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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
May212015

The Chasm: Leaping Between Health Care Policy and Reality

Why is it that what is developed in health policy to transform delivering care doesn't seem to succeed?

I suppose this question depends on how you define "success".

Is "success" finding greater efficiency?

Is it providing more value or more quality?

Is it simply reducing cost to government?

Is it providing more services with less funding?

Is it simply getting along with less?

Is it creating some kind of tangible legacy?

Is it creating a continuum of care?

Is success generating Big Data and creating more Health Information Technology?

Is it creating teams where everyone works together?

Is it allowing patients to die at home if this is their wish?

There has been much "policy development hand wringing" from many groups on efforts in these areas. Politicians, policy makers, and providers have all attempted to provide input over many, many years.

Why then, with so many people working together (and well paid to work on these efforts) for decades on these issues, has the "success" been so insignificant in constraining health care costs that government routinely reverts back to constraining delivery of care including the slash and cut approach?

We saw it in the 1980s with the introduction of the Canada Health Act.

We saw it again in the 1990s with Ontario NDP "Rae Days", caps and clawbacks, and hospital cuts.

We see it in Ontario now with Premier Wynne's heavy handedness with physician negotiations where cuts have become the solution once again.

Why isn't success defined as meeting the needs and goals of the patient in their own care?

Why isn't success defined as allowing patients the freedom to access the care they need in a way that meets their needs?

Lots of questions exist surrounding these issues but one of the most significant reasons that health transformation cannot be achieved in reality and why any "success" is muted is that every 10-15 years the policy cycle renews. Every 10-15 years lessons previously learned are forgotten. There is no health care policy succession planning and with every cycle that ends, the next group of politicians, policy makers, and providers start fresh with the belief that the current system can be made more efficient and meet growing demand. All this despite decades of attempts that demonstrate otherwise.

Wisdom in health care planning does not exist.

There is a vast chasm that exists between health care Theory, borrowed or created, and health care Reality. No amount of policy development can change that until there is a transfer of experience and wisdom from those who have come before to those that are coming after. We do this in medicine. Why not in health policy?

How can this be accomplished?

First, let us all acknowledge that many health transformation efforts fail.

Then, create a living document that includes all of the policy changes and their results.

Perhaps then we can bridge the chasm between Theory and Reality and avoid the cyclical lapses that seem to confound finding true sustainability.

As always, I am grateful for your comments and contributions particularly in my absences.

 

 

Reader Comments (755)

You are no longer responsible for your health. We are, and will provide you services to deal with all your health needs from the common pool. When you make poor decisions, we will fix them at no penalty to you.
May 21, 2015 | Unregistered CommentermovingforwardOntario
Sure....
Since the Ontario health care system is at tottering edifice built on a defective foundation ,"success" ,from the perspective of the government , is simply to keep it relatively erect....not to have it collapse on its watch.
May 21, 2015 | Unregistered CommenterAndris
As Dr. L. expresses, the goal now is to just keep it running. Idealism is being overwhelmed by reality.
May 22, 2015 | Unregistered CommentermovingforwardOntario
It is infinitely ironic that I have read this new post from within an "IDEAS" course run by Health Quality Ontario. Also, of note is that at least one, and perhaps several of the participants did not know what a Health Link is. An entire "revolution " will come, and inevitably go, without being known. Because Health Link funding is being choked off, in many cases before a beginning could be made. Whether or not you believe this to be a wise idea it will inevitably fail for want of even modest funding support
May 22, 2015 | Unregistered CommenterSemi rural doc
The issues are fine, the problem is all cost more money, and find more need for more services, which require more money. Central is having diffilculty coming to grips that costs do not go down, demand goes up. This redistribution of wealth stuff is nice in theory, but we all just want more..
May 22, 2015 | Unregistered CommentermovingforwardOntario
The issue is, what is the core policy?

All essential needed health care is controled by the state system, or core needed services are available below a certain level, and above that a sliding scale of individual out of pocket funds will be required.

We are going to have to answer that soon, as the rising number of people wanting full support from the state, and complete access to expanding medical services rises.
May 22, 2015 | Unregistered CommentermovingforwardOntario
Ontarians don't seem to understand that infrastructure and health human resources exist. They just aren't being used to full potential because of lack of public funds.

Whether Melnyk was covered by OHIP and met the requirements or whether he paid out of pocket or whether he had some kind of insurance to cover his care here in Ontario should not matter.

Ontarians, there are empty ORs, empty hospital beds and idle surgeons because SINGLE PAYER CANNOT MEET DEMAND.

The Medicare Righteous amongst us bare their teeth to protect an entity that does not need defending. It needs change.

Sigh.

http://ottawacitizen.com/news/local-news/why-was-eugene-melnyk-a-foreign-resident-eligible-for-surgery-in-ontario
R

Whether it was paid for by OHIP, or privately, is not the issue. Good care was made available, and no one was displaced. Why can t this be seen as an example of building flexibilty into the system, rather than an opportunity to ratchet in down even tighter?.
May 22, 2015 | Unregistered CommentermovingforwardOntario
It boggles the mind:

http://www.cbc.ca/player/News/Canada/BC/ID/2667578102/

Ageism? Confusion? Denial of Care? Delay of Care..
Failure of the single payer system.
Success of Sourh Korea's private system.
May 22, 2015 | Unregistered CommenterMerrilee Fullerton
R

The single payrr system is not failing. It merely has different priotity. Individualized, prompt, health care, is not the first priority. Wealth redistribution is.
May 23, 2015 | Unregistered CommentermovingforwardOntario
"It’s always been tough for foreign doctors to get a medical licence. Stories of doctors driving cabs are more than urban legend. But in recent years, it’s gone from bad to worse. Foreign doctors are elbowed out of the way by a group you might not consider international at all: Canadians who get rejected by medical schools here, go abroad to study in places such as the Caribbean, then apply for residency in Ontario.

In just eight years, the number of Canadians seeking to return has grown to 800 from about 250. Last year they took two-thirds of the 200 or so residency slots Ontario funds for international medical grads."

http://www.torontosun.com/2015/05/22/canadians-who-study-abroad-taking-residency-spots-from-immigrant-doctors
May 23, 2015 | Unregistered CommenterEklimek
DrK

Welcome back.

Interesting issue regarding all the unused medical potential, coming into a declining funding pool. One will fondly remember the good old days, of 2014!
May 23, 2015 | Unregistered CommentermovingforwardOntario
So is another one of the questions, what will be the reshuffle that occurs in the fixed physician revenue pool, that will be in place by 2017? How and who will be organizing and enforcing the reshuffle? Which are the winning groups, and which are the losing groups?

It will remain an interesting 4 years.

A much less liberal government than people were anticipating.

Teachers will be legislated back by Wednesday.
May 23, 2015 | Unregistered CommentermovingforwardOntario
Yes, welcome back eklimek! I hope all your bits are mending well!

mfO asks:

"what will be the reshuffle that occurs in the fixed physician revenue pool, that will be in place by 2017"-mfO

Good question.
Leads us to other questions.

The sale of Hydro One is not a long term solution. Wynne would need to sell of a biggie every year to gather up the billions she needs to fund growing health care needs. ANd even if she did, we have the little problem of all the infrastructure that needs replacing from sewer and water to roads and hospitals. It isn't pretty.

So nothing has changed. Health care will have ongoing rationing in a single payer environment despite surging demand related to demographics, pharmacogenomics and new scientific and technological development...not to mention longevity.

I really don't think that most elderly seniors are going to accept the "duty to die" approach. It's too hard to tell exactly when death will occur so avoiding futile care both by patient and provider becomes problematic.

I was shocked by the case of the BC man who went to South Korea. Yes folks, it really is that bad here.

The university profs who are health consultants appear to be set on driving the MD income down. Only problem is the education isn't shortening or getting less expensive.

I feel bad for the MDs coming here from other countries and unable to find work but don't they have access to the internet where they are?

If you are a heart surgeon in Iraq in a major city I assume, does a supposedly highly educated individual like you not have the ability to communicate outside their own country?

Hmmm. One wonders about the education.

MDs and patients are in for a very difficult time for the next 30 years unless we have a Hybrid. Unfortunately, many still believe the claptrap about two tier care and fight against it.

It will be interesting to see if Dr Day is successful in his bid for President of DoctorsBC. I see that Oppel is running now too.

Things have got to change. MDs need to get a grip on what is coming. Meanwhile Dr Danielle Martin is speaking at various university medical schools. They won't know what hits them.

Too bad.
R

The physicians are the first group forced into government servitude. Other groups will follow "for the good of us all".
May 23, 2015 | Unregistered CommentermovingforwardOntario
Another article from the Daily Mail ' Sea, sand and surgery ...' A global guide for British NHS patients ( and Canadian for that matter ) of where to go to have surgeries and procedures carried out when the official queue gets too long.

" Success " from the patients' perspective is not the same as " success " from the government's perspective.

Ontario's FP's will increasingly need to know the non Ontario options/ alternatives for their patients in their hour of need when the state health care system falls short.

The Turks and Cacos might get very busy.
May 23, 2015 | Unregistered CommenterAndris
DrL

The ordinary physician and other HCPs won't need to worry about non Ontario care. they will be able to say the level of care meets "local standards of care" and walk away. We have become accustomed to the fact that the system now runs on wait lists and wait times. Services are around, one just waits to get them. The margins grow in the "waiting pools" but all is under control. As it gets tighter, those at the margins will suffer more, but no resources are being made available.

Pressure is building, rapidly, to get at the pools of resources involved with intragenerational transfer of wealth through inheritance. The last big pool the state can get at. This is not about "fairness", it is about getting the money to those who "need" it most. The money to fix all the social determinants of health we haven't been able to fix with 40 years of social support, will be coming from that pool.

The ORSP is going to get lots of resources to central, that will no longer be available for intragenerational family inheritance. That now belongs to the state.
May 24, 2015 | Unregistered CommentermovingforwardOntario
Further consequences of the capped budget:

With at least three years of frozen revenue, but rising costs, it means less capital savings, thus less investment from the physicians in RRSPs, TFSAs, etc. Thus less capital in the markets, slowing the GDP.

Other big hit will be in the CME courses. Big drop in revenue following to those.

This is an interesting policy. It seems the ramifications of capping income, while not restricting access to services, doesn't fit the usual economical models used. It seems this isn't an economically model policy, but one purely based on income envy.
May 24, 2015 | Unregistered CommentermovingforwardOntario
" It seems this isn't an economically model policy, but one purely based on income envy."-mfO

Ah yes, income envy. That's a little bit like comparing apples to oranges. A secure public service job with benefits, paid holidays and pensions is not the same as MD "income" but that is how it is being portrayed.

How does one calculate the "income" of a public servant with generous income, benefits, sick leave and pension until 99? What does that work out to if squashed into usual MD earning years of 30-35 years. (Let's face it, MDs over 70 typically don't keep a torrid pace).
Excerpt from link above:

"Few are opposed to evidence-based medicine. What’s the alternative? Ignorance-based medicine? Hunches? However, the real world applicability of evidence-based medicine (EBM) is frequently overstated. Our ideal research model is the randomized controlled trial, where studies are conducted with carefully selected samples of patients to observe the effects of the medicine or treatment without additional interference from other conditions. Unfortunately, this model differs from actual medical practice because hospitals and doctors’ waiting rooms are full of elderly patients suffering from several co-morbidities and taking about 12 to 14 medications, (some unknown to us). It is often a great leap to apply findings from a study under “ideal conditions” to the fragile patient. So wise physicians balance the “scientific findings” with the several vulnerabilities and other factors of real patients. Clinicians are obliged to constantly deal with these messy tradeoffs, and the utility of evidence-based findings is mitigated by the complex challenges of the sick patients, multiple medications taken, and massive unknowns."
R

But you are proposing that physicians consider the individual physician deals with the individual social determinants of health of each patient in providing indivualized care.

That goes against the global belief that only a population based fixed grand scheme can fix the SDOH, which only central care provide.
May 24, 2015 | Unregistered CommentermovingforwardOntario
Those FP's whose primary loyalty is to their patients as opposed to the state may well have a Rolodex full of off shore health facilities:

Norway's Scanhealth Haugesund hospital for cataracts , prostates, hips and cardiac.

Spain's IVI clinics in Madrid ( they can film patient's embryos as they develop in the incubator ).

The Czech Republic's SurGal clinic for knees and hips....also weight loss surgery, sports injuries.

Turkey 's Cosmmedica hospital for hair transplants, breast implants, tummy tuck etc.,

Lithuania's Nordorthpaedics orthopaedic surgery clinic in Kaunas for feet, hips, knees, shoulders and elbows.

Hungary for dental surgeries, implants , veneers, crowns, bridges etc.

South Africa for rhinoplasties at the Cape Rejuve8.

Belgium, the Netherlands and Luxembourg have their clinics catering to those waiting for line ups in statist health care systems.

India's Neera clinic for orthopaedics.

Thailand's Thainakarin hospital for hernias, heart bypasses and valve replacement.

Our own continent has its escape valves as well.

As the Ontario/ Canadian systems implode...our FP's may well become the equivalent of medical travel agencies.

" Success " will be judged by how satisfied their patients are as opposed to how satisfied the MOHLTC and the government are.
May 24, 2015 | Unregistered CommenterAndris
Andris

Please forward the rolodex. Might as well start now.
May 24, 2015 | Unregistered CommenterEklimek
Are we at the point, where, few/some/many FDs are dissatisfied with the wait times for reasonable patient care?
May 24, 2015 | Unregistered CommentermovingforwardOntario
Nice list Andris! Thanks!

"population based grand scheme" cannot fix the Social Determinants of Health issues. Epigenetic understanding says so.
Andris, how have you been collecting the list?
R

Central doesn't believe basic biology applies. We all have equal potential, and are denied that by social structure, not biology. If we fix the social structure, the basic biology won't apply.
May 24, 2015 | Unregistered CommentermovingforwardOntario
False premise but it sells well.
May 25, 2015 | Unregistered CommenterMerrilee Fullerton
R

It does sell well, but may be the root of the issue. We all support levelling the access to opportunity playing field. In the end, however, people will stratified, some with more, some with less resources. The issue is if you have more resources, and have paid your share of social support, can you use the resources as you see fit, or does the state get to control your excess resources?

That is the struggle going on. The next years will be stressful as we socially figure out the next end point. New Brunswick is an interesting province, within the federation, that is closest picking its direction, driven by rapidly shifting economic realities. Will we federally step in and help, at the expense of the have provinces, all which have less, for their own populace.

We are coming into year 9 of insufficient growth in the GDPs. Maybe it is time to reevaluate "growing" our way out.

The physician population in Ontario may be in an advantageous position, to look for opportunity to find new resources not encumbered by the restrictions imposed by the existing model. Growth in a reducing pool isn't going to happen. The new graduates need to very carefully examine the economic model that is being proposed, as they figure out their futures.
May 25, 2015 | Unregistered CommentermovingforwardOntario
"The physician population in Ontario may be in an advantageous position, to look for opportunity to find new resources not encumbered by the restrictions imposed by the existing model. Growth in a reducing pool isn't going to happen. The new graduates need to very carefully examine the economic model that is being proposed, as they figure out their futures."-mfO

Bingo.
If you haven't read it already, here is important read from Dr Day:

http://www.leg.bc.ca/cmt/40thParl/session-3/health/submissions/organizations/CIMCA.pdf
R:

The funding model being put in place by central is a most fascinating thing. Truly, central has seized control of all the capital available for physician payment, and will disperse it completely based on its political agendas. Neither the patients, nor the providers, are part of the health care system. We now don't have a health care system, we have a resource distribution plan run by state employees for political purposes. They control the internal profit margin needed by central, and only after that profit has been extracted (private insurance, pension plan increases, etc.), is the residual available for dispensing.

It really can't be called a health care system anymore.

The new physicians better carefully review their ideological stands because thing is not going to change.
May 25, 2015 | Unregistered CommentermovingforwardOntario
"We now don't have a health care system, we have a resource distribution plan run by state employees for political purposes."-mfO

Can I have your permission to use that line?
"central has seized control of all the capital available for physician payment, and will disperse it completely based on its political agendas. Neither the patients, nor the providers, are part of the health care system"-mfO

You've expressed the reality very well. Thank you.

Whatever happened to "The plan is good" ?
Use anything you want.

The plan is good. Most people don't get what the plan means.

Now the teachers are about to find out.

The fiscal cupboard is bare.

Austerity begins. Watch New Brunswick. It is the "canary in the coal mine" of the federation.
May 25, 2015 | Unregistered CommentermovingforwardOntario
One is going to have pity the ED staff. It is going to get bad. Stay away from the margins, hopefully you can stay out of EDs. Waiting time is going to soar.
May 25, 2015 | Unregistered CommentermovingforwardOntario
I've been speaking to some parents of hopeful future MD candidates. They have no knowledge of the unemployment issues or of the difficulties getting back to Canada should one choose to do MD out of country.

They simply have no idea.

When I try to discuss public funding of infrastructure ie hospital beds and OR time and unemployed orthopedic surgeons etc they simply do not want to hear it.

Ignorance is still bliss.
R

Its similar to parents proud of their childen aspiring to any trade.

At this time short of a political bombshell the Ontario liberal majority will steer the ship aground. The apparatchik have no concerns as long as they emerge without penalty.
May 26, 2015 | Unregistered CommenterEklimek
"The apparatchik have no concerns as long as they emerge without penalty. "

and this includes Physician "Leads".
I also have discussions with people who work in the health care field, MDs included, who have no idea what a Hybrid system is.

You'd almost think we were in North Korea when it comes to health care. Few seem to know alternatives to the present system. Most go along with the propaganda machine. Many look to their system whether political or medical and seek to appease. Their livelihoods depend on agreeing with the status quo.
That's why it can not changed. Those in it benefit too much, and the clients have no say.
May 26, 2015 | Unregistered CommentermovingforwardOntario
It must be changed.
May 26, 2015 | Unregistered CommenterMerrilee Fullerton
Congratulations to Dr Day on his tireless and courageous efforts to improve health care access FOR ALL.
May 26, 2015 | Unregistered CommenterMerrilee Fullerton
I recently saw the fees listed to see a GP at Walmart or CVS Pharma in the USA at $US80 or an NP $US45. The current A7 code in Ontario for an intermediate assessment at $33 less 3.15% is a complete joke.

Hybrid system in Australia from a friend of mine.

"Your doctors' remuneration leaves a lot to be desired (capitation)

Here our health system " Medicare" is federally funded. Medicare refunds $33 for a basic consultation but the provider can set his own fees. Typically these are recommended by the relevant groups. My brother charges $65 for a basic neurology consult. He is in a good position of close to retirement and can be choosy about his patients. His attitude is if they don't want to pay the fee then it is OK to go to another practice. He has a full day as it is.

My GP charges $55 for a basic consult so he gets $33 from the govt and $22 from the patient. My previous renal guy was charging $190 per consult of about 10 mins. My current one is $125 and often we spend up to about 20 mins."
Thanks for that insight CICM.
We need a Hybrid system.
May 27, 2015 | Unregistered CommenterMerrilee Fullerton


Legalizing Physician assisted suicide....."it is striking that even in the face of so much uncertainty, Canadian society generally seems trustful rather than fearful, and the Court's decision has hardly triggered a culture war."

http://www.nejm.org/doi/full/10.1056/NEJMp1502442#t=article
May 28, 2015 | Unregistered CommenterOutPatientPharmD
His last major effort was to get IVF funded by government. Quebec experience with funding IVF should be self-explanatory. Create a "free" service and the demand will soar.

In the case of gov't funding of IVF, the theory was that it would decrease the costs of care overall as it would limit the number of eggs fertilized and would decrease the costs associated with birth, hospitals and neonatal care.

It did not reduce costs and I believe the gov't funding for IVF in Quebec has either been scrapped or restricted again to control costs.

This should be a lesson for all of those individuals who promote National Pharmacare. It will be another bottomless pit or will have so many restrictions that people who believed they would be covered will not be covered. Sound familiar.

Theory vs Reality.

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