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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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Friday
Oct232015

Predictions for 2015 to 2019 in Ontario

This past year has been an interesting one. We have a newly elected Liberal government at the federal level coinciding with three more years of an Ontario Liberal government.

What does it mean?

First, let me congratulate the posters on this blog for their continued interest in the health care challenges facing us now and in the future. They have been correct on many fronts over the past decade and have earned  a gold star for predictions so far. I do feel honoured to have such insightful and accurate contributors to this site.

So a big "THANK YOU!" to all past and present posters! I value the perspective they bring. It is refreshing to read comments that tell it like it is.

At times we have been accused of nihilism by other lurkers and posters but I think it is more a result of facing challenges in a realistic way that others may not find  "hopey-changey" enough. If that is the case then so be it. I shudder to think what would happen if we all underestimated the challenges ahead and sat quietly, afraid to voice concerns and ideas. 

Hope is fine and well but what we really need is realism coupled with courage along with support for individuals and groups that are willing to provide diverging perspectives from the status quo that is in such need of change.

Enough said. I will spare you my comments on the OMA at this time.

 

Let's look at the challenges ahead with a simple list:

1. Aging population with increasing longevity requiring more care of all kinds

2. Relative economic stagnation partly resulting from aging population but also from global circumstances

3. Flat-lining fertility rate which is contributing to generational imbalance

4. Increased immigration that is not necessarily contributing to GDP

5. Rising expectations of public for more "free" health care and more "free" social supports

6. Scientific advances that are increasing costs of many treatments and contributing to longevity

7. Pressures arising from Hospital and Pharmaceutical demand

8. Inability of provincial governments to fund all necessary health care and social supports

9. Inability of the federal government to balance its own budget while accommodating provincial demands

10. Inability of the public to understand current and future financial pressures as debt rises across provinces and at the federal level

 

Now let's look at what has been tried over the past twenty years to attempt to address the cost pressures resulting from the issues above:

 

1. Primary care transformation- so far a failure to either reduce costs overall or to reduce waste

2. Electronic Medical Records- to date have failed to reduce costs or overall adverse events or errors.

3. Interdisciplinary Care- has not resulted in reduced costs or better outcomes. It will contribute to rising costs of care as relatively fewer workers will drive up labour costs in the future.

4. Efficiencies-for every efficiency found there are more new discoveries and complexities that drive up health care costs

5. Telehealth and HealthCareConnect- have not resulted in decreased use of ERs of primary care. They drive UP costs

6. Centralized Referrals- no evidence of more timely access to care overall. Current cuts to health care in Ontario have a very real likelihood of driving up wait times that will not be measured as specialists refuse to add more pts to their lists

7. Community Care Programs-these have not reduced costs and recently information relating to the cost of CCACs demonstrates the high administrative costs associated.

8. Aging at Home programs-these are akin to holding back the floodwaters as years of Boomers will be aging behind our current frail elderly. An accordioning of elderly will occur as people cared for in the community come to need more institutionalized care

9. Remote care- hopes that remote monitoring may prevent hospitalizations is yet to be seen. Will it result in increased visits similar to many screening modalities that do not confirm disease but simply lead to further investigation or unnecessary interventions?

10. Rationing of care by Health Ministries using the "value for money" efforts-no doubt that rationing does reduce costs but it creates pentup demands later. This is well-known.

11. Choosing Wisely Canada-efforts to reduce unecessary testing and treatments have been limited in success. New understanding of precision medicine based on an individual's unique genetics and epigenetics will be problematic for such programs.

12. Pay for Performance- these programs are turning out to be problematic. Clawbacks for hospital readmissions appear to be mainly cost savings oriented and not truly related to the quest for quality care. They are just an excuse to reduce funding to health care providers and institutions.

13. Cuts to MD payments and Nursing layoffs-these are cyclical and not solved by any transformation efforts to date.

 

Given the challenges outlined and a smattering of politically correct efforts already tried, here are some predictions for the next five years:

1. PM Trudeau will be met with financial obstacles to funding the provinces and territories with more billions for health care but will do it anyway. He will achieve nothing tangible. Health care is a black hole for government funding.

2.  Minister Hoskins will step down in a year.

3. OMA's Charter Challenge will require more funding from Ontario's MDs. OMA will  move forward with the Challenge while quietly hoping it could just find some comfortable solution with government onside. How else will the OMA presidents manage to find nicely paid government funded positions post presidency?  Past OMA presidents will suggest that bargaining with government is very hard on them and that the membership has no idea what it entails.

4. Patients will continue to see wait times grow.

5. Elderly people will continue to be denied resonable levels of Home Care.

6. Pharmaceutical costs will not come down overall as some manufacturers are squeezed and sell off various lines to other companies who then readjust and repurpose the old medication but at higher prices.

7. Federal Liberal government drives up the national debt by running annual deficits for at least the next four years. The aging population is unable to rally with more productivity and the debt balloons.

8. Ontario is unable to spark its business sector since energy costs have been driven through the roof and the infrastructure expansions do not improve gridlock because more people including new immigrants choose to live in Toronto. More money spent with limited to no improvement.

9. Assisted suicide morphs into Duty to Die

10. Pot is legalized but the tax revenue is insufficient to balance the reduced productivity related to booze, gambling and drug addiction coupled with an aging population

11. A small segment of the population remains productive but is penalized for the hard work through increased taxation and increased inheritance tax.

12. More costs for water and gas and electricity and increased property taxes drive many seniors out of their homes and the Aging at Home program fails and fails spectaculary.

13. Hospitals are grid-locked

14. No national seniors strategy is capable of solving local health care need. Feds provide money but it evaporates...maybe goes to Teachers unions in secret payments ---could happen!

15. Ontario continues to ration MD income insisting that it is THE problem for sustainability and MDs are easy targets. Young MDs change their practice pattern and find other ways to create income beyond providing health care. Older MDs retire. Middle-aged MDs become more overburdened and less efficient.

16. Nurses take on more adminstrative roles in the province and are hired to consult on medical care. Kathleen Wynne's nurse daughter is hired as a Primary Care Group authorization expert at the behest of Baker-Price and controls MD licenses (not likely but still worth a chuckle...who knows, stranger things have happened in Ontario Health Care Lite!)

17. Dr Day's Charter Challenge is finally heard and goes all the way to allowing patients to access care they need without government obstructing them.

18. By 2019, fed government has driven up debt so high that credit rating agencies are giving Trudeau a talking to.  Ontario has added another 100 billion to its debt and "Central" is ready to allow Private health care options along with Regulated Extra Billing started by Quebec's Health Minister.

19. Canadian Doctors for Medicare is as strident as ever and getting lots and lots of press by The Medical Post.

20. Public finally realizes that a Hybrid medical system's time has come. Some citizens are happy, some are not.

 

What do you think?

Have your say!

 

Thanks to all who lurk, linger, and enlighten!

 

 

 

 

 

 

 

Reader Comments (636)

R:
As usual,a good summary. The prime issue will be the struggle between the ideologies - the maypole dancers versus the luddites. It grows tiring. Taxes must go up to provide a better fair network, including in that a reduction of social independence at the upper and lower levels. The very rich need less, and the very poor, with biological issues, will need to be cut off.

Sorry to be crude, but we must address, at both ends, changes. It will be painful.

In Ontario, physicians will be reined in, but some patients need to get, their services will be capped also. They will b, escorted out, because they are too expensive.
October 23, 2015 | Unregistered CommentermovingforwardOntario
" We trained hard---but it seemed that every time we were beginning to form up into trams we were reorganized.

I was later to learn layer in life that we tended to meet any new situation by reorganizing and what a wonderful method it can be for creating the illusion of progress while actually producing confusion, inefficiency and demoralization".

Petronius Arbitrer ( 27-66 AD )
October 23, 2015 | Unregistered CommenterAndris
Ipaditis again, teams morphed into trams.
October 23, 2015 | Unregistered CommenterAndris
The war against the young begins. New Grad Entry Program: join a fho as a new grad, restricted billing, no FFS, 40hrs/wk, quality metrics, make $160-200K max.

http://www.health.gov.on.ca/en/pro/programs/ohip/bulletins/11000/bulletin_11000_mn.aspx
October 24, 2015 | Unregistered CommenterThe Little Birdie's Scribe
Android, would that a Petronius Arbiter of such intelligence and satiric wit were around to produce a commentary on our current circumstances, although MFO occasionally comes close...
October 24, 2015 | Unregistered CommenterSybil
I anticipate a more soviet style health care system with its Polyclinics and the demoralization and corruption that goes with it , with a fat , bloated, bureaucratic health care dictatorship with its nomenklatura sitting on top, crushing all below much like Jabba the Hutt ...with shortages of everything for everybody appart for the members of the nomenklatura.and high government officials.
October 24, 2015 | Unregistered CommenterAndris
The full Price-Baker report has been posted on the MOH and OMA websites if anyone is still looking for it. And, in addition, it looks like Thursday brought out a new grad program condition set that prevents them from billing OHIP if they join an acronym practice in areas designated as NOT high needs, and limits income to 160-200. If you want the details, it's in the INFO Bulletins.
October 24, 2015 | Unregistered CommenterSybil
Sybil....does that mean a salary only as per the CHC's....I take it that FHG's are included in the acronymed practices....that they can only work at FFS WIC's with billings limited to a possible maximum of $160,000-200,000 minus 30%+ overheads?

Servicing let's say $200,000 in student loans....it makes offers South of the border all the more attractive...I've heard of some offering to pay off such student loans and to help to find employment for their spouses.

Spouses are going to be a big problem in particular if the spouse is well settled in a law practice for example in a supposedly medically over serviced area.
October 24, 2015 | Unregistered CommenterAndris
Nicely released on a Friday, move two to the new system. MOHLTC salaried position, capped, where it allows.

The ones over 60 will get out in the old system, the ones 30 or less have only the new salaried MOHLTC directed system ( very similar to the state school system) in which to develop their careers, to experience, and those from 30 to 60 will see the old system, on which they have been planning their lifestyle, disappear and be pulled into the new system.

Next number of specialist consultants allowed per LHIN.

At fixed salaries and 55% combined tax rates, the economics of 11 + years of schooling/training will need to be revaluated.
October 24, 2015 | Unregistered CommentermovingforwardOntario
http://www.health.gov.on.ca/en/pro/programs/ohip/bulletins/11000/bulletin_11000_mn.aspx

Notice the October 23 bulletin has been removed - premature release has been retracted?
October 24, 2015 | Unregistered CommentermovingforwardOntario
The MOH must be concerned. Phone polls are happening in Ontario with questions framed in the mho's favour. e.g..
Do the Doctors who received over 60% raises since 2003 and are the highest paid in Canada deserve more money?
October 24, 2015 | Unregistered CommenterERDOC
Most interesting that the New Graduate Entry Program (NGEP) bulletin 11138 (6 pages), dated September 1,2015 but posted October 23, 2015 has been pulled off the OHIP site.

The one offering year 1 - up to a maximum of $162,000; year 2 up to $178,000; and year 3 $207,000 based on meeting targets.

Also the one which negated payments if services are provided by provider not a member of the FHN/FHO.
October 24, 2015 | Unregistered CommentermovingforwardOntario
It sounds like FFS has become a holding pen for new Ont GPs until a salaried position is available regionally.
October 24, 2015 | Unregistered CommenterRealist
The full Price-Baker report has been posted on the MOH and OMA websites if anyone is still looking for it. And, in addition, it looks like Thursday brought out a new grad program condition set that prevents them from billing OHIP if they join an acronym practice in areas designated as NOT high needs, and limits income to 160-200. If you want the details, it's in the INFO Bulletins.
October 24, 2015 | Unregistered CommenterSybil
Premature bulletinitis...what's the significance of its removal?

Surely not a change in their plans.

As for polls with slanted questions in favour of the MOH , it points to the government attempting to covering its arse as doing what it is doing "in the name of the people", spreading any potential blame for future dislocations onto the public itself after all " we were only following the public's wishes".

As for a FFS "holding pen" ....certainly a holding pen for new graduates , but also as a 'penal colony' for deviant doctors to be cast into if they are found to be disruptive in any way, not genuflecting sufficiently enough to the will of their masters.
October 24, 2015 | Unregistered CommenterAndris
Can others confirm it is gone?
October 24, 2015 | Unregistered CommentermovingforwardOntario
Nope.
The page you requested is not available at this location.
October 24, 2015 | Unregistered CommenterRealist
Very odd, but could just IT maintenence issues. Could be premature release, atthempt to retract but then recognize, it is out.

Most interesting is the date, september 1, 2015, but not posted until october 23.
October 24, 2015 | Unregistered CommentermovingforwardOntario
Try locating INFOBulletin 11137 posted by the Primary Health Care Branch.
October 24, 2015 | Unregistered CommenterSybil
I have a copy of it stored. I still find it not available on the website. hopefully just an IT things.

If the physicians can't link all these things together, they deserve what is going to happen. Cap the revenue pool, allow FFS to bill away and control that by claw backs, and start to create the salaried lines, with negation if services are provided by another person. This is indentured servitude. The morale of the servants will not be good.
October 24, 2015 | Unregistered CommentermovingforwardOntario
Health Care Professional
Six Figure Salary
Galley Slave

You will have metrics imposed (ie number of patients seen, procedures done, etc) according to guidelines. Deviations will be written up. Those who do not see enough patients as per the metrics will have their incomes docked.

Errors, missed diagnoses, lack of follow up due to metrics will be YOUR fault. The College will not support you. Patients will abuse and threaten your life. You will not be able to eat or go to the bathroom during your shift. You will need to answer your own telephones (can't afford the secretary), do your own BPs, and much of the billing and scheduling yourself.

Welcome to the pharmacists' world in Big Retail.
(Maybe central used Big Retail as a model????...)
October 24, 2015 | Unregistered CommenterOutPatientPharmD
Big retail is the model, in that much of this copies the US Affordable care act, which is retail model based. There the "profits" are publicly traded as companies get listed and the "public" can access the profit opportunities. In Ontario, the "profits" and internalized and only accessible to government management levels and union leaders.

Deal's done. Decision's made, the processes of servitude are being rolled out.
October 24, 2015 | Unregistered CommentermovingforwardOntario
Will MDs in Ontario and across Canada "get it" or will they fall prey to the world of being too busy to notice what is happening to them?

The young ones have no idea.
They have been warned.
October 24, 2015 | Unregistered CommentermovingforwardOntario
The FHO administrative stipend for the office support came in at 0 on its budget line this month. The physician leadership stipend was paid, though. Does anyone know whether the administrative stipend has been revoked? If yes, that's a problem because it's a large chunk of the only admin position we have. MFO?
October 24, 2015 | Unregistered CommenterSybil
My colleagues were able to download the bulletin and is accessible on the Sgfp site.

Not paying the FHO Administrative stipend for the office support?

Why would they do that?
October 24, 2015 | Unregistered CommenterAndris
Sybil:

Don't know. LOTS is being rolled out. Some of it is not well coordinated. People better carefully read the OHIP bulletin. First of several changes.
October 24, 2015 | Unregistered CommentermovingforwardOntario
It would seem to me that only the silver spooned grads could afford to sign on to this latest scheme....those from impoverished backgrounds with hefty student loans on their backs could not afford to do so.
October 24, 2015 | Unregistered CommenterAndris
Andris: As an unnecessary expenditure. No one needs administration unless it's to compile data for the MOHLTC to demonstrate how well or badly we are meeting targets.
October 24, 2015 | Unregistered CommenterSybil
And that is not what the administrative stipend is for... sorry, should have added that. The stipend is there to manage the financials, the bank accounts, the IT, the call schedules etc....
October 24, 2015 | Unregistered CommenterSybil
I cannot download the Bulletin 11137 either. What was in that one which is different from 11138?

Today I attended a CME at U of Toronto and at lunch the topic turned to the government clawbacks. The oldest doc at the table who has been practicing 40 years said he was going to retire within two years because he would not work under these conditions. Two others bragged that they were only 5 years from the exits.

The older doc then asked us to gaze out across the room and pick out of the 75% female and 25% of male docs which ones would go to "battle" if the OMA called for it? The average age in the room was likely well over 55 and I saw only a handful under 40 who turned out to be paramedical types.

He then said none of his four daughters went into medicine and proceeded to list off the leadership positions they currently held across North America. He did not make this claim in a hubristic fashion rather he was sad at the decline of this once great career choice and proud profession, but more importantly his point being that there is a dearth of leaders or 'fighters' in family medicine.

I asked him if he had read the excellent blog post by Dr. Whatley on whether or not physicians have been trained to surrender in Ontario? He replied "no", but said that is exactly what he meant when asking us to gaze out on the crowd. I then asked gingerly, as there were three women at our table, if possibly family medicine was becoming a pink ghetto and the female family doc beside me immediately piped up and said, "yes".

Maybe it was the dark cold dreary day but I left that CME having a much clearer picture of where we stand which is sadly defeated and demoralized. There is no ready army of fired up young men willing to go to battle to protect their jobs but rather a bunch of old worn out men and women who have been selected and trained to surrender.

I suspect a big part of this reaction is learned helplessness and like the ant in Solzhenitsyn's tea cup which after being pushed to the bottom of the cup one too many times just didn't bother trying to climb out.

I think Dr. Whatley's post from today offers the only realistic solution to this new environment we find ourselves in. Move or find a new job rather than to end up a dead ant.

http://shawnwhatley.com/doctors-response/
October 24, 2015 | Unregistered CommenterCanary in a Coal Mine
CICM, thanks for painting the picture.
About 8 yrs ago I told the OMA SGFP exec that family practice was likely to become the pink ghetto of medicine. There was silence. A rep from the OCFP who was female stared at me blankly. Oh well.
I went to a meeting in September of 2014 as arranged by the Physician Lead in my region. It was clear the bureaucrats were grabbing the reins. I retired early 5 months later.
October 24, 2015 | Unregistered CommenterMerrilee Fullerton
Here is an excellent piece that shows how the complexity that is being created is resulting in lots of busy work at huge costs. This can't go on. We are driving out the very people who provide care while the numbers of people shuffling papers and numbers are increasing. It's crazy stuff.

Laugh or cry at this one:

http://www.torontosun.com/2015/10/24/inside-ontarios-bloated-health-care-bureaucracy#.ViwlbnSvM2k.twitter
October 24, 2015 | Unregistered CommenterMerrilee Fullerton
Excerpt:

"The Ministry of Health funded Health Links through the Local Health Integration Network (LHIN). So we put a proposal together and took it to the LHIN. The LHIN’s IT department liked the idea, but wanted to get input from the ministry. The ministry liked the idea, but wanted us to get the input of eHealth Ontario, the independent agency trying to create electronic health records. eHealth told us to come to a “regional network meeting.”

At the meeting, they thought the idea was good, but asked for the ministry’s eHealth liaison to comment. The liaison referred it to the ministry’s IT group (yes, the ministry has both an eHealth liaison group and an IT group) who wanted to ensure compatibility with a “provincial solution” — even though we were told to develop a local one — and suggested we review with the LHIN IT department.

After a year of “circling back” (a phrase I learned from these guys that I came to detest) we finally gave up, funded the project ourselves for $70,000 — less than a salary on the province’s Sunshine List — and my complex patients are now starting to see the benefits."
October 24, 2015 | Unregistered CommenterMerrilee Fullerton
It is done. The ideology has shifted. Physicians are agents of the state, not agents of the patients, in Ontario.

Next on the "big" agenda, proper "death control" rules. A more "progressive" view is needed to be adopted for those MDs involved with LTC.
October 24, 2015 | Unregistered CommentermovingforwardOntario
Re Dr. Whatley's comment....we went into medicine to fight disease and pestilence...not governments...as a Child if 8 I was dreaming of fighting elephantiasis, sleeping sickness and malaria ...not governments...I didn't go into medicine to fight governments and still don't really comprehend why they so dislike my kind....the individuals who are in government need us when they and their loved ones become ill...yet they hate us at the same time.

Albert Schweitzer , whose picture was over my bed as a child, was never hated by those that he treated in Africa...why am I?
October 24, 2015 | Unregistered CommenterAndris
DrL:

They dislike the privilege, and that what is being addressed. Physicians are now, in Ontario, viewed as assets of the state, controlled by the state. Those very skilled ones, will continue to do well. the rest, will join the state workforce. They will serve as the rationers of care. They have allowed themselves to go from the seekers of resources to provide the best care possible to their individuals under their care, to the distributors of the allocated, restricted, resources which, knowingly are not the best. Each day doing their job, knowing it is not "the best", but adequate. Those between 30 to 60 are going to struggle with that. The old will just retire out, the young are happy to be employed, with a good income.

The problem will be the older patients, will be discouraged. They were expecting better for their retirements.
October 25, 2015 | Unregistered CommentermovingforwardOntario
Answering my own question , Machiavelli stated that there were only two causes for hatred, namely fear and and envy.

What is it that they fear?

What is it that they envy?

One wonders whether enslaving that which they fear and envy will reduce their hatred?

One senses that it won"t.

The word is getting out to those pondering entry to medical school...many will likely go elsewhere, in particular those from families with a strong family tradition of entering the medical field.

Those who value their individual freedom will distance themselves from the oppressive world of governmental bureaucratic dictatorship.
October 25, 2015 | Unregistered CommenterAndris
It is based on the desire to do good, based on the belief my good is better than your good. The balance of the common good versus individual good.

However, what is left off the ideology is how much of my resource must you take to do good, at the expense of me doing good for my family. What is reasonable balance?
October 25, 2015 | Unregistered CommentermovingforwardOntario
1. No consciencous objection.
2. More patients seen, less money available per capita.
3. New graduates not picked up by central have restricted capacity to work, and ability to develop their skills.

Central is eating the young ones up. The consequence over the next decades will be massive.
October 25, 2015 | Unregistered CommentermovingforwardOntario
The next shoe:

If central can get through this next step MOHLTC committee on fee review. That will adjust most fees down, eliminate some, and place caps on volumes allowed per year to maintain quality.
October 26, 2015 | Unregistered CommentermovingforwardOntario
On the one hand we have Schumpeter's creative destruction....and then we have this....more in line with Pol Pot's Khymer Rouge destruction with the young of the profession in particular dispatched to the killing fields with a touch of Mao's barefoot doctors with iPhones that keep track of them in real time and observing what they do, making certain that they provide quality care as defined by the Party.
October 26, 2015 | Unregistered CommenterAndris
I wonder if the pressure on new family medicine grads is really intended to drive them away to make way for nurses to take over primary care. Nursing unions did pose the takeover of primary care by 2020 just a few years ago.
October 26, 2015 | Unregistered CommenterRealist
Primary care by MDs in Ontario is ending. With these latest moves, anyone considering building a 40 year career in primary care, would be as safe as building a 40 year career on horseshoeing.
October 26, 2015 | Unregistered CommentermovingforwardOntario
mfO, seems about right...
Farriers can make quite a decent income...Ed , a blacksmith with his own smithy ,could earn a good income teaching ex FPs a new trade free from government dictats, guidelines, protocols and from being supervised by those who don't have the foggiest idea about horseshoeing.
October 26, 2015 | Unregistered CommenterAndris
Go to any primary care CME at the U of Toronto lately and the writing is on the wall. Half the attendees are NPs, PAs. or other non-MD providers. Purportedly these providers are cheaper but they are definitely easier to control as they are on government salary.

The biggest problem with these 'team' CMEs is that they have been dumbed down for the non-MD attendees. I have make a decision to no longer attend any 'team' CMEs. The quality is just not there and the cost is far too high to hear a lecture I would have received 20 years ago in medical school.
October 26, 2015 | Unregistered CommenterCanary in a Coal Mine
Wow, take a few days off and ba-bam! The world implodes.

<<Don't know. LOTS is being rolled out. Some of it is not well coordinated.>> - mfO

Par for the course, right?

Sometimes I wonder if it is done because Central can't plan a two-car parade or if it is done strategically to purposely contribute to confusion.

Nah.

Its the former.
October 26, 2015 | Unregistered CommenterExecutive Lead Blogger

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