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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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Monday
Aug242015

The Baker-Price Report

Let's talk.

The Price Report has been circulated around for some time I understand. It seems to be elusive on the "internet of things" so that means it is in a crevice at the Ministry of Health and Long-term Care...the same place that refuses to provide the current utilization costs of Ontario's physicians to physicians.

This ghostly report apparently contains a plan to allow Patient Care Groups to set the demand for MDs. No space for an MD in a certain region/hub, no job. This isn't much different from what exists now in terms of publicly funded health care infrastructure being the limiting factor but it does create a whole new realm of freedom killing logistics for new MDs and a whole other layer of obstruction to care.

It's a sad state of affairs when a government that expounds on the virtues of transparency and accountability won't provide the details of its plans and I use that term loosely.

What Patient Care Groups will do is attempt to herd MDs into areas where the Ministry would like them to go. This has been tried in a number of ways before. None of the government efforts have been effective mostly because MDs are very intelligent and resourceful and resilient and find other ways to accomplish their goals and meet patient need.

The herding may have the opposite effect and result in MDs finding other livelihoods associated with medicine or simply moving to jurisdictions where their expertise is appreciated in a more holistic way.

The needs of northern communities and other more rural and remote areas have been met to some degree with MDs who rotate through often on a weekly or a monthly basis. With the PCG scheme will they continue to come? Would the mechanism by which MDs are herded lend itself to this approach? If not, some of these areas could find themselves worse off than before.

Now, I must admit I have not read the Baker-Price Report. I have seen parts of it. But to all of the new MDs looking for permanent or semi-permanent postings, be concerned.

The Ontario Medical Association has been quiet on this front. Perhaps it doesn't have the Baker-Price Report either. This doesn't seem to be a very good way to run a health care system--keeping MDs in the dark about their futures, their ability to earn a living and shooting any kind of transparent negotiation process all to bits.

Surely, when Dr Eric Hoskins trots out into the media to set "the record straight" about his government's achievements in creating new MDs he ought to include the plans for their future positions.

Given the cuts to medical residencies along with the bravado about how many more MDs Dr Hoskins and the Ministry want to take credit for, one has to wonder how how many MDs are going to waste and if not driven from the province, how the government will pay for their services.

Currently, the Ministry isn't sharing much. Not their plan. Not the utilization costs...not too much of anything except its big stick.

Good luck with that.

It hasn't worked before and it won't work now.  Perhaps Dr Hoskins' next plan is to build a big wall around Ontario to keep Ontario MDs-it would be a logical next step given the demonstrated brashness and short-sightedness seen so far from Ontario's Ministry of Health. 

For your interest, here is the executive summary:

 

Executive Summary In late 2013 the Ministry of Health and Long-Term Care (the “Ministry”) convened the Expert Advisory Committee on Strengthening Primary Health Care in Ontario to address current challenges in Ontario’s primary care system. The Ministry identified four policy questions of particular interest:

1. How can we ensure all Ontarians are attached to a regular primary care provider?

2. How can we ensure that Ontarians who need the services of an interprofessional care team can obtain them?

3. How can we improve integration in Primary Care, both among primary care providers and between primary care and other parts of the system?


4. How can we ensure Ontarians can access primary care after business hours and on weekends
when needed? In response, the Committee has proposed a vision for a cohesive primary health care system for Ontario, based on a redesign of the province’s existing primary care sector.

The redesign includes the following features:

1. A population-based model of primary care delivery, designed around Patient Care Groups
(PCGs); which are fund-holding organizations that are accountable to the Ministry through the
Local Health Integration Networks (LHINs).

2. Groupings of Ontarians are formed based on geography5, akin to the assignment of students
within the public school system. Citizens within each grouping are assigned to a PCG. The PCG ensures universal access to primary care for all of its citizens; there are no unattached patients.

3. Funding to each PCG is determined on a per capita basis, reflecting the demographics,
geographic rurality of the population, socio-economic status, and projected health needs of its catchment population6. The PCG then contracts with its local primary care providers, honouring existing relationships and agreements currently in place, to deliver primary care services to its
citizens. Primary care providers, along with the local Public Health unit and municipal services, are responsible for the health of the population within their catchment area.

4. The model recognizes that a citizen’s health is determined by many factors beyond the health system and supports partnerships between primary care and other sectors to build a culture of
community health and wellbeing.

5. The model ensures clear lines of accountability between primary care providers and patients,
and between care providers and the broader system. 5 Partially based on analysis of natural groupings of primary care entities by ICES

6 Funding levels will be determined in partnership with Public Health and others involved in epidemiological
analysis and research.

 

7. The model ensures better integrated care, both horizontally (coordination between primary health care practice settings) and vertically (coordination between primary health care and other parts of the system). This model has the potential to enhance the horizontal and vertical integration component of Health Links’ activities.


8. The model ensures that quality and fiscal responsibility are rewarded. Provider groups and individual providers, who may be subcontracted to provider groups, are contracted with based
on their ability to achieve quality benchmarks and any additional criteria/metrics captured in
their accountability agreement. Contract granting and renewal will be performance based, and support may be available to providers when performance does not meet standards.

9. The model offers the benefits of economies of scale through the PCG central functions but also allows and rewards adaptation to local needs.

10. The focus is on the functions of a PCG necessary for effective primary health care delivery, not
on who performs them. Current structures and organizations will be leveraged wherever
possible, and when new structures are required they will replace an existing entity, not add a new one.

 

Here's the link:

http://health.gov.on.ca/en/common/ministry/publications/reports/primary_care/primary_care_price_report.pdf

 

 

Reader Comments (320)

"Health Human Resources

"- Some regions may have a surplus of certain types of providers and many will have gaps. The Patient Care Group's (PCG's) contracting mechanism is expected to address this issue as PCGs determine and contract for the health health human resources needed to satisfy their accountabilities to patients. This is anticipated to result in a more equitable distribution fo HHR as it will support the movement of healthcare providers to currently underserved regions and away from regions in which there is a surplus."

"- Moving to the PCG model will require time for appropriate phasing and sufficient planning to ensure the necessary HHR is available to reflect the population assigned to the PCG. Where HHR is a concern, recruitment and retention strategies need to be engaged and supported in collaboration with Health Force Ontario".

- Patient Care Groups: A new model of population based primary health care
(Price, Baker et al, November 13, 2014) page 20-21 "
Thanks ELB and Sybil and mfO.
http://www.health.gov.bc.ca/library/publications/year/2015/health-human-resources-policy-paper.pdf

Three groups are highest consumers of services.

Chronic illness
Mentally ill/substance abuse
Palliative care

Moving care givers around does not change this.
August 24, 2015 | Unregistered CommenterEklimek
That's an excellent point eklimek.
We can coordinate all we want. We can attempt to address the social determinants of health.
However, it will become a cold, harsh reality that preventing the list above is well beyond our current means.

I'm hopeful we can improve some lives with health care. I'm realistic about what can be achieved,
If health care dollars directed to hubs, integrated care and "under serviced areas are just for political show" then let's understand that.
If they are truly intended to give everyone equal health then we are about to find out that Complexity trumps Good Intentions.
We can try, but let's be realistic about the outcomes and understand if efforts and $ might be spent more beneficially.
August 24, 2015 | Unregistered CommenterRealist
R:

Bad health exists because of bad systems, which we can fixed by mandating and locking in health care practitioners. Although this has not succeeded in any jurisdiction that try it, it will work in Ontario. Believe.

Remember, biology does not dictate the occurrence of disease load; it is our social structure that does, as it does in all the other 200+ nations which also have equally flawed social structures which cause the same distribution of disease load across their populations.

"guns don't kill people, people kill people" or "biology doesn't kill people, people kill people"
August 24, 2015 | Unregistered CommentermovingforwardOntario
R:

One doesn't need to worry. We know the future. Roughly, local boards, allocating resources to its funded physician positions. No other spots but those funded through the boards. Movement from region to region controlled by waiting for openings to apply to. Been tried. Works exactly like school system.
August 25, 2015 | Unregistered CommentermovingforwardOntario
Talking about killing people...


“We kill more people now than cars do.” Last year, more people died in the U.S. from opioid-related deaths than from car accidents.


By Sharon Kirkey, National Post August 24, 2015 – 10:44 pm ET
HALIFAX — The leaders of Canada’s medical establishment were told by one of their own Monday that “weak” doctors are bowing to demands from patients and over-prescribing opioids blamed for an epidemic of drug-related deaths.

Doctors who prescribe heavy-hitting narcotic painkillers such as oxycodone often don’t understand them, Dr. Douglas Grant, CEO and registrar of the College of Physicians and Surgeons of Nova Scotia, told delegates at the Canadian Medical Association’s annual general council meeting here.

“What I frequently see is undisciplined, unstructured and arbitrary use of these medications,” most often by “a well-intentioned, but weak-willed and under-informed physician who has lost control of the patient-doctor relationship,” said Grant, who is also president of the Federation of Medical Regulatory Authorities of Canada.
August 25, 2015 | Unregistered CommenterEklimek
In today's NP an article on how trees make people far healthier....adding 10 trees to every block makes residents healthier by the equivalent of raising household incomes by $10,000.

Each health team should have an arborist....planting trees is a far more effective approach to making the population healthier , far more cost effective than training MD's who promptly go out and kill people....of course the citizenry will have to be educated ( by the arborist) not to stand under trees during thunder storms and ice storms.
August 25, 2015 | Unregistered CommenterAndris
[Sorry - a quick rebuttal post this turned into a rambling rant...again]

<<The needs of northern communities and other more rural and remote areas have been met to some degree with MDs who rotate through often on a weekly or a monthly basis.>> - Dr. F

With all due respect, Dr. F, I do not accept that the needs of rural and remote communities have been met at all. Reliance on frequently changing, itinerant physicians is absolutely no replacement for a constant, stable physician presence.

Based on about two seconds of thought, I suggest that itinerant physicians in rural and remote areas are the equivalent of urban walk-in centres. Yes, they serve an immediate purpose for the patient but they are far from an ideal solution to a comprehensive, longitudinal and integrated primary care system.

I can appreciate that working in small communities presents physicians with different challenges. You're always "on". Purchases at local stores (including the LCBO) are scrutinized by many ... almost like a sport. You are seen as a 'top wage earner' without any due regard for what it truly takes to earn that wage.

So it takes someone really special to be a physician in rural and remote areas and I offer my deepest appreciation for those who decide to practice in those communities...not all can do it well - even for short periods of time.

But it provides an incredibly rewarding and fulfilling lifestyle for those seeking that kind of self-actualization.

I have met many nomadic itinerants - don't get me wrong...most are really nice people and are fine clinicians. We need to have some. But I think that the manner in which the system has evolved (or in simpler terms, 'been unmanaged' or 'left to be driven by unintended consequences') has allowed their numbers to grow well beyond a necessary range.

I can understand the desire for the government to introduce Patient Care Groups to apply some level of accountability to the currently unaccountable primary care system. But let's remember that it was this government that opened Dr. Pandora's Box and introduced the FHNOTs and such over a decade ago. It will be a challenge to reign it back in.

And true to the myth, the only thing left inside the box after Pandora closed the lid was hope.

Just my view from the margins.
August 25, 2015 | Unregistered CommenterExecutive Lead Blogger
Modern day locumitis that afflicts the younger generation, from the government's perspective, fits well with the ' needs of rural and remote communities' ....looking at their blogs when their time is up, they simply drop tools and go to the plane and fly off leaving hot potatoes behind them...hopefully another locum is flying in on the same flight to pick up the tools and the hot potatoes.
August 25, 2015 | Unregistered CommenterAndris
You may both be correct but speaking of different issues. There is a difference between newly graduated underemployed peripatetic locums traversing northern Ontario and contractual deployment to underserviced areas. Motivation and skill set may be substantially different.

But the risk of death still increases with distance to adequate emergency care.

.
August 25, 2015 | Unregistered Commentereklimek
The model to be used will be very similar to the school system. Fixed budgets with contracts for existing positions, with limited budget for "subsitutes".

The old style medical independent practitioner model is being eliminated. May not like it, but it is going.
August 25, 2015 | Unregistered CommentermovingforwardOntario
"The model to be used will be very similar to the school system. "


Super. When does private school equivalent become legal in Ontario health care?
August 25, 2015 | Unregistered Commentereklimek
As we all know, there will be no non public option.
August 25, 2015 | Unregistered CommentermovingforwardOntario
"Super. When does private school equivalent become legal in Ontario health care? "

Thanks for the laugh.

So Mfo will or will it not be like the school system in Ontario. Sounds more like a Soviet command and control system.

Where the control will be via corrupt boards and those boards decide on physician resources required, but no private tier pressure valve will be allowed when the system's quality becomes unacceptable. And what about those nasty biannual teacher strikes? Do we get to strike too?

Eight weeks off a year, DB pension supported by the taxpayer, $1200 of massage every year, sabbatical program,...please do tell or are those benefits only for the government's favourite union groups.

Sounds like it going to be all stick and no carrots? At some point the docs will push back, but it is clear the MOH is still finding mush.
August 25, 2015 | Unregistered CommenterCanary in a Coal Mine
Is this the same Price and Baker,...from the UK?

http://www.biomedcentral.com/1471-2296/15/158
August 25, 2015 | Unregistered CommenterCanary in a Coal Mine
Tell me it ain't so.

"The care of patients with certain chronic conditions in the community, if appropriately organised, can achieve the same health outcomes as ambulatory care by hospital specialists. However, shared care by GPs and specialists for patients with chronic heart failure after discharge from hospital can deliver better patient survival."


.... compared to unshared care after discharge form hospitalist??

This observation in chronic heart failure will revolutionize Ontario and spur establishment of multidisciplinary shared PCGs for all?

Has anyone stopped to ask if this might be an ecologically valid generalization of treatment in chronic heart failure to all conditions?
August 25, 2015 | Unregistered Commentereklimek
These are beliefs being put into real world use. Central control is better, it will improve things. A bekief system.
August 25, 2015 | Unregistered CommentermovingforwardOntario
CICM: No, I think these are not the same folks. I glanced at some bios and our authors were made right here in Canada...which may be a piece of the problem.

The meeting with the LHIN re PCGs comes closer and closer. No response to my call for participants among our group until today when almost everyone decided they want to hear what the LHIN PC Lead Physician has to say.

In trying to gage how to approach this without rattling them so much that they find objective evaluation (as far as that's possible) difficult, I'm going to approach it from the perspective of just yet another funding model, but with its own particular wrinkles. And a model that cannot be implemented all at once, but has to begin in a sensible workable way. That is, it starts out on a relatively modest basis ramping up over a period of time. I'm not sure I believe this myself, but I need the group engaged enough to get to the heart of the matter and get their heads around it for their own protections.

Of course, no one is sure what the scale of the starting point is going to be...and that's a bit of a problem if one is going to try to approach this in an intelligent informed way. If we are going to have to do this, then, we have to figure out how to do it in the way that's best for the patients, and in a way that the providers can live with. So our group needs to have a grip on how it will go about this if it has to.

A week tomorrow is the big event...
August 25, 2015 | Unregistered CommenterSybil
Thanks Sybil. Keep us posted and good luck.

Thanks to all of you here who continue to give me a bright spark in the day.

Eklimek..I'm with you..."super"...when do we start...

ELB, I think the nuance of my phrasing wasn't so good. Of course the needs of the rural and remote and the north have not been met. Perhaps I should have written clearly "attempted to be met"...

"With all due respect, Dr. F, I do not accept that the needs of rural and remote communities have been met at all."

In any case, eklimek sums it up best:

"But the risk of death still increases with distance to adequate emergency care."

And while we build super duper central palaces to make sure the liability risk is covered off...the rural folk are basically forgotten as the urban utopia expands with light rail, daycare for all, free drugs, and don't forget Centres of Excellence!

Ah, the vote buying just gets more substantial as the pandering goes on.

The North is a big problem though. Rapidly growing young population without high quality tertiary care. Big issue.
If we cannot easily recruit to rural practices, say, one to two hours outside an urban centre then how can we expect to recruit farther out than that? And, as has been said before, current graduates are mostly not equipped to deal with less than a full team or indeed with the routine uncertainty every family practitioner faces on a daily basis.
August 25, 2015 | Unregistered CommenterSybil
"as has been said before, current graduates are mostly not equipped to deal with less than a full team or indeed with the routine uncertainty every family practitioner faces on a daily basis."

Perhaps there is too much training going on in Toronto.
In all honesty, if medical practitioners would sooner go to certain locations beyond Canada than work where they are "required" to work, what possible government manipulation is left? Forced labour? Military recruitment? What?
I know of a new specialist graduate who chose to move to Australia rather than go to Saskatchewan (and Saskatchewan is looking pretty good right about now!)
That may not seem very Canadian, but the person did not like cold winters. So there you go. What'ya gonna do? Build a wall?

Do we force Engineers to go where government dictates? Architects?
Big Government appears go have become too big for its britches....not a good thing.
R:

We are the government. We are here to help. Most can not move, leave, or whatever. They must deal with the plan. Central knows that. Needed bodies can be found by adjusting the standards. As you know disruptive behavior, can and will be dealt with, and conscientious objection to any central mandate is not allowed.

Resistance is futile.
August 25, 2015 | Unregistered CommentermovingforwardOntario
We will be assimilated.
August 25, 2015 | Unregistered CommenterSybil
Dr Day's Charter Challenge becomes increasingly significant.
Physicians in Ontario HAVE been assimilated, and are now "budgetable".That was the goal. A fixed budget for the physician population. The health economists' golden dream. Achieved, and not reversible. Other Canadian jurisdictions will be adopting Ontario's plan within the decade. Physicians as state employees.
August 25, 2015 | Unregistered CommentermovingforwardOntario
"Blackmer raised the idea of mobile euthanasia units, such as those used in the Netherlands, “that can go from community to community, and help with assisted dying.”

http://news.nationalpost.com/news/canada/0826-na-assisted-death

A mobile unit (or several?) for each LHIN or PCG?

Seems as if things are moving very fast. And no conscientious objection is tolerated. I-800-itstime?
August 25, 2015 | Unregistered CommentermovingforwardOntario
Oh!
I saw that too,
It's plain to see the bias at the CMA.
"Mobile euthanasia units"
Equal Opportunity Death Squad at your service!
Wouldn't want anyone to be left out now would we!
It's MontyPythonesque.
August 25, 2015 | Unregistered CommenterRealist
"The CMA is also developing a two-day course on care at end of life, including the “technical aspects” of administering a lethal injection or prescribing a fatal overdose."

It's hard to believe I'm really reading these words.

Sure, a two day course should do it. EasyPeasyLemonSqueazy.
August 26, 2015 | Unregistered CommenterRealist
PCG and physician as state employees...forcing them to work in specific areas.
Sounds like the soviet gulag...


On the other hand, 90% of all Ontarioans are within 5km of a pharmacy. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3082386/

Maybe because pharmacies are still at least 50% private? and required by law to be owned by a pharmacist? (except for those in existence before 1954 ie Shoppers)

Plus pharmacists are still trained to be practice solo....no referrals and you rarely get to work with another pharmacist.

This provides interesting reading which may be relevant, as Sweden had a government monopoly on drug/pharmacy distribution for 40 years...
http://www.willach-pharmacy-solutions.com/au/news/press/Learning-changing-market-Sweden-pharmacy-industry.php
August 26, 2015 | Unregistered CommenterOutPatientPharmD
Let's hope the CMA is not going to call upon Arizona executioners for their lethal injection formula.

It is interesting that big pharma no longer wants to have their drugs used for involuntary end of life injections but one wonders about voluntary end of life injections? Seems a little hypocritical to call the former an execution and the later ''healing" if deemed acceptable to use the same drugs.

"For both moral and public relations reasons, pharmaceutical companies no longer want any association with the death penalty process. Their drugs are to be used for healing only."

http://www.npr.org/2015/01/06/375399560/botched-lethal-injection-executions-reignite-death-penalty-debate
August 26, 2015 | Unregistered CommenterCanary in a Coal Mine
One must have some empathy to the older physicians in Ontario whom must be in shock, seeing their profession going from one as being caring for an individual's healing needs, to being the employed driver of the "mobile euthanasia unit" to those who couldn't get the needed care.
August 26, 2015 | Unregistered CommentermovingforwardOntario
Why do physicians want the role of "biology ceasers"?

Why not, since the times have changed, split caring for biology into two roles, both requiring appropriate regulations. One requires a license to be a "maintainer or restorer" of biology, the second, a license to be a "ceaser" of biology?

For those physicians who wish both roles, they maintain competence in both areas, for those who which not to be involved in either role, they pick the role they wish.

I, for one, am becoming hesitant about the motives of a state employee who holds both roles, in tough economic times.

Things do move fast these days.
August 26, 2015 | Unregistered CommentermovingforwardOntario
At the scene do you call 911 or 666?
August 26, 2015 | Unregistered CommenterEklimek
It will be interesting to see who claims the service fee for the "cessation of biological function"!
August 26, 2015 | Unregistered CommentermovingforwardOntario
"Is this the same Baker-Price?"-CICM

http://www.biomedcentral.com/1471-2296/15/158

Not sure but it seems likely.

So much health management, so little improvement.
Andris, don't forget about Kevorkian. I suppose the justifiers just think he was ahead of his time.

That slippery slope is looking more like a greased slide....."mobile euthanasia units". Really.
Realist,

Sybil above said that he/she thought the authors were different but it sure seems odd to have one Baker-Price duo in Canada and another pair in the UK but both in academic family medicine looking at team care.

Maybe someone with a report could look at the initials to confirm. The British authors are Richard Baker and Egle Price.
August 26, 2015 | Unregistered CommenterCanary in a Coal Mine
CICM:

David Price, MD
Provincial Primary Care Lead; Chair of the Department of Family Medicine, McMaster University; Chief of Family Medicine, Hamilton Health Sciences

Elizabeth Baker
Provincial Nursing Lead; Primary Health Care Nurse Practitioner; Legal Nurse Consultant
August 26, 2015 | Unregistered CommenterSybil
Thanks Sybil.
August 26, 2015 | Unregistered CommenterCanary in a Coal Mine
So far:

One party - balance budget now, no new taxes.
One party - balance budget now, more taxes
One party - don't balance, more taxes
One party- don't balance, more taxes

Majority government - balance budget now, more taxes
August 26, 2015 | Unregistered CommentermovingforwardOntario
"Majority government - balance budget now, more taxes "

I dont see how you got to that
McMaster and a Nurse.
NDP majority.
August 26, 2015 | Unregistered CommentermovingforwardOntario
Might want to rethink the exhaust inhalation method.

http://lostallhope.com/suicide-methods/carbon-monoxide-co-poisoning
August 26, 2015 | Unregistered CommenterEklimek
I believe the NP is also a lawyer.

There were other authors/experts on the panel, but, of course none of them getting their hands dirty in the trenches as far as one can make out. It's an academic exercise, conceptual in approach, with the devil in the details of implementation.

Monday's work with it caused me to have a double order of fries and gravy for lunch and ice cream and two glasses of wine for my dinner. Perspective restored...sort of...
August 26, 2015 | Unregistered CommenterSybil
"Mr. Mulcair promises an NDP government would “use any budget surplus” to restore the 6 per cent escalator. “Money alone cannot solve the problems facing our health-care system. But without money, we won’t solve a thing,” he told the Canadian Medical Association in 2014.

The approach promised by Mr. Mulcair and Mr. Trudeau has a clear track record of failure. Despite its good intentions, the 2004 health accord negotiated by former prime minister Paul Martin reduced pressure on the provinces to overhaul the outdated architecture of their health systems. As the Naylor panel noted, most of the $41-billion transferred under the accord was used to increase doctors’ fees rather than invest in innovation or more cost-effective ways to deliver health care."

http://www.theglobeandmail.com/globe-debate/more-federal-cash-for-health-care-is-not-the-solution/article26115857/
August 27, 2015 | Unregistered CommenterCanary in a Coal Mine

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