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At Nanaimo Regional General Hospital, for instance, waiting times in emergency have been cut by 50 per cent, fuelled by incentives as high as $600 for each extra patient admitted to an acute-care bed within 10 hours and lesser amounts for other treatment targets.

In Prince George, the number of MRIs, rewarded by $275 per procedure beyond a set baseline total, is targeted to go up by a third this year, representing 1,250 additional screenings.

The volume of shoulder surgeries, bringing in nearly $3,000 a pop for added procedures, is scheduled to virtually double, from 63 to 123.

A government report on the program’s first year of operation estimates that the influx of only $53-million in new money resulted in 67,000 more emergency patients being treated on time at the 14 hospitals involved, and 36,000 additional procedures performed at B.C.’s 23 largest hospitals.

Other aspects of the multipronged program include additional sums going to hospitals for taking on difficult cases and financing the introduction of a surgical quality-care system for B.C. hospitals.

Les Vertesi, executive director of the B.C. Health Services Purchasing Organization, which is overseeing the radical shift

not all of the $250-million earmarked for the program’s first two years is being claimed, because hospitals continue to struggle to improve capacity

Overall, about 17 per cent of hospital funding in B.C. is covered in various ways by the new approach.

“Throwing money at the problem may work, but an unintended consequence is that you essentially say to people: You don’t have to perform, until we give you money,” Mr. Lewis said.

Dr. Butcher of the Northern Health Authority added there is a risk of hospitals becoming too attached to activity-based funding. “It can artificially change your focus to procedures that generate revenue,” he cautioned, rather than doing what the patient really needs.

Not performing up to snuff can result in penalties.

Overall, however, patient-focused funding mostly rewards rather than punishes.

cataract surgery has become much quicker and more efficient, but the prices haven't gone down as a result because government has done nothing

Statistics from the Organization for Economic Co-operation and Development show that Canada is one of the highest health-care spenders, but has below average numbers of doctors, nurses, hospital beds, CT scanners and MRIs. Another study, the euro-Canada Health Consumer Index, found that Canada finished in the bottom third in a "bang for the buck" comparison with European countries.

choice and competition are what drives the more effective European systems

the act that governs medicare stifles innovation and competition, except in Quebec, where the federal government turns a blind eye to innovation and private sector involvement

Flaherty's plan to limit spending increases is sensible and necessary, but it requires no political courage. The much more important move would be to allow provinces to experiment with European ideas and introduce more innovation and competition

Randall Denley is a member of the Citizen's editorial board.

One of the most significant drivers of cost increases was compensation for health-care workers. CIHI data suggest the number of health-care workers in hospitals grew by 21% in the decade to 2008 and their wages and benefits grew faster than other workers in the general labour market.

Physician expenditures was the second-largest category of public-sector health-care spending increases — rising 6.8% a year in the decade to 2008. Within this category, compensation for doctors grew 3.6% a year.

The number of CT scanners nearly doubled between 1997 and 2010, while the number of MRI machines increased five-fold.

David Hume, the 18th-century Scottish philosopher. Hume realized that, although people talk about causes as if they are real facts—tangible things that can be discovered—they’re actually not at all factual. Instead, Hume said, every cause is just a slippery story, a catchy conjecture, a “lively conception produced by habit.” When an apple falls from a tree, the cause is obvious: gravity. Hume’s skeptical insight was that we don’t see gravity—we see only an object tugged toward the earth. We look at X and then at Y, and invent a story about what happened in between. We can measure facts, but a cause is not a fact—it’s a fiction that helps us make sense of facts.

our stories about causation are shadowed by all sorts of mental shortcuts

when it comes to reasoning about complex systems—say, the human body—these shortcuts go from being slickly efficient to outright misleading

causal explanations are oversimplifications

the power of statistical correlation, which has allowed researchers to pirouette around the problem of causation

statistical significance, invented by English mathematician Ronald Fisher in the 1920s. This test defines a “significant” result as any data point that would be produced by chance less than 5 percent of the time. While a significant result is no guarantee of truth, it’s widely seen as an important indicator of good data, a clue that the correlation is not a coincidence

require that we understand every interaction before we can reliably understand any of them

we often shrug off this dizzying intricacy, searching instead for the simplest of correlations. It’s the cognitive equivalent of bringing a knife to a gunfight.

Although the scientific process tries to makes sense of problems by isolating every variable—imagining a blood vessel, say, if HDL alone were raised—reality doesn’t work like that. Instead, we live in a world in which everything is knotted together, an impregnable tangle of causes and effects

the R&D to discover a promising new compound now costs about 100 times more (in inflation-adjusted dollars) than it did in 1950. (It also takes nearly three times as long.)

it’s not just MRIs that appear to be counterproductive

an in-depth review of biomarkers in the scientific literature

83 percent of supposed correlations became significantly weaker in subsequent studies

we’ve constructed our $2.5 trillion health care system around the belief that we can find the underlying causes of illness, the invisible triggers of pain and disease

If only we knew more and could see further, the causes of our problems would reveal themselves. But what if they don’t?

We keep trying to fix the back, but perhaps the back isn’t what needs fixing.

more than 40 percent of them were later shown to be either totally wrong or significantly incorrect

two leading drug firms, AstraZeneca and GlaxoSmithKline, announced that they were scaling back research into the brain. The organ is simply too complicated, too full of networks we don’t comprehend.

85 percent of new prescription drugs approved by European regulators provide little to no new benefit

According to the Centers for Disease Control and Prevention, things like clean water and improved sanitation—and not necessarily advances in medical technology—accounted for at least 25 of the more than 30 years added to the lifespan of Americans during the 20th century

the things we can see will always be bracketed by what we cannot

If your finances permit, you can jump the queue for publicly funded nursing care and, in some cases, pay upwards of $5,000 per month to stay at a private facility.

And the public health authority Capital Health pays more than $1 million each year to a private clinic, Scotia Surgery, to perform hundreds of orthopedic operations.

The author and professor arrived armed with reports, information graphs and a copy of her book, Health Care in Canada: A Citizen’s Guide to Policy and Politics.

Private enterprise hasn't made health care more efficient, but rather more sluggish, the longtime Labour Party politician said. Bloated corps of lawyers, accountants and consultants hired by government now fret over tenders and contracts, which must be watertight, he noted. Dobson cited one case in which a woman suffering from a serious hemorrhage bled out during surgery because the private clinic didn't have an emergency blood supply. "The answer from the clinic was the contract didn't say we had to have an emergency blood supply," he said. Dobson is touring Ontario cities with officials from the Ontario Council of Hospital Unions (OCHU) and CUPE to discourage provincial plans from bringing more surgeries and procedures into the private fray.

However, with the shift, the ministry hopes to provide patients with "quicker access to complex surgeries because hospitals will be able to get to more complex procedures sooner." Ontario hospitals have struggled to do more with less in an era of cost-cutting and provincially mandated, balanced budgets. But giving private operators a bigger piece of the pie won't lower wait times nor reduce costs, said Dr. Wayne Taylor, executive director of the public policy think-tank Cameron Institute. "I don't see any value added in having something privately owned or publicly owned if it's still government money. What we need frankly is private-pay health care so that people have a choice." However, firms aren't exactly chomping at the bit to delve into health care, the former McMaster professor added, calling it a low-return investment.

Many MRI operators in Ontario dropped off the map about a decade after they set up shop, he noted. "Half of them are still around. Half of them went out of business." A number of private clinics in Hamilton provide OHIP-insured services, such as the Hamilton Endoscopy Centre on James Street South, Pain Care Clinics - Hamilton West, on Main Street West, and the Hamilton Vein Clinic on Upper Wentworth Street. Dobson argues private-sector imperatives and health-care needs are strange bedfellows, recalling how earlier this year one firm operating a U.K. hospital threw in the towel when its care fell under scrutiny and business looked bad. That was Circle Health, which gave up running Hinchingbrooke Hospital after three years because it was "no longer viable," the BBC reported. "The ultimate discipline in a market is if you can't make a go at it, you go bust, and it closes down. Well, you can't allow it to close down because patients need to be looked after," Dobson said.

Taylor, however, who calls the National Health Service a "disaster," says the private-public operating debate is a "red herring." He has heard of some "quality issues" at privately run colonoscopy clinics. If a doctor punctures a colon at a hospital, there's backup, Taylor said, but, in private clinics, "I don't know." Success depends on proper regulation, Taylor said. The Liberal government has come under scrutiny for not providing adequate oversight of private clinics, notably after a bacterial outbreak at a Toronto pain clinic in 2012 went unpublicized as it infected nine patients there.

It's been a long couple of years, but recently after switching to a gluten-free diet and developing a program of naturopathic supplements, we've seen some improvement, going from multiple seizures a day to multiple days without seizures, and Nicholas's development exploded during this time: new words and tasks mastered almost every day with the decrease in seizure activity. We found a daycare for a few hours a day, a few days a week, to help Nicholas socialize and aid in his development. He loved going to school and being with his friends and his teacher, and he learned many new things while there. He was developing so well there that we were going to admit him for full days this summer and enroll him in kindergarten at this facility next year because we felt this learning environment was the best for his needs.

After two long years we were starting to achieve some normalcy in our lives. Nicholas was functioning well, playing with his friends and was rehearsing for his first concert. Maybe my wife could even look at starting some kind of a career again. Recently, things changed. The ignorance and insensitivity of some people came to light. After picking up Nicholas from school, my wife received a phone call saying that they could no longer accommodate Nicholas's needs. There was no place for him to safely take a nap after having a seizure, and we would need to come pick him up after he had one. After six months of attending this school, now all of a sudden he could no longer be accommodated. The reasoning they gave us didn't make sense - a book could fall on his head while he's asleep, and if he needs to sleep then we feel it is best he did this at home.

After arranging a meeting with the owner of this "educational facility" we were just given the runaround about why Nicholas's seizures were suddenly an issue. We were given a sales pitch about how it was the owner's dream to open this facility, and her love of teaching children, and even though this is a for-profit institution she does not make money as she puts it all back into the school. There was still no real reason as to why she could no longer accommodate my son other than the fact that there was nowhere for him to safely sleep after a seizure, in a daycare that has cots and multiple classrooms and offices, and Nicholas has a government funded one-on-one assistant. After more questions about inclusion and having to accommodate special needs people, the answer that was given, that has been bouncing around my brain all week, was "we are a private institution and we don't have to take in anybody."

So there it is, the bottom line answer - all of the love for children and teaching them seems to be as long as your child is perfect and you have the money to pay. If you have to be "accommodated," then it's not worth the effort. So the joy and adulation of seeing our son begin to grow, of watching him in his concert, of having a chance at being "normal," was shattered because it was too much trouble to accommodate his needs.

We were never given the real reason, did a staff member complain? Did another parent complain? Is there a "normal" kid that is looking for Nicholas's slot who would be less trouble to accommodate? We may never know the real answer. But that's OK. After a few days to recover and clear our heads, we are determined that things will work out. We've worked hard, in particular my wife has worked hard, in the last two years to give Nicholas everything that he needs to learn and develop and be healthy. We've seen the progress that has been made through the hard work and support of our family and friends, his doctors, his therapists and others. This work will continue. Nicholas's development will continue. And things will be fine, despite the ignorance of others. We will persevere and give Nicholas the best life possible, with the help of people who truly care about him and are able to "accommodate" his needs every step of the way. Rod and Susan Downey Portugal Cove-St. Philip's

Jenkins proceeded to not only arrange an appointment with the surgeon, but accompanied Maureen to the hospital and provided the surgeon with a detailed medical history of her previous encounters with the specialists. Once the details of her case were laid out, the surgeon quickly diagnosed her complaint and recommended back surgery.

Unfortunately, the issues Maureen faced in accessing the appropriate care and treatment are not uncommon. For many patients, simply navigating the health care system can often feel like wandering through a maze. Especially for seniors, staying on top of appointments, medications and lab tests can quickly become overwhelming. “It’s easy to get lost… it’s not that [patients] don’t have faith in their providers, they just have questions and there’s no one to ask,” explains Jenkins.

"It's now up to the government to act and decide whether it will cover the cost of certain services and the use of medical equipment in private practice, or if it wants to revise the agreement on the accessory fees with the medical federations." Under the Quebec Health and Social Services Act, doctors who work in hospitals cannot bill patients for medically necessary services. These same physicians must abide by certain conditions in their private practice, since they have not opted out of medicare. They can only charge for "medications and anesthesia agents" in private, and they are not allowed to bill patients for the use of medical equipment. However, there is one exception to the rule: private radiology clinics in Quebec can bill patients for MRI scans - a sore point with Health Canada, which has argued that the exception violates the accessibility provisions of the Canada Health Act. In addition, Quebec did negotiate with the medical federations a list of fees that are permitted, such as the use of liquid nitrogen to remove moles ($10) or the use of a topical anesthetic for a minor eye wound (also $10). Over the years, many physicians in private practice have started billing for many more items and services, sometimes prompting investigations by the Régie de l'assurance maladie du Québec (RAMQ).

Murphy’s story stems from an acute doctor shortage in Cape Breton. The Nova Scotia health authority estimates about five per cent of Cape Bretoners are without a doctor, more than 5,000 people. Provincewide, the rate is about 10 per cent, meaning about 94,000 Nova Scotians don’t have a family physician.

The pay-per-use model would use the same model as what the party calls a "two-for-one" system that's currently in place for MRI scans: for every scan paid for privately, the clinic offering the CT scan would be required to provide a second scan at no charge to a patient waiting for a scan on the public list.

They allocated billions of dollars for five kinds of procedures, all disproportionately afflicting seniors who, after all, vote in elections more than young people and use the health-care system more. The procedures were: hip and knee replacements, hip-fracture repairs, cataracts, and radiation. More than a decade and billions of dollars later, how are we doing? What did all that money and effort produce? In a nutshell: middling results. Initial data were released in 2006. From then until 2015, some improvements occurred, according to a recent report (www.cihi.ca») from the Canadian Institute for Health Information (CIHI). Between 2011 and 2015, wait times shrank for some procedures in some provinces, but increased for other procedures elsewhere.

One challenge is obvious: the population is aging. Ergo: more need for cataracts, more falls causing hip fractures, more joints giving out, more youthful athletic injuries becoming painful in later years. Aging puts governments on a treadmill. More money and improved allocation of medical resources result in more procedures but demand keeps growing. For example, between 2011 and 2015, 25 per cent more hip-replacement operations were done, but the number of patients being treated within "benchmark" time frames actually fell.

What are these benchmark time frames? Governments establish them to measure progress or lack thereof, based on what medical experts think are appropriate times to wait before procedures are undertaken. The benchmarks are rather generous and can be irritating to patients in pain. They are also somewhat misleading. The hip and knee benchmarks are six months. That period measures only the time between when surgery is recommended and the surgery occurs. It does not measure what is often the most aggravating part of the health-care system: getting an appointment with a specialist who might then recommend surgery.

Combine the two waiting times - see a specialist, have surgery - and Canada's record looks less than average compared with other advanced industrialized countries. One challenge plaguing the Canadian system for joint-replacement surgeries is the endemic fight for operating time in hospitals. Orthopedic surgeries have to be slotted into ORs, which are needed for emergencies, life-threatening problems, very complicated surgeries for cancer or neurological procedures. Orthopedic surgeries, except for hip fractures that have to be repaired swiftly, can wait, and wait.

Here's a telling irony. A surplus of orthopedic surgeons now exists in some parts of Canada. There's not a surplus of surgeons versus demand for their services but rather versus the OR time they are allocated. In other words, more surgeries could be done because surgeons are available but operating-room time is not. The result is that some young surgeons are going to the United States or working part-time. Trying to fit surgeons and patients into hospital OR allocations on a timely basis is made more difficult by the straitjacket of the Canadian system or at least the view, bordering on secular theology in some quarters, that everything must be done in a public hospital rather than in private clinics operating under funding arrangements with the state.

Saskatchewan has used this method - private delivery of publicly funded and regulated services - which partly explains why that province finishes first in the CIHI report for timeliness of procedures. Quebec also used this system, until the Liberal government, led by a neurological surgeon (current Premier Philippe Couillard), ended the experiment.

If the results are so-so in recent years for the five procedures identified in 2004, CIHI numbers suggest backsliding for diagnostic imaging. For six provinces that provided data, waiting times for MRIs increased "significantly" as they did for CT scans. Waiting times for cancer surgeries have remained stable.

Dryly and accurately, CIHI repeats what everyone who thinks about the future of health care knows: "With a growing and aging population in Canada ... demand for priority procedures will likely continue to increase."

Quebec has many private clinics. One performs 200 joint replacements per year; some 30 per cent of patients come from other provinces. When Philpott threatened to penalize Quebec for extra billing by MDs, its health minister, Dr. Gaétan Barrette, retorted that Quebec was not subject to the Canada Health Act. He is wrong. The CHA was passed unanimously in 1984, thus every Quebec MP voted for it. The solution is not to break the law, but to amend it.

Philpott admits "innovation" is required. Yet governments are constrained by blindly adhering to certain parts of the CHA, while ignoring others. As Ben Eisen of the Fraser Institute has emphasized, provinces have been forbidden to experiment with user-fees, copayments, etc. that would encourage individuals to use health services more responsibly. A "two-tier" system has always existed. Federal prisoners, Workplace Safety and Insurance Board patients, members of the military and RCMP, politicians and professional athletes usually obtain more timely care - often at private facilities. For those not near an inter-provincial border and not a member of a "special group," the main option for timely care may be to go to the United States. This provides employment to American doctors and nurses and profits to U.S. hospitals. Wouldn't it make more sense to allow all Canadians to spend their after-tax discretionary income on health in their own province? Frozen hospital budgets have caused excessive wait times for knee and hip replacements as operating rooms often don't function at full capacity. According to a 2013 survey, 15 per cent of Canadian surgeons considered themselves underemployed and 64 per cent cited poor access to ORs. About 25 per cent of nurses in Newfoundland and Labrador work only part of the year.

If orthopedic surgeons had access to additional "private" OR time, wait times could be shortened for all Canadians and new employment would be created for health-care professionals. If hospitals were permitted to operate electively on Americans and other foreign patients, this would bring in extra revenue and relieve the strain on provincial health ministries. So that MDs did not abandon the public system, they could be required to work 25 to 30 hours per week in the public system in order to receive government reimbursement for malpractice insurance. Most MDs would confine their practice to the public system. They deserve fair treatment. Philpott should amend the Canada Health Act to mandate binding arbitration when provincial negotiations fail, as they have in Ontario. Since 1984, the population has grown and aged, new diseases have been recognized, and new drugs and technologies have developed. Some 32 years ago, it was understood that Ottawa would pay half of health costs. Now it covers less than a quarter. We need to amend and modernize the Canada Health Act. Where wait times are excessive, certain diagnostic services and surgical procedures should allow for private access for all Canadians - not just a select few. This would maximally utilize expensive equipment and provide new employment for nurses, technicians and surgeons. It would provide extra revenue that would help to keep universal public health care sustainable and accessible for all Canadians. Ottawa should then enforce all sections of the Canada Health Act on all provinces and territories. Dr. Charles Shaver Ottawa