November 2000 Fraser Forum: A Health Policy Tale of Two Provinces
Prolonged waiting times for medical treatment are an inescapable and undeniable feature of the Canadian medical system. Evidence for this is all around us. Look at recent issues of leading medical journals, which describe longer waits for Canadians compared to residents of other developed countries for total knee replacement (5.5 months versus 3.5 weeks for Americans: Bell, et al., 1998) and cardiac bypass (5.5 months versus 4.4 months for Germans and 0 months for Americans in one study: Collins-Nakai, et al., 1992; longer waits than Swedes and Americans in another: Carroll, et al., 1995). Or, consider the results of the latest Harvard University survey of generalist and specialist physicians in five countries (Australia, New Zealand, the UK, and the US, in addition to Canada): Canada has the highest fraction of generalists (74 percent) and specialists (84 percent) who fear a future in which "patients will wait longer than they should for medical treatment" (Blendon, et al., 2000).
That future is, unfortunately, already here. In The Fraser Institute’s recent survey of specialist physicians, the doctors in each specialty in each province were asked to provide both actual and "clinically reasonable" waiting times. This data permits approximately 120 province-specialty comparisons (e.g., comparison of actual and reasonable waits for orthopaedic surgery in New Brunswick). In 83 percent of these juxtapositions, actual waiting time exceeds reasonable waiting time (Zelder, 2000b).
Moreover, actual waiting time is growing. For Canada as a whole, waiting time between visiting a general practitioner and receiving treatment from a specialist grew 5.3 percent, from 13.3 to 14 weeks, between 1998 and 1999. Canada’s overall jump is modest compared to that in Saskatchewan, however. While Saskatchewan occupied last place in both years, its grasp on the bottom rung is much firmer in 1999, as its waiting time jumped from 20.2 weeks in 1998 to a calamitous 34.5 weeks in 1999.
At the same time, some provinces have experienced much slower rates of growth, and even decreases in waiting. For example, waiting time fell in both Manitoba and Ontario between 1998 and 1999. Quebec, which was tied for the shortest wait in 1998, saw its waiting time rise by only 4.2 percent, from 11.9 to 12.4 weeks.
Quebec is of particular interest because of its unique behaviour in my recent analysis of government health spending and waiting times (Zelder, 2000a). In that research, I found that in general, provinces that spent more per person on health care had no shorter waiting times than provinces that spent less, during the period 1993-1998. Because an inverse relationship between spending and waiting (more spending, less waiting) can be thought of as a necessary condition for a province’s health system to be regarded as functional, this illustrates that the provinces as a whole are part of a dysfunctional system. Examined province by province, however, Quebec is the only province where higher spending did lead to significantly reduced waiting. As well, Quebec has exhibited the shortest waiting time in four of the last seven years of the survey, and was second-, third-, and sixth-shortest in the other years.
What explains Quebec’s success, relatively speaking, in maintaining shorter waiting times and in getting results from its government health spending, and the simultaneous failure of Saskatchewan? As a corollary to my finding that higher per capita government health spending had no impact on waiting time, I discovered that increases in one (and only one) component of spending—drugs— led to decreases in waiting time. Consequently, it is reasonable to examine Quebec’s spending patterns to determine if it was able to keep waiting time low, and reduce it by spending more, due to a disproportionate focus on drugs spending.
The evidence indicates that it was, at least in part. Since 1993, the Quebec government has spent more on drugs than the other Canadian provinces, on average. Among the individual provinces, Quebec has also been among the highest spenders during the last 7 years. In particular, on a real per capita basis, Quebec was the highest spender on drugs in 1998, and was second highest (behind Ontario) in 1994-1996, 1997, and 1999, and third highest in 1993 (behind Ontario and British Columbia). As a percentage of total government health spending, Quebec was the highest spender on drugs for the period 1997-1999, was second (to Ontario) in 1994-1996, and third in 1993 (behind Ontario and Nova Scotia).
But Quebec’s drug spending gap only explains part of the difference. According to my earlier calculation of the beneficial effect of higher drugs spending, when Quebec spent $16 more (per person) on drugs than the Canadian average in 1996, its waiting time should have been about 1.1 weeks below the Canadian average. But, in actuality, the Quebec wait in 1996 was 2.9 weeks below the Canadian average. This means that some other factor must explain the additional Quebec advantage, 1.8 weeks in this case.
A logical candidate would seem to be strike activity. More intense strike activity in the health sector would be expected to lengthen waiting times, as the supply of services would shrink during strikes. Tests of this theory in my analysis of waiting time found no such connection, however. Data from HRDC enumerating the number of strike days lost per province were adjusted for population, generating strike days lost per capita as an index of strike intensity. But this variable was statistically insignificant in explaining waiting time differences among provinces for the period 1993-1998.
In 1999, however, health sector strikes were a significant determinant of waiting time. Quebec, in fact, had the third highest strike rate in 1999, 18.6 strike days lost per person. This may explain why, despite Quebec’s high drug spending, its waiting time rose from 11.9 to 12.4 weeks between 1998 and 1999.
More dramatic were health sector strikes in Saskatchewan, which had the highest rate of strike days lost in 1999, 56 per capita. In fact, only Manitoba, with 70 strike days lost per capita in 1996, had more intense strike activity during the period 1993-1999. Was this surge in strike activity, from 3 days per capita in 1998 to 56 in 1999, the sole cause of Saskatchewan’s 71 percent increase in waiting time during that interval? While this cannot be answered with certainty, no other measurable factor changed nearly as much during this time.
Undoubtedly, mysteries will always remain in attempting to explain provincial differences in waiting times. For now, we know that provinces that wish to reduce waiting, within the confines of the current maldesigned system, should emphasize drug spending and avoid substantial strike activity. Were Saskatchewan to do this, it would, happily, look much more like Quebec.
References
Bell, Chaim M., Matthew Crystal, Allan S. Detsky, and Donald A. Redelmeier (1998). "Shopping Around for Hospital Services." Journal of the American Medical Association 279:1015-17.
Blendon, Robert J. et al. (2000). The Commonwealth Fund 2000 International Health Policy Survey of Physicians (digital document — http://www.cmwf.org/programs/international/hsph_physicians_ chartbook_431.pdf).
Carroll, Richard J., Susan D. Horn, Bjorn Soderfeldt, Brent C. James, and Lars Malmberg (1995). "International Comparison of Waiting Times for Selected Cardiovascular Procedures." Journal of the American College of Cardiology 25:557-63.
Collins-Nakai, R.L., Huysmans, H.A., and Scully, H.E. (1992). "Task Force 5: Access to Cardiovascular Care: An International Comparison." Journal of the American College of Cardiology 19:1477-85.
Zelder, Martin (2000a). Spend More, Wait Less? The Myth of Underfunded Medicare in Canada. Fraser Forum, August.
________ (2000b). Waiting Your Turn: Hospital Waiting Lists in Canada (10th ed.). Vancouver: The Fraser Institute.
Martin Zelder (martinz@fraserinstitute.ca) is Director of Health Policy Research at The Fraser Institute. He has a Ph.D. in economics from the University of Chicago.
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