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Looking for Solutions in Health Care for 2006 and Beyond

Our health care system needs to change to accommodate new demographics, new technologies and new pharmacologic advancement.

The roots of compassion and caring in health care should not change however, and it is with this in mind that the dialogue of change should be had surrounding health care.

How can we adapt to different needs that emerge as our population ages?

How can we  find sustainability in the midst of so many new advancements?

How can individuals become more empowered in serving their own health care needs?

What role does the individual have in enabling the  health care of others  beyond paying taxes?

Many questions like these need to be answered and if we are willing to look with open minds at the problems within our health care system, and beyond political posturing, then we can find new  solutions to take us further into this century. 

 

 

 

 

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Thursday
Sep082016

B.C. Courts will bring into Focus the Hard Questions about Canada’s Health Care System

 

Canada’s health care system has been called many things including a “jewel” and “the very essence of what Canada is all about”. It has also been called “sclerotic”, “archaic” and for politicians it has become “a sacred cow”. For many Canadians, our health care system has become a mirage. Aside from the illusory notion that our health care is “free”, many cannot explain how it works and how it is financially sustained. Many cannot access the care they need.

However, this mirage is going to be drawn into clear focus in the weeks and months ahead as the B.C. Court is hearing a case put forward by surgeons and patients that accuse the B.C. government of denying them their rights to timely medical care.

Perhaps the B.C. case will allow Canadians to begin the necessary discussions about how our health care must change to address the serious systemic shortfalls within it. We have a strained health care system due to an increasingly aging population, more pharmaceutical options, more medical technology with associated potential interventions, and emerging science that requires more medical research and money.   

For people waiting for care, or denied care, or whose disease is treatable elsewhere but not here, the limitations of our current system have become numbingly clear.  We should walk a mile in patients’ shoes to understand the importance of the B.C. Charter Challenge for those who have been denied timely care. While the outcome of the case is important at an individual level, it will also resonate at a societal level – throughout our country.

Some people choose to frame the case as a “private vs public” health care battle and foresee the destruction of Medicare if B.C.’s provincial health care service loses the case. However, at a foundational level, the case is a challenge about the rights of Canadian patients in a system that denies timely care.  What rights does a patient have? What recourse should a patient have? What suffering can the government health insurance plan fairly impose on an individual patient, if any?  (In a country that has recently witnessed the Supreme Court of Canada rule in favour of an individual’s right to die, one might expect that it would also rule in favour of an individual’s right to live.)

Now is the time to ask the difficult questions about what we want from our health care system that was designed for another era and which, despite transformation, is a laggard in the developed world. Many of us who have been part of the on-going debate about patients’ rights and the short-comings of the system recognize that we can and must preserve what is fair and equitable about Canada’s health care system and move forward to improve what is not.  

There are some important questions that must be fully discussed.

Must we pit patient against the system? What is more important, the patient or the system? Can we not all agree the system must exist for patients? So, the question then becomes “How to provide more care to more patients?” In that context, how is it ethical to preserve a system that cannot meet patient demand despite almost fifty years of trying?

How comprehensive a system can we afford? Do Canadians want modern health care that keeps up with change, or do they want an archaic system designed for fifty years ago? As pharmaceuticals become more and more prominent in treatment options, many Canadians want to include pharmacare in our country. However, the cost of Canada’s government funded system makes it difficult to move forward in publicly funding other areas of care such as eye care, dental care, and newer pharmaceuticals for cancer and other previously untreatable diseases.  How can a better balance of services be achieved that will meet our expectations for an advanced health care system?

There’s the important issue of “Universality”. Do Canadians want universal health care coverage in theory or in reality? The term “universal” does not mean “government funded”. It simply means coverage for everyone. There are many ways to provide coverage for everyone in a truly universal system that creates access instead of imposed rationing. Many other countries have hybrid systems for medically necessary care and manage to achieve universality at lower cost and with better outcomes. Why aren’t we looking at and learning from other better performing systems? And, what of portability of care in Canada? Do Canadians want a system that provides similar services across the country, or do they want the system to be determined simply by the degree of rationing required in each province?

What is to be done about the under-utilized infrastructure and medical workforce? What do Canadians want, more government rationing of care or more ways for more patients to access care? Canada has less than the average number of physicians per capita compared to many developed countries yet we cannot fully employ our medical workforce due to costs associated with utilization of government funded services. Operating rooms and surgeons sit idle, hospital beds may exist but are “unfunded”. Hybrid systems of other developed countries have more providers, more hospital beds, and better access to medically necessary care at lower cost than Canada’s health care system.

Canadians must have this honest and difficult discussion about our health care system if we are to create a truly universal system with quality health care that addresses patient need. I believe the B.C. Charter Challenge will help in this dialogue. Contrary to rhetoric about the case being an attack on Medicare, it is not. Given the history of our country, Medicare will continue, but we must acknowledge its faults. A more robust health care system is needed, one that is truly universal, comprehensive, and accessible and not so negatively impacted by government short comings both in funding and in vision.

The B.C. case will bring our health care system into much clearer focus. It will drill to the core of the debate. If we are to give patients the dignity and respect they deserve, then we must acknowledge that they are part of the solution and give them the necessary freedoms that are currently lacking.

Sunday
Aug142016

Wynne's Dysfunctional Approach to Solving Ontario's Healthcare Challenges

**Please note that the original journal entry from August 14 has been modified to reflect the vote result from  August 15.

 

 “Abdication, Distraction, and Deflection.”

 Ontario’s doctors voted NO to the tentative Physician Services Agreement between the Ontario Medical Association and the Wynne government that would have doctors co-manage the Province’s ailing health care system. The results of the vote from August 14 were shared the following day. Of voting OMA members, 63.1% voted Against the Agreement, 36.9% voting For the Agreement. The rejection is indicative of the negative view of Wynne’s overall approach to healthcare in the Province – one of abdication and deflection.

Given that Ontario is at a pivot point in health care that will affect patients, physicians, and the province for many years to come, the vote result will be important.  Simply stated: it is a bad deal, indicative of Wynne’s overall

 Abdication

The Wynne government has demonstrated its abdication of responsibility to patients by limiting the physician services budget for patient care below what can conceivably meet patient demand.  Instead of dealing honestly with the surge in health care need due to our growing population, new advances in science and technology, and an aging population with all of its associated requirements the Ontario Liberals are using health care to balance their budget. They have used rationing of patient care to offset the burgeoning debt that they have created through mismanagement and wasteful spending.

The centrepiece of the Liberal government-OMA deal was Wynne’s design to use  Ontario’s doctors as its collaborative rationing tool through co-management of the Physician Services Budget. This would have bureaucrats and doctors, together, deciding on the healthcare cuts to meet the government’s scheduled budget targets. Obviously, neither the OMA nor the Liberal government appear to have the interests of patients at heart. If they did, they would not be resorting to rationing under the guise of “co-management” and “collaboration”.

 Distraction

The Liberal government-OMA deal included components to address Relativity (the relative difference in the OHIP fee codes of some MD specialities compared to lower fee codes of other specialities). Although some physicians believed this was a positive attribute, it will require Ontario’s physicians to be internally focussed on slicing and dicing their profession – rather than spending time and resources on providing input into major structural issues that afflict health care delivery.

While the OMA is distracted with Relativity, the Wynne government master plan is to bring in more bureaucratic management in the form of Bill 210, The Patients First Act. Doctors kept busy with co-managing the rationing of care allows the government to move forward with minimal resistance to its major expansion of powers that allow it to unilaterally impose accountability agreements. Individual freedom for both patients and providers is at risk with this legislation.

 Deflection

The Ontario Liberals are intent on deflecting blame for costs of their own debt and waste onto the Province’s health care system and its providers. It is harder and harder to provide publicly funded patient services when the government is spending approximately one billion dollars a month on servicing the massive debt it created over the past decade through waste and mismanagement. Consider what can be paid for with a billion dollars per month: the medical staff, operations and procedures, the equipment. With the deal and physicians given a co-management role, the Wynne government has found a deceptive way to deflect public criticism from government decision-making.  

 As a disturbing aside, thousands of physicians who oppose the government’s current rationing plan are not “dissidents” as some government spokespersons and media have referred to them. By branding physicians who perceive solutions differently from the government as non-collaborative the government is attempting to quiet dissenting voices and deflect attention from its own failed policies. It’s a ruse. Differing perspectives could be used to create a more respectful and compassionate plan for health care transformation. It is often at the interface of opposing views that the best solutions will be found. It would be wise for our political and association leaders to do more listening and less deflecting.

The Liberal government’s approach has created a dysfunctional healthcare system

The Wynne Liberal government’s deal with the OMA suggests this government is clueless on how to proceed with its healthcare challenges. Constraining the freedom of physicians in a command and control system where they cannot meet patient demand and then labelling this as being in the “public interest” is disingenuous at best.

This is not the way to create a leaner and more efficient health care system or a way to meet the growing demand for patient care. Instead of squeezing the breath out of our public health care system, as our population grows and ages Kathleen Wynne should be answering the question “How can we provide more care to more people?” If we want innovation and “modernization” of care, it will not be found in rationing or managing wait lists. More management and more bureaucracy are not what we need.

As this deal so clearly illustrated, Wynne’s healthcare legacy is an abdication of duty, deflection of responsibility and distraction from her government’s wasteful ways. Hardly inspiring. Hardly a vision. Ontario can do better – it must do better.  The vision of health care in the future cannot be about rationing care, denying care, and limiting the freedoms of providers and patients.  It must be about empowering patients and empowering providers including Ontario’s physicians in providing more services and more care, not less.

The rejection of the deal was the ethical and appropriate response to a poorly considered health care rationing master plan pushed by the Wynne Liberals. Ontario doctors have spoken with resounding support for patients. However, any celebration of the rejection of this deal should be dampened by the reality that there is much work ahead to be done to shore up Ontario’s hobbling healthcare system. Let’s start with the resignation of Dr. Eric Hoskins.

 

 

 

Wednesday
Jul132016

The Tentative Ontario Doctors' Deal-What it means to you

Whether you are an MD, a patient, or an Ontario resident, you should know what the tentative deal between the Ontario Medical Association and the Ministry of Health means to you. In essence, this deal will not provide greater access to care, nor will it meet the growing demand for care. With the proposed co-management arrangement, the Wynne Liberals will be dictating doctors’ services to an even greater extent, making it harder for many patients to get the care they need and harder for physicians to provide it.

It is clear something had to happen as Ontario MDs have been without a contract since 2014. Of the contract details, two proposed aspects are being heralded as breakthroughs: the 2.5% “increase” for doctors and the “co-management” of the system by physicians and Ministry of Health officials.

The sudden news of a 2.5% “increase” annually for four years arriving on the coat tails of the hard-nosed negotiations by the Ministry seems too good to be true. Understanding the details is critical to understanding what this contract really provides.

The 2.5% “increase” is for total services to be provided by physicians via the “Physician Services Budget” or PBS. Just as the name implies, this is a pool of money that government provides for physician services. It does not mean that your local physician will receive a 2.5% pay increase. This does not signal that s/he will now be paid more and able to provide more patient services or that patients will have improved access.

So, what does it mean then?

The 2.5% “increase” is simply an expansion of the funding pool to be spread across more people and more services as our population ages and expands over the duration of the four-year contract. However, this falls short of the demand for physician care. It is estimated that the need for physician services rises on average by 3.1% per year. That 2.5% “increase” per year is simply a continuation of the underfunding of the health care system by the Wynne Government.

Once again, hidden behind the headlines we see that political optics drive the self-serving Liberal agenda. This deal is not about access for patients or empowering front-line providers to meet the demand for care. If it was, it would have taken a very different form. Instead, the tentative agreement is all about self-preservation, by both the Ontario Medical Association and the Ontario Liberal government. It’s about how best to sell the public (and the physicians) on the merits of a possible contract that will continue to underfund health care.

The harsh reality across Ontario has many medical clinics struggling to stay viable and hospitals being forced to cut front line workers in order to meet their budget obligations required by law.  Meeting the growing need for patient care is being made harder and harder under the Ontario Liberal government. As costs of overhead continue to rise due to flawed provincial energy policies (and now we all must brace ourselves for the introduction of the provincial carbon tax), costs of operating medical facilities will grow—whether they are hospitals or community clinics. Under the Wynne Liberals, it is harder and harder to provide medical care to a larger and aging population.

It is an understatement to state the Ontario Liberals have been undisciplined in their management of tax-payer dollars. The waste, spending scandals, and mismanagement are well-reported over many years. Ontarians have a billion dollars a month siphoned off to pay interest on the Wynne Government’s debt instead of addressing patient need and funding for patient services. Now, under this tentative contract, physicians will be co-opted into “co-managing” the health care system hand in hand with this reckless government. Is this something to be celebrated as the headlines suggest? Where is the independent physician organization that can stand up to government’s self-serving political agenda?

Co-management of Ontario’s health system is a slight of hand given the government’s ability to pay for the services Ontarians require is diminished with every monthly billion dollar interest payment. As is the Liberal tradition of naming their legislation, the new deal is being sold to physicians and to patients as “The Best Deal Ever for Everyone.” But it isn’t—far from it.

Physicians, patients, and the public in general should understand that the tentative agreement as it currently exists will not provide more access to care or meet the growing demand for care. What it will create is further rationing of care required contractually to be done by physicians. And, unfortunately, Ontario’s physicians, through their provincial association and the new “co-management” arrangement, will be co-managing our health system’s retractions.  

Ontarians and the province’s medical community are to learn more about the details of this Ministry of Health-OMA agreement in the weeks ahead. One can only hope that there is a more serious review of both the inadequate funding and proposed "co-management” arrangement. Our doctors deserve better; Ontarians deserve better.

 

Friday
Mar112016

Dr Hoskins' "Patients First" Transformation-More Bureaucracy in Disguise

With the Ontario government's "Patients First: A Proposal to Strengthen Patient-Centred Health Care in Ontario" Discussion Paper making the rounds, I am reminded that a book should not be judged by its cover.

Look deeply into the details and the consequences of this paper despite its unchallengeable title. You should be unsettled. There is nothing "patient-centred" about the paper and the consequences will be deleterious for patients and providers as more resources are siphoned off to a bureaucracy that appears to have lost its way. 

LHIN Capacity Role and Function

Much of the interest in integration stems from the United States where a robust primary care system has not existed historically. Unlike the US situation, Ontario has had a robust primary care system for many decades which has functioned well to serve the population for the most part.  Tinkering by government over the past twenty years has not achieved desired outcomes.  The cost of government attempts to integrate and coordinate are significant and the outcomes uncertain. 

Having unevaluated LHINs tasked with integrating care is a project to keep the LHIN bureaucracy occupied.  In attempts to create more value through integration, government is attempting to justify its creation of LHINs in the first place.

Although the concept of “local” in primary care makes sense, true local care is at the interface of the patient and the physician where patients and their needs are treated as unique. It’s not possible to standardize patients or their needs.

The approach that government has shown to the complex nature of patients and primary care predicts that government created LHINs lack the necessary insight to appropriately coordinate primary care further.

LHINs tasked with integrating primary care are simply a mechanism to redistribute primary care physicians without representation.

Sub-LHIN Organization

Further coordination of publicly funded care may seem laudable at first glance. However, evidence of the consequences is lacking. In complex systems such as health care it is difficult to predict the results of change.

The creation of sub-LHINs creates further levels of bureaucracy and requires more governance structures that have potential to become unwieldy. The inflexibility that is created poses concerns about interconnected failures. As one area becomes bogged down with complex governance, associated areas will also be affected. The ability to adapt to rapidly changing advances in health care will be diminished. The concept of independent practices which provide flexibility and rapid adaptation will be lost.

The advantage for government will be the optics of creating “added value” of accountability agreements. However, this is cause for concern as physicians may  be limited in their access to sub-LHIN regions resulting not in primary care MDs going to underserviced areas but instead,  leaving the province altogether;  biding their time in some other line of work; or furthering their education while waiting for a practice opening.

 

Physician Leadership at the LHIN and sub-LHIN level

In current health care transformation it is usual to see “physician leaders” selected for their willingness to support the government agenda. This might seem reasonable except that the consequence of creating what are essentially political patronage appointments serves to solidify policy change that has politics at heart and not necessarily patients.

If patients were truly “first” in health care transformation efforts, there would be greater ability for the system to adapt to respond to individual circumstances. This is not the case.

The result of “partnering with local clinical leaders” who seek career advancement and compensation for their efforts will be that the sub-LHINs effectively become a conduit for the “local clinical leaders” to negotiate with government.  The OMA as the “exclusive representative of physicians” could cease to exist simply because other mechanisms of interfacing with government have been encouraged to evolve.

The OMA could continue to exist but its main function would be significantly diminished.

There would then be a need for a true representative union for practicing physicians whose main leadership role is not to please government.

Access and Equity

The responsibility of LHINs for improving health equity and reducing health disparities is a daunting task that is noble in theory but problematic in reality.

It is understood that medical care is not the only contributing factor to overall health and that there are many variables contributing to individual and population health.

 LHINs having the power to change personal health caused by external factors is a very big stretch.

A major concern regarding more funding funnelled to LHINs for integration and coordination is that more funding for bureaucracy will be required. Taking a loosely coordinated system between family doctors, consultant specialists, and focussed practice physicians and making it more bureaucratic and costly will divert tax dollars from much needed services for an aging population such as Long Term Care and Home Care.

LHIN involvement in primary care “access and equity” appears to be about forced distribution of physicians and allotment of patients rather than improving personal health. The concept of Patients First appears to be for optics only.

Public Health

The government proposes to give LHINs more authority for local health planning and responsibility for managing accountability agreements with health units. In concept, government is creating mini health ministries. Public health units have been some of the most cost-effective mechanisms for delivering preventative services and population health.  By absorbing health unit budgets into LHINs the costs and or cuts to services will be hidden from public view and scrutiny. This is not a transparent way forward. The benefits and costs of such maneuvering must be carefully weighed.

Home Care

Home Care is increasingly important as our population ages.  Integrating Home Care can be done but as long as funding for it remains inadequate the coordination efforts are misspent. More communication regarding patient care plans is meaningless when many patients can’t actually access the care they need in the first place.

Transfer of CCAC

LHINs acting in both the management of community services and in the delivery of community services are in conflict of interest.

 Burying community care in LHINs risks harming the ability to evaluate not only the budgets related to community care but also the quality of the services provided. Once again, public scrutiny may be diminished and understanding the value of this manoeuvre will be problematic.

Preserving Physician Remuneration Models

Flexibility is a desirable goal for modern health care. No one payment model can address all patient need. However, the uncertainty that government has created in its recent movement away from honouring agreements with primary care physicians is problematic for improved transformation that is cost-effective.

Role and Function of the Ministry and Use of Performance Metrics in Accountability Framework

 Increasingly accountability is tied to performance measures. The process by which local performance measures are established must be clearly defined and understood by all parties. Unintended consequences of performance measures in one aspect of care have potential to affect the care in other areas.

Physicians and hospitals pushed to provide care that can meet performance and budget targets will have an impact on patient choice. This is an important consideration in the context of “Patient First” discussions.

Role of E-Health

While generating data may have positives for research and scientific developments, there is conflict in spending more public dollars to integrate “patient information across the continuum” when vulnerable patients currently cannot access adequate Home Care services or affordable Long Term Care.

If our health care system cannot meet basic needs of vulnerable patients now, how will it meet the needs of growing ranks of patients with advanced dementia? Assuming that e-health can accomplish toileting and feeding patients with advanced dementia is problematic. The numbers of patients with advanced dementia is poised to increase dramatically with potential to overwhelm hospitals, ERs, and primary care. E-Health cannot replace human interaction with frail patients with dementia.

Conclusion

Without the inclusion and in-depth consideration of physician insights, any Patients First initiative is designed to be an optics-only exercise at best. At worst, it will lead to further destabilization of health care in Ontario resulting in hardship for patients and associated failures in care improvement.

Physicians should be cognizant that cloaking policy in sunny terms with public appeal does not equate with well-considered policy that includes highly valuable physician input.

Wednesday
Jan132016

Palliative Care in Canada

Way back in the 1980s it dawned on me that as a soon-to-be family doctor it might be wise to know a thing or two about Palliative Care. It seemed reasonable that I should know how to alleviate the suffering of my patients from various end stage illnesses. So I took a two week elective.

The hospital I trained at in Alberta in 1986 happened to have a palliative program and I learned about  hypodermoclysis and the like. I also learned about the staggering ability of the human body even when it is failing to tolerate ever increasing amounts of narcotics.

It was a serious topic for an elective but the staffperson in charge of the unit was a bright soul and the patients were always grateful. Physicians at the hospital knew their loved ones would get good care there. Unfortunately, the program was shut down several years later....perhaps a victim of its own success or perhaps because of the optics of having the beds filled with mostly "MD relatives".

Over my medical career I discovered that my skills in this area were not needed. The hospitals had Palliative Care teams and patients did not die at home for the most part. If that was the wish of the family there were Palliative Care MDs who would provide this service. I never did use the hypodermoclysis procedure but I did use lots of empathy.

In any case, the resurgence in interest in Palliative Care is driven not only by demographics but also by the Right To Die movement along with the Supreme Court of Canada ruling on Physician Assisted Suicide.

As hospitals are overwhelmed with Alternate Level of Care patients, the concept of patients dying at home has taken on new zeal and while the Feds plead for more time to come up with some kind of legislation to solve the murky areas surrounding PAS I wonder if legislation will ever come to be just as there is currently no legislation for abortion.

I do believe that more access to robust palliative care can be a real solution to alleviating suffering of patients rather than resorting to Physician Assisted Suicide. More training of family doctors will be required and more funding for access will be needed.

It is worth noting that caring for patients in their homes is a relatively inefficient use of medical services. This access to care will require time and the skills of physicians. It will impact availability of health professionals for other areas of care. There will be trade-offs.

It is time to understand again what was understood thirty years ago. Palliative Care is an important part of compassionate care. Too bad it took so long.