Information Access News

The proposed Interim Federal Health Program cuts (discussed further here) have not only motivated individual physicians to action, but also mobilized groups of health providers nation wide. On May 11, physicians across Canada held protests, an occupation and issued press releases in an effort to catch the Minister responsible, Jason Kenney’s ear.  More recently, the Canadian Medical Association, College of Family Physicians of Canada, Royal College of Physicians and Surgeons, Canadian Nurses Association, Canadian Pharmacists Association, Canadian Association of Optometrists, Canadian Association of Social Workers and Canadian Dental Association sent a joint letter to the Minister requesting that the planned IFHP cuts be rescinded. A full list of media coverage is below.

Medical groups slam plan to cut refugee health coverage – Ottawa Citizen (May 18, 2012)

Refugee health reform assailed – CMAJ (May 18, 2012)

Refugee health cuts are bad for all of us – Hamilton Spectator (May 17, 2012)

They aren’t all ‘bogus’ refugees, as portrayed by Kenney – Winnipeg Free Press (May 17, 2012)

Why cutting health care for asylum-seekers makes no sense – Globe and Mail (May 15, 2012)

Canadian doctors occupy government offices over healthcare cuts - Guardian (May 12, 2012)

Doctors fight for refugee health care – Hamilton Spectator (May 12, 2012)

Physicians occupied MP’s office over cuts to refugee health care – Toronto Star (May 11, 2012)

Doctors stage sit-in over refugee health care costs – CBC News (May 11, 2012)

Doctors demand changes to proposed refugee health policy – CBC News (May 11, 2012)

Doctors protest refugee health cuts – CBC News (May 11, 2012)

An attack on vulnerable refugees - Ottawa Citizen (May 9, 2012)

Cuts to refugee health insurance dangerous, inhumane, doctors say – National Post (May 7, 2012)

Doctor worries federal cuts could harm refugee health – CBC News (May 3, 2012) 

Jason Kenney, Minister of Citizenship, Immigration and Multiculturalism, has been a very busy man as of late. In less than five months, he has sought to redefine Canada’s threshold for asylum seekers and to tighten the handshake that welcomes them to their new home. For those in the medical community providing care for and advocating on behalf of refugee patients, these efforts have caused considerable consternation. After a closer inspection of Bill C-31 and the more recent overhaul of the Interim Federal Health Program, it is not a stretch to see why.

Bill C-31 or the Protecting Canada’s Immigration System Act was first introduced to Parliament in February 2012 with the intention of clamping down on ‘bogus’ refugees, speeding up claimant processing times and reducing government costs. Stretching a healthy fifty-six pages, C-31’s most objectionable provisions related to health include:

• Automatic detention of asylum seekers for up to one year without review if deemed to land via an “irregular arrival.”
• An embargo on permanent resident applications and family reunification for five years after arrival.
• Conditional permanent residency with the possibility of a later revocation.

As a group of Ontario based physicians pointed out in a Toronto Star column, prolonged detention of refugee claimants leads to increased risk of suicidal thoughts, post-traumatic stress disorder and self-harm. This comes in addition to incubating infectious diseases and exacerbating chronic ones. Public outcry has led Kenney to amend this portion of the bill, granting review of detention at 14 days and 6 months. But the remainder stays unchanged. Delayed family reunification will still serve to weaken already fragile social supports and health, while revocation of already granted residency will still lead to social isolation, slow improvement of language skills and poor mental health.

In addition to the above reforms, C-31 also builds on the 2010 Conservative led legislation, Bill C-11, or the Balanced Refugee Reform Act. It divides refugee claimants into two categories: those from ‘Designated Countries of Origin’ (or DCOs) and those not. The stated aim of DCO policy is to deter abuse of the refugee system by those who come from countries generally considered ‘safe.’ One would expect a panel of experts to make such a crucial distinction – but not according to Minister Kenney. Bill C-11 contained no parliamentary oversight, but created a panel of public servants to make recommendation to the Minister. C-31 goes one step further, eliminating this provision and granting the Minister unilateral authority to deem which countries are considered ‘safe’ and which are not.

The DCO distinction is not an esoteric one. It has direct and very harsh implications for more recent reforms to refugee health services provided under the Interim Federal Health Program (IFHP). These changes do not require legislative reform; no Parliamentary vote or committee review is required. Their scope (though not their consequences) requires only the approval of Prime Minister Harper's Cabinet.

Like C-31, the stated aim of the IFHP change is cost-savings. It currently costs the Canadian government 84 million dollars annually – the Harper government is aiming for a reduction of 20 million. To achieve their ends they are leaving no category of refugee unaffected, even rolling back services for those who are government sponsored on recommendation from the United Nations High Commission on Refugees (UNHCR).

For these refugees, ironically deemed ‘protected persons’ in government releases, pre-reform benefits equate approximately to those available under most provincial social assistance programs. Post-reform changes will bear little resemblance to this, with health coverage available only for conditions deemed to be of an ‘urgent or essential nature’ or those to ‘prevent or treat a disease that is a risk to public health or a condition of public safety concern.’

What does that mean in practice? A ministry briefer illustrates a few examples. Come Canada Day, a protected person can be assessed for coronary artery disease by a physician, but their statins and anti-hypertensives will not be covered. A protected person will still be able to see a nurse or physician for a diabetic assessment, but will receive no coverage for insulin. For protected persons, many vaccines don’t even meet these new thresholds. All of these examples are significant changes from current policy. For claimants from the newly created DCO category, the news is even worse. Coverage has been completely eliminated for prenatal care, labour & delivery, as well emergency services. Every DCO acute myocardial infarction will go unfunded.

Kenney has defended these reforms on grounds that asylum seekers should not enjoy a level of government funding that Canadians themselves don’t receive. Physician and advocates have responded with both moral and economic arguments. Andre Picard has pointed out that it is exactly the vulnerability of refugees that necessitates broader health services. Dr. Mark Tyndall has also provided a reality check - the real challenge is connecting refugees with unfamiliar preventative services and primary care, not stopping ‘abuse.’ A Hamilton Spectator health provider Op-Ed highlights that according to the Ministry’s own data, refugee claimant’s per capita health costs are only 10% of Canadians, a number that is expected to rise with cuts to prevention.

Jason Kenney’s stated ends are to strengthen Canada’s refugee selection process and to save government dollars.  But by choosing a path ignoring evidence contrary to his means and by adopting a hostile stance to those on refugee health’s frontlines, he risks doing just the opposite. Bill C-31 and the IFHP reforms come into force in less than 6 weeks. Minister Kenney, you still have time to change course. July 1st deserves to remain a celebration for Canadians already here and for those that have yet to come. 

As the newest member of the Open Medicine blog team, you can expect posts from me that focus on the intersection of health and elected politics. If I had started posting some months ago, you might have seen stories on the 2014 health accord, the health scandals in Alberta/defection of Raj Sherman and the recent ICES report on primary health care reform in Ontario. While I can't always promise to strike an impartial tone, you can look forward to posts that seek clarity in often messy situations.

When not blogging for Open Medicine or Tweeting via @DanyaalRaza, you can find me in the midst of a Family Medicine Global Health & Vulnerable Populations Fellowship at the University of Toronto. My first set of posts will focus on this area - specifically, proposed reform to refugee health care in Canada.

I look forward to hearing your thoughts on each post, and the opportunity to respond to each of your posted comments.

Happy reading,

DR 

Today, Facebook does its IPO - initial public offering. That means it begins offering shares of its stock for public trading on a stock exchange.

Non-lawyers out there may be wondering what is involved, legally speaking, in "going public"? Read more » about The Lawyering Behind Facebook's IPO

The Cyber Intelligence Sharing and Protection Act ("CISPA") is the latest example of a depressingly common situation in Washington DC -- well-meaning legislators unfamiliar with technology try to rush through a statute about a high-profile Internet issue (here, cybersecurity). Proponents of the bill say they want to faciliate information sharing between the federal government and the private sector. What they don't seem to understand is that existing laws already permit most kinds of cybersecurity information sharing. Read more » about The Unintended Consequences of CISPA

I recently returned from a university-sponsored junket to New Orleans, where I attended the 2012 meeting of the American Academy of Neurology.  I learned a few things, met a few people of interest to me, and took a stroll or two through the displays in between sessions. In one (smaller) hall, there were daily displays of posters from academic institutions all over the world. In the larger hall (at the very back of which we were served a soggy and repetitive lunch), scenes like these were to be beheld:

Novartis, makers and patent-holders of the first oral MS therapy to date, provided a helpful disclaimer:

Outside the exhibit hall, representatives of BrainPAC were ready to take your donation.

"What do you use the money for?"

"The money is used to make donations to various Congressmen and Senators, in exchange for which they meet with us and listen to our issues."

Ah, Democracy!

This week, David Levine interviews Prof. Daniel Margocsy of Hunter College, co-editor of States of Secrecy, a forthcoming volume of the British Journal for the History of Science. Read more » about Daniel Margocsy - Hearsay Culture - Show #162 - KZSU-FM

This week, David Levine interviews Prof. Hamilton Bean of the University of Colorado Denver, author of the book No More Secrets: Open Source Information and the Reshaping of U.S. Intelligence. Read more » about Hamilton Bean - Hearsay Culture - Show #161 - KZSU-FM

As Silicon Valley hones its political agenda, Marvin Ammori has become the go-to First Amendment guy--as evidenced in January, when he helped destroy PIPA and SOPA. His method: "You're only going to win if you have better ideas, better persuasion, and better ability to organize people."

Read the full story at the original publication link below.  Read more » about The 100 Most Creative People in Business 2012

With cell phone cameras everywhere, it has become common for members of the public to film encounters with the police. Whether the police are behaving professionally or engaged in an unprovoked assault, citizen video provides oversight and potential evidence. But some officers are unhappy with this form of public accountability and have responded by arresting people who try to film them. In an important decision this week, the Seventh Circuit ruled in ACLU v. Alvarez that the public has a First Amendment right to film police. Read more » about Seventh Circuit Upholds First Amendment Right to Film Police

Steven Lewis
President, Access Consulting Ltd., Saskatoon SK Canada
Adjunct Professor of Health Policy, Simon Fraser University
Steven.Lewis@sasktel.net

Star players get paid a lot of money in baseball. Alex Rodriguez, the Yankees’ third baseman, signed a ten-year, $275 million deal in 2008, the year he turned 33. Canadian Joey Votto, the slugging first baseman for the Cincinnati Reds, will get $225 million over the next ten years. Eleven ballplayers’ current annual salaries are over $22 million.

Baseball is all about winning, and winning is all about performance. Unlike health care, baseball has uniformly high quality data on a dizzying array of performance metrics. Thanks to the thriving science of baseball analytics, general managers know pretty precisely how a player’s individual statistical profile contributes to his team’s won-loss record. You can actually quantify the extent to which a stolen base or a triple influences the probability of winning a game. The go-to contemporary stat is “wins above replacement” – the number of wins a player contributes to his team’s annual total compared to a replacement player minimally fit to play big league ball.

Given the utter simplicity and clarity of the goal – winning – and the availability and validity of data (arguably spectacular), you’d think pay for performance (P4P) would be hard-wired into players’ pay structure. Baseball is merit-based capitalism in its purest form: you get paid what you’re worth, and what you’re worth is a function of measurable performance. But the major league collective agreement forbids tying contracts to statistical performance. It has recently gone so far as nixing bonuses for reaching certain career milestones, such as 3000 hits.

Is baseball fouling one off its own foot, or are the stewards and players of the game onto something important?

The Major League Players’ Association is a highly sophisticated and successful union. Its main job is to get good pay, good working conditions, good pensions and other benefits for its members. It naturally prefers that the great bulk of pay should be in the form of base salary rather than performance-based incentives. It’s fine to pay me $15 million a year in the expectation that I will hit 30 home runs, drive in 100 runs, and play third base with fearless aplomb. But it’s not okay to pay me $5 million base and $10 million contingent on reaching these statistical targets.

It’s pretty obvious why players prefer this arrangement. But why don’t winning-obsessed owners, armed with great data, fight it to the death?

It’s because they’re not stupid. To begin with, most pay really is based on statistical performance, only the pay is deferred. The Los Angeles Angels of Anaheim aren’t paying Albert Pujols $20+ million a year based on his potential; they’re paying him for his consistently brilliant performance over his first 11 years. For players under 35, performance over the last few years is a pretty good predictor of  performance this year. In other words, the baseball market is highly performance-oriented, but the pay is mainly time-lagged.

More importantly, though, individual statistical targets can get in the way of team performance. Suppose you get a big bonus for hitting 35 home runs. It’s the last week of the season, the game is close, there’s a man on second, none out, tough pitcher on the mound. The team needs you to hit a ground ball to the right side to advance the runner to third. But you’re stuck on 33 home runs, and your personal incentive is to swing for the fences. Or maybe your team has clinched a spot in the playoffs and it would be better to rest you for a few meaningless games at the end of the season. Not so great if you’re a few hits short of an incentive target, and the manager has to choose between giving you a shot at a wad of cash and doing what’s best for the team.

Don’t you love a paradox? Baseball pays huge attention to statistical performance indicators, but shies away from target-based payment. Health care basically ignores tonnes of statistical evidence but many are rushing headlong towards target-based payment. And to heap irony atop the paradox, there are composite performance scores in baseball, like the aforementioned Wins Above Replacement, that could form the basis for payment without corrupting the enterprise. Even so, for pretty sound reasons, baseball won’t go there. In health care, there are no similarly valid omnibus measures of the performance of, say, a family doctor. Yet doctors have negotiated bonuses for performing simple tasks like ordering regular tests for diabetics or screening for certain cancers, both of which can and should be done by a computer.

How did this apparent absurdity become commonplace? It is a perfect illustration of the chasm between theory and practice. P4P sounds like a good idea. But health care and health are way too complex to make it work as well as it might in baseball. The link between what providers do and patient outcomes is not nearly so linear and immediately tangible as the relationship between a team’s on-base-plus-slugging average and the number of runs scored. Moreover, you can’t pay for performance unless the indicators are unambiguous and simple to measure. It’s easy to measure whether you’ve done Pap tests or ordered mammograms. It’s hard to measure whether you’ve helped a frail elderly person with four chronic conditions avoid complications over a ten-year period. That’s why P4P typically pays for the former and has no clue about how to reward the latter.

The result? Health care frequently pays extra for achieving targets that require no special skill or effort, and have little impact on the health of really sick patients. It’s a bit like paying outfielders extra for catching routine pop flies. In health care as in baseball, doing things the right way will get you a better result. But once you define “the right way” as a select list of cherry-picked activities and build the P4P scheme around them, you deflect attention from ends to means, and undervalue less tangible and discrete, but more important elements of success.

Baseball wasn’t always so wise. It used to overvalue some metrics, like batting average, and undervalue others, like how many balls a shortstop fields in a year (the greater the ground covered, the more balls fielded, and the fewer that reach the outfield for a base hit). Teams that developed and embraced better metrics ended up getting better returns on their investment (more wins per dollar) – that’s the essence of Moneyball.

Using data to define and improve performance is great. Tying people's pay to their recent aggregate performance may seem counterintuitive, but it makes pretty good sense. Tying this year's pay to achieving this year's individual statistical targets – particular in team sports like baseball and health – is fraught with moral hazard. Health care needs to understand the difference if it wants providers to focus on what they achieve rather than what they do, and to respond creatively to patients’ needs rather than the target-triggered ring of the cash register.

The Task Force on Internet Hate, created by the Inter-parliamentary Coalition for Combating Anti-Semitism (ICCA), formally approved a motion May 7 establishing the "Anti-Cyberhate Working Group," during their meeting under the auspices of the Stanford Center for Internet and Society in Palo Alto, California.    

Read the full story at the original publication link below.  Read more » about ADL Teams With Internet Industry Leaders To Convene Cyberhate Working Group

Over 30 legal academics from current or potential future Trans-Pacific Partnership Agreement (TPP) negotiating countries wrote to United States Trade Representative Ron Kirk today. The letter, the text of which is posted below, criticizes the USTR decision to cancel full day stakeholder presentations for the current round of negotiations being held in Dallas, Texas. Read more » about Law Professors Call for Trans-Pacific Partnership (TPP) Transparency