This report presents the results of the second annual Canada Health Consumer Index (CHCI). As with our first index in 2008, this year’s study demonstrates that healthcare-system performance is significantly better in some Canadian provinces than in others. Our analysis also shows that even the highest performing provinces in Canada have significant room for improvement. As the International Euro-Canada Health Consumer Index demonstrated again in 2009, Canadian healthcare still lags well behind most European healthcare systems. The top-scoring provinces in this year’s CHCI should be recognized for their relatively strong healthcare-system performance in comparison to other Canadian jurisdictions. However, the most important lesson to be drawn from our two major 2009 healthcare reports is that Canada still has much work to do in order to reach the level of excellence that exists in many European countries.
For the second year in a row, Ontario finishes first in the CHCI by a wide margin. It performs well in every area of the index, including the two most important categories, wait times and patient outcomes.
British Columbia is the runner-up for the second consecutive year, performing well in four of the five categories measured, with the exception of patients’ rights and information. British Columbia performs particularly well in the medical outcomes component of the Index, finishing in a second-place tie. An example of the province’s strong performance in this area its emergency readmission rates for common surgeries such as hysterectomies and prostatectomies. British Columbia has a risk-adjusted emergency readmission rate of just 1 per cent following hysterectomies, the lowest rate in the country.
New Brunswick, Alberta and Nova Scotia round out the top five. Alberta ties for first place in the heavily weighted patient outcomes category, but the province’s score is brought down by the fact that Albertans continue to face long waits for certain medical services. Particularly troubling are the long waits for cancer radiation therapies. Only 70 per cent of cancer radiation therapies are performed within the benchmark of 28 days from the decision to treat. This compares unfavourably with neighbouring British Columbia, where 95 per cent of patients begin their radiation therapy within the 28-day wait-time benchmark.
Prince Edward Island finishes in sixth place, well clear of the four remaining provinces, which are clustered at the bottom of the index. Manitoba, Newfoundland, Saskatchewan and Quebec finish in the seventh through tenth slots respectively. Manitoba, Newfoundland and Saskatchewan have similar total scores and are separated by just 24 points out of 1,000. They are about 200 points behind first-place Ontario. Although each of these jurisdictions has areas of relative strength, their overall healthcare-system performance is well below the Canadian average.
Long waits for care are a serious problem in all of the lower performing provinces. For example, the federal and provincial governments in Canada have jointly agreed that surgeries for hip fractures should take place either on the day of admission or the next day. In British Columbia, a highperforming province, 68 per cent of hipfracture surgeries take place within the designated time. In Manitoba, however, only 52 per cent take place within this timeframe. In Saskatchewan, the situation is even worse, as just 48 per cent of hip-fracture surgeries take place either on the day of admission or the next day. Reducing wait times for care is one of the most important things these provinces should work on to close the gap between themselves and top-performers such as Ontario and British Columbia.
Quebec finishes in last place in this year’s index, but the province’s low score requires some explanation. Throughout the index, we have assigned “poor” scores to provinces that do not collect data for indicators that are tracked by all of the other provinces. This rule, which is meant to reward transparency and punish opaqueness, affected Quebec’s score much more substantially than it did any other province due to unusual data collection and reporting processes in the province. Quebec must keep track of similar healthcare data as the other provinces to allow for inter-provincial comparisons and to permit its citizens to hold politicians to account if the province’s performance is poor in a particular area. Although Quebec’s low score is driven primarily by anomalous data collection and reporting, it should be noted that some areas of weakness are identifiable and that these areas of weakness also contributed to Quebec’s low score.
For example, Quebecers are far less likely than other Canadians to have regular access to a family doctor. Just 73 per cent of adult residents report having access to a family doctor compared to over 90 per cent of residents in Nova Scotia and New Brunswick.
Interestingly, our analysis did not detect a relationship between per capita healthcare spending and healthcare performance. Some low-performing provinces such as Manitoba are among the biggest healthcare spenders, and some high-performing provinces such as Ontario have low per capita spending. Clearly, there is no simple link between higher levels of healthcare spending and improved performance. The poor results shown by low-performing provinces are not caused by a low level of healthcare spending, and the problems that exist in these jurisdictions likely cannot be solved by simply throwing money at the problem. Clearly, solutions other than simply increasing spending are needed to improve healthcare-system performance. This report describes a few such reforms that could dramatically improve healthcare performance across the country.
• Make Healthcare Truly Portable.
Some provinces provide medical services more efficiently than others do. Residents of less efficient provinces should be able to travel to provinces where treatment slots are open.
• Enact Patients’ Rights Laws and Wait-time Guarantees.
The Canadian provinces, in co-operation with the federal government, are taking steps in this direction, but they should accelerate the pace with which they are creating guarantees of timely care. Long waits are the biggest single problem in the Canadian healthcare system, and wait-time guarantees are a useful tool that can be used to improve this situation. Canadians deserve guarantees, backed by the force of law, that they will receive prompt, high-quality healthcare services when they are confronted by a medical problem.
• Move to Patient-based Funding.
Most Canadian hospitals are still funded through the global budgeting model in which hospital revenue is determined by bureaucratic processes not directly linked to the number of patients treated or the quality of hospital outputs. Under patient-based funding, the government pays hospitals for the actual services provided. By encouraging hospitals to provide excellent care to more patients, patient-based funding is one of the most effective ways government policy can work to address the problems in healthcare. The majority of Organization for Economic Co-operation and Development (OECD) countries, including many European countries such as Sweden and the Netherlands, has already implemented some form of patient-based funding, and this approach has proven capable of dramatically improving healthcare-system efficiency.
Governments across Canada should ensure that their citizens have timely access to excellent healthcare services. All ten provinces currently fall short of this goal, and we hope this year’s CHCI will help policymakers and citizens in each province identify areas where there is a need for aggressive reform efforts.
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