Executive summary: A Blueprint for Action
Over the course of the Canada 2020 Healthcare Summit, several recurring themes emerged that point to a potential role for the federal government in creating a sustainable health system for all Canadians.
Fiscal and demographic implications of population aging:
Due to low levels of debt relative to gross domestic product, the federal government has more fiscal room to manoeuvre in the coming years than provincial governments, which will bear the brunt of the fiscal and demographic pressures of population aging.
The following recommendations made by conference delegates address ways the federal government could support the country as it transitions from having more retirees than working-age Canadians:
- Keep older Canadians productive for a longer period of time and increase the productivity of the rest of the labour force to help offset the incremental costs of providing health care to a larger cohort of seniors.
- Leave an infrastructure legacy to boost the country’s productivity levels.
- Help the provinces shift more services from hospitals to the community by ensuring that the home and community care sectors are adequately funded.
- Support the health and well-being of informal and family caregivers, whose unpaid work is an important contribution in containing health-care costs and keeping the system sustainable.
- Develop an insurance plan to encourage Canadians to set aside money to fund long-term care.
The implications of disruptive technologies and service delivery:
The conference heard repeatedly about the need for the country’s health system to break down barriers that are related to jurisdiction, professional practice, or technology. Another theme was the need to spread innovative ideas rapidly and at a scale where it can truly produce meaningful change.
The following recommendations made by conference delegates address ways the federal government could support innovations in technology and service delivery:
- Drive system change by breaking professional practice silos; use evidence to drive policymaking and change practice.
- Have patients and families work as partners with service providers to co-design health systems that work better for them.
- Enable health-service providers to develop and procure technologies and other capital investments that improve efficiency and patient care.
- Create a national research-and-development centre, along the lines of the U.S. Center for Medicare and Medicaid Innovation, for health-service providers to learn from each other, scale up local innovations and fine-tune promising practices.
- Create a Canadian version of the Organization for Economic Cooperation and Development, which would compare provincial health-system performance, use evidence to drive change and promote shared learning among providers.
- Deploy federal agencies such as the Public Health Agency of Canada, Canadian Institute for Health Information and the Canadian Agency for Drugs and Technologies in Health
- Create a comprehensive and transparent system of performance measurement based on health outcomes to track how well each region of the country delivers quality care.
- Give Canadians the tools to be in control of their own health by granting them ownership and access to their personal health information.
- Creating a framework for Canadians to have early access to drugs in development.
- Experiment with different service-delivery models in areas where the federal government has direct responsibility: veterans, First Nations, correctional services.
Using existing health-care resources more efficiently:
The conference heard that the current health system is not designed to meet the evolving needs of Canadians, especially those with complex health conditions.
Canada also remains a higher-than-average health-care spender when compared to other advanced economies. Health care is a $215 billion industry in Canada – larger than the energy sector. About 70% of expenditure is funded publicly through tax dollars, while the remaining 30% is paid through private insurance, or out of pocket by Canadians. However, the system does not produce the health and value outcomes for the amount of money that goes into it.
The following recommendations made by conference delegates address ways the federal government could support key structural reforms to make the system more efficient and resilient:
- Shift payment for health services from fee for service and volume-based funding to payment based on patient and value outcomes.
- Shift the focus of reform from population aging to chronic-disease management, which could be a greater threat to the sustainability of the system.
- Shift the focus of health services – and funding – away from disease management to disease prevention.
- Bring more health and social services to where Canadians want them.
- Encourage the integration of the primary and acute care sectors.
- Explore ways to use existing tax dollars earmarked for health care differently, such as creating personal health accounts for all Canadians.
- Explore more partnerships with the private sector.
Opening remarks: Reflections of a former health minister
In her remarks to open the conference, Deb Matthews, deputy premier of Ontario and president of the Treasury Board, reflected on her five years as Ontario’s health minister and gave her former self some advice:
- Create a sustainable system that preserves the single-payer model and reflects the Medicare principles of access based on need rather than ability to pay.
- Get real about the demographic shift toward an aging population.
- Drive system change by breaking professional practice silos and using evidence to drive policymaking and practice change.
Matthews observed that the current health system works well for providers, but not for patients, especially those with complex health conditions.
The system must be redesigned with the needs and perspectives of patients in mind, which means providers must do business in an entirely different way, said Matthews.
While there will be winners and losers among providers, the only result that matters is whether the system changes lead to value for money and better care for patients.
Matthews concluded her remarks by emphasizing that providers should stop thinking about what change means for their profession or organization and, instead, focus on doing what is right for patients. That’s the way to protect universal health care in Canada, she said.
Presentation: Fiscal and demographic context
Kevin Page, former parliamentary budget officer, and David Dodge, former governor of the Bank of Canada, outlined some of the fiscal and demographic challenges facing Canada in the coming decades.
According to Page, economic growth has slowed. Government revenues are down. A major demographic shift is underway as Canada adjusts to the reality of having more retirees than working-age Canadians. These features of the economy are likely to be protracted and structural over the coming decades.
In the face of these challenges, how much room does the federal government have to take on extra debt? Page said due to low levels of debt relative to GDP, the federal government would have more fiscal room to manoeuvre in the coming years than provincial governments, which will bear the brunt of the fiscal and demographic pressures.
However, the reality is that Canada remains a higher-than-average health-care spender when compared to other advanced economies. Health care is a $215 billion industry in Canada – larger than the energy sector, said Page. About 70% of expenditure is funded publicly through tax dollars, while the remaining 30% is paid through private insurance, or out of pocket by Canadians.
Over the past two decades, annual health-care expenditures have grown faster than the economy, with a particularly sharp rise in drug costs starting in the 1990s. The growth in drug costs started to flatten in 2010, but Canada remains a top spender at $766 per capita – second only to the U.S. ($1,000 per capita).
Recent history has shown that restraint in health-care spending is often short lived and only happens during tough economic times.
Page wondered if Canada could continue to bend the health-care cost curve over the long term.
Meanwhile, the aging population will fuel greater demand for long-term care, starting in the region of the country that is aging most rapidly: the Atlantic provinces.
Page concluded by observing that as population aging accelerates, the federal share of health-care spending continues to shrink.
Comment: Demography is not destiny
In his remarks, Dodge noted that demography is one area of economics where forecasts mean something. Canadian policymakers have known for a long time about the demographic shift toward an aging population, but they have not done enough to prepare for it.
The scope of change required is not only in the health-care system, said Dodge. Investments are also needed to improve the productivity of the labour force. These investments are a critical means of sustaining the health-care system.
However, Dodge suggested population aging is not as dire as has been predicted because of a few factors:
- This generation of Canadians over the age of 65 is healthier than previous cohorts. The key is to keep them healthy for as long as possible so that the health-care costs are not as severe.
- This generation of Canadians aged 65 and over is well educated and well trained. The key is to encourage them to be productive contributors to the economy for as long as possible.
Dodge concluded with this observation: Keeping older Canadians productive for a longer period of time and increasing the productivity of the rest of the labour force are two strategies that could offset the incremental costs of providing health care to a larger cohort of seniors, especially as more Canadians live longer.
In response to a question from the audience about how older Canadians can leave a legacy, Page said there is a role for those in their 50s and 60s to mentor the generation coming after them. They can also encourage politicians to leave an infrastructure legacy to boost the country’s productivity levels.
Opening panel: Disruptive delivery of health services
A four-member panel, moderated by Susan Smith, co-founder of Canada 2020, discussed the merits and shortcomings of “disruptive” models of health-service delivery that displace established incumbents and their practices.
In her opening remarks, Dr. Cindy Forbes, president of the Canadian Medical Association, challenged a remark made earlier by Deb Matthews about the health system working well for providers, but not patients. In fact, said Forbes, the system doesn’t work well for providers either. That’s because poor integration and care coordination leaves providers spending a lot of time trying to access services for their patients.
Forbes also challenged the perception that health-care providers don’t welcome change. In fact, providers have welcomed the change efforts launched over past decade and have been active participants in them. However, providers are not always invited to the policy table to help shape that change.
Given that history, one disruptive change that Forbes welcomed was the commitment by federal Health Minister Jane Philpott to involve all provinces and territories in the negotiation of a new health accord.
Forbes made three points:
- Shifting the focus of the health system from hospital-based care to home- and community-based care is a cornerstone of the Canadian Medical Association’s seniors strategy. However, the system doesn’t have adequate resources to provide Canadian seniors with home and community care. The federal government has a role to play in ensuring those sectors are adequately funded.
- More Canadians are providing informal care to their loved ones. These unpaid caregivers are at risk of burnout if they are not well supported. More needs to be done to ensure they can continue contributing. They play an important role in containing health-care costs and keeping the system sustainable.
- Providers need support to develop and procure technologies that improve patient care.
Maureen O’Neil, president of the Canadian Foundation for Healthcare Improvement, noted that the founders of Medicare in Saskatchewan originally envisioned an integrated, patient-centred system, in which hospitals and physicians were funded out of the same bucket of funding rather than separately. Fifty years later, policymakers are still having the same conversation and Canada’s health-care system remains a pilot project.
O’Neil proposed that the federal government create a platform for providers to learn from each other and scale up local innovations. She called for the establishment of a Canadian version of the Organization for Economic Cooperation and Development, which would compare provincial health-system performance, use evidence to drive change and promote shared learning among providers.
O’Neil said one disruptive idea that could serve as a template for First Nations leaders in other parts of the country is the federal government’s historic handover of the management of on-reserve health services to First Nations in British Columbia.
Stacey Daub, CEO of the Toronto Central Community Care Access Centre, expressed her excitement at the prospect of new federal leadership serving as a catalyst for change. The health-care sector in Canada has been at a crossroads for 40 years, caught in a perpetual pattern of incremental change, she said.
The majority of health-care dollars are still spent on hospitals, drugs and physicians. Providers perform the miracles very well, but the everyday experiences of care are where the system fails patients, said Daub.
She proposed that the federal government:
- Establish a population-based approach to health care, effectively segmenting patients into micro-communities around which services are organized and delivered.
- Create a comprehensive and transparent system of performance measurement to track how well each region of the country delivers quality care.
- Identify meaningful practices that produce the best outcomes for patients and share the most effective approaches with providers across the country.
- Give Canadians the tools to be in control of their own health by:
- Granting them ownership and access to their personal health information.
- Giving them a role in redesigning the health-care system to make it more responsive to patients.
- Exploring ways to use existing tax dollars earmarked for health care differently, such as creating personal health accounts for all Canadians.
Alex Munter, CEO of the Children’s Hospital of Eastern Ontario, proposed that the federal focus of health-care reform shift from population aging to chronic-disease management, which, he argues, is a greater threat to the sustainability of the system.
Because population aging happens slowly, it is a more manageable fiscal pressure over the long term than the burden of chronic diseases such as diabetes, mental illness and complications arising from premature births.
The other federal focus of reform should be technology, Munter said. At the hospital where he works, the majority of patients have parents in their 20s and 30s who are used to getting all their information and services online. And yet when they go to the hospital, they find that staff still use fax machines.
Electronic health records reduce medical errors and improve patient safety, efficiency and connectivity between patients and providers.
Munter said the previous federal government stepped away from Canada Health Infoway, leaving hospitals like his to pay for electronic health systems out of their operating budgets. Where the federal government can make a difference, he noted, is in helping hospitals and home-care organizations make the capital investments needed to improve productivity and efficiency.
Panel discussion: What role can the federal government play in the disruptive delivery of health care?
The panel discussed some of the existing system’s shortcomings, which prevent it from delivering high-quality care for patients. While high-performing systems in other jurisdictions deploy teams of providers that focus on preventing disease in patients, Canada is not “staffed up” to do that kind of health-promotion work, said O’Neil.
As the fifth largest health-services provider in the country, O’Neil observed, the federal government has an opportunity to be an innovator in areas where it has direct responsibility: veterans, First Nations, correctional services. And she noted that federal agencies such as the Public Health Agency of Canada, Canadian Institute for Health Information and the Canadian Agency for Drugs and Technologies in Health could all be deployed differently.
Instead of musing about how the system should change, policymakers should reframe the issue around how to improve the service delivery for patients, the panel noted. O’Neil proposed that the federal government convene deliberations with Canadians about how they would like their health services delivered when it comes to palliative care, for example.
Daub made the case for exploring more partnerships with the private sector by pointing out that any disruptive innovations that have improved health-care efficiency have not actually come from within the sector itself.
Audience member Durhane Wong-Rieger, president of the Canadian Organization for Rare Disorders, raised the theme of patient-centred care. She noted that the term has become meaningless and that patients-as-partners is a more relevant descriptor. The panel agreed that as partners, patients should have a role in designing a health system that’s right for them.
A final theme that emerged during the panel discussion was how the federal government can ensure that vulnerable populations with complex needs get access to health services. Daub emphasized the need to move toward a population-health approach by bringing health and social services to patients when and where they need it. O’Neil gave the example of Ontario’s Health Links, which help patients with complex conditions navigate a fragmented patchwork of unconnected providers.
Panel #2: Disruptive technologies
A three-member panel discussed the health system’s ability to adopt and adjust to emerging technologies, some of which give individuals the ability to monitor and manage their own health. The panel was moderated by Zayna Khayat, Senior Advisor, Health System Innovation and Director, MaRS EXCITE.
Khayat gave an overview of the different types of innovations and the factors that drive their development. In the context of health care, innovations are new or better ways of performing valued services whose demand continuously outpaces society’s ability or willingness to pay for them.
Innovations can drive down the cost of labour and delivery. Innovations can root out inefficiencies and ineffectiveness. Innovations can treat or reverse a chronic disease, reduce avoidable hospital admissions, or push the boundaries of science.
Khayat described incremental innovations that produce gradual improvements; disruptive innovations that create new markets and value, while displacing established incumbents or practices; and breakthrough innovations that radically alter accepted norms, practices or understanding.
An invention, idea, or pilot project is not an innovation until it has been implemented on a meaningful scale. The ability to scale up pilot projects is a perennial challenge in health care, said Khayat.
Michelle F. Browner, Senior Director, Platform Innovation & Partnership Management, J&J Innovation outlined some of the company’s emerging technologies that have the potential to transform health care. They include a contact lens that can monitor the glucose levels of its wearer, which could improve diabetes management.
This emerging technology reflects a burgeoning field in which the pharmaceuticals industry has placed great hope: studying patterns from massive groups of genes, proteins and the chemical fingerprints that specific cellular processes leave behind to not only improve the detection and management of disease, but also, increasingly, anticipate its onset.
Dr. Hoangmai Pham, Center for Medicare and Medicaid Innovation, described the mandate of the U.S. agency, which administers a public health-insurance program for Americans over the age of 65, low-income families and children in need.
As both a payer and regulator, the centre decides when it’s appropriate to cover the cost of a treatment or technology. The centre also determines what is a reasonable price to pay providers, Pham explained. The centre has a $10-billion budget over 10 years to test new payment and service-delivery models.
At any given time, the centre runs up to 40 demonstration projects. However, a demonstration project does not automatically qualify as a disruptive innovation, Pham noted.
When demonstration projects show sufficient impact to be scaled up, the centre tries to strike a balance between facilitating rapid adoption and minimizing the shocks to the market so that people have time to absorb and adapt to the disruptive change, said Pham.
The center also identifies which fields are ripe for the adoption of disruptive innovations, while providing feedback, performance data and technical assistance to drive learning and improvement activities.
From the centre’s perspective, said Pham, the role of a research-and-development centre is not only to test innovations, but also to serve as a practice arena for providers to figure out how to do things differently, not just what to do.
Because of the sheer size and scope of the Medicare and Medicaid program – it is located in all 50 states and covers 50 million Americans – the innovations facilitated by the centre often become sector-wide breakthroughs that are adopted by private insurers across the country.
Bill Charnetski is Ontario’s first chief health innovation strategist at the Ministry of Health and Long-Term Care. He has been on the job for less than three months. Given that the provincial government now spends $51 billion a year on health care, providers must be mindful of the cost of service delivery, Charnetski said.
As the baby boomers enter their retirement years, they will usher into the health system their expectations and demands as consumers. If they don’t get what they want when and where they want it, they will find what they need elsewhere, said Charnetski. He believes the high expectations of baby boomers will help drive significant health-system change.
Panel discussion: What are the challenges that stand in the way of disruptive innovation?
The panel acknowledged that disruptive technologies originate from outside-in rather than bottom-up at many health-care organizations. Pham and Browner talked about the importance of bringing together vendors who are co-developing new solutions with the end users who have an unfulfilled need. Pham suggested that a virtual marketplace would allow for more direct interaction between end users and developers.
Charnetski identified four challenges:
- Ontario has a glut of pilot projects, but few innovations that demonstrate high impact.
- Companies have difficulty getting their made-in-Ontario innovations purchased in Ontario.
- Pathways need to be created to scale up the adoption by end users of innovative tools and practices.
- Funding for early-stage commercialization of innovations remains difficult to access.
Panel discussion: What are the top two or three disruptive innovations that you would like to see emerge?
Charnetski cited two:
- Decentralization: Shifting health services out of hospitals and into home care, long-term care and aboriginal care. Charnetski observed opportunities in the community-care sector for large-scale change.
- Connectivity: Providing patients and providers with the same information at the same time to empower a circle of care to be formed around patients.
Browner noted that the pharmaceuticals industry is now at the stage where there is enough scientific understanding about the causes of some diseases to change their course, rather than simply treat their symptoms.
At J&J, a variety of monitoring technologies are emerging that, for example, ensure the right person is taking the right drug at the right time, Browner said. There are also technologies in the pipeline that allow for small doses of drugs to be released into a person’s system in a sustained and time-controlled way over the course of a month or longer, which would reduce how frequently patients would need to take their medications.
Keynote speech: How innovation and collaboration can lead to healthier communities
Josh Blair, Chief Corporate Officer, TELUS and Executive Vice-president, TELUS Health, shared a video about a team of Montreal doctors who used the company’s wireless platform to start a mobile clinic that provides health services to 800 homeless Montrealers.
Blair then challenged his audience to imagine what the impact would be if small innovations such as the Montreal clinic were scaled up across the country.
He believes that this country has top-notch providers who deliver great outcomes, but are constrained by what they can achieve.
To take the system to the next level, Blair suggested that the time is right for the federal, provincial and territorial governments to collaborate in identifying innovations that have proven to be effective and scale them up across the country.
Blair gave the example of the 15,000 family physicians across the country who use the company’s electronic medical records. Of the physicians who use the TELUS platform, 3,000 now use the company’s app to access patient charts securely on their smartphones or tablet computers.
The app allows them to organize their workflow whenever and wherever they want. Some doctors have started taking photos of their patients’ rashes, for example, to better document and integrating them into their electronic charts.
Blair pointed to two other examples of small-scale innovations with the potential for large-scale quality improvement:
- A home health monitoring system that enables patients with congestive heart failure to receive more rapid response and treatment from their providers, resulting in fewer emergency-room visits and hospital readmissions.
- A personal health-records system that enables young people with mental-health challenges to be monitored daily by their care team for any symptoms that require quick and early intervention.
Blair concluded by saying the federal government can play a role in:
- Providing seed money for innovations because provincial budgets are stretched.
- Bringing together the partners that allow small-scale innovations to be expanded nationwide.
Special guest: Hon. Jane Philpott, PC, MP, Minister of Health
In her remarks, Philpott stated that creating a sustainable health system is at the core of her mandate. She admitted that the task feels “daunting,” but believed she had spent her entire life preparing for it.
Philpott said the lessons she learned as a doctor, living and working in west Africa and Canada, have helped her understand that the twin goals of having a sustainable health system and keeping people healthy and prosperous require more than health care; they require fair access and equal opportunities for everyone.
She suggested that almost every policy decision made by a government has an impact on the health of its citizens.
Philpott outlined some of her priorities, as spelled out in the Prime Minister’s mandate letter to her.
She acknowledged the importance of what has been a recurring at this conference: the increasing recognition that putting more money into the system is not the answer; rather, the country’s health system needs to break down barriers, spread innovative ideas and make better use of existing resources.
Philpott then invited the audience to send her their ideas for better service integration and new funding models, among other things.
She concluded her remarks by looking ahead to:
- The imminent start of negotiations with the provinces and territories for a new multi-year health accord.
- The launch of efforts to improve home care for Canada’s aging population.
- The ongoing work to improve health services for First Nations.
- The launch of efforts to legalize and regulate marijuana.
- Introducing tougher regulations to eliminate trans fats and reduce salt in processed foods.
- Developing the government’s response to the Supreme Court’s decision on doctor-assisted death.
Special presentation: Winner of the Facebook DementiaHack – “Team TakeMeHome”
A team of graduate students from the University of Toronto reflected on their experience creating a mobile-phone application that could help individuals with dementia navigate their communities.
The project was part of a weekend hack-a-thon, which gave the group the chance to “build cool stuff, help folks affected by dementia, get support to push your product to market.”
The team had 30 hours to come up with a “minimally viable product.” The result was TakeMeHome, an app that adapts existing mapping technologies to help people affected by dementia with way-finding. The idea behind the app was to provide those individuals and their caregivers with the means to lead more productive, fulfilling lives.
The team came up with idea after hearing the stories of how people living with dementia felt trapped in their homes because they worried about forgetting how to find their way through their neighbourhoods. Those personal stories informed the team’s approach when designing a solution.
Keynote speech: How does Canada compare with other countries in health-system performance?
Robin Osborn, Vice President and Director, International Program in Health Policy and Practice Innovations at The Commonwealth Fund, began her presentation by pointing out that the conventional wisdom – at least among Americans – is that the United States has the best health-care system in the world.
In reality, it’s the most expensive and doesn’t produce the outcomes for the amount of money that goes into it.
By comparing its health-system performance with that of 10 other advanced economies, the U.S. can get a better understanding of where it needs to improve. It can also look to other countries for ideas on how to improve.
Osborn highlighted key findings from the 2012 Commonwealth Fund International Survey of Primary Care Doctors and the 2014 Commonwealth Fund Survey of Older Adults, which measures how well the health system takes care of seniors, especially those with multiple chronic conditions.
On a number of indicators, Osborn showed that the U.S. ranks at or near the bottom when its performance is compared with that of 10 other countries.
Meanwhile, Canada’s performance is only slightly better than that of the U.S., meaning this country also ranks at or near the bottom of the pack on a number of indicators that measure quality, access, efficiency and equity.
The survey results paint a picture of a health system that has a weak primary-care foundation. While most Canadians have a primary-care provider who acts as the first point of contact for people seeking medical services, fewer than half of all patients get an appointment to see their provider when they need it, especially after hours and on weekends.
The result of an underperforming primary-care system is high rates of emergency-department visits, hospital admissions and readmissions, especially for seniors with multiple chronic conditions, such as congestive heart failure, chronic obstructive pulmonary disease and advanced-stage cancer.
These patients are more likely to receive conflicting information from different doctors, experience gaps in care after they are discharged from hospital and experience drug-related adverse events.
Osborn said these are the patients that policymakers need to be concerned about because in the U.S., they are the 10 per cent of the population that accounts for 65 per cent of total health-care spending.
These patients also tend to have lower income and education levels, which, in and of themselves, can drive up costs by as much as 15 per cent. Not surprisingly, these patients are the least satisfied with their care, according to the survey results.
Osborn went on to highlight some of the features of high-performing systems. For example, countries that spent $2 on social services for every $1 in health services tend to get better outcomes for the money spent.
In the UK and Sweden, where the performance of individual primary-care providers is monitored closely, providers, driven by a sense of professionalism, have shown a strong motivation to improve when shown the number of their patients that have been admitted to hospital.
Osborn listed a number of other innovations from around the world that the Commonwealth Fund considered noteworthy:
- Low-cost, high-quality open-heart surgery at India’s Narayana Hrudayalaya Hospital: This facility performs the highest volume of open-heart surgeries in the world and produces results that are as good as those at the Cleveland Clinic in the U.S. Because of the high volume of surgeries, the hospital has greater buying power when it comes to purchasing equipment and supplies, allowing them to treat many more patients at a lower cost. The hospital also practises tight financial controls by giving every manager and physician a daily profit-and-less statement so they can monitor their own performance closely.
- [email protected], Singapore: Accessible, cost-effective care for the elderly, the program leverages telemedicine technology to allow medical professionals to diagnose, monitor and treat elderly patients remotely between hospitals and nursing homes.
- Brazil’s family health program: Cited as the most successful primary-care reform in the world, the program provides services to 55% of population through community health centres that provide a one-stop shop for preventive care, chronic-disease management, triage and referral, child-wellness checks and prenatal health education. Infant mortality rates were cut in half during the implementation of the program.
- The “call-and-check” program in Jersey, United Kingdom: As part of their rounds, postal workers check in daily or weekly on isolated, frail and elderly people who sign up for the service. The postees deliver medications and reminders about upcoming doctors appointments, ask about immediate concerns, relay any requests or concerns to their client’s doctor or local authority and inform them of social activities that might interest them. The program is at an early stage and is being evaluated.
Panel #3: How are other jurisdictions managing change?
A three-member panel discussed trends in health-service delivery in other OECD countries that face similar fiscal challenges as Canada. The panel was moderated by Simon Kennedy, deputy minister of Health Canada.
Kennedy opened the discussion by asking panellists to describe the major preoccupation in their jurisdiction around health-system sustainability and quality.
Elizabeth Fowler, Vice President, Global Health Policy, Johnson & Johnson, drew on her experience as an architect of the U.S. Affordable Care Act. While a common perception of the legislation, known as Obamacare, is that it was designed to increase the number of Americans with health insurance, another aim of the legislation is to bend the health-care cost curve while improving outcomes.
Fowler provided some examples of reforms that are happening under Obamacare. They include new penalties for:
- Avoidable hospital readmissions
- Hospital-acquired infections
- Low-performing hospitals that don’t measure up to quality and efficiency targets relative to their peers.
Fowler said about 87,000 fewer patients died in hospitals and nearly $20 billion in health-care costs were saved as a result of a reduction in hospital-acquired conditions from 2010 to 2014.
The next phase is a gradual roll out of a bundled payment program, which reimburses hospitals at a set fee for an entire episode of care, rather than a fee for every procedure performed during a patient’s admission. Hip replacements will be the first procedure to be reimbursed under a bundled payment model.
Fowler said reforming the entire reimbursement system, which for 50 years has been based on fee for service, will take time. She wondered whether the U.S. would be able to maintain the flattening of the health-care cost curve over the long term.
And while she sees more collaborations than ever being established within the health-care sector, there are still organizations that resist change under the belief that the Affordable Care Act will be repealed.
Michael Macdonnell, Head of Strategy, National Health Service, United Kingdom, provided an overview of the NHS, which pays £100 billion a year in funding and reimbursements. Under a five-year health accord, the UK is shifting the focus away from investments in acute care and more on disease prevention.
Macdonnell emphasized that the accord is focused on actually doing disease prevention, rather than just talking about it. This strategy is designed to address the three major challenges facing the UK health system: aging, chronic diseases and rising consumer expectations among the younger generation.
Macdonnell pointed out that social care and physical care are currently two separate program streams, as are primary care and acute care. Efforts are underway to integrate those parallel streams. The NHS is also working with 50 “vanguard” organizations to demonstrate new care models, such as integrated primary and acute care systems.
Funding models are shifting away from fee-for-service based on activity volumes to capitation models in which payment is based on results.
Macdonnell said his group sees itself not only as a chequebook, but also as a midwife for innovative ideas to run a lean health system based on delivering value for money.
Katharina Janus, Professor of Healthcare Management, Ulm University, Germany and Director of the Center for Healthcare Management, Columbia University, began her presentation by stating unequivocally that jurisdictions are not managing change. They are trying to rule and react to it.
Janus said like other countries, Germany spends a lot of money trying to encourage integrated care but silos still exist, with some notable exceptions. Any successful pilot projects often come from bottom up, meaning innovation only happens at the organizational, not the system level.
The changes that work are not necessarily the result of incentives imposed from top down, which is the German way, she observed.
Janus warned about the unintended consequences of having policymakers simply invest more money in health-system reform, without reciprocal accountability and engagement in strategy and implementation.
Rather than using money as an incentive to drive change, Janus urged policymakers to spend time understanding the needs of health providers and appealing to their sense of professionalism.
Janus ended her presentation by making two additional points:
- Fragmentation and decentralization are opportunities, not barriers, because they encourage a multitude of experiments.
- Science is important, but stories are also powerful in driving change.
Panel discussion: Are there any below-the-radar issues that merit greater attention?
The panel discussed “sleeper” issues, starting with moderator Kennedy’s suggestion that precision medicine and mental health are two areas where there are more policy implications than meets the eye.
Osborn agreed, noting that mental health and physical health are often treated separately, with the result that neither is treated particularly well. Service integration between those two disciplines is a real challenge.
Another overlooked issue is how to bring more health services to where patients want them, said Osborn. That is how to make the system work better for patients.
Macdonnell identified three under-examined issues:
- How to get better at picking innovations and deploying them in a way that makes sense and unlocks value.
- How to engage individuals to care about health-care quality and be involved in their own care.
- How to come to terms with the health-care workforce of the future, which will demand more flexibility and entirely different roles from what exists today.
Fowler identified two emerging issues:
- How to measure health-care quality and outcomes, given that existing metrics are imprecise and poorly understood, resulting in scepticism about whether the right things are being measured.
- How to present quality and outcomes data in a way that is open and understandable and useful to the average patient.
Janus identified two sleeper issues for Germany:
- Care coordination
- Striking the right balance between the high value Germans place on safeguarding the privacy of their health-care information and the development and implementation of new technologies that harness vast amounts of personal health information.
An audience member posed the following question to Kennedy in his role as Deputy Minister of Health Canada: In personalized medicine, there are innovations that reach patients, but the challenge is getting payers to cover the cost. What role does Health Canada play in ensuring that those innovations are adopted by the health system?
Kennedy acknowledged that this is an ongoing policy challenge, particularly for treatments of rare diseases and personalized medical treatments that, by definition, only target a small population. The Canadian Agency for Drugs and Technologies in Health performs some of those assessments, but there is no easy answer to the question. The issue also requires ongoing collaboration with international partners.
Janus suggested that building multilateral coalitions could lead to legislation being introduced, but that is a very lengthy and painstaking effort. Fowler noted that the U.S. Medicare program covers orphan drugs without conducting an assessment for it. Macdonnell agreed that precision medicine is not only a big issue for government, but also for the companies conducting clinical trials.
Closing Panel: Changing the Conversation
A three-member panel discussed ways to redefine the public conversation and change the dialogue on what it means to have health-care sustainability. The panel was moderated by journalist Evan Solomon.
He noted that the political will isn’t always there to drive change, complicated as the health care file is by jurisdictional conflicts, regional differences in demographics and disruptive technologies, such as new-generation drugs.
Jaime Watt, Executive Chairman, Navigator, presented his research on Canadians’ views of health care. He noted a shift in public opinion among Canadians who regard health care, not as a social value, but as a commodity. This shift reflects the broader trend of Canadians viewing themselves as consumers rather than as citizens or taxpayers.
No cohort feels more strongly about this perspective than baby boomers who, by their sheer numbers and affluence, have high expectations of every service they consume, including health care.
Watt’s research shows that boomers:
- Expect health care to be delivered on their terms, when they want it.
- Have an intense desire for change because they see that the existing system is not flexible enough to meet their needs.
- Cherish access and choice above their concerns about cost and technological advances.
- Don’t discriminate between public and private delivery of services. Indeed, private participation in the health system is no longer forbidden. That doesn’t mean boomers are prepared to adopt a U.S.-style system. Use of privately delivered services must still be paid out of public funds.
- Use data to drive their purchase of various products and services, including health care. For that reason, they will demand information to inform their choices.
Watt concluded that Canadians are ready for a national conversation about health care that leads to change and choice. However, politicians who would rather not deal with the issue are not only out of step with Canadians, they are on the wrong side of what the public wants, Watt said.
Fred Horne, former Alberta Minister of Health and Wellness, responded to the message from Watt’s presentation about politicians having a role in leading health-system change. In his experience, Horne said, people wanted him to fix health care – but not change it.
During his time as a provincial health minister, Horne observed a desire by Albertans for access and choice in health care. But he also noticed a desire by Albertans – and all Canadians – to get those basic things right.
For example, all Canadians yearn for a seamless care experience. At a minimum, that means they expect to only have to tell their personal health story once. After that, they expect their information to be shared among all of the providers involved in their care.
As a health minister, he found it hard to strike a balance between getting the basics right and talking about the future.
Horne identified three structural reforms that need to be addressed:
- Primary care: Ensuring that all Canadians have a primary-care provider that they can call their “medical home,” where their health information is well managed, their care is well coordinated. That requires integration with other sectors of the health system.
- Compensation: Fees paid, not just to physicians, but all providers, should shift away from fee for service and volume-based funding. Instead, payment for health services provided should be aligned with patient outcomes. The role of evidence will be key in determining whether public payers should fund certain interventions.
- The role of the private sector: The day that health spending reaches 50 per cent of provincial budgets will be watershed moment that creates an opportunity to explore a wider range of partnerships with the private sector.
He suggested that the new federal health minister start by improving the day-to-day care experience of patients and families, then seek consensus from Canadians in reimagining Medicare for the future.
Jeffrey Simpson is a Globe and Mail columnist and author of Chronic Condition: Why Canada’s Health-Care System Needs to be Dragged into the 21st Century. He outlined three key points:
- Define health-care sustainability correctly. A sustainable health system is not just defined by meeting the demand for services to meet Canadians’ evolving health needs in a timely way over the long term; it is also about managing spending to ensure health care does not crowd out a government’s ability to deliver on other services at an appropriate level of taxation.
- Other advanced economies are facing the same challenge as Canada in controlling health spending. It’s encouraging to see that the public conversation has evolved beyond the mistaken notion that Canada has the best health-care system in the world.
- Take spending projections with a grain of salt. Annual increases in health spending have levelled off in recent years with slower economic growth, defying projections that assumed average annual increases of six per cent through the next two decades. The question is whether the current average annual increase of two per cent can be maintained going forward. It would require enormous political will.
Panel discussion: Given that Canadians’ attitude toward health care has shifted to a consumer mindset, how should the federal government position itself on this issue?
The panel discussed potential roles that the federal government could play. They include:
- Enabling the adoption of new technologies, with Canada Health Infoway as an example of a federal agency that facilitates the adoption of electronic health systems.
- Creating a framework for Canadians to have early access to drugs in development.
- Developing a long-term care insurance plan.
Horne said the federal government should recognize the crucial input of provincial and territorial governments on these issues by positioning its involvement as a national or pan-Canadian response, rather than a federal one.
The conference concluded with rapporteur Jennifer Vornbrock presenting a summary of the key ideas discussed throughout the day.