What`s Bugging Canada`s Doctors?

The MSA concept is straightforward. Every year, government would fund an MSA for each Canadian based on expected medical expenses, as determined by age, sex, and medical condition. Individuals would use the account to cover medical expenses and hold on to the surplus if they under spend. They would access a catastrophic insurance fund for costs above the MSA, though they might be required to cover some reasonably small portion of the extra costs, a requirement that would not be applied, under most formulations, to poor people.

The CMAJ article, “Medical Savings Accounts: Will they reduce costs,” by Evelyn Forget, Raisa Deber and Leslie Roots, argues MSAs won’t reduce costs, but it does this by misrepresenting the MSA idea.

The article uses Manitoba as an example. The average Manitoban costs the medicare system $730 a year. The authors say that if each Manitoban were given a $730 MSA, healthy people would get a nice bonus while the catastrophic fund would be stuck with the bills for older, sicker people. The problem is that MSAs are not based on a population average. They are tailored to match each individual’s expected medical expenses.

The authors make a drive-by reference to basing MSAs on age and sex, but reject this since medical expenses vary among individuals in the same age and sex cohorts. Well, yes. But, MSAs take account of medical conditions. A 30-year old with a heart condition would receive a larger MSA than a healthy 30-year old.

Another CMAJ article argues that incentives to save on medical expenses won’t produce savings. “Demand-side controls have historically been used extensively and found wanting: they do not lead to effective expenditure control, they generate widespread inefficiencies,” according to this article.

This violates common sense and a pile of fact-based research, including the most comprehensive study of patient behavior ever conducted, the Rand study. This study showed that incentives to save reduce expenditures but with no deterioration in patient outcomes, except for poor people with a chronic condition – the very reason most MSA plans exempt the poor from any out of pocket costs.

This isn’t the first time CMAJ articles have bashed reform. Authors of a recent CMAJ article made the extraordinary claim that private hospitals would “kill” 2,200 Canadians annually if they were allowed to operate in Canada.

These claims were based on a “meta-analysis” of studies comparing non-profit and private hospitals in the United States. A meta-analysis examines statistics in a number of studies to weigh the overall evidence.

Out of hundreds of relevant studies, the authors selected just 15, using murky criteria at best. They included one study that was not published in a peer reviewed journal. Half the studies, including the largest, found no difference in death rates. The second largest study found lower death rates in private hospitals.

Even stranger, the study excluded publicly-run US hospitals. Yet, US public hospitals are most directly comparable to Canada’s hospitals, which are staffed by public sector unions and have their key decisions made in government health departments. Because of this curious omission, the study has no relevance for Canada.

Yet, in a CMAJ commentary, Dr. David Naylor, Dean of the University of Toronto medical school, praised the study’s findings. This is odd considering he also said the study was “flawed methodologically,” inappropriately employed meta-analysis, and utilized “a tossed salad of patients, institutions, variables and outcomes.”

Let’s hope Canadian doctors are more careful when they read scientific studies. I don’t want mine prescribing treatment based on a study she knows used defective methods, mixed-up data, inaccurately described the disease, and seemed unaware of other research on the topic.