Privatization, Cannabis, Medical Assistance in Dying, Transgender Issues & More, with Andre Picard

Solving Healthcare with Dr. Kwadwo Kyeremanteng

Privatization, Cannabis, Medical Assistance in Dying, Transgender Issues & More, with Andre Picard

Key Takeaways Do we really have a universal healthcare system? Yes and no, says Mr. Picard. ”We have the least universal, universal healthcare system in the world,” he says. Despite…
January 28, 2020

Privatization, Cannabis, Medical Assistance in Dying, Transgender Issues & More, with Andre Picard

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Kwadwo : 00:00 Yo, y’all wanted more of André Picard. We are delivering. We’re talking cannabis. We’re talking PharmaCare. We’re talking medical assistance in dying. We’re talking privatization of healthcare. Episode 14 with André Picard. Let’s go.

Kwadwo: 00:18 Welcome to Solving Healthcare. I’m Dr. Kwadwo Kyeremanteng. I’m an ICU and Palliative Care physician here in Ottawa and the founder of Resource Optimization Network. We are on a mission to transform healthcare in Canada. I’m going to talk with physicians, nurses, administrators, patients and their families, because inefficiencies, overwork and overcrowding affects us all. I believe it’s time for a better health care system that’s more cost effective, dignified and just for everyone involved.

Kwadwo : 00:53 Thanks for tuning in everybody. We are super excited about this episode with André Picard. We cover a lot. We cover some of the questions that we saw on social media, on Twitter and on Facebook, but what I want you guys to really take away from this episode is how a lack of clear objectives and goals within our healthcare system really can impair care, and impair resource utilization. I think that was a huge eye-opening point that André and I get to talk about here in this episode amongst the other things, but it’s a real eye-opener. Every other area within business, healthcare, your own health, your career goals, you, all of us have clear goals and objectives, but what are our goals in healthcare? Is it to reduce infant mortality? Is it to improve on mental health services? What are our objectives? These are the real questions we should be asking ourselves.

Kwadwo : 01:56 Okay. Before getting into the show, I want to tell you about our sponsors, As I said, I love these guys. They are online counseling service that provides accessible, affordable, and convenient counseling services that are readily available by a video chat, via telephone, via text messaging, and they cater to your needs, whether it’s teen counseling, whether it’s marriage counseling, whether it’s health care providers, addressing compassion fatigue. They’re fantastic. So if you guys are looking to sign up, use promo code Solving Healthcare, and you’ll get a 10% discount on their services. Our other sponsor today is The Podcast Critical Levels. This is hosted by my boy Zach Cantor and this show’s awesome. It’s about paramedicine and the issues around paramedicine, but they also dive into issues that involve us all. Specifically, he had a great episode with Dr. Zemek about childhood concussions, which as a father of three boys that are involved in hockey, I was completely engaged in. It was a great conversation.

Kwadwo : 03:08 This guy’s going to be a star, so you guys are game, listen to him on iTunes, Spotify, or Stitcher, anywhere you could listen to podcasts and, it’s a guaranteed gamer man. Good job Zach. Lastly, I want to give a shout out to the Department of Medicine at the Ottawa Hospital. These guys have supported this show tremendously. I want to give a shout out to Abhilash, Sandra, D D, Tracy, you guys are amazing. They’ve assisted with marketing, on updated website on the Department of Medicine page. I’ll leave links to that on the show notes. It is proper, but yeah, love you guys for all the support and uh, appreciate it. All right, let’s dive into it. André Picard, the author of “Matters of Life and Death.” And you heard him on Episode 13. Amazing journalist, 40 years of experience and he really delivers on this episode. We talk about it all and I can’t wait for you guys to listen to it. So we’re just going to dive into it. Enjoy Episode 14.

Kwadwo : 04:14 So I touched a bit on universal healthcare and in how, I’m not sure in Canada we can truly say that we have universal healthcare. I’m wondering if you had any thoughts in terms of privatization. You know this is coming up a lot in terms of ways of making healthcare more sustainable, dealing with wait times and so forth. What are your thoughts in terms of privatization?

André Picard: 04:40 Well let me start with the universality part of the puzzle. So we have, in Canada we have this notion that we have a universal system, but we have the least universal universal healthcare system in the world. I think once you put it in those terms, you go, “Oh hold on. Is that true?” Because we cover hospitals and we cover physicians a 100%, we cover very little of everything else. We cover about 45% of drugs publicly. Well, 30% of home care, uh, 30- 35% of long-term care, 6% of dental care. We’re all over the map and it’s irrational. So we don’t have a universal healthcare system. So that’s the first part of the puzzle. I always said, I like to use the analogy of a basket. So we have this Medicare basket of services. Right now we have a basket that’s very narrow and very deep. It’s hospitals and physicians.

André Picard: 05:29 We pay for all of it, even though some of it probably shouldn’t be paid for. And then the other stuff we don’t cover near enough. So I think we need to make this basket a lot wider and a bit shallower. So we cover a lot more, but we give some people some responsibility for the rest. So that brings us to the, the second part of the privatization talk. And I think a lot of the talk about privatization in Canada, the way to shut down any discussion about healthcare is to say, “Oh, you’re going to privatize, we’re going to be like the U. S.” Well, I think that’s it. I think that’s nonsense. I think it’s a false dichotomy. I think the reality is every, no health system can cover 100% of everything for everyone all the time. So we’re going to have some private healthcare,. We have to realize that from the outset.

André Picard: 06:18 So the question is not will we have private healthcare? The question is where do we have it, how do we regulate it, and how do we make sure that everyone gets the essential care that they need at an affordable price? So that’s, you have to have these philosophical parameters and then how we deliver the care. To me, it doesn’t really matter. I don’t care if it’s delivered by a privately, publicly a mixture. What matters is that people get the care and that it’s accessible and that it’s affordable. So that that’s my philosophy. I get some grief for that, but I think that’s how we have to have the discussion about privatization. It’s not black and white. It’s about how do we regulate it, how do we ensure that it’s delivered fairly and comprehensively, et cetera. I think in Canada, the problem we have is we have a badly administered public health care and badly regulated private health care. So we kind of have the worst of both worlds. A lot European countries have a lot of private health care, but it’s very strictly regulated. It’s not a free for all the way it is here. So there’s different ways to, to have get that balanced right. And again, you’ve got me on my pet topic.

Kwadwo : 07:27 That’s part of my game. It’s interesting because actually I’ve never heard it framed that way is that we’re the, how’d you put it, in terms of universal healthcare, we’re the…

André Picard: 07:36 …the least universal in healthcare.

Kwadwo : 07:39 Yeah, I like that. And I mean cause it’s often people forget that they’re like, oh we don’t have any private health care in Canada. But you know, if I go see a physiotherapist I’m paying out of pocket. And it’s true. It’s like where do we want to put our private resources? I mean, well some of the topics that come up or worries I hear people mention is like resource drain where like some of the best surgeons or physicians or whatever, allied health professionals, would just strictly go into the private sector. But it’s kind of like you mentioned if you regular, if you’re like anything that you’re going to do that’s semi new or complicated will take some nuance. And so yeah, you know, maybe you need to restrict how much time physicians could spend in the private sector. Maybe that’s a solution, but certainly to think that we can’t have any element of private healthcare in 2020 or beyond I think is a bit ignorant at this point.

André Picard: 08:41 Well, you’re right. It’s about setting parameters. So if you look at a country like France, a many doctors practice in the public system and the private system, but there’s strict regulations. So if you want to work in the private for every hour you give to the private system, you have to give an hour to the public system. So that’s, that’s a way of getting some balance there. It’s not a, you know, it’s not an either or. In Canada you can opt in many provinces, not all, but in many provinces you can opt out of the public system and then you can charge whatever you want. There’s no limit. I’m not sure that’s a good system. Now very few doctors do because our Medicare system is actually very generous for doctors and it’s a good system, very little bureaucracy compared to systems like the U. S. So there’s the greatest beneficiaries of Medicare have been physicians. We shouldn’t forget that.

Kwadwo : 09:27 Yeah. I feel like it’s so taboo, but we need to go there and I, I don’t know what, will make us go there. What I’m getting at is what is our breaking point? Because baby boomers, are getting to prime time, health care, utilization, age, you know, we keep saying that we can’t keep this up in terms of healthcare delivery and spending. So what’s next? Like what do you see? What’s going to happen in Canada in your, in your humble opinion?

André Picard: 10:00 Well, you know, I think that we have to realize that healthcare is really important to us. Uh, we have to find a way of delivering it. And as I said before, we obsess a lot too much about the cost. Do we spend too much on healthcare? I am often asked that question and I always give the same glib response.

André Picard: 10:16 I always say, I have no idea because I don’t know what we’re trying to achieve. So we just spend, you know, we spend the way we spend, we don’t have any set public health goals in Canada. So unless you have goals, it’s hard to save for we’re getting, achieving what we’re trying to do. So I think that’s, we have to do some basic stuff.

Kwadwo : 10:34 What kind of goals would you have us, would you have in mind?

André Picard: 10:38 Yeah. So I look to many countries do this. So you look to a country like Sweden. So Sweden publicly publishes every year a list of its public health goals. So for example, I take one in Canada and Canada, we have an abysmally the high rate of child mortality compared to most of the world. So I would say in Canada, we want to bring our rate of child mortality from three per thousand to two per thousand.

André Picard: 11:05 That would be a public health goal for me. And then we find out a way to do that and we spend the money that’s necessary to do it. So that that’s how you have, goals and then you work to achieve them. People often get uncomfortable when I say, “You know, we have to treat it more like a business.” And that’s what a business does. A business says, here’s the goals for the year. Often those goals are related to profit, but we don’t have, that doesn’t have to be the goal in healthcare. The target, the goal can be, you know, we’re going to ensure that our child poverty rate falls by X percentage points or that, the cesarean delivery is going to be less disparate from one end of the country to the other. So there’s all kinds of goals you can set once you have goals. It’s easier, I think, to, to figure out how to spend appropriately.

Kwadwo : 11:48 You know where you’re trying to go. You have purpose.

Kwadwo : 11:53 Yeah. It’s funny cause you always hear on a lot of whatever endeavors that you, you, you go on that, you know, you need to set goals and, and write them down or discuss them, be clear on what your objectives are. And it’s funny if you asked me what, you know, what are the goals are Canadian healthcare system, that’s not an easy question. Yeah. To make Canadians healthier or whatever. But is that really specific enough? Is that like, what does that actually mean? You know? Yeah. No, that’s a, that’s a great point.

André Picard: 12:25 When I, when I do talk to, I often ask the audience, I say, what, what is the statement of purpose of Canadian Medicare? So we spend a quarter of a trillion dollars every year or $256 billion on healthcare. What is its purpose? So I often ask that to audiences and the question, the answer is always silence. So I tell them, you’re right, we don’t have any, you’re all right. You don’t just answer nothing. And when you put it in those terms, I think people go, “Wow, we spend all this money and we don’t, what’s the purpose of it?”

Kwadwo : 12:54 Yeah, wow.

Kwadwo : 12:56 I’m actually speechless because yeah, what really is our goals, you know? Yeah. I mean it’s, even if you think about it in, in specific niches, like you know, when I’m in ICU, I know my goals are clear. When I’m in the Palliative Care, my goals are clear. You know, when they, when we look at a system level, it’s not clear at all. You know, we might have a bunch of issues but we’re not prioritizing them. We’re just blanketly throwing money in and dealing with fires. Wow.

André Picard: 13:29 And Palliative Care is a really good example. You know, you have very specific goals once the patient is there, but whatever. What are our goals as society to ensure that the right patients get there? In Canada between 17 and 35% of people who should have palliative care get it. We do a terrible job of ensuring people are treated well at end of life. And you know, I can’t, it’s hard to imagine something that’s more important than alleviating people’s pain at the end of life to not see them die a horrible death. And we just haven’t, we don’t have goals. We don’t have, we haven’t made that a priority. You know, again, it’s the Canadian classic thing. Once you’re in power, you know, you’re in palliative care, we have fabulous Palliative Care. So many people are denied access to that, that it’s criminal.

Kwadwo : 14:16 Yeah, and the thing that people may or may not realize is even when it studied the benefits of early Palliative Care, like there’s a study out, it’s almost 10 years old now that it was stage four cancer patients got either early Palliative Care or just standard care up to the discretion of their team. And the patients that got early Palliative Care, not only were their symptoms improved, but they actually lived longer, ironically. And so, yeah, I mean you’re definitely preaching to the choir in terms of Palliative Care resources. I mean, you know, when you, when you look at trying to improve the experience for the family, for the patient, making sure that the, you know, they’re not suffering and you know, even from a resource point of view like the patients are less likely to occupy acute care beds as a result. It’s just a, it is a bit mind boggling that this is not emphasized more.

André Picard: 15:12 Yeah. And it’s a reminder. What you’re saying is reminder. I don’t, I don’t think we lack money. I don’t think there’s any lack of money in our system, we’re one of the biggest healthcare spenders in the world. But I think it’s how the money is allocated, is the problem. We don’t spend smartly. We don’t get value for money.

Kwadwo : 15:27 This is, this is my, I mean, this is like my mission, Andre. It’s like I see it day in, day out us putting in money into interventions that have no benefit. Even, there’s a simple, this is a very simple example, but you know, I think it clarifies things you could have if someone comes into the ICU when they’re, they need to be resuscitated with IV fluids. There’s normal saline that you’ve, we’ve all seen that costs maybe a $1 .30 and then there’s some more sophisticated fluids that cost about $50 to $60 for the same amount of volume.

Kwadwo : 16:03 So 60 times a price with no, like if you could study it through the union, there was no additional benefit for you getting that fluid. You know, and we, we spent thousands on it and if there’s no reason for it. You could have an oral antibiotic that’s just as effective as an IV antibiotic, but people will still order the IV one because it makes it feel better. Throwing away money just cause, you know, for lack of understanding or just because of a lack of lack of a will to change, it’s just, it’s all over the place. And then instead we could be putting it into places that matter. That’s a, this is, I don’t know if this is what drives me nuts. You know, I see my physio-therapist position gets cut , I see my social worker position get cut, things that actually are going to make a difference into the patient experience and improving care.

Kwadwo : 16:56 I’m going to have to cut these positions. Yeah. It’s crazy to me.

André Picard: 17:00 Yeah. And you remind me of, I remember visiting a unit for girls with eating disorders at a hospital and they had cut the psychological care so they were no longer getting psychological care. So what was the result is they ended up spending many more months in hospital. I had great, a tremendous cost, way more money than it costs to fund a psychologist. A different budget, et cetera. It’s just a lot of irrational stuff like that happens and it just, it actually costs more money, not less. I know people, 90 year olds with dementia and cancer are getting a hip transplant. What’s the good of that?

Kwadwo : 17:36 Absolutely. It’s and stuff that has been studied and we know are unlikely to benefit and we still offer it. And you know, I mean when you give that example of arguably who might be the most valuable person in an eating disorder ward, I would think it would be the psychologist. Wow.

Kwadwo : 17:56 That reminds me, we did get a bunch of questions on Twitter when we were doing this show and, and one of them, you’re a popular man. One question that like really stuck with me and, and I don’t think there’s an easy answer to this, is how do we break the cycle of these four year,

Kwadwo : 18:18 cycles where governments are in power. And so they, the budgets are reflective of that. So there’s so much sort short, shortsighted, you know, budget, budget, intervention cuts because we got to balance the budgets despite the fact that some of these cuts are gonna make things worse in the long run. Is there a solution to this problem?

André Picard: 18:38 Well, again, yeah, I think there is a solution and again, we can learn from looking at other jurisdictions. I think one of the things that distinguishes Canada is the level of political micromanagement. So there’s way too much interference from that. The Health Minister’s office reacts to what’s on the front page of a newspaper. That’s how our system runs. It’s like I always call our health ministers, firefighters instead of fire prevention officers, that’s what they should be doing. They should be setting the philosophical goals, as I talked about before. These are the goals that we want to achieve and we should have professional administrators running the system so that, that’s what I see when I go to countries in Europe, like the Netherlands and France, they’re professionally managed. They’re run like a business. And the government essentially keeps their nose out of it, and the public doesn’t want their noses in it. So I think it’s really to let the managers manage.

Kwadwo : 19:30 Mmm.

André Picard: 19:30 One of the worst jobs in Canada has to be a healthcare administrator because you have all this responsibility and you have no power and you’re constantly second guessed by politicians. It’s a terrible position to be in. So what do they do? They just cover their butts. They try and not make waves and we just go along, you know, try and keep quiet and nobody wants to catch the attention of the Ministry of Health because it’s always going to be bad news. So I think it’s this professionalization, that we have to aim for. And it’s weird cause we don’t do it in any other part of our government. You know, the Transport Minister doesn’t call and tell the airport what flight should be going out. And that’s, that’s how it works in healthcare. It’s absurd. So I think that problem is easily solvable, but it’s going to take some, some political guts for people to say, listen, hands off, I’m going to let the, you know, Ontario Health. So, you know, say take Ontario Health, this new system, theoretically you should be able to do that. That should be an independent entity. Government gives them their allocation of money, go for it, run it that it should be run that that’s how a system works in most countries and that’s how it should work here.

Kwadwo : 20:42 Have you seen a province, the healthcare system that works better than others?

André Picard: 20:47 That’s when I traveled around the country. I always know that’s going to be the first question when I do a talk. I’m obsessed in Canada. Are we the worst or are we just sort of in the middle? That’s everybody wants to be in a major of Canadians. So I think, I think the answer to it is we don’t know cause we don’t measure things very well. I think anecdotally we know that every province does some stuff really well. So we all have areas of excellence. I often describe Canadian Medicare as “islands of excellence in a sea of mediocrity”. We have a lot of mediocrity. We have that but have a lot of great stuff. So New Brunswick has tremendous paramedicine. Manitoba has really good homecare. Quebec has really good primary care with CLSC’s.BC has a really good handle on its drug program. So there’s all of these provinces that do things well.

André Picard: 21:37 And the frustrating things for me is we don’t learn from each other and copy each other. We do quite the opposite. We always try to reinvent the wheel. But to get back to your initial question, who does it best overall? I’ll just go with my gut feeling cause again, there’s no measures, but I think these days, I think it varies. I think Alberta used to have by far the best health system, sort of a pioneered the regionalization model, and it does it really well. It allowed the regions to, to run in the way we talked about, you know, you’re the boss and you run it and the government keeps its hands out and until the government started meddling again, that worked really, really well. So I think Alberta was a leader for a long time. I think now probably Saskatchewan. Saskatchewan is a really good size, but a million really good size too to run a system.

André Picard: 22:26 Ontario is kind of a dog’s breakfast. They’re trying to fix this with a reorganization, but it’s really the most disorganized system as a result. I think one of the ones with the, with the worst outcomes, unfortunately. I don’t think there’s a best and I don’t think there’s a worst, but there’s a lot of good and there’s a lot of bad overall. Unfortunately.

Kwadwo : 22:45 No, I can appreciate your answer. I’m originally from Alberta and one of the things that was taking place before I left was single electronic medical health record. You know, they had this, I’m forgetting the name off the top of my head, but you know, taking the bull by the horns and saying, you know, this is ridiculous. We should all be under one system and oh it should, all hospital charts should be able to speak to each other to a certain extent.

Kwadwo : 23:15 And this was, I mean this was in 2005 when I left, so yeah, I do. I could, I could see where you’re coming from. And yeah, at the time they still had the like a health authorities is what they would call them. Like which pretty much had as you described, a free reign. Relatively speaking to, to work in the way that was most effective for their community. It’s a really good point you bring up though. It’s, you know, a little bit more independence for some of these administrators to, you know, to try and do the right thing for their, for the community and to be able to get to their needs. Yeah, I mean that’s a, that’s a fair point and that you don’t hear about every day, but yeah, certainly in Ontario this is what we’re attempting. All right. I’m going to ask you a bit of a controversial one too.

Kwadwo : 24:02 Is there a party that you feel like since you’ve been doing this for 40 plus years, it seems to do a better job of this than others?

André Picard: 24:11 Well, you know, the, I think one of the biggest problems in Canadian politics is that there’s very little difference between the parties, violent agreement on, you know, essentially the status quo. And that’s, to me, it’s always frustrating to me during election campaigns, there’s very little discussion of healthcare because there’s no disagreement. Everybody sort of has this, well, Medicare is great and we don’t want to talk about it attitude. NDP, Conservative, Liberal, all the same approach. And I think a lot of it goes back to there’s a famous quote to attributed to Joey Smallwood, who is the premier of Newfoundland, one of the Fathers of Confederation. He once said that, “I’ve never had a discussion about healthcare that didn’t lose me votes.” To this day, politicians feel like that…

André Picard: 24:56 You start talking about healthcare and it becomes a losing proposition because you can never satisfy everyone. So the parties kind of agreed to to say nothing. We have these little discussions around the edges occasionally because there’s never any serious talk of performing healthcare regardless of the party. So short answer, no, there’s not one that’s better than the other. What we do know is that the lesser a party’s chances of being elected, the more bold their promises are for healthcare. So that, that’s the sad reality.

Kwadwo : 25:24 Fair enough. Okay. I’m going to touch on a few more questions that some of the our friends were, were asking. So in terms of new cannabis legislation, what’s your, your overall opinion on our approach?

André Picard: 25:43 Yeah, so I’ve been long a proponent of, I, don’t believe that, you know, drugs should be regulated the way they are now.

André Picard: 25:51 I’m a big believer in, legalization of all drugs because I believe people are going to use them and we have to make it safe for them to use, and educate them, et cetera. So that’s my premise that I operate from. Lots of people don’t like that view, but I have a very libertarian view about drugs and I think it’s viewed from a public health perspective, that that’s the most rational approach. Now when we take cannabis, I think that legalization of cannabis was long overdue. We started discussing this in the 1970s with the Lyddane Report and finally two years ago we got around to legalization. Now what’s happened since then? I think it’s been kind of a bust in a bust economically, socially, medically because we’ve replaced this criminalization with a whole bunch of stupid regulations. There’s way more laws about cannabis use now than there were before it was legalized.

André Picard: 26:45 So it’s kind of a, we’ve undermined what we were trying to do. From the business perspective, that’s the story that gets the most attention in Canada is our cannabis companies are all going bust, because they’re, the sales are not what they expected. We could have built an industry here that export it, its knowledge around the world, but, there’s so much red tape and regulation that we’ve denied ourselves that, right. So, and I think we’ve kind of messed up this good idea. We’ve get it done it very, very badly unfortunately. So the reality is what the reality is, a lot of people still buy on the black market. The government stores have a product, but they have long wait lines. You know, there’s the Canadian way. We wait for everything. We even wait for in line outside to buy our pot. So I think it’s kind of been a huge disappointment, unfortunately.

Kwadwo : 27:35 Yeah. It’s, um, I do hear you about the, from a like a public help perspective on legalization cause certainly, you know, putting somebody in jail or putting them in a spot where they can’t have a job based on a substance that people are going to use anyway. It seems, you know, um, not right. But my concern personally is the use, especially amongst the youth. Like I think there’s some detrimental affects that maybe we’re not appreciating. Like I know we see a little bit more psychosis in lead adolescence, early adult age. I just kind of wish it was studied a bit more before we’re like, hey, you know, let’s just throw it out to the world, but you know, I, do hear from the public health side for sure.

André Picard: 28:27 You know the youth, the youth issue, whether it’s cannabis, whether it’s vaping, whether it’s tobacco, that’s a particularly challenging one.

André Picard: 28:34 And those things are all illegal. It’s always been illegal for young people. Probably always will be. And that’s not the issue. That’s not the way we’re going to deal with that demographic. We have to, we have to teach them. Uh, we have to recognize that they’re young people, so they’re going to be risk taking. They’re going to be experimenting and we have to deal with that reality instead of being moralistic about it and saying, “Oh, we’ve got to ban, vaping, we’ve got to ban cannabis.” They’re going to use it. So let’s make sure that when they do they do it safely, uh, they do it rationally as much as possible for a teenager to do anything rationally. I think we just have to be much more pragmatic about this stuff. I think that’s, to me, that’s the big lesson I’ve learned about writing about public health for a long time is. ..

André Picard: 29:15 You really have to put your opinions aside and be very pragmatic about this stuff and realize it’s going to happen. So how do we make it as safe as possible? How do we reduce harm? Harm reduction has to be the driving force of our, our public policies. And the worst thing for harm reduction is, is prohibition. Prohibition is always failed regardless of the substance.

Kwadwo : 29:37 Yeah. Fair enough. I guess it’s always the question, which I guess we don’t know. It’s just, you know, what is that safe level? What is a, what is the amount or the approach that, you know, is truly reducing harm. But yeah, a lot of questions in terms of, you know, the approach. How about, another question that came up was regarding PharmaCare. I think you’ve, you’ve written a bit about PharmaCare and Canada. Oh, any thoughts on that?

André Picard: 30:07 Yeah, so an issue we’ve written a lot about because it, it actually did get debated politically.

André Picard: 30:12 Again, I think PharmaCare is necessary. We need to, you know, we’re the only developed country aside from the U.S. that doesn’t include drug coverage and our, and our universal health plan. So that’s something that’s needed to be fixed for 50 years. So we have to do that. So we’ve done it to a certain extent, but we’ve done it in a very haphazard way. So we have 102 public drug programs in Canada. We have to make some sense of that. We need some, some more centralization, more logic. But I think the really important thing that’s lost in the PharmaCare debate is we have to define what we mean by PharmaCare. So we have a lot of people talking about, you know, we need this single universal system. Sure. That’s one way of doing it to be, it’s not necessarily that way, but the most important thing is what are we going to cover for who and why?

André Picard: 31:02 So how are we going to get value for money, uh, for our drugs? And I think the way to do it is not to copy what we’ve done with, with the physicians and hospitals, we’ve covered those 100% and it doesn’t work. We’ve had a lot of waste. We have a lot of, stuff that’s not done because we spend too much in those areas. I think we have to be careful not to repeat the mistakes we’ve made earlier. I think we have to be a little smarter to decide what we’re going to cover and that, that to me is the essence of the debate. There’s no question that we should cover. Drugs are really important. If we’re going to have universal healthcare, but universality doesn’t mean covering every product for every person all the time. Ensuring that everyone has the essentials in an affordable way and those are different things .

Kwadwo : 31:49 That certainly was one of the few healthcare related topics that came up during this past election.

Kwadwo : 31:57 And that was a, it’s funny, those are my exact thoughts when it came up, I’m like, what is, what does that actually, what does formal care actually mean? Like what are we actually debating here?

André Picard: 32:09 Yeah, there was no, there was no real debate. There were a bunch of platitudes that were uttered, but that wasn’t debate because they, the parties never defined what they meant. You know, they said, we’re going to bring in, in this program, but what exactly is the program going to be? And then, the fact that the Federal parties were debating this, neglecting the fact that ultimately it’s up to the provinces, that that was a big problem as well.

Kwadwo : 32:32 Excellent. Excellent. So, okay, André, what are your thoughts on medical assistance in dying?

André Picard: 32:38 Yeah. So another issue that we took a long time to deal with. So I started covering that issue in the early eighties.

André Picard: 32:45 Then it got a lot of steam with the, in the early nineties with Sue Rodriguez kind of died off for awhile and then came back. So that again, we finally brought in this legislation to give people more choice at the end of life to minimize their suffering. So I think that was a really big important piece of legislation. Now the problem was that the legislation was, was flawed and it was inadequate and we, we’ve got to fix it. So we’re at that point now. In fact, a new public consultations have just started about expanding the MAID legislation. So that’s going to happen. The court has ordered it, but it’s always frustrating with these issues, how slowly we go, how cautious the politicians are. Thank God we have an activist court in Canada. Or we, we’d have much worse health care. Of course, it forced us to do stuff that we know we should do, but politicians are too, too wimpy to do on their own.

André Picard: 33:37 So I read the important issue. I think we have to recognize it. Very few people are ever going to get an assisted death. That’s going to be one, 2% very tiny percentage. But I think it’s a really important philosophical point, a theoretical point that people have choice that end of life. I think that’s what’s most important about this debate is giving patients more control. And I think that we’re going to see that now we’re going to see the really tough ones. Does that apply to people with dementia? Does it apply to people with mental illness? Does it apply to children? There’s some really, really tough debates coming. But again, I, I stay in my bubble about being pragmatic. I think we have to give people options and then we have to ensure at the same time that there are protections. So that these things aren’t abused.

Kwadwo : 34:22 So basically what I’m hearing is we can’t use this slippery slope argument as a reason not to implement this. People deserve to have that choice in terms of, how they want to end their life.

André Picard: 34:37 I don’t know how many times I’ve said in my columns that not every slope is slippery, but I think we actually remember that, that that’s kind of a banal argument. Not every slope is slippery there is, we have to have buffers in place to ensure there aren’t abuses, but that doesn’t mean denying people rights to want them. No one should be forced to take, to have an assisted death when they don’t want to. No one should be choosing assisted death for lack of alternatives like lack of Palliative Care, lack of long-term care. That’s unacceptable. Not no one should be denied and assisted death who wants it?

André Picard: 35:11 Who’s making a rational choice? We can do all those three things at once. They are not mutually exclusive.

Kwadwo : 35:19 Exactly. In your book “Matters of Life and Death” you touch on transgender issues. Where do you see some of these issues in 2020?

André Picard: 35:30 Well, I think it’s just an example of what we talked about at the outset, it’s an evolution. You know, it’s a new patient group, a new demographic that’s standing up and being heard, and that the health system has to adjust. This notion of treating gay men was unthinkable in the 70s and 80s, no, they’re a bunch of perverts, and we hear a lot of that same when you’re around a long time, you start to hear these echoes and we hear that now about transgender, Oh, we can’t possibly do that. We can’t use different pronouns. Oh, the language has always been the same, but the things evolve.

André Picard: 36:03 Language evolves. Medicine has to evolve and I think this is these developments are good. They challenge us, they force us to think differently. Unfortunately, there are abuses or wrongs that happen along the way that forces us to deal with this, but I think it’s, it’s a very positive development that we’re talking about. Like gender fluidity, that the gender is a social construct. I think these are really important things for physicians and few for future physicians to think about and to talk about. And how do they treat their patients well regardless of their gender or how they identify.

Kwadwo : 36:38 Super important topic and definitely one for a future episode. André, what about the wait times we’re seeing overall whether in emerge or if you’re waiting for a hip. Do you see any solutions in the near future?

André Picard: 36:55 Yes. So again, I think wait times is the systemic issue.

André Picard: 36:58 So it’s about creating more flow in the system. It’s about breaking the bottlenecks. You know, as we talked about earlier, at the long rates in our emergency rooms have very little to do with emergency care, right? They’re all about bottlenecks. It’s about inability to admit people, inability to, to get people out of hospital. We have this perversity in Canada called the ALC patients, (alternate level of care) patients who live in hospitals. I’ve done stories about this. I met a patient who’s been living in a hospital for 10 years because there’s no alternative for them. This makes no sense. It makes no sense from a business perspective and makes no sense from a patient care perspective. Ethically, all these things are wrong and we have to fix them. But you know, in some provinces, one third of all hospital beds, are ALC patients. They are people who have been discharged but have nowhere to go.

André Picard: 37:51 So these are, this is how you deal with wait times is you deal with things across the spectrum. No easy solution. It can’t be overnight, but we have to correct the errors we’ve made of of bad planning. You know, we all, we hear often and over and over again, Oh well,it’s the aging boomers. You know, that’s what’s overwhelming our system. We’ve known about the boomers for 60 years. No surprise here. It’s just a bad planning, lack of foresight. And we have to fix it.

Kwadwo: 38:20 Agreed. But what can we do now? Like if I’m, you know, the Minister of Health or I’m a lead for a health authority and I got these tons of ALC patients, what can we do?

André Picard: 38:33 Well, I think, again, if look at it and say from a business perspective, what do you do in a business if you have this problem? You have a mixture of carrots and sticks.

André Picard: 38:42 So you start punishing hospitals that have ALC patients. Why did patients, you know, that perversity is that hospitals actually like having ALC patients because they require less nursing care. They’re understaffed on nursing. They get paid the same amount of money, require less care. So it’s actually a good thing for them, which is wrong. It shouldn’t be a good thing. So you have to punish them financially. And that will solve the problem pretty quickly. They’ll get them elsewhere. We have to incentivize people to have more long-term care homes. Most of our long-term care homes are private businesses and we have to ask ourselves why people don’t go into this business. That’s because the rates suck , it’s because there’s way too much regulations. We have to make it easier for people to provide spaces for people who need it. And then we have to deal with the other pieces of the puzzle, which is home care.

André Picard: 39:30 I think we’ve, put far too many resources into people getting home care just to get them out of hospital quicker from short-term surgery and we haven’t invested enough in the chronic part of the puzzle. So again, from a business point of view, way cheaper to care for those ALC patients in their homes costs a fraction of the cost. So take that money and use it differently. And if you don’t do that, then you’re going to be punished. So the carrot and stick approach, all this stuff is solvable. And I know it’s solvable because I see, I don’t see these problems in other countries around the world.

Kwadwo: 40:05 Interesting. We kind of talked a bit about how to create change in healthcare and you do bring up the carrot and the stick. And I mean money talks. One of my main incentives to do research around costs is because that’s the language that that’s a change language.

Kwadwo : 40:24 That’s the language of administrators, of politicians. So if you could show a financial benefit for any intervention, like that’s when things actually start to move. And so withholding funds so that change can occur. You know, I think it can go a long way, but certainly just sticking with the status quo is not good enough.

André Picard: 40:48 But I would add the proviso that if you’re going to have carrots and you’re going to have sticks. People have to have accountability and they also have to have power. So you can’t punish a hospital for having ALC patients, but not giving them the power to resolve it. I think, again, when you have a regionalization is supposed to be the solution to this, right? So the way a regionalization is supposed to work is that they should say, here’s our overall budget. We’re not spending it well by having these people living in hospitals, we should spend it on home care or we should spend it on long-term care facilities. So you have to have the power to move that money around and that that’s how the issue will get resolved. Ultimately give people, accountability and power to fix things.

Kwadwo: 41:29 I love it. You know, trusting in the people that you’ve invested into, trying to make the healthcare system better.

André Picard: 41:36 We pay healthcare administrators a lot of money, let them administer.

Kwadwo : 41:40 Mmm, no, that’s, that’s a great point, André. One thing I like to do is always end on a positive note and allow our guests to talk about a story or a time where they’ve felt that your job has had a big impact in general. And you did give this story earlier

Kwadwo : 42:00 about, um, you know, the AIDS patient in Toronto, but is there an any other time where you felt that you covering health care and being as engaged as you have been, that you’ve really made a difference?

André Picard: 42:16 I think there’s all those little stories like we talked about, you know, the one patient who, who got better care because of your story, little policy changes. Those are always moving. But to me there, to me, there are two big things in my career that stand out. I wrote for a long time about the tainted blood tragedy. So this came out of my coverage of AIDS. I started covering, you know, there were four groups who were infected with AIDS and one of them was always forgotten. This little group of hemophiliac and transfusion patients. So we started focusing on them and this became, this became a huge story. It became an exposure of one of the worst, probably the worst public health scandal in Canadian history. About 30,000 people were infected with HIV and hepatitis, not because of mismanagement of the blood system, because of lying to people because et cetera.

André Picard: 43:06 I have a whole book length version of this rant, but, that issue that the tainted blood issue I think is one of my proudest moments because it really did bring relief to a lot of people. There was more than $5 billion in compensation paid out. Ultimately, our drug regulation system changed profoundly as a result of that. And I’m not taking credit for that solely, but we did get the ball rolling. So I think that’s really important story in my, my legacy, if I could put it that way. And there’s another one very similar, but on a smaller scale that a very touching one was a work that I did with my colleague on the, thalidomide survivors. So there’s a group of five people who are affected by thalidomide in the 1950s, sixties, left with, you know, missing limbs, et cetera.

André Picard: 43:54 Those folks live the long time suffering in poverty. And we came back to that a few years ago and wrote about these forgotten survivors. And again, the result was a quite a large compensation package. People getting their lives back, people who are forgotten, you know, we got to tell their story. And there’s a lot of, a lot of touching, touching stories as a journalist to hear from that and when you actually change people’s lives. So those are two of the biggies for me. But all the little ones day to day, you know, they, they keep you going.

Kwadwo : 44:27 Yeah, no, I got to tell you, André, it’s truly is a privilege to be able to have this conversation with you. And I could truly echo the amazing, inspiring work that you’ve done over the years that has impacted Canadians and people worldwide and given people a voice, increasing awareness on many health care related issues. And I got to tell you, I learned a ton today. You know, I got no political, no policy, game. I’m not educated from that front, but the things we talked about today was super eye-opening, especially like the silo stuff and the regionalization aspect of, of things like the way you framed it. And it’s just, I don’t know, there’s a lot to digest and a lot to think about, but, you know, I’m hoping my listeners are feeling similar to me and feeling pretty inspired and I’m truly grateful that you took some time to do this and I hope to have you on again.

André Picard: 45:30 A pleasure. And you know, I always remind people, you know, I, my job is to sort of summarize and to translate all this. I meet all these brilliant people and my job is sort of steal their ideas and make them pithy and accessible to the public. So I can’t forget that I know nothing. I learned all this stuff from other people and I think my only skill is really being able to boil stuff down and simplify it and hopefully communicate it in a way that people can understand and act on.

Kwadwo : 45:55 Yeah. Well I’ll tell you it’s working. Awesome. André, thank you so much. There’s going to be links to all your books, your Twitter handle, everything in the show notes and, thanks again for doing this.

André Picard: 46:07 Thank you. I look forward to it.

Kwadwo: 46:09 Thank you. Thank you so much for listening to Episode 14 with André Picard. I hope you all enjoyed it. If you guys want to follow him on Twitter, it’s @picardonhealth. If you want to follow or support this show on Facebook, on Twitter, on Instagram at Kwadcast, you could send comments to [email protected] and please let us know how we’re doing. We were looking to always improve on the show, the five star rating on iTunes. If you’re up for it, leave a review. Thanks again guys. We’ll talk soon.



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