Rethinking the Welfare State: The prospects for ... - e-Library

Rethinking the selfare state 102
every citizen or resident whom they treat there is no incentive to screen out high-risk
patients. In turn, the government as sole supplier of health insurance benefits from the
ability to pool costs. That is, the costs of providing care to costlier patients are spread
over the whole of the population. A single-payer system is also likely to involve
significantly lower administrative/transaction costs than a multipayer system.
Another benefit of the system is that it is more attentive than others to distributive
justice concerns because every citizen or resident is formally entitled to whatever
medically necessary services they require. However, the Canadian experience suggests
that this claim should not be overstated for there are a variety of health care related goods
and services that are not consistently publicly funded. The most significant of these are
prescription drugs required in non-hospital settings and nursing and other medical
services needed in the home, medical devices such as artificial limbs, ambulance
services, and dental and vision care. 26 It has also been argued that constraints on
government funding have resulted in a deterioration of health care provision in remote
areas. 27 Moreover, a recent study finds that socio-economic status may impact on one’s
likelihood of accessing health care services. 28
A final benefit of the single-payer/fee-for-service system is that it maximizes
individual autonomy. Every individual is free to seek as much medically necessary
attention as they desire and individuals are further free to choose their own family
physician. Despite this domain for choice, however, there are features of the system that
continue to constrain exercise of effective patient autonomy. A central concern with the
current system is the lack of adequate collection, management and use of information.
Canada spends a tremendous amount on health care, yet has surprisingly little
information on factors such as the costs and benefits associated with providing various
services, the expected outcomes for different procedures and the lengths of waiting lists.
Such information is often spread across different components of the system, but is central
to ensuring accountability and efficient resource utilization within the health care system.
Patients also lack information about the quality of particular doctors or hospitals and, as a
result, cannot make informed choices. Doctors lack information on the health histories of
patients, such as records from visits to other doctors or hospitals, and on the efficacy of
advances in medical knowledge. Without this information, physicians and other health
care professionals may not be able to provide appropriate care or may offer duplicate or
unnecessary services. 29 A public information strategy should include publicizing the
status of waiting lists by institution and reporting on individual physicians with regard to
wait times, outcomes and volume of various procedures, since evidence suggests higher
volumes are tied to better outcomes. Governments should ensure easy access to all such
information, via the Internet. Such detailed information is a fundamental aspect of
encouraging individuals to exercise effective choice in the area of health issues.
Evaluation of research and technology is also important. Advances in health
technology have tremendous potential for increasing the quality of care, but they come at
a price. In a publicly funded system governments must ensure that the returns on health
technology warrant the significant financial investment required. Evaluating clinical and
cost effectiveness of treatments while reviewing new and existing technology can ensure
greater quality control for services provided. By emphasizing evidence-based decisionmaking,
health practitioners and consumers can be more confident that the services they
provide and consume are effective. 30