In Conversation with Dr. Gordon Henry Guyatt, MD, MSc, FRCP, OC – Distinguished University Professor, McMaster University

Image Credit: McMaster University/Professor Gordon Guyatt.

By Scott Douglas Jacobsen

Professor Gordon Guyatt, MD, MSc, FRCP, OC is a Distinguished University Professor in the Department of Health Research Methods, Evidence and Impact and Medicine at McMaster University. He is a Fellow of the Canadian Academy of Health Sciences.

The British Medical Journal or BMJ had a list of 117 nominees in 2010 for the Lifetime Achievement Award. Guyatt was short-listed and came in second-place in the end. He earned the title of an Officer of the Order of Canada based on contributions from evidence-based medicine and its teaching.

He was elected a Fellow of the Royal Society of Canada in 2012 and a Member of the Canadian Medical Hall of Fame in 2015. He lectured on public vs. private healthcare funding in March of 2017, which seemed like a valuable conversation to publish in order to have this in the internet’s digital repository with one of Canada’s foremost academics.

For those with an interest in standardized metrics or academic rankings, he is the 14th most cited academic in the world in terms of H-Index at 222 and has a total citation count of more than 200,000. That is, he has the highest H-Index, likely, of any Canadian academic living or dead.

We conducted an extensive interview before: here, here, here, here, here, and here. This interview in Canadian Atheist does mean pro- or anti-religion/pro- or anti-non-religion. It amounts to a specific topical interview. Here we talk about private versus public healthcare focused on Canada.

Scott Douglas Jacobsen: You gave a talk in March of 2017 on private and public healthcare. With regards to the advantages and disadvantages of an argument within the talk, I wanted to explore this presentation. You laid out the argument in the lecture.

When it comes to the general factors that come into a discussion on private and public healthcare funding, what tend to be the main factors that tend to come up in such a discussion?

Professor Gordon Guyatt: When I gave the talk, I ask people, “How should we decide? How should we decide on the relative merits of public and private healthcare funding?” There are a number of things that people raise.

One is health outcomes. It depends on the ultimate goal of healthcare such as keeping people healthier: “What is the impact on people’s health?”, “What is the impact on access to care?”, “What is the impact on patient satisfaction?”, “What is the impact on autonomy – often characterized as a choice?”, and so on.

Those are a number of factors that people raise when they are thinking about it. Of course, there is healthcare cost. How much will we be spending on healthcare?

Jacobsen: When it comes to private healthcare funding, what seems like one of the main factors for people?

Guyatt: There is a lot of misinformation. So, one of the major drivers is “things aren’t working the way they are now. There has got to be a better way, at least with respect to physician and hospital services. Perhaps, we should try something different.”

A lot of the times, it will come down to that. You are looking for something different. It depends on who you are talking to, where their perspectives might make a difference.

The outcomes of private versus public funding will differ depending on who you are. If you are very rich, it is a different calculus compared to if you are very poor. It changes across that spectrum. It is very different if you are a healthcare provider versus a healthcare consumer.

So, incomes may influence your outcome. When I talk to audiences, there are notions that people have about what is affordable. There are notions people have about what it will do to their own income.

Those will influence things. Often it starts off with “public funding of healthcare is not sustainable.” To deal with that, I ask, “What do you think has happened to healthcare expenditures as a proportion of the Gross Domestic Product (GDP) over the last 7 years?”

I give options: gone up every year, most years, and so on and so forth. People are surprised with the answer. It has stagnated or declined. So, as a percentage of GDP, healthcare is lower than 7 years ago. Also, they tend to be surprised when you inform them: in 1991, it was 10% of GDP for all healthcare expenditures.

Now, it is a little bit below 11%. That is over more than 25 years. In terms of public healthcare expenditures, it is more extreme over 25 years, about 7% to 7.5%. This shapes the perception people have about healthcare spending constantly going up as a share of our national wealth when that is not true.

In general, that leads people to rethink the unaffordability of public funding of healthcare. Often, that is the first thing in people’s minds.

Jacobsen: I want to bring some information from prior interviews to contextualize some of this because it may slant some of the perspectives that you may have on it as well. Of course, the facts you are providing are facts, so do not change.

You ran for the NDP four times and lost “honorably” four times.

Guyatt: I do not know about honorably.

Jacobsen: [Laughing] I have friends in their 80s. We go for coffee sometimes. One of them ran provincially and federally. One time for the same party. One time not. In that context, NDP tends to have platform positions and policies that lean particular ways, often in the favor of the public regarding healthcare.

When it comes to people, taking an outside perspective, who are looking at the favourability for themselves or people they know, the private funding model for healthcare had a big item on the freedom to choose.

Often, the people who would have the disposable income and the perspective that may orient them towards that would be an older population with the disposable income and with a more conservative or libertarian stance.

Guyatt: In terms of that, first of all, be careful, there are older people who have managed to accumulate income during the course of their lives. There are people who have not managed to accumulate as much at retirement.

Those are different perspectives. The issue is if one were talking about the values issue. The value comes down to equity versus what people call “autonomy” or “choice.” On the one hand, there are people who say, “You should not have financial barriers to high-quality healthcare. Everyone should get the highest quality healthcare that the system has to offer.” That is one value.

Another is “people should be able to choose how to spend their resources like in pretty much every other area of our world. They should be able to spend their money on a better house or a better car. It should be the same in healthcare. You should be able to choose how you spend your resources visàvis healthcare.”

That is a fundamental value and preference divide, which tends to follow a left-right distribution. The folks on the left value equity more. The folks on the right value choice or autonomy more.

Jacobsen: If you take out the one value of autonomy or choice, overall, what provides a better outcome for the general citizenry?

Guyatt: Let’s go through it:

Let’s say one thinks it is a good thing to constrain healthcare expenditures and says that you do not want too much GDP going towards health, the dramatic contrast with that concern is the United States and more or less the rest of the high-income countries.

The United States is about 55% private and 45% public. The rest of the Western world – Canada is relatively low at 70% public. Scandinavia, you have a number of countries over 80% public. France and Germany are about 75% public.

The United States is this big outlier with a much smaller proportion public than the rest of the Western world. Not coincidentally, they take the cake in terms of percentage of GDP spent on healthcare in the vicinity of 18% now.

So, the reasons for that is administrative costs are in Canada perhaps 16 and 17% of our healthcare expenditures. In the US, it is over 30%. As soon as you make people pay privately, everybody has to buy health insurance, then you have huge administrative costs.

Insurance companies have to be set up. They have to set up packages, compete with one another. There is huge documentation required for every health service, so you have this big administrative cost associated with private funding. That is one thing.

Second thing, governments cannot constrain healthcare costs, essentially. They cannot set boundaries effectively within a private funding model. In terms of constraining healthcare costs, public funding is an out and out winner by a long margin.

Jacobsen: What internal to the society variables makes the United States such an outlier with the other developed nations, especially the rich developed nations?

Guyatt: I think most people would say that the United States in terms of that value that we were talking about earlier. That is, the value one puts on autonomy versus the value one puts on equity or social solidarity. The US public has extremely different values.

So, that the fact that it could even be an issue that you could legally insist that people purchase insurance for their healthcare in one way or another – by governments making it available to them. It would inconceivable in Western Europe that that would be a question.

It is generally the attitude towards social programs right across the spectrum. Social solidarity, equity, support for the disadvantaged, so on and so forth, is much more highly valued in Western Europe and Canada than it is in the United States.

Jacobsen: I see this attached to your work with Evidenced-Based Medicine with the part that was added on later in the research with “values and preferences.” Culture influences values and preferences even to the extent of administrative costs being swallowed.

Guyatt: Yes, you are absolutely right. Way back in 2002, when Roy Romanow did his work on a recommendation to the government about a healthcare recommendation, he surveyed Canadians in a variety of formats.

He found we put a high value on equity. If you were making the same survey in the United States, you would get very different results. I think in terms of the implications of financing and what you pay. There is a lot of misinformation.

Even having said that, definitely, Americans would be horrified at the idea that you couldn’t pay for quicker or better healthcare. Certainly, in terms of social solidarity and equity as values, the United States and Scandinavia are perhaps at the extreme poles.

Jacobsen: With aging populations in North America and Europe generally, what will likely have to be the next moves in cultures that value equity over autonomy with regards to the amount of taxes that are taken from the public for the healthcare expenditures?

Guyatt: Most of the Western world in terms of the aging population, and also Japan, are substantially ahead of North America. A big thing that people do not realize in terms of healthcare for populations and the aging of the population is that the huge bulk of expenditures comes in the last year of life.

The implications of that are that we are all living longer, but whether our last year of life occurs between 70 and 71 or 90 and 91. That is the big bulk of healthcare expenditures. People get sick. Then in the last year, when they are sick, that is when they need the big expenditures.

We have done pretty well in constraining costs. The drivers that have put costs up are less the aging of the population and more technological advances. Technological advances that have really driven up costs when they have been driven up.

It depends again on what we are ready to pay for. The technological advances, be they drugs or surgical devices or whatever, improve health. We live longer, longer, and longer. Yes, we may have to, if we want to take advantage of all of the technological advances that are going to continue even though the last 7 years it has not gone up, spend more of our GDP on healthcare.

If we want to do it efficiently, it will have to be public expenditures. It reminds me of where we can be very confident. In the next 100 years, we will next have to get to what the US spends at 18% of its GDP as long as we stay with public spending.

Jacobsen: Technology becomes cheaper over time. Phones were for the rich decades ago. They were not good. But they became better. The poorer were able to afford them and the phones were far better. 

Guyatt: It is a great point. 50 years ago, everybody had to live with their debilitating hip osteoarthritis or knee osteoarthritis. Now, hundreds of thousands of people are getting their hips and knees replaced.

That ended up costing money for years. The hip and knee replacements have become much more efficient. People used to stay in the hospital a week after the hip replacement. Now, it can be the same day. It is a good point.

I guess that is part of the reason that we have over the last 7 years have not had health care cost going up as a percentage of the GDP. Some of the technological advances drive up costs, but some of them end up constraining costs as we learn to do things more efficiently.

Another huge example of that is it used to be 45% of our healthcare expenditures were spent in the hospital. Now, it is 30%. There has been a gigantic shift to doing things as an outpatient, which is a much more efficient way of operating.

Jacobsen: If you look at Canada and its valuing of equity more than autonomy, does the trajectory seem clear in terms of funding that the public will be supporting for healthcare?

Guyatt: People continue to put a high value on healthcare. I would anticipate that if, in fact, the curve starts swinging up again. We could quite reasonably tolerate, for instance, a 1% increase in our GDP devoted to healthcare. People will tolerate that pretty easily.

Jacobsen: That is something I want to make more concrete for the 1% increase. What would that look like in practical terms?

Guyatt: Everyone [Laughing] would have to pay 5% more in tax burden. Of course, it is how you distribute that. If it were in a Trumpian way, the rich would pay less and everybody else would pay more.

Or you could distribute it in various ways. It means a relatively marginal increase in taxes across the population.

Jacobsen: What do you think the American administration is not necessarily getting right?

Guyatt: It is clear that the US way of delivering healthcare is extremely inefficient, extremely inequitable. It turns out on average that there are not better outcomes achieved and probably not as good outcomes in many areas.

They are wasteful and poor outcomes. It is not a very good deal.

Jacobsen: People are paying more for worse outcomes.

Guyatt: So, we did a study in the vicinity of a decade ago. We did a systematic review of health outcomes for similar conditions in Canada and the United States. There were about 30 conditions that we looked at in the research.

There were 15 of them for which there was no difference, essentially, between Canadian and US outcomes. There was about 10 of them with Canadian outcomes as better and 5 with American as better.

Our first submission, when we first submitted this paper, said that the US is paying more and they are not gaining in anything. The reviewer said, “What do you mean they are not gaining anything? The Canadian outcomes on average are better.”

We became less conservative after our peer reviews. On average, the Canadian outcomes are better. The very conservative statement is that the Americans are paying more on average for worse outcomes if you look across the spectrum.

We are constantly decrying the support for evidence in political decision making (academics). The continued support for universal healthcare. The governments, Kathleen Wynne extended healthcare to the under 25.

But we would be paying less for equal or better drug coverage on a national pharma care program, whether politicians got that message and were able to communicate it to people. You would pay less, but the total expenditures would be less because you would be paying less for your drugs.

In the way the US may be paying somewhat fewer taxes – even though that is somewhat questionable, but their payments are gigantically more. Were we to have a national pharma care program, what Canadians would gain in terms of decreased drug expenditures would more than make up for any increased taxes, there is no groundswell for universal pharma care.

Jacobsen: One other variable comes to mind when you say that to me, which is the split between long-term and short-term planning. If you take a long-term perspective or style of planning tied to an equity perspective, the financial outcomes for the country as well as the health outcomes of the citizenry go up. is that true?

Guyatt: Yes, it is the same thing. If we had a national pharma care program, the administrative cost would go way down. There are big administrative savings, immediately. Secondly, it puts the government in a much better position to negotiate with the people who are producing the drugs.

When health economists have modeled this, there is no question that what we as a citizenry would pay for drugs would go down.

Jacobsen: You are one of the leading voices or authorities in the country in terms of the medical field, medical discipline. So, what do you think would be preventing the public going into an equity perspective on all relevant domains in medicine given the obvious benefits laid out?

Guyatt: A number of things, the intense misinformation, I give these talks about what has happened to healthcare costs over the last 7 years; nobody gets it right. Everybody thinks they have gone up as a percentage of GDP. There is massive misinformation.

I am speaking to people in medical school and doctors. You would think that the people who would know would be the people in medical school. They would know more than others. The facts I am talking about are largely repressed.

Jacobsen: Why? [Laughing]

Guyatt: We can speculate about that. However, the balances, when we say, “Okay, for the country, it is going to cost less to have the public funding. Outcomes, if anything, are going to be better. Equity is a hands-down winner.”

But that perspective differs. In other words, that may be true for the population as a whole, but the wealthy may do better in terms of finances because they are the ones who pay proportionately more taxes.

They would prefer to be accessing and paying for higher quality care. Who controls the media? Well, I would argue the people with money control the media. When I give these talks, I start off saying, “You got it wrong! You are all completely wrong with regards to healthcare spending. How come?”

I ask people to speculate. Somebody comes up with all sorts of interesting answers. Somebody eventually comes up with the answer I suggested to you. I think it has to do with what is best for Canadians on average is not necessarily best for affluent Canadians who control the media.

Jacobsen: Also, taking a generational and emotional perspective, you have trained generations of leaders in the field. Being involved in some of Academia, I know some of how it works. 

You know people as friends either deceased, unfortunately, or are still some of the leaders in the field who themselves have trained people who have become leaders themselves. It is a big tree of people who know one another.

So, you have a much greater sense or better sensibility of the feelings of the doctors when they likely also realize, discuss, and debate the misinformation that is out and the source that you just pointed to.

What are those feelings?

Guyatt: First of all, my point once again. I can go before just about any medical audience, including an academic audience, and only a small proportion will get it right about what is happening with regards to healthcare funding.

Even the most educated in the profession, we are insular. We tend not to take a broader view of all sorts of things. Second, I gave the talk where I go through all of this stuff. I was invited to give the talk to the ophthalmologists in Toronto.

Who are generally known as a conservative group of people, they are among the highest billers, but smart people. They listen to the facts. The other thing I end off with. I go through the public healthcare being the winner in health outcomes, cost containment, and equity. The only one it is a loser in is autonomy.

I say, “With this balance sheet, why is there still a debate?” One of the things that was pointed out was that these guys do the LASIK surgery. It is private and so on. They are aware that within a privately funded system their incomes will be better.

These guys have big incomes. But the other thing that is going on in terms of societal perspective for individual rich people, it differs from the societal perspective for the rest of us. The story differs for healthcare providers, especially clinicians.

So, the winners and losers are different if you take a broad societal perspective or if you take particular groups within society.

Jacobsen: There are responses that aren’t very strong in my perspective, but that can be made in response. People will say, “These are class differences of interest. That is a liberal hype or conspiracy theory.” Something like this.

What would be an appropriate response to that?

Guyatt: Do you think the interests of rich people differ from the interests of poor people?

Jacobsen: [Laughing] Yes.

Guyatt: Well, there’s your answer.

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