Canada 2020 Policy Lab: The National Pharmacare Initiative

Pharma Policy Lab

Canada 2020 will be hosting a Policy Lab on National Pharmacare Initiative on Thursday, May 29th 2018  in the Canada 2020 Studio in Ottawa.

On May 29th, Canada 2020 is convening a full-day session on National Pharmacare, in response to the government’s Budget 2018 commitment to create an Advisory Council on the Implementation of National Pharmacare. In the Budget, the government cites the high costs of drugs and the statistic that one in ten Canadians cannot afford the prescription drugs they need as reasons why a National Pharmacare plan is needed.
The Canada 2020 Policy Lab will help us think through a number of issues and opportunities surrounding National Pharmacare, with particular emphasis on:

  • What are the major bottlenecks in implementing National Pharmacare? How can these bottlenecks be addressed? Are there any risks of “catastrophic” implementation failure, and how can these risks be reduced?
  • How can the federal government best work with other stakeholders, including (but not limited to) provincial, territorial and Indigenous leaders, private insurers and the pharmaceutical industry in designing and implementing a National Pharmacare program?
  • What international models should the government consider (and avoid) if they choose to implement National Pharmacare?

To learn more about Canada 2020 Policy Labs, click here.
To apply to be a part of the Canada 2020 Policy Lab on National Pharmacare Initiative, click below:

Canada 2020 Health Summit Report

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:

  1. 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.
  2. Leave an infrastructure legacy to boost the country’s productivity levels.
  3. Help the provinces shift more services from hospitals to the community by ensuring that the home and community care sectors are adequately funded.
  4. 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.
  5. 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:

  1. Drive system change by breaking professional practice silos; use evidence to drive policymaking and change practice.
  2. Have patients and families work as partners with service providers to co-design health systems that work better for them.
  3. Enable health-service providers to develop and procure technologies and other capital investments that improve efficiency and patient care.
  4. 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.
  5. 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.
  6. 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
  7. 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.
  8. Give Canadians the tools to be in control of their own health by granting them ownership and access to their personal health information.
  9. Creating a framework for Canadians to have early access to drugs in development.
  10. 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:

  1. Shift payment for health services from fee for service and volume-based funding to payment based on patient and value outcomes.
  2. Shift the focus of reform from population aging to chronic-disease management, which could be a greater threat to the sustainability of the system.
  3. Shift the focus of health services – and funding – away from disease management to disease prevention.
  4. Bring more health and social services to where Canadians want them.
  5. Encourage the integration of the primary and acute care sectors.
  6. Explore ways to use existing tax dollars earmarked for health care differently, such as creating personal health accounts for all Canadians.
  7. Explore more partnerships with the private sector.

Canada 2020 Healthcare Conference

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:

  1. 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.
  2. 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:

  1. 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.
  2. 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.
  3. 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:

  1. Establish a population-based approach to health care, effectively segmenting patients into micro-communities around which services are organized and delivered.
  2. Create a comprehensive and transparent system of performance measurement to track how well each region of the country delivers quality care.
  3. Identify meaningful practices that produce the best outcomes for patients and share the most effective approaches with providers across the country.
  4. 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:

  1. Ontario has a glut of pilot projects, but few innovations that demonstrate high impact.
  2. Companies have difficulty getting their made-in-Ontario innovations purchased in Ontario.
  3. Pathways need to be created to scale up the adoption by end users of innovative tools and practices.
  4. 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:

  1. 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.
  2. 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:

  1. 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.
  2. 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:

  1. 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.
  2. GeriCare@North, 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.
  3. 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.
  4. 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:

  1. How to get better at picking innovations and deploying them in a way that makes sense and unlocks value.
  2. How to engage individuals to care about health-care quality and be involved in their own care.
  3. 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:

  1. 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.
  2. 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:

  1. Care coordination
  2. 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:

  1. 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.
  2. 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.
  3. 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:

  1. 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.
  2. 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.
  3. 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.

Rethinking the scope of health care in Canada: a renewed federal role

How Canada ensures it provides a universal, affordable, and high quality health care system that accommodates technological innovation and changes in delivery over the next few decades is a particularly important challenge. The increasing concerns about adequate financing, demographic shifts, and inequality both within and across generations only add to the complexity of the discussion. With a new federal government with an ambitious policy agenda, this summit is not just well-timed, it is a critical part of the conversation.
The recently elected federal liberal government campaigned on strengthening Canada’s publicly funded health care system.  It rightly pointed out that while Canada’s healthcare system remains a point of pride for Canadians, there are a number of areas, including financing prescription medications, home care and mental health, where Canadian Medicare lags behind many countries in the OECD.

The Comprehensive Care Canadians Need

The current conception of medically necessary care in Canada excludes many services necessary for especially vulnerable Canadians. A number of health policy advocates and scholars (including me at times) have called for the federal government to consider providing pharmacare, additional services for the elderly, and support for disadvantaged Canadians. Elements of all of these are critical to providing comprehensive care.
Canada has failed to keep up with the changing nature of health care delivery.  This failure can perhaps be explained by the way our system is organized around methods and places of delivery. Disruptions to traditional ideas of delivery have taken many forms:  prescription drugs now treat many conditions, technologies take care out of the hospital or doctor’s office, and people wish to communicate with health care providers and the health care system in a variety of new ways.  As health care has evolved, Canada’s health care system has passively privatized, as new forms of delivery are predominantly paid for privately (through private insurance or out of pocket). A consequence of this passive privatization is that the system is not as equitable or universal as we might like it to be. Indeed, it has left many residents of Canada behind.

Maintain the Integrity of the Public System

Now is the time for the federal government to play a leadership role in updating the design of Canada’s healthcare system: to modernize it to meet its goals of both improving the health of Canadians and protecting Canadians from the economic consequences of poor health and medical costs. And to do so in a way that promotes equality and universality.  The federal government should protect the boundaries of the public system by providing the legislative (and perhaps financial) foundation for a more comprehensive and equal health care system. A reconceived and comprehensive publicly financed system would have the benefit of helping define the ongoing role of the private sector at the same time, and so potentially avoiding future challenges to the integrity of our public system.
This would be a huge advance in the role of the federal government.  Rather than simply transferring money, the federal government could encourage healthcare innovation that improves the way in which we treat the healthcare needs of the Canadians.
We need to clarify the role and scope of the publicly financed portion of the health care system. That is, we must clearly define what the public benefit will cover and for whom.  In the absence of such streamlining, the healthcare system cannot be expected to achieve its goals, and the private system cannot step into an optimally helpful supplementary role. Knowing what healthcare was used to be easier. Care performed in hospitals or by doctors was considered to be a core benefit available for all.  If a doctor didn’t do it, it wasn’t medicine.  The task is considerably more difficult now.
For Canada’s system to keep pace we must put in place a systematic way of evaluating what is appropriate for public funding. Going beyond the questions of how, by whom or where the care is delivered seems to me to be our best chance of having our publicly financed institutions evolve along with the technology of health care delivery and system management.  Any framework that tackles this project of evaluating what we want to fund will also have to consider what we do for people who want more, better or faster service. How do we tackle the private side of health care financing?  In part, I’d suggest, by getting the public side right.

Moving into the Future of Healthcare

Whether through medications or “disruptive” technology,  or other as-yet unforeseen  avenues, new ways of treating people, preventing disease and of interacting with the health care system will continue to multiply in the years to come.  How, therefore, do we design a public benefit that recognizes this fluidity and unpredictability?
First, we should note that while health care technologies change rapidly, the underlying health needs of the population change much more slowly and in more predictable ways.  We have many of the same diseases and health problems that we had fifty years ago, even if the way we treat them has changed several times over those decades.  Therefore, we should design the public benefit around these health needs, not around providers, or treatments. The question shouldn’t be: should insulin be covered or should services by psychologists be covered (at present neither are universally covered in Canada). Rather, the system should be framed so that funding is targeted at diabetes and mental health disorders, and the most effective treatments for those conditions.  If we agree that chronic conditions such as diabetes and mental health are among our health care needs (and I think most of us would agree they are), then the most effective way of treating them should be publicly financed.

Healthcare Needs Should Define Treatment

Of course, it is not the case that our health care needs do not change at all. They do, although much more predictably and more slowly than health care interventions. We can predict, for example, that our long term care needs will increase as the population ages.  What is more difficult to plan for is what exactly long-term care delivery will look like in 20 years.
We are then left with dealing with the concept of “most effective.”  Ongoing advances in both technology assessment and “best practices” development among physicians offer reasons to be optimistic (examples would include NICE in the UK and the Israeli Medical Basket committee as far as technology assessment is concerned, and places like Intermountain Health and the Mayo Clinic as far as best practices implementation among physicians is concerned). There are models out there for effectiveness assessment that we can look to for ways to improve , in other words. Most effective does not mean newest or more expensive. Sometimes more effective treatments will even cost less.  What’s most important, however, is that by focusing on effectiveness we need not be restricted to those methods of treatment that we currently envision as part of the health care system.

A Plan for Moving Forward

So what does all of this mean? In my view, the federal government should re-conceive the requirement for federal funding and for compliance with the Canada Health Act so that all eligible residents are provided with a benefit that covers a comprehensive set of health care needs, not specific services. Advisory panels (these could be national and would reflect the required expertise) would determine the most effective way of treating these needs on an ongoing basis and provinces would then be expected to cover these forms of treatment as part of their commitment to Medicare.  In this way the federal government would take on a leadership role in defining what universal health care coverage ought to mean in Canada. And while the federal government would not deliver most care, it would continue to assist in providing the funds to finance it.
It would no longer be the case that entire areas of essential health care like prescription medications would be left to the private sector. Private financing that alters the incentives in the public system (for example, by covering services like essential medications or treatments that complement doctors and hospital services) should be discouraged.   Because the standards of care provided in the public system are established based on the latest expertise and evidence, they should lead to a relatively high level of quality.  Therefore, the private domain would be defined by treatment for which there are more (cost-) effective options or for items that we do not consider part of the broad essential needs of a population. This sounds limited, but the scope for non-essential health care is in fact broad and so it is likely that the market would continue to thrive. The public domain, however, would be defined by the best evidence on how to meet a broad set of communally agreed-upon population health needs.
There will, of course, be some who perceive any private financing as inequitable. There will likely always be treatments that, while not cost-effective or evidence based, appeal to people who have the resources to purchase them.  Allowing for avenues for individual choice in pursuing these options (we already allow for executive health care services in Canada where individuals or corporations pay for a much more exhaustive set of preventative health services) seems to me a reasonable compromise in a free society with a strong commitment to public benefits. But if we get the public system right, privately financed care will only mean the kinds of differences in access that we tolerate in a market society; it will not add to inequalities in health and quality of life. And safeguarding equality in these essential areas should be our primary goal.

Mark Stabile is Professor of Economics at the University of Toronto, Sciences Po, and INSEAD (as of 2016) and a fellow at the Martin Prosperity Institute at the Rotman School of Management. From 2007 to 2015 he was the founding director of the School of Public Policy at the University of Toronto. He is a member of the advisory board for Canada 2020.


Searching for Canada’s Michelle Obama

“Mom, I should eat broccoli because Michelle Obama says I should eat broccoli.”

What music to the ears of parents and policymakers!
A week ago, Canada 2020 hosted the fifth and final panel of the year in our signature speaker series, The Canada We Want in 2020. The topic was ‘confronting the crisis in public health’, specifically how we can come together to combat obesity and related chronic diseases.
One of our panelists was the dynamic and accomplished Melody Barnes, former White House Director of Domestic Policy to President Barack Obama, and chair of the administration’s task force on childhood obesity. Melody was also heavily involved in the First Lady’s Let’s Move! campaign aimed at persuading Americans to embrace healthy living.
Canadians are up against the same public health challenges as our American neighbours. According to recent data published in the Canadian Journal of Public Health, 25% of the Canadian population is estimated to be obese.  Obesity rates here in Ontario are above the national average at almost 29% and, on the current trajectory, an estimated 70% of Ontario’s current kids will enter middle age obese or overweight.
Rates are already higher in other provinces and amongst particular social groups (aboriginal Canadians and those from lower socio-economic groups, especially disadvantaged women). In some Atlantic provinces obesity rates already exceed 35%.
Childhood obesity is a particular problem: research shows that early onset obesity increases the risk factors for a range of chronic diseases – including diabetes, coronary heart disease and atherosclerosis.  Obesity in females during late adolescence is also associated with psychosocial behavioural abnormalities in adulthood.
If we are to change this trajectory, we need to consider evidence-based policy approaches that have successfully improved obesity-related health outcomes. The following are some of the key messages and insights that emerged at our event:

  1. Promote healthy living without demonizing different body types.
    The body-mass index is used to estimate overweight and obesity rates amongst different populations.  However, in our efforts to address the growing obesity epidemic we should not be concerned with the final output (weight) but rather the inputs (sedentary lifestyles, eating food of poor nutritional quality, etc.) that affect our health outcomes. Obesity is simply a proxy measure for increased disposition to myriad chronic diseases that will lead to soaring costs of healthcare delivery and a diminishing quality of life in years to come.
  2. We cannot educate our way out of this crisis.
    Two of our panelists, Melody Barnes and Alex Munter (President and CEO of the Children’s Hospital of Eastern Ontario) repeatedly emphasized this point.  It is imperative to educate individuals about the importance of healthy eating and active lifestyles so that they can make informed choices. However, information alone is not sufficient: Canadians also need better access to nutritious lunches at school cafeterias, grocery stores that stock fresh produce at affordable prices, safer parks and recreation facilities and other health-promoting infrastructure. This is where governments have a particular role to play. With their support, the healthy choice can become the default choice.
  3. Improving health outcomes is not just the responsibility of individuals but also of the collective ‘us’.
    Confronting the crisis in public health requires different (and sometimes opposing) forces including government, industry, NGO partners, health practitioners and individuals to act together. There is no magic bullet, no one miracle program and no single player that can succeed on its own. The programs and initiatives that deliver results have two things in common: they are uniquely tailored to address the specific issues faced by a given community and they are supported by multiple stakeholders.

In Canada, certain corporations stand out for their efforts to address the issue of obesity.  For example, Coca Cola Canada has recently announced that it will make nutritional information more transparent by featuring calorie counts on the front of all packages.  The company’s new marketing guidelines include a self-imposed ban on buying advertising space in media directed at audiences comprising more than 35% children under the age of 12.  In addition, Coca Cola is supporting physical activity and nutritional education programs, such as Breakfast Club of Canada. Loblaw is also making concerted efforts to bring in more nutritional information through its Guiding Stars program and its in-store dieticians.
Hopefully other companies will follow this lead. But it is also likely to take regulation (such as that proposed in Ontario’s recent Healthy Kids Strategy) to make sure that young children are not subject to junk food advertising and, thus, that parents are better able to control the nutritional messages reaching their children. Such regulation has already proven to be very effective in Quebec where the ban that has been in place since 1980 is estimated to have reduced junk food consumption amongst children by 13%.
Certainly, governments have an important role to play, and not just in the direct area of health promotion. As Alex Munter noted, the government of Ontario is addressing two key social determinants of health with its focus on poverty reduction and mental health and addiction. And the federal government is increasingly moving towards being a facilitator of partnerships and an enabler of best practice.
The First Lady of the U.S. has provided a very visible rallying point in that country – people respond to her sheer force of personality. Children look up to her; they want to eat their vegetables for her. That’s not a policy lever, but no one can say it’s not effective.
Here in Canada we do not have such a figure, but, encouragingly, we do have a federal government that is becoming more active in this space and that has demonstrated, in its recently released 2013–2016 Preventing Chronic Disease Strategic Plan, that it has a good understanding of the challenges it must address. It sees itself as an information hub, willing to fund partnerships and to act as a catalyst in the prevention of chronic disease, much of which is attributable to obesity and overweight.
As Alex Munter reminded us, “public policy always lags culture, and the culture on healthy eating is changing fast.” That bodes well for the future, but we should not underestimate the sustained effort that it will take to change the trajectory of ill-health into which we have fallen.
Aqsa Malik is a research associate at Canada 2020, an Ottawa-based think tank on the role of the federal government, and PhD. candidate in Neuroscience at the University of British Columbia. Diana Carney has just stepped down as Canada 2020’s Vice President of Research.
For more information and to watch a video of this panel or read the full background paper, click here.

Confronting the crisis in public health

Author: Aqsa Malik
Release Date: May 22, 2013
Pages: 26
This paper was prepared as background material for the Canada 2020 event ‘Confronting the crisis in public health’ on May 28, 2013 in Ottawa, Canada. It was written by Aqsa Malik, who is finishing her Ph.D. in Neuroscience at the University of British Columbia’s Brain Research Centre. The Foreword was written by Diana Carney, Canada 2020’s Vice President, Research, who was also the editor.
It is our conviction at Canada 2020 that there is and should be a role for the federal government in assuring the health of Canadians. While the provinces work on the mechanics of healthcare delivery, is there scope for the federal government to provide true leadership around public health issues, both to ease the financial burden on health systems and increase Canadians’ quality of life?
This paper joins other research and commentary written for our Securing the Health System for the Future policy stream, one of five areas of work that comprise the Canada We Want in 2020 project.
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The need to experiment in healthcare

This month the Health Council of Canada published the 2012 Commonwealth Fund International Health Policy Survey of Primary Care Doctors. This informative study is based on a survey of more than 2,000 primary health-care workers across the country.
It focuses on how front liners perceive the system (Does it require minor or major change? Do patients get too much or too little care? Can they get diagnostic tests when they need them?) and how they themselves operate (Do they make home visits? Prescribe electronically? Monitor their own performance against targets?) (To ready the study, click HERE.)
It provides a fascinating insight not just into how we are doing, but also into how we are doing relative to other countries. Sadly, the answer is “not that well.”
Canada’s health system sits more or less in the middle of the pack on physicians’ perceptions of how much change is required: 40 per cent of respondents say the system needs “only minor changes” and our doctors themselves are happy (82 per cent say they are satisfied or very satisfied with practising medicine).
But does their happiness come at the expense of patient care? The disparity between physician satisfaction and the measures in the survey that would seem to translate directly into patient satisfaction, is telling.
As the report notes: “Compared to physicians in nine other countries, Canadian primary care physicians are the least likely to routinely provide same-day or next-day appointments (47 per cent). They are also among the least likely to make home visits (58 per cent) or have after-hours arrangements so that patients can see a doctor or nurse without going to a hospital emergency department (46 per cent).” But doctors themselves may be oblivious to this, because Canadian primary care physicians are also among the least likely to work in practices that regularly review clinical performance against targets (41 per cent average, varying between 62 per cent for B.C. and 19 per cent for Quebec).
Overall, then, this is not an uplifting survey. It finds that “In overall national performance, Canada shows no relative improvement in any areas of access to care … since 2006.”
Canadians are always wont to compare our system to the U.S. This makes sense, but only in geographic terms. There are numerous examples of mixed public-private systems around the world that exhibit substantially greater cost effectiveness and better medical outcomes than our own. None is perfect and all systems struggle to rein in costs, but should we not be learning from elsewhere? And isn’t the Health Council survey a good place to start identifying our deficiencies?
At Canada 2020, we have been gathering information on an alternative public-private hybrid model currently being tested in the U.K. (a country in which 95 per cent of primary care workers say their patients can get after-hours service outside a hospital emergency department and where 96 per cent of physicians regularly review clinical performance against targets).
In 2012, The Circle Partnership was awarded a 10-year contract to manage a publicly funded, full-service hospital in Huntingdonshire. The National Health Service continues to employ most of the hospital’s staff. Health care remains free and universal at the point of delivery, but private-sector incentives have been introduced. Doctors, nurses, and other Circle employees collectively own 49.9 per cent of the company, while the rest is owned by a group of hedge and venture capital funds.
The model is relatively simple: if efficiencies by Circle yield a surplus at Hinchingbrooke Hospital, profits will be shared by the hospital, the NHS, and Circle. If the hospital continues to post a deficit under Circle’s management, Circle will earn nothing and has agreed in its contract to be responsible for the first £5 million of fresh debt.
It is too early to judge Circle’s success. On the one hand, the hospital’s emergency room, which regularly failed to meet targets in the past, was ranked first of 46 hospitals in eastern England after six months under Circle’s administration. Monthly targets for cancer treatment, which had last been met in June 2010, were being fulfilled every month and the length of a patient’s stay after hip or knee surgery fell from an average of 5.6 days to 2.6 days, allowing for faster turnaround of rooms.
On the other hand, Circle has yet to demonstrate its ability to keep costs under control (although it is early days yet). The hospital’s losses reached £4.1 million within eight months, just over double the £1.9 million of debt that Circle had predicted for the hospital by that point.
Here in Canada, no legislation prevents the introduction of private health-care administration. What’s more, our current system should lend itself well to the transition because Canadian primary-care doctors are already paid under a fee-for-service system, rather than earning a fixed salary.
It seems, though, that the largest roadblock to introducing a similar model to Canada lies in public resistance to change. Opposition to any linkage between the private sector and health care remains strong (back to that American comparison problem) and a number of Canadian facilities that have incorporated private incentives have been closed, despite their success (for example the Canadian Radiation Oncology Services clinic in Ontario and a private clinic at Montreal’s Sacré-Coeur Hospital).
But aren’t we Canadians open-minded people? Surely we can open our minds to alternative ways to deliver universally accessible publicly funded health services. The Circle model may not be the perfect solution, but it is well worth watching from our shores if only for the reason that health care improves most when the medical community does what it does best: experiments.

We can save money and improve health care

Ontario needs to find $2 billion in annual health care savings.
Provincial premiers and health care stakeholders had been gearing up for a noisy battle with the Conservative government around renewal of the 2004 Health Accord.
Confounding expectations, in December 2011, Finance Minister Jim Flaherty announced a unilateral renewal of federal health funding. The “deal” provides six per cent annually for the next five years, and after that no less than three per cent per year. This unanticipated federal generosity leaves the provinces with the ability to manage federal health care dollars as they choose.
It also deprives them of the federal government as a convenient scapegoat.
It places full responsibility on the provinces for shaping the future of health care delivery within the universalist and public principles of the Canada Health Act.
The Ontario government is committed to holding spending growth in health care to 2.1 per cent per year, down dramatically from a historic, eight-year growth rate of 7.4 per cent. To meet its target, Ontario will need to find $2 billion of annual savings. The recent Ontario Health Action Plan highlights aggressive bargaining with doctors and health care unions as well as lowered drug costs as key cost-saving strategies. However, even if real zeros can be achieved in these areas, such strategies will yield only about half the required savings.
What other cost-cutting measures might the provinces consider that could improve patient care?
Fewer health organizations
Ontario’s Drummond Commission questioned whether the 2,500 separate governance bodies in the Ontario health care system actually result in effective governance. His answer: probably not.
More importantly, we should ask whether more governance means better health care.
Individual governance bodies are largely concerned with the quality of the care in their own institutions. Transitions of care are not governed by anyone; no single organization is responsible for the patient journey across many health care settings. The one per cent of patients with multiple conditions who account for 49 per cent of total health care costs, are under-managed. Many simply fall between the cracks.
Reform is therefore required not only for cost-saving reasons, but also to improve quality of care.
Get rid of processes that are unnecessary orredundant
In Saskatchewan, Premier Brad Wall is implementing the Toyota Corporation “lean” philosophy as a way of removing unnecessary and inefficient processes from health care delivery. Significant savings are being achieved.
At the same time, Ontario patients being discharged from hospitals may undergo as many as three home-care assessments, all before a single home-care visit takes place (one by the hospital to determine if home care is needed; one by the Community Care Access Centre to determine the appropriate kind and number of visits; and another by the actual home-care provider).
We are spending a disproportionate number of public dollars in the management and assessment of need rather than on the care itself. The government should cut out duplication, streamline administrative layers and put the money into front-line care and home-care visits.
Reduce unnecessary readmissions to hospitals
Unplanned readmissions to hospitals are significant and, according to various studies, often avoidable. Shortened hospital stays mean that patients may be discharged quicker but sicker. In Ontario, the readmission rate is around 15 per cent. This is high. Many different problems can emerge for patients post-discharge. However, a study conducted by the University of Toronto found discharged patients were about 28 per cent less likely to be readmitted to hospital within seven to 30 days if they had a home-care visit within one day of discharge. That statistic alone merits action.
Use health care professionals more effectively
In Ontario we operate on the assumption that each medical emergency call means an ambulance dispatch to the ER. In Nova Scotia, calls are triaged and dispatched by paramedics through one centralized system. A medical communications officer determines the right service for each patient, whether it is ground or air ambulance or an extended care paramedic (ECP). ECPs have advanced training in geriatric care and can treat elderly patients for things such as stitches, replacing catheters, etc. in their place of residence. One year into the program, more than 70 per cent of callers avoided a trip to the ER.
Move services out of hospitals
Today, about 80 per cent of all hospital surgery is conducted as day surgery on an outpatient basis. This represents a vast cost improvement for the hospitals. However, we are still conducting surgeries in the most expensive setting — one constructed to house infrastructures required for complex care and in which labour costs and staffing levels are very high. There are more than 700 Independent Health Facilities licensed in Ontario. Some of these facilities could provide uncomplicated procedures with higher efficiency and volumes.
It is also well known that volumes lead to better outcomes — practice does make perfect. At the Kensington Eye Clinic, for example, the volume of cataract surgery has led to economies as well as greater access.
Innovative change can curb health care cost growth while improving outcomes and patient safety. The challenge is to make innovation work for patients and for taxpayers.

Whither the health debate?

The current federal health accord expires in 2014. Most expected that, by now, we would be entering a period of protracted wrangling over what would replace it. Instead we face something of a void.
In December 2011 the federal finance minister unexpectedly – and unilaterally – announced a surprisingly generous new offer to the provinces: continued 6% annual increases in federal transfers for three years after the current health accord ends, after which transfers will be pegged at the rate of nominal GDP growth with a guaranteed base of 3% a year.
This money comes with no strings attached. The federal government seems to have abandoned the semblance of a policy role in healthcare, beyond its fiduciary responsibilities to aboriginal health (enshrined in the Constitution), its responsibility for military healthcare, its funding of health research, and its role in drug approvals.
What does this mean for us, the consumers – and ultimate financers – of healthcare in Canada?
The healthcare authors in our book, The Canada We Want in 2020, writing before the December 2011 announcement, all agreed that the there was an important leadership role for the federal government in healthcare. In particular, they suggested that an active federal government, acting in a sensitive and collaborative mode, could help address many of the core challenges that our system faces. These include:

  • addressing the disparity in care across provinces/communities (developing, en route a meaningful set of common indicators);
  • stimulating a process of modernization so that our healthcare system better addresses current needs (such as chronic rather than acute care and addressing the high cost of outpatient drugs/the need for a national pharmacare programme);
  • ensuring better and more consistent evaluation of which procedures should be funded (evidence-based not media-driven decision-making);
  • institutionalizing a culture of innovation in healthcare;
  • placing a clear focus on healthcare outcomes, within a systems approach, rather than concentrating on inputs and procedures;
  • helping to forge a societal consensus on paying for healthcare and providing leadership on diversified revenue sources.

This pro-federal leadership viewpoint is also espoused in a March 2012 Senate report entitled, Time for Transformative Change: A Review of the 2004 Health Accord. This largely unpublicized report notes: “…..there is a need for federal leadership in promoting healthcare reform across jurisdictions.” (p. 83).
Apparently, the federal government disagrees. All these deep and difficult challenges will now be left to the provinces. It has therefore provided a swift answer to the question posed in our volume by Philippe Couillard, physician and former Quebec Minister of Health: Does [the federal government] want 2014 to be a low-profile rubber stamping event or does it wasn’t renewal of our health system to be part of its legacy?
For if renewal does take place – and that is a big if – it must be the provinces that take the lead (and thus the glory). Whether they will be capable, or willing, to do this remains to be seen. The challenge is all the greater since many of the problems of healthcare, such as inter-provincial disparities, may actually be exacerbated by the new federal stance. Under the new arrangements, federal funding will be allocated on a strict per capita basis across the country. (At present it is a mixture of per capita payments and tax points which means that certain provinces, notably Alberta, receive much less per capita than others). The new arrangements could have a negative impact on those provinces with a higher proportion of older – more expensive in healthcare terms – Canadians.
Though Canada’s health system scores well on important indicators (for example, we are above average on life expectancy at birth and at age 65, though dismally below average for the aboriginal population), ours remains one of the most expensive systems in the world. Health spending accounts for 11.4% of GDP, almost 2% above the OECD average.
Sadly, the problem of financing healthcare has not miraculously disappeared with this announcement. Increasing amounts of money still need to be found and if new sources of revenue are not identified (for example, the type of social insurance premium that our author, Mark Stabile talked about in his piece), healthcare financing will continue to squeeze other priorities in both federal and provincial budgets.
Neither have the severe problems around First Nations’ healthcare been resolved. The federal government has recently announced that its National Aboriginal Health Organization will cease to operate by June 30, 2012. It is not year clear what path has been chosen for moving forward in this area.
Maybe, though, the provinces will surprise us. Now that their energies need no longer be wasted on battling the federal government on healthcare, perhaps they will be put to better use innovating, modernizing and refocusing.  Time will tell. Polls suggest that most Canadians still want a federal role in health. But, regardless of who is taking the decisions, our contention at Canada 2020 is that the policy issues around healthcare for all Canadians must remain firmly in the spotlight.