Drummond and Health

A large number of recommendations in the Drummond Report have to do with health care.  There is a lot there - much of which we have heard before in terms of things like focusing more on home care, patient centered care and evidence based care.  Indeed, the first recommendation on health care made by the Drummond Report is the most likely to be adopted by the provincial government given its affinity for planning:

Recommendation 5-1: “Develop and publish a comprehensive plan to address health care challenges   over the next 20 years.  The plan should set objectives and drive solutions that are built around the following principles..."

Those principles include being patient centered, a fully integrated system-wide approach, more emphasis on chronic care and home care, disease prevention, etc...A plan to address health care over the next twenty years is definitely something that would appeal to the current provincial government and they would be able to apply the expertise acquired in doing the Northern Growth Plan - which also has a long-term horizon of decades and has yet to yield anything tangible.  Indeed, the propensity to embrace a planning rather than an action culture is one of the things that is wrong with Ontario today and in my opinion a key factor in its poor economic performance.  While planning frameworks are necessary, they appear to have become ends in themselves rather than a means to an end.  But I digress.  Back to health.

While much has been made of Drummond's recommendation to bring in a payment freeze for physicians and the remarks that they are among the highest paid in the country, one recommendation appears to have flown under the radar.  Here it is:

 

Recommendation 5-59: "Compensate physicians using a blended model of salary/capitation and fee-for service; the right balance is probably in the area of 70 per cent salary/capitation and 30 per cent fee-for-service."

The Drummond Report appears to advocate a big move away from fee-for-service.  It will be interesting to see what the reaction to this will be. 

Drummond and the North

Wednesday will see the unveiling of Don Drummond’s recommendations for the repairing of Ontario’s finances.  Ontario is not experiencing the best of times.  Along with its deficit and debt, its economic growth has stalled, its population growth rate is slowing, its high electricity costs have been a factor in the manufacturing sector’s demise, and Ontario is receiving equalization. 

The Premier has promised a “relentless attack” on the deficit. Yet, it is difficult to visualize Ontario’s education and health Premier leading an attack on the spending programs he has invested so much of his reputation in.  Given that he has repeatedly stated he will not raise taxes, he is left with the options of expenditure cuts or economies via transformation and restructuring of government. In the end, there are really only three options for Ontario’s government after Wednesday – raise taxes, cut spending or some combination thereof.  While some of the recommendations Drummond makes may complement these courses of action, there will be no miracles.

Of course, if the Premier is waiting for the Drummond report to show him the way he is bound to be disappointed.  Many of the recommendations and suggestions have already been leaked and they make eminent sense.  The real question is how to go about implementing them. It will be interesting to see what suggestions if any Don Drummond has here. 

For example, universities can possibly save money by having professors teach more and Drummond has said as much in the media.  Yet most Ontario universities have collective agreements with their faculty that specify teaching loads.  Will the Ontario government pass legislation suspending those agreements?  Will the Ontario simply create new “teaching only” universities but which entail spending more money now to save money later?  Or will the Ontario government simply cut grants to universities with guidelines as to how the cuts are to be distributed and to increase teaching loads?  Yet, the grant stick has gotten weaker over the years.  Ontario universities now only get about forty percent of their revenues from government grants.  Will they be allowed to raise tuition more?

How about health care?  Can we transform its delivery by implementing electronic health records?  Sadly, it has already been tried once via the E-Health approach and look where that got the government?  How about more private-public partnerships to create efficient and innovative new service delivery?  Have we not tried that with ORNGE in the case of transport medicine – and where are we now?  How about efficiencies via regionalization in health care by dispersing more responsibilities to the Local Health Integration Networks?  Interestingly enough, Alberta, one of the pioneers in regionalized health care delivery has gone back to a centralized model.  One suspects it is easier to cut global budgets when they are centralized.

And what about Ontario's North?  The recent Census numbers show a stagnant population in a slower growing province.  In some sense, southern Ontario is becoming more like the North given the job losses, unemployment and slower income growth though that will not likely create any additional sympathy for the North.  When the empire is in turmoil, the legions are called back first from the frontier.  Any reductions in government services will have a major impact in our geographically dispersed and thinly populated region.  And what about the Northern Growth Plan and the need for government infrastructure investments in the Ring of Fire?  The government has been remarkably quiet on the Plan to Plan all Plans and one wonders if this means a shift in priorities when it comes to northern economic development policy - assuming that it ever actually was a priority.  Will the Drummond Report deal at all with how to invest in the North's economy in a cost-effective manner?  Will the Drummond Report urge an elimination of government economic development programs such as the Heritage Fund?  Wednesday should be interesting.

Balancing the Budget: The Ontario Plot Thickens

The Conference Board of Canada has waded into the Ontario pre-budget deliberation process with a report that says Ontario will be unable to balance its budget for a decade as a result of sluggish economic growth and shrinking government revenues.  Moreover, the Conference Board has focused on reining in health care costs as the most important factor in dealing with the budget balance – which hopefully can be achieved by 2021-22.  Aging and slower labor force growth can be expected to reduce Ontario’s economic growth and hence the growth of government revenues. 

According to a report on Global News, Premier McGuinty is disputing the prognosis of the Conference Board that Ontario will not be able to balance the budget.  I have to admit that while Ontario does have a serious budget problem, the Premier is probably right in not getting too obsessed with the Conference Board report.  The Conference Board is predicting a dismal decade of economic growth for Ontario but then it has also been predicting major upturns for Thunder Bay’s economy for at least five years and that has not happened either.  (See my post Forecasting Thunder Bay's GDP Growth).  The point is, circumstances change and predictions are revised.

Ontario has been experiencing slow economic growth for about a decade now.  During the period 2000-2011, its provincial government expenditures grew at an average annual rate of 5.7 percent while its revenues grew 4.5 percent.  For the period 2008 to 2011, expenditures grew at 6.7 percent while revenues grew at 3.0 percent.  In 2011-12, total revenue was 108.8 billion dollars and expenditures 124.8 billion for a 16 billion dollar deficit.

Let’s assume the following scenario.  For 2012-13, the Ontario government freezes total government spending at 124.8 billion dollars (note the Table is in millions of dollars).  The year after, it implements some of the recommendations of the Drummond Report and then cuts 3% in spending from the total Ontario government budget – a cut of about 3.8 billion dollars in spending.  After this, it allows spending to grow at 1 percent annually.  At the same time all of this is happening, we let total government revenue grow at 2.5 percent annually - below the average rate for 2008-2011.  The result, by 2017-18, there is indeed a balanced budget (see the Table below).  This is not a painless exercise. In real terms (adjusted for inflation) these represent real reductions in resources.  Assuming 2 percent inflation, between 2012-13 and 2017-18, total spending would rise less than 1% while prices would rise 13 percent.  In real terms, government spending would shrink 10 percent. 

The budget deficit could shrink even faster if economic growth recovers somewhat and revenues rise faster, which is not outside the realm of possibility given the slight rebound being detected in the United States to which much of Ontario’s economy is tied.  It could also shrink faster if larger upfront cuts are made.   It is certainly not going to be any fun governing in a decade like this but it will be possible to balance the budget ahead of schedule provided a government is able to set out a plan and stick to it in a disciplined fashion.