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Dynamic Chiropractic Canada – August 1, 2008, Vol. 01, Issue 01
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North America's Health Care Crisis

Will the Solution Be Health Care or Wealth Care?

By Don Nixdorf, DC

Americans and Canadians continue to live with a Medicare crisis. The spotlight to this topic is always turned on with an election or pending change in physician payment models.

The spotlight is always turned off after an election or settlement of payment. This is currently demonstrated by the presidential election in the U.S. The light will be turned on again in Canada, province by province, as each confronts its budget crisis. The most important participant - the public/patient - must be made aware and urged to participate in protecting Medicare.

The challenge, however, is becoming aware and participating in solutions while the spotlight is still on. Will patients/consumers participate in a manner that will demonstrate they have the experience to identify the best practice-based evidence and have the right to choose their care? Choice is a right and the outcomes must be at the core of health dialogue, planning and reform. Reflecting on the majority of reports in Canada and the U.S., their content remains overshadowed or ignored in favor of the simplistic choice of paying more for the same. Demand for services is impacted by population demographics (age and growth), injury and illness patterns. Science and technology themselves are visible cost drivers but often create new efficiencies.

In addition, health personnel resources are subject to cycles and political decision-making. Impacting all these topics, however, are the most important elements of daily health care - early and correct diagnosis, along with the most effective treatment by the most qualified health provider. Ignoring criteria and principles leading to better outcomes has contributed to repeated commissions, reports and studies, with the repetitive result of squandering billions. If funding remains the only focus of policy change and implementation, there will likely never be enough money and tomorrow's health care results will be the same as yesterday's.

Cash or Care

Health care is a partnership between the public, provider and often multiple insurance authorities. This partnership exists first for society and must respect each person's need for optimum health care outcomes. Federal payment plans in the U.S. (under Medicare and Medicaid) and in Canada (through the Canada Health Act) have limited roles as sources of cash to support funding administration and primarily medical practitioners. Neither plan, however, has any responsibility to ensure the patient receives the most appropriate diagnosis or treatment. Whether by redistribution of taxes or premium-based insurance, funding impacts choice and accessibility, not only in hospitals but also for all daily health services chosen by the public (the overwhelming majority of which occurs outside of hospitals).

While there is no single answer to the health crisis, the chiropractic profession can play a major role in promoting public awareness of health and improved health delivery. It is the latter where the chiropractic profession has the opportunity to lead in each state and province, as at least one-third of all daily health services - whether billed to public or private insurance - is for spine and related conditions. Ensuring this major health service is provided by the right doctor relieves unnecessary spiraling costs and provides immediate relief to often-cited reports of medical practitioner shortage. The growing crisis will not allow health authorities to ignore this opportunity and the incredible published evidence in its support. Continuing to ignore patient and fiscal solutions will broaden the context of liability for all health authorities.


Empowering and Respecting Patient Choice: The success of health planning and implementation should embrace the following principle: "The greatest untapped resource in health care is the consumer. Well-informed patients get better care and also assist in better prevention. The issue at hand is how to get the right information into the hands of the right person and at the right time. The development of a comprehensive self-care strategy that supports not only individuals but also health care professionals will take advantage of existing resources."

Education: We graduate health-illiterate individuals each year. Three actions must happen to stop this illiteracy. First, students should be provided basic health information and empowered to make healthy choices throughout K-12. Second, examples should be developed and promoted by all stakeholders to create a culture of healthy lifestyle for all adults. Without a knowledge base and the empowerment to use it, we will continue to produce health-illiterate adults whose primary source of education are news headlines, TV programming and pharma ads. Third, chiropractic education opportunities should exist to establish teaching and research centres in collaboration with public universities.

Access: In order to maximize Medicare resources, greater integration and access must exist among all regulated health providers. Health authorities fully know the cost of duplication of exams, tests and consultations in the health care system. Allowing greater access to all public services, including appropriate access to electronic health records, will accelerate clinical care and reduce costs to the whole system.

Funding: Funding through a public, single-payer model can achieve the lowest cost for individuals, regardless of when care is needed. This model exists but is not fully implemented, despite the apparent intent of stated sections of the Canada Health Act. Section 9, "Comprehensiveness," includes a reference that federal funds should be available for services from professions "where the law of the province permits," which includes the chiropractic profession. The Canada Health Act does not limit the funding of necessary health services. Health funding should recognize and include the services that reduce pharmaceutical costs and their dependent nature. Substantive health issues, including spine and spine-related conditions, comprise one-third of all daily health-care office visits. This large population-based problem allows for opportunities to lower costs through funding policy that recognizes the benefits and economy of scale. A patient-centred Medicare system will support the patient's choice of their most effective care. The current system continues to do exactly the opposite, with spiraling costs and increased iatrogenic-based care.

Public utilization of health services continues to be influenced by the policies of public and private insurers, including workers' compensation boards and auto insurers. Payors should recognize all primary-contact health providers on an equal basis. This is an absolutely necessary recognition to not only fully integrate primary health care, but also to fully acknowledge the public's right to choose who their primary care provider will be at their time of need.

Challenges to Health Authorities

The continued challenges can be viewed as the "seed" of opportunity for government and all health authorities to work toward a restructured system for health care that is comprehensive in its recognition of outcomes. Alternately, it can be the "stone" of refusing to change, accepting continued higher costs and substandard outcomes. The moral compass will be challenged.

Historically, each profession has approached patient care with the assumption that their primary responsibility lies with providing high-quality care, while government should administer funding and payment to providers. The segregation of fee-for-service funding from actual patient care has created a gaping wound in terms of outcomes.

The responsibility of government is to lead health care restructuring through law-making and organization of services. It is clear the issue is not an inability to pay for health care, but rather the model of funding, while ensuring and respecting patient choice, not provider monopoly or payment.

Chiropractic and the integrity of public policy have been repeatedly examined through public process, with major recommendations to benefit patients. These processes include the New Zealand Royal Commission and Wilk v. AMA, among many other government reports. The opportunities largely wait to be implemented in specific sectors, including government and private health insurance, workers' compensation plans, auto insurers, and meaningful interprofessional relations.

Chiropractic has always been a core service of the public's necessary care. The treatment and prevention of health conditions that consume an estimated one-third of all daily Medicare services demand a strategic plan to support public health and lower health costs. Chiropractic can contribute to this strategic plan in a manner that will not only reduce cost and improve outcomes, but also will provide a solution to reported shortages of medical manpower.

Onerous institutional support is not required, but government resolve should ensure there are no barriers to public access to family chiropractors, including hospital and institutional health centres. In order to provide the best overall form of health delivery, this is a necessary and desirable standard of care. From the public's perspective, unaided by media headlines and insurance definitions, regulated health professions are not alternative, supplemental or complementary. More appropriately, they are mainstream or core services supporting their health care needs.

The future of health care delivery is characterized by an increased need or demand for public and provider groups. The severe pressures documented in previous reports are today's reality. Sustaining Medicare requires promoting and respecting patient choice, and being aware of and implementing improved patient outcome in future health planning, not solely fiscal policies that increase or reallocate rising health costs.

We can no longer plan for the next decade. We must plan for next year to sustain quality health care.

Dr. Don Nixdorf is the executive director of the British Columbia Chiropractic Association and the B.C. College of Chiropractors. He served as president of the Council on Chiropractic Education Canada from 1993-1995 and chair of the Commission on Accreditation from 1995-1998. Dr. Nixdorf is the author of Squandering Billions - Health Care in Canada.

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