Autumn 2000. It was the time of the Clair commission, which the Minister of Health, Christian Dubé, drew inspiration from in his recent reform project.
On October 28, 2000, therefore, about fifteen representatives of health professionals met in North Hatley, at the invitation of the Agora, to propose a reform that was finally realistic, following a presentation by Dr.r Maurice McGregor, cardiologist, former dean of the McGill Faculty of Medicine and former chair of the Council for Health Technology Assessment. A detail of his diagnosis: “40 years ago, in 1960 therefore, kidney failure quickly led to death, without great cost to the health system. Today, in the year 2000, dialysis alone costs Canadian taxpayers about $950 million a year. »
The essence of our report? From crisis to crisis, the same problems and the same cause: unlimited needs, constantly growing due to advances in medicine, and limited means, despite the enrichment of Quebec. The rationing of the services offered, the only way to maintain a public system that does not make you want to flee to the private sector. Conditions: that the services selected for the public sector be of the highest quality and that citizens participate in the choice of these services.
Since the number of services offered in the public health system is not yet transparently limited, the latter still fails to adjust to demand. Hence the waiting lists for surgery and overcrowded emergency rooms. Rather, the good services offered should be adjusted to the government’s ability to pay, an ability specified in the health agency’s annual budget.
Such an adjustment presupposes an effective method to ensure the participation of citizens in the major decisions that affect them. In 2000, the eyes of enlightened reformers were on what has been called the Oregon model.
It was first necessary to establish a list of priorities among the 1600 possible medical interventions. This is the task that 1048 citizens, first divided among 50 small local assemblies to then form a single council, assigned themselves, with the help of experts who provided them with precise data on the effectiveness of the interventions studied. . They succeeded in classifying the 1600 interventions studied in order of priority, giving more importance to preventive measures than to curative measures. For example, prenatal care prevailed over organ transplants. Once the list was established, it remained for the council to draw the line after the 500e or the 1000e intervention, according to the resources provided for in the budget.
When I was still closely following this experiment, its success seemed compromised by ethical problems related to services refused to certain disabled people.
We could take the Oregon model again, adapt it to our situation. What we cannot do, concluded McGregor, “is to continue to increase services at the expense of hospitals and think that they will continue to meet the demand.”
“Limiting the acquisition and use of health technologies, ie rationing, will not be easy. It will first be necessary to recognize frankly that our resources are not without limit, that we cannot afford everything for everyone. Decisions about what to limit should be made openly and in accordance with agreed principles. For example, we could probably agree that when we spend our common resources, we should try to get the maximum benefit for every dollar spent. In other words, we should consider the cost-effectiveness of an intervention before deciding whether to adopt it or not. »
What Happened to the Health Technology Assessment Council? It has been integrated into the National Institute of Excellence in Health and Social Services. Beyond the watered-down vocabulary, its real mission is to counterbalance, including in the public square, the marketing of the pharmaceutical industry in particular. Does it fulfill this mission adequately? He could do it in a big way with a council like the one we are proposing.
For the moment, to my knowledge, it is in theAlter medical-pharmaceutical dictionary of Dr. Pierre Biron that we find the most free, the most complete, the most rigorous… and the least costly critical spirit. The author has been working there on a voluntary basis for twenty years, and access to his site is free.
It goes without saying that the quality of evaluation, the independence of researchers and the free dissemination of their results are a condition of any reform worthy of the name.