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This article was published 22/7/2017 (1157 days ago), so information in it may no longer be current.

Opinion

It has been a month of nearly unprecedented change in the health-care system.

Almost daily, the Winnipeg Regional Health Authority has announced reductions or eliminations in programs and services, many of which require layoffs or the elimination of vacant positions and the loss of services to tens of thousands of Winnipeggers.

An outpatient audiology program at Health Sciences Centre and outpatient occupational therapy and physiotherapy programs have been cut. Eliminated as well was the Mature Women’s Health Centre at Victoria General hospital, which provided gynecological treatment to women dealing with menopause and hysterectomies.

These program-specific decisions come in the wake of larger systemic cuts, including the massive reorganization of hospital emergency departments, the closure of four Quick Care clinics, the end of 24-hour service at the Misericordia urgent care centre and the elimination of 132 WRHA management positions, 73 through layoff.

Ostensibly, the WRHA has said all of these decisions were prompted by an edict from the province to cut spending to alleviate an anticipated $83-million deficit for the current fiscal year. The deficit was created when the province brought down its April budget, which included funding to the province’s network of regional health authorities. Although overall funding did go up, it did not go up enough to meet the WRHA’s forecasted expenses over the year.

However, while that explains why the WRHA has been making the cuts, it does not explain how it has arrived at the specific programs to cut. This is where the much-debated KPMG audit of health-care service delivery comes into play.

Although the Tory government broke a campaign promise by refusing to release the full KPMG audits, the WRHA confirmed that the province did share the results with the WRHA. The main finding was that Manitoba’s health-care system was overstaffed, and not just in the management ranks at the health authorities.

A WRHA spokeswoman said KPMG apparently identified a number of areas where "the WRHA has more generous staffing models than nearly any other jurisdiction across the country," and pointed to this area in particular as a driver of Manitoba’s per-capita expenditures for health-care services being among the highest in Canada.

"The identification of Manitoba staffing models as an outlier, when compared to other Canadian jurisdictions, has pushed us to take a hard look at how we staff every area of our system."

Premier Brian Pallister has long railed against the former NDP government for spending among the most of any province on health care, while also experiencing some of the worst outcomes. And it is true that based on the most recent information, Manitoba has consistently spent more than most provinces on a per-capita basis.

A 2016 report from the Canadian Institute for Health Information (CIHI) showed that Manitoba spends $7,120 per capita on health care, second only to Newfoundland and Labrador ($7,256) and just ahead of Alberta ($6,995) and Saskatchewan ($6,838).

However, the per-capita costs don’t do a good job of explaining why the costs are higher, and don’t generally do anything to factor in the profile of the patient populations being served, geography and other factors specific to each province. Did the KPMG audit attempt to explain or analyze the variation in the health-care challenges in each province, or just apply a two-dimensional calculation that looks at the numbers of health-care workers against the size of the population?

Not being able to see the audit, we may never know. And that’s too bad, because there is some evidence that while KPMG may think that staffing outpatient physiotherapy services is a "driver" of per-capita expenditures, there are other data suggesting the problem may lie elsewhere.

CIHI does an analysis of the three biggest spending streams in provincial health care: hospital costs, drugs and payments to physicians. Manitoba actually ranks below the national average on hospital and drug costs, by a large amount; on physician fees and salaries, Manitoba has the third-highest per-capita spending. Even so, to date the WRHA has, for the most part, steered clear of decisions that would affect physician remuneration.

There are also some questions about whether the WRHA is able to calculate the full effect of its spending cuts.

Take the decision to cut occupational therapy and physiotherapy. The cuts made were to a program that was, in essence, providing a non-insured service. Patients admitted to hospital routinely get access to physical therapy as part of the recovery process; the therapists being cut were providing similar services on an outpatient basis — that is, for patients not admitted to hospital, or post-release.

Réal Cloutier, the WRHA’s interim president and CEO, said in an interview that most provinces do not provide publicly funded outpatient treatment of this kind, and when the government is attempting to slow health-care spending, it was an area ripe for a reduction.

However, Cloutier did concede the authority is not entirely clear on how this will impact patients. Some will have access to private insurance to pay the cost of therapy; others will be able to afford to pay out of pocket. The WRHA will try to income-test all those receiving outpatient treatment to ensure the most needy are still covered.

Even so, Cloutier said some people who really cannot afford the treatment will likely have to go without.

And that raises an interesting dilemma for the Pallister government. To help bring down the rate of growth in health-care expenses, the RHAs, spurred on by Finance Minister Cameron Friesen, are trying to cut or reduce in those areas that involve either an uninsured service or where Manitoba provides a level of service, at a level of staffing, that exceeds other provinces.

It is not certain, however, that this strategy results in a better health-care system. Cutting the mature women’s program at the Vic may make fiscal sense, given that there are other medical professionals who can effectively provide the same support. However, proponents point out that focused, co-ordinated treatment for women dealing with hysterectomies and menopause translates into better overall health and fewer expensive hospital admissions. That means cutting programs such as this could be penny-wise and, in the long run, quite pound-foolish.

Similar concerns surround the cut to occupational and physiotherapy. Yes, it was not an insured service. But is the additional support a cost-effective insurance policy against the high costs of poor overall health and possible readmission to hospital? That is a question that cannot be answered by a clutch of accountants undertaking a fiscal analysis of health-care programming.

With health care consuming more and more of overall provincial government spending, we should all expect to see a rationing of certain kinds of services. However, it’s important for government to ensure that it is focusing its efforts on the areas that have the least negative impact on the health of the people it serves.

In the absence of the audits, we seem to be involved in a process that is focused mostly on cost control and not better health outcomes.

dan.lett@freepress.mb.ca