Friday, September 24, 2010

Bringing market forces into the hospital

I headed into the local hospital for a quick day treatment in a clinic last week.
Two doctors were waiting to see a cluster of us. But the nurse who usually worked that clinic room was on holidays, which had been scheduled for some time.
The hospital hadn't arranged a replacement nurse. One doctor decided he couldn't work without nurse support. So half the patients were sent home to be scheduled for an appointment in another month or two.
That's a good example of the kind of problem the government hopes to fix with "patient-focused funding."
It makes sense. Now, the Health Ministry sets a budget and provides funds for the health authority. The authority allocates the money to different services, including hospitals, and decides how many surgeries, for example, it can do with the cash.
So there are no consequences for cancelling treatments because someone in the hospital didn't arrange a replacement nurse. The patients still have to come back. The hospital doesn't lose any funding.
Under patient-focused funding, that changes. The government holds back more of the block funding it once sent to health authorities. Hospitals and health authorities get paid a set amount per treatment on a per-patient basis.
Under that approach, the failure to get a nurse would be costly. Those cancelled treatments would mean lost revenue. So there would be an incentive to solve the problem.
Just as there would be an incentive to do things faster and at less cost, bringing in more revenue.
A hospital might decide to set up two adjacent operating rooms to do the same procedure, for example. While one patient is being operated on, another can be prepped for surgery. As soon as they're done, the teams switch places and the process starts again.
That would mean lower costs per patient. If the government were paying a set fee, the hospital or authority would have extra money for other projects.
It could even ask hospitals to bid for right to provide hip surgeries, for example, and pick the most cost-efficient.
There are catches, of course. The most obvious is the risk that corners will be cut. The B.C. Medical Association supports the idea, but wants safeguards to make sure cheap and fast doesn't take priority over patients' health and safety.
And the incentives, so far, aren't individual. It's hard to say if the person who didn't line up a replacement nurse would be motivated to act differently by the promise that the hospital would get more money as a result.
The bigger problem is likely that there are no real rewards for success.
The government is still rationing services. So even if a hospital is brilliant at some surgery, getting better results at a much lower cost, the Health Ministry will tell it to stop when the quota is done for the year.
Everyone involved can do great work, with no real reward.
There are solutions. The government, for example, could provide guarantees to medical service plan clients. Hip surgery in six months, or we fly to you to Seattle for the operation and pick up all the bills. Hospitals would know it was worth getting really good at hip replacement, because the ministry wouldn't want to fly patients to the U.S.
The whole initiative is just getting going. The government has set up a Health Services Purchasing Organization, headed by Dr. Les Vertesi (who is also Gordon Campbell's brother-in-law) to manage the process and is looking to have a large share of health spending managed this way.
By next year, the government hopes about $170 million will be taken out of health authority budgets to be spent by the purchasing organization.
There is another issue in all this, large enough to warrant a second column. Vertesi has been a strong advocate of a allowing a private health care alternative for people who can pay more for speedier treatment. And the patient-focused funding, Health Minister Kevin Falcon, could be used to buy services from private clinics.
That's not necessarily a bad thing. But it does raise some serious questions, which I will look at in a future column.
Footnote: Falcon announced an extra $23 million in "patient-focused funding" for tests and surgeries. Up to 33,000 patients would benefit, he said. Which means the $800,000 the government spent on the pro-HST flyer it tossed in the garbage would have helped 1,150 patients on waiting lists.

Tuesday, September 21, 2010

Honouring Sindi Hawkins

Former Liberal MLA Sindi Hawkins died today after a long battle with cancer, which she turned into an opportunity to raise awareness and money for cancer research and treatment.
Hawkins was a genuine, nice, funny, smart person. She greeted everyone - Liberals, New Democrats, journalists, janitors - with warmth and interest and respect.
She was a sharp and effective health critic when the Liberals were in opposition. But not a jerk or a critic striving for cheap points. She raised real concerns.
After the 2001 election, a former New Democrat staffer noted, when the Liberals had a 77-2 majority and many of the victors were unkind, Hawkins was unfailingly polite and courteous to the opposition. After her first illness, her family cooked an Indian feast and served it at the legislature to thank the staff and politicians from all parties and journalists who had been rooting for her. It was a fine day
Her death is a loss. And it's a sad reminder that political life could be so much better. Sindi Hawkins showed politicians don't have to be foolishly partisan or constantly looking to score points. She showed you can disagree on policy while still respecting the person on the other side of the issue.
Imagine if all MLAs decided to honour Sindi Hawkins by emulating her grace, kindness, courtesy and commitment to the broad public good each time they stepped through the doors of the chamber.

When did the government really decide to sell B.C. rail?

Interesting post (as is often the case) at on the timing of the decision to sell B.C. Rail and, more specifically, on conflicts in the government's claims.
Then transportation minister Judith Reid insisted in the summer of 2002 that B.C. Rail would not be sold or privatized. But, pacificgazette notes here, former MLA Paul Nettleton says Gordon Campbell told him and the other Prince George MPs in February 2002 that the promise to maintain the railways as a Crown corporation would be broken.
Which is consistent with evidence at the B.C. rail corruption trial today that in January 2002 the Crown corporation executives were given rich severance agreements to kick in if the railway was sold.

How Campbell can ease recall's sting

Recall campaigns are ugly.
The goal is to convince voters to fire an MLA. So campaigners talk about the rotten, incompetent person representing the voters in Victoria.
And it looks like we're into recall season.
Bill Vander Zalm and the Fight-HST crowd gave Gordon Campbell a choice this week.
Accept their proposals for how and when the HST referendum would be conducted or face three recall campaigns against Liberal MLAs in January, with an extra campaign launched every month after that.
It was all pretty clever. Vander Zalm even announced a Survivor-style competition for those ridings hoping to be the first to launch recall campaigns. The challenge is to sign up canvassers over the next eight weeks; ridings with the most participants launch recall campaigns first.
Even the five conditions the anti-HST campaigners set were crafted to place Campbell in a tight corner.
Two of the demands - to make the initiative binding and require only a simple majority vote to kill the tax - had already been accepted by Campbell last week in a surprise announcement. (The initiative legislation says the threshold is 50 per cent of all eligible voters, not just those who show up at the pools. Even then, he result isn't binding.)
The other three demands were tougher.
The Fight-HST People wanted the referendum held under some legally binding framework, like the Referendum Act, with spending limits and other safeguards.
They wanted the question to be drafted by Elections BC and approved by "both the government and Fight HST."
And they wanted the referendum held this year.
Pushy. But except for the timing, Fight HST isn't really out of line. Don't forget, the group succeeded in a petition process which was supposed to result in a vote next September on the bill to kill the HST that they had drafted. That's the law.
Now Campbell appears to be making up his own rules.
A little compromise and consensus is in order.
The Liberals certainly won't accept a vote this year. They hope time will ease the anger over the way the HST was introduced and let them convince people the tax is a good thing.
And they want the advantage of being able to draft the question.
But that doesn't mean they have to stand by passively as the recall campaigns are launched.
Recall efforts are damaging for the party in power. The biggest tactical recall effort was Kevin Falcon's "Total Recall" which targeted all 40 New Democrat MLAs in 1999.
Falcon maintained he wasn't a Liberal then, though it came out that he had previously been paid about $800 a week by the Liberals on a six-week contract, campaigned in a Lower Mainland riding for the party and gave Campbell "speech ideas, but not complete speeches," as Mike Smyth wrote in the Vancouver Province.
Total Recall flopped. Falcon couldn't raise enough money.
But that didn't really matter. The New Democrats had to focus on the threat to MLAs and, as a result, paid less attention to governing.
Campbell won't accept the Fight-HST proposals. But he should address the underlying the issues.
The commitment to a simple majority and binding outcome needs some legislative backing. It's not enough for a premier, who might not be in the job a year from now, to make a promise he can't keep.
And Campbell can say now how the referendum question will be developed and when the public will see it.
He can also explain why the vote should wait until next September, rather than being held in March. If the HST is really important for investment, the uncertainty is hurting British Columbian. He's changing the rules around other aspects of the vote. Why prolong the pain?
Campbell can't likely stop the recall campaigns. But with the right responses, he can make life a lot easier for the targeted MLAs.
Footnote: To be successful, a recall campaign must collect signatures from 40 per cent of registered voters within a 60-day window. It's a high threshold, which has never been reached. (Although one campaign might have made it; the MLA resigned before the signatures were counted.)
But the anti-HST group starts with a battalion of volunteers and a strong base in most ridings.