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Dr. Danielle Martin on lessons from Canada

The Lown conference is known for attracting experts who speak out boldly on issues that matter… and this year’s crop of speakers may be one of our best. So we’re conducting interviews with our keynotes as we lead up to the main event April 9-10 in Washington DC.


KEYNOTE INTERVIEW: This week we have an interview with Danielle Martin, Associate Professor of Family and Community Medicine at the University of Toronto, co-founder of the Women’s College Hospital Institute for Health Systems Solutions and Virtual Care, and practicing family physician. Martin is the author of the bestselling book, Better Now: 6 Big Ideas to Improve the Health of all Canadians, which outlines feasible and affordable policies for improved health care, inspired by Martin’s patient stories and personal experiences.

Lown Institute: Some Americans see Canada as a utopian health system – what are the imperfections or downsides to the Canadian system we might not know about?

Dr. Danielle Martin: No health care system is perfect. I’m grateful to work in a publicly funded, universal health system for physician and hospital care, but that doesn’t mean we have it all figured out.

One area where Canada really struggles is in access to prescription medications. Our universal system pays for drugs in hospital, but not outside the hospital. Many people have drug plans through their employers, but many don’t – with the result that millions of Canadians don’t take their medicines as prescribed because of concerns about costs.

Another area where we have work to do is on wait times for non-urgent procedures and treatments, like cataract surgeries, hip replacements and non-urgent advanced imaging. While it depends on where you live, in Ontario, people can wait anywhere between 49 to 131 days for a non-urgent MRI for shoulder or chronic pain in their knee.

What is interesting about both of these challenges is that we can solve them without spending a lot more money. In the case of prescription drugs, the evidence is overwhelming that it would cost less than we currently spend to have a universal public drug program, because we pay so much for our drugs in Canada. And when it comes to wait times, interventions like centralized intake and team-based models of care can make a huge difference.

How has the lack of prescription drug coverage shaped how Canadians prescribe and take medications?

About 1 in 10 Canadians cannot afford to take their medications as prescribed. This is a particularly daunting issue for low-income Canadians, for people who are self-employed and for those who work part time or on contracts, because in many cases drug benefit plans are not offered through their employers.

For those who are covered through employer-sponsored private plans, there is a significant risk of overprescribing and off-label prescribing, because these plans have few – if any – requirements that prescribing be based in good evidence.

So we have a situation where millions of Canadians can’t access necessary drugs and millions more are taking too many drugs. This urgently needs to be fixed.

Are there successful bright spots or promising interventions you’ve seen in Canadian institutions/communities that you think should be scaled up?

There are many inspiring examples of bright ideas that should be scaled up across our health care systems in Canada. Where I work at Women’s College Hospital for example, instead of having an emergency room, we have an Acute Ambulatory Care Unit. We recognized that in many cases, patients were waiting for hours in emergency rooms just to gain access to imaging tests and treatments that weren’t truly emergent, so we created a place that would offer them rapid access.

In western Canada, a program called Rapid Access to Consultative Expertise (RACE) allows family physicians to get advice from specialists by phone in real time, reducing the need for referrals to specialists and keeping care closer to home.

The list goes on. There are lots of innovative programs in Canadian health care. Our challenge isn’t coming up with great ideas. Where we fall down too often is in the spread and scale-up of those ideas, in making them available across the country so that everyone who would benefit from them gets access.

We talk a lot about the policies or laws we need for the next health system, but what VALUES do you think need to be in America’s next health system?

I always say that health care is not just about money and medicine. It’s about the answers to some very fundamental questions about how our society operates. It seems to me that the United States is going through a period where values are being tested, and while this might be very challenging, it’s also an opportunity to reprioritize and declare what kind of country you want to be.

In Canada, the value that access to health care should be based on need, not ability to pay, is core to our health care system and also to our national identity. The notion of medical bankruptcy is unheard of, and would be considered by nearly every Canadian to be a failure of community. At its core, that’s about equity of access to high quality services. And to me, the notion of bringing evidence as much as possible into the conversation about how we live up to our values is equally important.