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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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.


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.

Reader Comments (678)

For every dollar spent on coordination there is one less dollar on delivery. Money diverted to projects distant from patient care benefits those who don't actually deliver care. Is government feeding the monster it has built?

What are the measurable benefits in health outcomes to be expected by this most recent transformation? Is this simply the next iteration of nonmeaningful restructuring?

If no health outcomes are affected how will we know? Is any measurable outcome proposed?

Recall that improved health care services and products are constantly developed that beneficially influence outcome. What does this intervention by government add?
March 11, 2016 | Unregistered Commentereklimek
Yes, government is feeding the monster it built.
It's like a dishonest person being caught in a lie. They fabricate and embellish until they are called out on it or until the negative consequences emerge.

It's tough to watch Minister Hoskins attempting to justify the existence of LHINS let alone 80 sub-LHINs.

Unless you look with an educated and critical eye, it all sounds so's "Patients First"!

It is not any such thing.
March 11, 2016 | Unregistered CommenterRealist
eklimek, government will carefully choose performance and accountability measurements that don't tell the whole story but that can either reflect well on government or poorly on providers and institutions in which case they can have their funding "adjusted".

This will occur despite the reality that many, many outcomes and performance measures will be beyond the ability of providers and institutions to alter substantially.

It will simply be a new approach to rationing.

Come on folks, we can't go on like this.
March 11, 2016 | Unregistered CommenterRealist
As Merrillee pointed out in her presentation, Ontario had a robust primary care system that worked well....then , god help us, the political class decided to "improve" is called the Politician's syllogism

1) We must do something.

2) This is something.

3) Therefore, we must do this.

4) To improve things , things must change.

5) We are changing things.

6) Therefore , we are improving things.

As mentioned in the past ' an elephant is a mouse built to government specifications'....and that is what they are busy constructing....a massive top heavy MOHLTC/ LHIN/ mini LHIN mammoth , with resources from the coal face diverted , as Ed stated, to feed and maintain the parasitic monstrosity.

Their version of " Improvement" will result in a growing faceless kafkaesque health care bureaucracy that will force the medical profession to practice nonesense and our patients, their clients, to suffer the consequences of that nonsense....let's hope that they themselves will fall victim to it.

" You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing".( Sowell)
March 11, 2016 | Unregistered CommenterAndris
Physicians are no longer independent providers dealing with the patient. They are widgets in a centrally driven plan. Just get use to it. Just get the accountability for care transferred to the planners.
March 12, 2016 | Unregistered CommentermovingforwardOntario
" To be or not to be ( a widget) --- that is the question: whether 'tis nobler in the mind to suffer the slings and arrows of outrageous fortune or to take up arms against a sea of troubles and by opposing end them"....
March 12, 2016 | Unregistered CommenterAndris

You can not reverse things. The rich will be taxed more, the older wealthy will see loses of the saved up wealth, and more stuff will be free.
March 12, 2016 | Unregistered CommentermovingforwardOntario
As for that ironic ' Patients First' slogan....the powers that be must have been sniggering when the focus group came up with that one..." The first shall be last and the last will be first"

In 2 weeks the Feds will come up with their budget....if that fiddles with professional incorporation within its anticipated small business taxation changes it could well be the last straw for many.
March 12, 2016 | Unregistered CommenterAndris
How is forced rostering in any way "patients first". I am just an Ontario resident of no importance and don't want to roster with anybody. Where are my rights. I currently get my mini care in a walk-in outside of my LHIN in downtown Toronto. I will lose that completely as it's not true primary care. I have no private pay option. What is broken with primary care that needs to be fixed, nothing in the GTA at least that I can see. Stop treating me as a problem that needs to be solved. Go throw the money at the elderly-home-care-LTC folks that want to live forever in whatever debilitated state. It ain't me.
March 12, 2016 | Unregistered CommenterVera
Vera, I agree that primary care is not the problem and more attempts to reorganize it will not solve our current challenges.
As for people's choice about life or death, it has been my experience the vast majority of people want to live.

I caution anyone who suggests that the lives of other people are not worth living to avoid judgements. They simply cannot know how another person perceives their own value and quality of life.
March 12, 2016 | Unregistered CommenterRealist
Andris, it is human nature to begin to believe what is repeated often enough. I'm fairly sure that the powers that be believe they are doing wonderful things and have good intentions. Unfortunately, huge amounts of groupthink exist in health care policy ranks not to mention the eagerness of many to seek career advancement by supporting the status quo and comfortable health care dogma.

It's a case of The Emperor Has No Clothes.
March 12, 2016 | Unregistered CommenterRealist
We are in the age of authoritarian elitist, where those in power believe their views are best. There are things wrong with allowing individual choice. The state knows best what must be imposed. The issue is how must the state is willing to push. The state intends to redistribute wealth. Is the state prepared to force those receiving the wealth to conform to "good" health practices. If you are on the receiving end, can we force BMI reviews, force nicotine blood levels, and mandated drug screening.
March 13, 2016 | Unregistered CommentermovingforwardOntario
Rebuilding healthcare (again).

First what is the problem? From centrals point of view, it is that people get sick. Central believes if we are were just well, everything would be fine. It believes we can all be well. Central is wrong in its premise. Thus all redesigns are doomed to fail. The majority of health care, ongoing costs, are chronic illnesses, generally driven by poor genetics, or poor social conformance. We can't do much about poor genetics, and we refuse to act on poor social conformance because we don't wish to take away individuals freedom to be stupid. We are stuck. Thus we redesign what was working for most, to deal with our inability to address the problems.
We have done such a poor job, that we have actually reconstructed our system, to embrace "waiting" as a health care norm. We have taken medical care, which was high end, and able to treat many issues, effectively, and well, and loaded it up with social care issues, such that 30-50% of our medical resources are being applied to social care issues. Time to revert to a MOH, and a Ministry of Social Support. The current plan is really wrecking the medical acute care system.

On top of that, it is time to stop saying, aging is not having an impact, and will require more resources to get ahead of the rising aging dependency ratio. The majority of the aging will not have good enough health so that can going cruising on ships, until they die. Most of us "wither" away.
March 13, 2016 | Unregistered CommentermovingforwardOntario
" Is the state prepared to force those receiving the wealth to conform to "good" health practices. If you are on the receiving end, can we force BMI reviews, force nicotine blood levels, and mandated drug screening."-mfO

Reminds me of the Paris climate change pledge. Redistribute lots and lots but with no way to enforce the "pledge" not much will change.

As for your last post mfO, it's becoming increasingly clear that when genetics and family history predispose us to certain diseases, more screening and testing is helpful to identify the disease with or without a treatment that is 100% effective. Prevention through screening is quite expensive for government although may be very good for individual quality of life.

Prevention and screening modalities may be increasingly possible but will require forced compliance of various kinds or attempts at social behavior manipulation which requires limitation of individual freedoms and increasing judgement of various behaviors. None of these requirements are positive for a society that values freedom and individual rights.

In addition, one can prevent disease from tobacco addiction only to see it replaced with diseases resulting from marijuana, vaping, other highly dangerous drugs.

We see diseases like heart disease reduced but then find more cancers and dementia result.

I am not saying that we shouldn't be attempting to improve people's lives through prevention and health's just that these efforts will not result in lowering of health care costs.

You've heard me say that before. I support prevention and health promotion but everyone including policy people and politicians must understand these efforts DO NOT reduce overall health care expenditures over time. It's just fact.

The only event that reduces health care spending in Ontario to date is rationing and that is problematic for the coming decades because more single payer rationing will result in more and more waits and denial of care.

I'm waiting for the health policy regime to come out with public messaging that wait times are noble and a Canadian duty....Just watch.
"it is time to stop saying, aging is not having an impact"-mfO

You can say that again. Yell it...loudly.
As we move ahead, we will see loss of individual freedoms, because have 'socialized" our health care system. We can't afford individual freedom, when the cost of poor decisions is borne by all of us.

Tobacco has primarily been dealt with through taxation. You consume tobacco we have put sufficient tax on those products that the poor decision costs you are paying out of pocket. That could be extended by regular nicotine testing. However, we are left with the dilemma of will we refuse care for poor behavior.

Next will be vaccinations. If you don't have the mandate vaccinations, and become ill because of that, who should pay the bills?

The issue will be, if bad behavior occurs, who is responsible for readjusting care. The MD provider, of the bureaucrat who creates the policy. One thinks more and more providers will more to the sidelines about acute care provision, as they are forced to act on social rules, rather than medical care.
March 13, 2016 | Unregistered CommentermovingforwardOntario
You should remember that vaccinations are not 100% either.

The shingles vaccine that government is now going to cover is only about 50% effective. Once could add a screening test to see who will be a responder but even that would likely be acting on incomplete science and would have additional costs.

We are coming to an age where lots and lots of information is possible but won't necessarily change personal behavior which means outcomes won't be changed either.

We can screen and vaccinate but Nature is quite "progressive" it seems.

People can be informed and educated and supported in their own health and wellness but this doesn't change the fact that mutations occur, deleterious exposures occur, life happens.....
All true, but we have removed individual choice and interpretation, in a "one size" fits all health care model. The more we lock ourselves into this, the worse the problems will be.
March 13, 2016 | Unregistered CommentermovingforwardOntario
The rope needs to be loosened not tightened. Individual choice will become increasingly important as we understand in greater depth what makes each individual's health capacity unique.

One size does not fit all.
March 13, 2016 | Unregistered CommenterRealist
The issue is dealing with the "envy" culture we are creating, where failure to achieve, despite good efforts to the level the playing field are present, is viewed to be society's fault, not the result of biological variability.
March 13, 2016 | Unregistered CommentermovingforwardOntario
We can certainly attempt to improve societal impact on health. However, as these efforts fail to produce the desired outcomes, policy makers will increasingly need to embrace reality. Scientific advances may help with that.
Sadly, the science can't overcome social utopian "ideology".
March 13, 2016 | Unregistered CommentermovingforwardOntario
No, but at some point the costs become prohibitive.
Watch New Brunswick. It will show the way.
March 13, 2016 | Unregistered CommentermovingforwardOntario
I see that The Ottawa Hospital is the second hospital to be hit by ransomware in recent weeks...

e-health is going to have significantly more costs
<“We are confident we have appropriate safeguards in place to protect patient information and continue to look for ways to increase security. We would like to reiterate that no patient information was obtained through the attempt.>
Keep looking for ways to improve security for patient records because it is going to be a never ending battle from here on in...
Ransomware....yet one more peril regarding utilizing EMR and computers in general...paper , pen and ink medical practices are are far more safe and sound and , yet, are being eradicated.

The sky is the limit for ransomware and other malicious technological schemes.

Those facilities , such as certain hospitals in the USA , that advertise that they don't use EMR are going to flourish and prosper.
March 13, 2016 | Unregistered CommenterAndris
Issue with out of country services for patients returning to Canada needing care.

Remember the MS treatment that proved to be an illusion? ( Everyone desperately wanted to have the veins dilated.)

"Researchers who surveyed Alberta surgeons estimate that province alone is spending a minimum $560,000 annually treating complications in people who have travelled to Mexico and other destinations for cut-rate bariatric surgery.

Doctors say abysmally long wait lists in Canada for virtually the only obesity treatment proven to provide long-term weight loss is driving people out of the country for surgery. Yet most don’t receive co-ordinated, long-term post-surgery care."
March 14, 2016 | Unregistered Commentereklimek
Well, when you have to wait 5 years for a potential treatment there are people who will go elsewhere.

It's not that bariatric surgery doesn't work for many people.

This musts be repeated many times over in many places...ER crowding is not caused by lack of primary care access. It is caused by lack of hospital beds.
The ministry requires that all patients requiring bariatric services, including surgery, must be referred by their physician to one of Ontario’s Regional Assessment and Treatment Centres (RATC) for evaluation.

To learn more about Ontario’s bariatric registry please visit the link provided below:

U.S. Preferred Providers: Bariatric Services

If a specialist from an Ontario RATC determines that a patient is a suitable candidate for bariatric surgery that cannot be performed in Ontario, the specialist has the option of submitting an application for out of country (OOC) prior approval.

Please Note: Applications for OOC bariatric surgery will only be processed by the ministry if the prior approval application has been submitted by a physician working at an Ontario RATC.
March 15, 2016 | Unregistered CommenterEklimek
ah..get permission to leave the country for a service that cannot be had in a timely way here but that our "universal and comprehensive" system will assist in funding...

Is this the first of many more health care registries for which Ontarians will queue to get services they have already queued for several times?

Queue to get appointment in primary care.
Queue for appointment with specialist.
Queue for MD at Bariatric registry.
Leave country for care.
Return if complication...

It just gets crazier and crazier.

What will happen to patients leaving the country for cardiac care and cancer care?
Will we have registries for those too?
Will there be a queue for death?
All services will be provided through MOHLTC providers, whom will decide the position in line you get.
March 15, 2016 | Unregistered CommentermovingforwardOntario
I recognize you are pushing the extremes of the concept but did we anticipate in the 1970s that huge quantities of tax $ would be spent on efforts to deny patients timely care in their own country, province or territory?
March 15, 2016 | Unregistered CommenterRealist

We moved from a market based system, where the poor frequently got poor care, to a state run monopoly, underfunded, for the care we want, where solved issues by having bigger wait times.
March 15, 2016 | Unregistered CommentermovingforwardOntario

Your point must be underscored. Patient navigation and coordination is largely a response to scarcity of services. If the service were readily available, this subcultural manic organization of coordination and centralization would vanish overnight.

Patients could chose providers based on availability, performance and outcome. Strikes me that is truly "Patients First"
March 15, 2016 | Unregistered Commentereklimek

We can't reverse this. Too many vested interests in maintaining the present system. Into this, we will add "pharmacare". That will break it.
March 15, 2016 | Unregistered CommentermovingforwardOntario
"Patients could chose providers based on availability, performance and outcome. Strikes me that is truly "Patients First""-eklimek

Well said.
March 15, 2016 | Unregistered CommenterRealist
It's not a reversal that is required. It's simply loosening the stranglehold on HC by politicians that is needed. It is necessary.
March 15, 2016 | Unregistered CommenterRealist
In case you haven't seen this and still pay voluntary dues to the CMA:
March 15, 2016 | Unregistered CommenterRealist
"If implemented properly and with conviction, this idea will not only immediately improve physicians’ morale and increase their sense of engagement, it will also measurably reduce patient error, virtually eliminate waits, improve access to specialist care and save governments millions of dollars. This elusive dream is a reality if we want it.

The solution, as unappealing as it sounds, is rather simple.

We, as physicians, need to stand up and accept responsibility for what is going on in our dysfunctional health care systems across Canada. If we won’t fix the problems, who will?

At the individual level, we need to hold each other to account for our actions and inactions. The easiest way for this to happen is for all physicians to be in salaried positions on one-year contracts that can be renewed if they continue to meet performance standards.

The peer-review processes that are used to evaluate an individual’s performance from the time they apply to medical school to the time they finish their residency training unfortunately tend to end once they enter practice. Most of our professional practices are not reviewed by our peers, and this needs to change. Peers should review each other quarterly and the results should be made public. We need to measure the quantity and quality of physicians’ work, the outcomes of their work and their adherence to standards of care. As part of the evaluation process, we need to ask patients whether their physician is available when they need him or her and whether their physician treats them compassionately."
March 15, 2016 | Unregistered CommenterRealist
As promoted by the CMA and Dr Francescutti
March 15, 2016 | Unregistered CommenterRealist
"The easiest way for this to happen is for all physicians to be in salaried positions on one-year contracts that can be renewed if they continue to meet performance standards."

There is little doubt many would see about 1/2 the patient load currently followed. Each remaing patient might see the doctor longer. Each remaining patient might be more "satisfied" with more face time. This would be an excellent method of slowing service delivery and decreasing overall volumes. Where do we sign up?
March 16, 2016 | Unregistered CommenterEklimek
Ahh the salaried, one year, accountability system, with dismissal as control. Here's an idea. Pass legislation, that all publicly funded salaried jobs, are one year contracts, with dismissal privileges. One is confident the public sector unions will support this, and close shop?
March 16, 2016 | Unregistered CommentermovingforwardOntario
"We physicians, need to stand up and REFUSE to take responsibility for what is going on in our dysfunctional health care systems across Canada. We did not cause its problems; we are working in a dysfunctional health care system not conceived by us, not constructed by us and certainly not managed by was conceived by, built by and managed by elected politicians , bureaucrats and the self described health care experts that advised them.

We need to hold them to account for their actions and inactions. The easiest way to make this happen is for all the health care bureaucrats and the advising health care experts to be placed on one year contracts that can be reviewed if they continue to meet performance standards...."
March 16, 2016 | Unregistered CommenterAndris
This blog about Dr. Rob Lamberts, an American primary care physician who has shunned all aspects of his original practice model for a patient-centered model.

Love this quote: it applies here, too:

<<People don't clamor for better care nearly enough because they don't know how bad the quality of their care is; and the reason they don't know how bad their care is in quality is because they don't know how good it could be.>>

Would be keen to read clinician comments.
March 16, 2016 | Unregistered CommenterExecutive Lead Blogger

The blog has not given much but, whew that was close. Insight is pending further posting.
March 16, 2016 | Unregistered CommenterEklimek
"Patient-centredness" has become a buzzword for lots of excuses as to why patients aren't treated in a way that makes them feel that they matter.

We can argue all we want about what is Patient-centred and value and what is quality but in a system that treats patients as expenses it is not really a wonder that they are treated as things to be moved along...that holds for a publicly funded rationed care system like Canada's as well as for the US system that has wonderful innovations and some of the best quality care in the entire world.

System that reduce the middle man-woman are probably where we need to go as much as possible. Reality is that complex care is very expensive and will likely require 3rd parties.

In the context of basic primary care, it's possible to reduce it to minimum bureaucracy with direct billing as in the MD above...however, only the very basics would be covered. That might be fine for many young men. Not so good for elderly patients.

I wonder what the MDs practice patient profiles are like.

It's too bad we have to have this conversation but it will become more and more important that we do. Building ever growing complexity and bureaucracy isn't a source of value or efficiency or quality or patient-centredness.

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