell's plan for a second referendum is a clever solution to the narrow defeat for STV in May. The proposed reform just missed the required 60-per-cent threshold. But almost 58 per cent of voters backed the new system. It would be irresponsible for government to ignore that kind of message.
So Campbell announced another referendum for the fall of 2008. This time voters will have more details, including the ridings to be used under the new system.
Under STV there would be fewer, larger ridings, with two to seven MLAs each. Most of Greater Victoria could be one riding, for example, with four MLAs. On election day you would no longer just mark an 'X' beside one candidate, rejecting the rest. You would rank as many candidates as you liked.
When the votes were counted, the results would reflect the rankings. A voter might rank an NDP candidate first, and two Liberals second and third, and a Green fourth. All the votes would matter.
The result should be a more representative and diverse legislature, with MLAs who are more responsive to their communities.
Campbell's proposal makes excellent sense.
But the timing is looking like a problem. Chief Electoral Officer Harry Neufeld told a legislature committee that he is still working out all the planing details. But the tight timeline between the fall referendum in 2008 and the May election in 2009 means Elections BC will have to prepare to run the election under both systems, he says. That could mean a large cost, possibly tens of millions of dollars, to prepare for STV with the money wasted if - unhappily - the referendum should fail.
There are options. Holding the referendum along with the fall municipal elections offers some cost savings. But the overall savings might be greater if a standalone referendum in the fall of 2007 allowed Elections BC to prepare more effectively. Pushing the provincial election back six months to the fall of 2009 would ensure that the budget was debated before the vote and reduce the pressure on Elections BC to spend time and money preparing for two different kinds of elections.
A delay would also allow time to look at controversial appointment to the three-person Electoral Boundaries Commission. The commission was established back in the Vander Zalm days to take the politics out of rejigging ridings. It's always composed of Neufeld, a judge and a third member appointed by the Speaker, after consulting the premier and the opposition leader.
Bill Barisoff picked Louise Burgart of Fort St. James, part owner of Apex Alpine resort and a former school superintendent. NDP leader Carole James backed the choice, knowing Burgart from her own days as head of the BC School Trustees Association.
Burgart is likely an excellent person. But she's also a partisan Liberal, as the always diligent Sean Holman of Public Eye Online has reported. Apex has donated to the party. Burgart campaigned for successful Liberal candidate John Rustad and urged people to vote Liberal in a letter to the Prince George Citizen during the last campaign.
The appointment opens the door wide for future partisan appointments by the party in power, and a graceful way out would serve the public interest.
Footnote: The legislature's finance committee met behind closed doors last week to consider funding recommendations for Elections BC, the auditor general and other independent offices. Their recommendation may include comments on the best way to handle the whole process.

Surrey plan, Alberta test offer health care models

VICTORIA - Anybody wondering about the future of their local hospital should pay close attention to the overhaul of medical services in Surrey.
The problem was crowding at the Surrey Memorial Hospital, in the emergency room and the wards.
But the solution backed by the province wasn't a bigger hospital, or even just a larger ER. Instead the services are being carved up into separate centres, with the aim of reserving acute care hospital beds and high-end emergency care for those who really need them.
So the health region has just opened a "minor treatment unit" for people who don't really need the full emergency service but show up there anyway. Instead of clogging the waiting room and sitting for hours - and creating more delays for people who really need emergency care - they get sent off to the minor treatment centre.
A massive ambulatory care centre is going to be built nearby, sort of a junior hospital. People who need outpatient care, day surgery and other activities that don't require the acute care support can be treated there. It will include a primary care clinic housing family doctors, and people to help with chronic disease management.
The idea is simply. Get every patient into the system where it makes sense. Increased specialization allows cost-efficiencies and wait time management, and you can avoid the high cost of having someone who only needs minor first aid clogging a busy emergency room.
Health Minister George Abbott is an enthusiastic backer of the approach, being tried for the first time in B.C. He expects a similar strategy any time hospitals are built or expanded. "What we're seeing is very much a model for the future," Abbott says.
Hospitals in Salmon Arm, Kamloops, Kelowna and Nanaimo are already under increasing pressure. Abbott says a similar approach will be taken in those communities, although changes will likely be incremental.
The Canadian Centre for Policy Alternatives released a study this month that advocated taking the concept farther. Dr. Michael Rachlis said governments should be building more specialized surgical clinics for minor procedures and low-risk surgery. A clinic that does only knee and hip replacements can deliver faster, better care at lower cost, just like a service station that does only oil changes.
Rachlis also wants governments to pay a lot more attention to "queue management," the science of moving people from start to finish smoothly and quickly. He argues people wait too long for surgery even when enough operations are being done, because the system is clunky. Patients move through a series of tests and specialists visits with little co-ordination and frequent long delays. Simply managing that process efficiently cuts waiting times.
A report on an Alberta experiment this week confirmed that the approach can work. In the first eight months of a new approach to hip and knee replacements, the wait from getting a referral to specialist to surgery was cut to three months. It had been averaging 20 months.
The project included money to keep operating rooms open. But many of the gains came from managing patients' progress through the system, and eliminating needless waits for tests or to see specialists or physiotherapists. A change as simple as scheduling all tests and consultations for each patient for one day cut out long delays.
Any increased costs were recovered. People who wait almost two years for surgery lose income and suffer, and their health deteriorates. Because patients got surgery before their health began to fail, the average hospital stay was cut from 6.2 days to 4.3 days - an enormous cost saving.
Some of the principles may be harder to apply in smaller centres, although the idea of clinics that are also "minor treatment units" may may good sense where a full emergency room can't be justified.
But the new approaches, in Surrey and across the mountains in Alberta, show that health care problems can be solved within the current system.
Footnote: B.C. needs to make improvements. The province is meeting most of the first handful of wait time standards agreed to by the provincial health ministers. But the province isn't close to providing knee and hip surgery within the required six months. More than half the patients wait longer than that. Many wait much longer.