Should patients be accountable for their own health (-care costs)?

In Editorial by Edmund Kwok2 Comments

Free healthcare. That is the shining star of our nation’s healthcare system. In any international discussion or comparison of our system, Canadians pride themselves on the fact that access to essential health services is not prohibited by an individual’s ability to pay. Taxes collected from those who are financially better off, are redistributed to cover healthcare costs of the whole community, regardless of how old, how poor, how unfortunate, or how sick someone is.

Except that was not exactly the intention of those who shaped our healthcare system: we were not supposed to have unlimited, all-you-can-consume healthcare for everyone.

In the first half of his recent book, Chronic Condition, Jeffrey Simpson succinctly chronicles the birth of the modern Canadian healthcare system. His report on the tortuous political paths that eventually led to the Canada Health Act clearly highlights one important point: “free” healthcare where anyone can demand its use without limit, was never in the initial plans. Simpson recounts many examples in his book:

Sir William Beveridge noted: “Every insured person should make a … contribution of about one-quarter of the cost … if you have such a system people will realize that they cannot get unlimited benefits without payment for them, and I believe that is an element of sound finance.

The Hall Royal Commission, which formed the mould for Medicare (as Simpson puts it), clearly stated that: “The individual’s responsibility for his personal health … is paramount“, and that one must “be prepared to assign a reasonable part of his income by taxes, premiums or both to meet the costs of health services which will be faced by every person during the course of his lifetime.

In fact, throughout our brief history, the majority of the think-tanks who contributed to the development of our healthcare system today have stressed the importance of that fundamental principle of health economics: demand is near infinite, whereas resources from general taxation is certainly limited. It would be economically unsound to NOT consider healthcare premiums or some other method to help ensure individual accountability. As the Hall Commission so eloquently states: “It goes without saying that since … resources are scarce, it is the duty of the individual, as well as the practitioner prescribing them, to see that the services are used with prudence and economy.”

So what got in the way? Politics. Elevating national socialized healthcare was a no-brainer for any politic party’s platform – slapping on individual premiums or similar mechanisms for accountability was politic suicide. And so we’ve foolishly overreached our healthcare resources for years and years; but yet the discussion is still mostly focused on cutting costs from providers, with little/no focus on patients and how much individuals should be accountable for their own health.

Even in a publicly funded system, we need to ask how much should patients be accountable for their own healthcare costs. Consider these scenarios (based loosely on real common cases):

A 65 year old man who smoked like a chimney his whole life, refusing to ever try quitting; develops extensive metastatic lung cancer requiring multiple hospital visits for surgeries, radiation, and chemotherapy treatments.

A 54 year old female who spends all her money and energy into purchasing alcohol, and is completely intoxicated daily; repeatedly gets sent to the ER by her landlord because she vomits, urinates, and defecates in her own bed. Every time she sobers up in hospital, she refuses all rehab and social support, and willingly returns to the same cycle.

A 47 year old man who eats unhealthy foods, avoids any exercise, and is non-compliant with his cholesterol medications – suffers a heart attack requiring angioplasty, extended hospital stay due to his poor baseline functional status … only to return for the same after years of poor lifestyle choices and medication non-compliance.

A 23 year old female who chooses to participate in many extreme sports, and regularly injures herself requiring emergent orthopedic surgeries; often at the expense of bumping others on the wait list who have been off-work for months due to hip and back pains.

A 36 year old man who uses the ER repeatedly because it is more “convenient” than trying to see his family doctor; he is assessed every single time (which costs the system much more then a GP visit) because currently ERs are not allowed to turn such patients away at the door.

A 39 year old female who frequents multiple different ERs and hospitals, demanding redundant CT scans and MRIs despite being advised they are unnecessary tests.

The list goes on and on. How do we as a society, decide how much one individual’s life choices is worth more/less than someone else’s? How do we introduce mechanisms on an individual level without encroaching on the key principle behind the Canadian healthcare system: universal access regardless of ability to pay?

Deep down we all know these tough questions need to be answered. We simply cannot continue on our current trajectory of escalating healthcare spending in an all-you-can-consume system. Perhaps we (not just the politicians and providers, but patients alike) need to finally get serious about what the founders of Medicare had always envisioned as a fundamental pillar of a sustainable system: individual accountability.

Edmund Kwok

Edmund Kwok

Emergency Medicine. Quality Improvement. Patient Safety. Change Management. Healthcare Administration.

Frontdoor 2 Healthcare

Frontdoor2Healthcare, founded by Dr. Edmund Kwok in 2012, provides editorial and commentary on issues affecting Canadian healthcare from the emergency department’s “front door” perspective. Frontdoor posts allow for open sharing of the diverse opinions and perspectives of emergency physicians from across the country.

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