The 1% versus the 99%

Waste is worse than loss. The time is coming when every person who lays claim to ability will keep the question of waste before him constantly. The scope of thrift is limitless.

Thomas A. Edison

Health care costs in Canada continue to rise. Per capita spending on health care is estimated to be $5741 (US), accounting for about 10.9% of gross domestic product.¹ On average, provincial governments direct about 40% of their budgets to health care.² The 3 main areas of health care spending, in order, are hospitals (30% of costs), drugs (16%), and physician services (15%).² Although health care costs continue to rise, the rate at which they are rising has slowed somewhat since the decade between 2000 and 2010.² In spite of popular opinion, population aging is not the primary driver of rising costs. Overall, population aging is a modest cost driver, estimated at about 0.9% per year. The share of public-sector health dollars spent on Canadian seniors has not changed substantially during the past decade—from 44.6% in 2002 to 45.2% in 2012.² Nonetheless, governments are increasingly concerned with ways to curb health care costs in Canada, as well as to improve quality.

One area of focus on cost reduction and quality improvement has been so-called hot spots or super-utilizers of health care resources. Super-utilizers were first recognized and described by New Jersey–based family physician Dr Jeffery Brenner, applying concepts from the world of law enforcement—high-crime hot spots—to medicine.³ Super-utilizers are the 1% of patients who consume between 30% and 50% of health care resources and costs. In the United States, some have argued that a primary health care reform strategy aimed at reducing the costs incurred by and improving the care of super-utilizers is the way to go.⁴ Others have argued that health care reform focused on super-utilizers is likely to be ineffective in the long term for several reasons, one of which is the sustainability of large-scale improvement projects shown to have an effect on super-utilizers.⁵

In Canada, a country with universal, single-payer health care coverage and a social safety net that mitigates some of the factors that drive super-utilization in the United States, there has also been interest in targeting super-utilizers as a way of reducing costs.⁶ However, those researchers studying this population have called for a more thorough understanding of their diverse health care needs and health care use in order to drive improvement.⁷

An alternate quality improvement and cost-reduction strategy has been to focus on the 99%. Most Canadians receive their primary health care in the community, usually with family physicians. Family physicians (indeed most physicians) receive little education in medical school or residency about the costs of the medical tests that they routinely order and they do not acquire greater knowledge once they go into practice.^8,9

The March issue of Canadian Family Physician features the launch of an ongoing series from Choosing Wisely Canada (CWC) and includes a commentary by Wintemute and colleagues describing the goals of CWC and its focus on helping family physicians and patients engage in meaningful discussions and make informed decisions about unnecessary testing and inappropriate treatment (page 199).¹⁰ In order to support the role that family physicians can play in partnering with patients to improve our stewardship of precious health care resources, while also improving care and reducing harms, in the coming months Canadian Family Physician will feature a series of interviews with family physicians across Canada, the first of whom is Dr Anthony Train from Calgary, Alta, about how they have implemented a CWC recommendation (page 233).¹¹

Also featured in this issue of the journal is an important study by Littman and Halil from the Department of Family Medicine at the University of Ottawa in Ontario, which shows the potential cost savings if Canada were to pursue a more rational approach to medication prescribing (page 235).¹² They all make for valuable reading.

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