Sustainability of health care in Canada

Morris Barer and colleagues1 set out to “ascertain whether there is more than just rhetoric” behind claims that the Canadian health care system is unsustainable. Although their interpretation does not specifically confront this stated objective, they imply that the system is sustainable. I do not believe their data support this conclusion.

The authors' statement that “the combined effects of population growth, aging and general inflation . . . were virtually identical to the overall increase in physician expenditures”1 is misleading. Physician fees declined by 9.4% in real terms during the years studied,1 and fees were the only inflation-sensitive measure of the study. The increase in expenditures was therefore not an “effect” of inflation; rather, the effects of increased utilization were compensated for by the decline in real value of physician fees. Putting aside the important issue of whether this situation is equitable, it clearly is not sustainable: physician fees cannot decline in real terms indefinitely.

More important, the authors' data do not penetrate the effects of financial restraint on quality of care, a fact that they themselves point out.1 But this issue is the very crux of the perceived health care crisis. What happened to waiting lists for referrals, surgery and diagnostic tests? How were health outcomes affected? Is it appropriate to assume that age- and population-adjusted fee expenditures should remain the same (in real dollars) over this time period? Moreover, physician fees account for only 24% of health care spending in British Columbia;2 if there is a funding crisis, physician fees are only a small part of a larger problem.

A sustainable system must both control costs and provide appropriate health care. Barer and colleagues establish that the government of British Columbia controlled costs, but they do not establish that it did so in a sustainable manner.

Mark Fruitman Radiologist St. Joseph's Health Centre Toronto, Ont.