The emergencies are overflowing. Waiting lists for operations remain long. It is understood, our reforms have been failures, one after the other, and our health system is rotten, undermined by the private sector.
But is this really the case? Or at least, are we taking sufficient account of the enormous pressure on the system that comes from the burden caused by aging patients and the new treatments that have exploded in recent years?
To find out, I dissected the historical data on health personnel, among others. And I noticed that all things considered, the care requested by Quebecers is increasing faster than the personnel made available to them. This costly phenomenon linked to aging puts the failures of our system into perspective.
Let’s see. For the network, one inhabitant today is worth the equivalent of 1.3 inhabitants in the year 2000, for example, given their greater needs for care due to their older average age. These complex equivalence calculations were carried out by the Jacques Parizeau Research Chair in Economic Policies1.
Overall, we can therefore say that the population, which has increased from 7.4 million to 8.9 million inhabitants since the year 2000, is actually worth 11.8 million inhabitants today, in “equivalent inhabitants” from the year 2000. We therefore need many more personnel per capita today.
The consequences are clear. For example, the number of nurses in the public network increased from 96,000 in 2013 to almost 107,000 in 2022, according to the most recent data from the Canadian Institute for Health Information (CIHI). The ratio per 100,000 population has therefore increased, going from 1185 nurses to 1233. In principle, things should be better.
But this ratio of 1,185 nurses in 2013 has fallen by 12% today when we take into account the increase, to 1,038 per 100,000 “equivalent inhabitants”.
Same observation for doctors. The ratio per 100,000 equivalent inhabitants has fallen by 13% since 2015, going from 171 doctors to 149 today.2.
The network doesn’t stop at nurses and doctors, you might say. However, by broadening the analysis to all personnel working in health and social services – both private and public – we see once again that the per capita-equivalent ratio has declined since the 2013 peak. A chart is worth a thousand words.
Aging is not the only external phenomenon that creates pressure. The volume of services has also expanded considerably. Often, it is the private sector which insures them, but not only that. And in any case, the public suffers the impacts, directly or indirectly.
“There is absolutely no doubt that the system offers more services than before, in particular because of technology,” former Minister of Health Gaétan Barrette told me.
Examples ? Physiotherapy services have multiplied and allergy treatment has become more refined. Other examples: 25 years ago, we heard little about sleep apnea, not to mention that medical imaging was much less developed. And what about mental health!
Michèle Boisvert, expert in group insurance programs at Mercer, testifies: not only has the average cost of medications exploded – think of Ozempic at $5,000 per year – but also the scope of services3.
More people are using the services of group insurance programs and those who use them do so more often. There is also the behavior of the insured: the youngest use paramedical services more than their predecessors.
Michèle Boisvert, group insurance program expert at Mercer
Another phenomenon: many employers, sensitive to mental health, have increased their coverage, sometimes increasing the ceiling for reimbursements for psychologist consultations from $2,000 to $5,000. The bet is that the upstream consultation will reduce absences due to disability.
And there is, of course, the impression of free services, which increases volumes. “There is a lot of misunderstanding about who pays, a lack of education. Many people tell themselves that they are going to maximize their use of the services offered, for example for massage therapy, without understanding that it is they who pay in the end,” M tells me.me Green wood.
Data from the Canadian Life and Health Insurance Association (CLHIA) is revealing. On average, the 6.2 million Quebecers covered by insurance claimed $1,035 in 2022, almost double what they did 15 years ago.
Certainly, medications take up about half of this amount ($581), but paramedical care is growing much faster.
In fact, the amount claimed has almost reached $1.6 billion in 2022 for physiotherapists, psychologists and others, so much so that the average claimed per insured ($255) is up 131% over the past 15 years, compared to 74%. for medicines.
It’s difficult to attribute these factors to the nasty private sector, moreover. On this subject, Statistics Canada data on health and social services personnel are surprising.
First, we learn that Quebec has a much higher proportion of public sector employees in health (3,549 per 100,000 population) than elsewhere in Canada (2,949). Here, I did not use the per capita-equivalent ratio.
It is impossible to quickly explain the 20% difference between the two solitudes. Yes, Quebec is experiencing aging, but so is the rest of Canada.
Above all, we see that public employees in Quebec in health and social services have recently exceeded those in the private sector (to which I have added self-employed workers for the purposes of comparison), a first in 35 years. Conversely, the trend towards the private sector is accelerating in the rest of Canada.
Statistics Canada is casting a wide net for these jobs, it should be noted. They encompass all categories of care (dentistry, dietetics, physiotherapy, domestic care, etc.) or settings (public, private, community, autonomous)4.
What to conclude? It is clear that our health system, we often read, still has many problems with innovation and efficiency (think of faxes, among others). That our doctors still occupy too large a share of the remuneration.
But we forget to consider the enormous impact of aging and new care, which darkens the picture and increases costs. And that this trend is not about to change, judging by the demographic curve, in particular.
Can we take this into account before describing our system as mediocre?
1. Many thanks to Pierre-Carl Michaud, from HEC Montréal, and his team from the Jacques-Parizeau Research Chair in Economic Policies for this complex calculation of the equivalent population.
2. In the case of doctors, I was able to take into account that many of them work fewer hours than 10 years ago, for different reasons. I calculated the number of full-time physician equivalents using data on the subject from CIHI on compensation.
3. Treatment with Ozempic is often covered by group insurance for those who have diabetes problems.
4. Public employees represent 59% of public and private employees, but 52% when we add self-employed workers to the private sector.