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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
Sep282015

Politics and Pharmacare

I've written on this topic before several times but pharmacare keeps popping up during the lead up to the federal election on October 19. The political parties aren't talking about it much but others are.

One of the obstacles to creating a national pharmacare program in Canada is cost but an article that appeared in the CMAJ some months ago suggested billions of dollars in health care costs could be saved through such a plan. Others chimed in. It sounds so good.

But there are a few problems with the depth of this study.

In order to understand how billions of dollars in savings from a national pharmacare program are NOT possible, we need to understand several points.

1. The study looked backward not forward.

New medications associated with new screening tests and new biomarkers are on the horizon. Immunologics and biologics for chronic disease will not be curative but they will be expensive. New tests to assess who will benefit and who will not and new modalities for assessing cancer survivorship. It is not reasonable to exclude the costs of these medications and the costs of the tests and the costs of increasing chronic diseases from the assessment of potential cost savings.

2. National Pharmacare is intended as a sister program to Medicare in Canada.

While this may seem noble, our single payer health care system is not managing very well. Adding another big, bureaucratic system when we are already unable to meet demand in its predecessor does not make sense. Albeit that medicine is changing and more medications are taking the place of various procedures, the possibility of creating a "free" system for pharmacare will increase demand. We have seen the result of limitless "free" medical care with growing wait times and closures of hospitals to drive more care to the community where much of it remains unfunded.

What would be the result of a national pharmacare program that will be required to ration its availability? Which diseases would remain orphaned? Which would become new orphans? Which lobbying group would obtain coverage? Which political group will aim to benefit by promising what it can't later deliver?

3. Health care is a Complex System.

No matter how many times one puts "National" in front of a government program there can be no guarantee of the results. Making pharmacare a national program is an attempt to nudge more tax dollars from the federal government when the likelihood of savings is highly unlikely.

Once a national pharmacare program is in place it can't be taken back even if its costs soar to higher levels than expected. The supporters will say "Who could have known?"

Health care is like a balloon. Squeezing one area results in a bulge somewhere else. Blowing it up past its capacity results in a great big POP and structural failure.

While it is not possible to predict cost savings in such a system with so many variables beyond the actual cost of medication, it IS possible to predict that the demand for medications to be included in such a program will be ongoing. Political games will be played and effects will be felt elsewhere in the system...we just won't be able to predict where.

Does the unpredictability of such a system mean we should be doing nothing about creating a more universal system of pharmaceutical coverage?

No. It means that we should be looking at more reasonable ways to create coverage for the one in ten people who reportedly cannot afford their medications.

Instead of creating another complex bureaucratic system that will inevitably become politicized, let's look at the various programs that are working well to provide coverage for those in need.

4. A national pharmacare program requires provinces to relenquish power.

There are a multitude of provincial and territorial pharmaceutical plans in place to assist in medication coverage. Provinces hold the power when it comes to how to fund and how to manage publicly funded medications.

Will the provinces and territories accept that a national pharmacare program will define what they will have to provide? When it comes to provincial medical care provision, the provinces tend to show their disdain for federal direction. Sure, the provinces want more federal funding but when it comes down to directing the funds to their final destination, historically it appears that the provinces resist federal directives--happy to take the money, unhappy to be told how to spend it. And the federal government has limited tools with which to force the provinces to comply.

Will the provinces be willing to give up their power to the federal government? I doubt it.

5. If a national pharmacare program were to emerge, what happens to the ability of citizens to access private drug plans? Would they still be affordable or would they be so reduced in capability that their offerings would either be redundant or limited in nature?

Nothing in a complex system happens in isolation. Creating a national pharmacare program seems simple. It is far from it.

If we lose the ability of private insurance plans to cover certain medications what happens when a national pharmacare program determines that the cost of a certain drug is beyond funding? What happens when there is no significant private option to turn to?

We've seen this before. The single payer health care system has become monopolistic and denies patients care based on cost, availability, and rationing by other means.

What happens to patients when they are promised government pharmaceutical coverage but then the promises are broken? Sound familiar?

A national pharmacare program is not a solution. Instead, let us enhance the coverage for the one in ten Canadians who say they are unable to afford their medications. Hoping for billions in savings from a National Pharmacare program is unrealistic and misleading.

 

 

 

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

 

 

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.

 

 

Tuesday
Mar172015

Now is Not the Time for National Pharmacare

A recent CMAJ article by UBC's Steve Morgan PhD, and Danielle Martin MD and others entitled "Estimated cost of universal public coverage of prescription drugs in Canada" is making the rounds.

The Toronto Star picked this up and is now spreading the word about how affordable a National Pharmacare program could be stating potential savings of $7.3 Billion. This is misleading to say the least.

The abstract from the CMAJ publication includes as background that,

"With the exception of Canada, all countries with universal health insurance systems provide universal coverage of prescription drugs."

What the authors conveniently leave out is that Canada is the only developed country in the world that has a single payer health care system for medically necessary care. It is no surprise that it does not have universal public drug coverage. It can't even afford to meet demand for what it has already created let alone add other programs. The "game changer" CMAJ study conclusion is flawed on multiple levels.

First, let us acknowledge that despite many tens of billions of additional federal dollars in recent years, timely access to care in Canada is ranked last in comparison to many developed countries. The better performing systems are from countries with Hybrid systems that have universal medical care through a combination of  private and public funding mechanisms and which also have publicly funded pharmacare programs and even dental and eye care. 

Until Canada allows provincial health systems to evolve to hybrid systems using combination funding mechanisms, a National Pharmacare program is unaffordable, not because of the cost of the medication necessarily but because of the burden of single payer health care delivery.

It is not unusual for government programs to exceed their anticipated costs and for any savings promised to be elusive. We can look at the cost of Canada's former Long Gun Registry that was anticipated to cost 2 million and which reached 2 billion. Look at the cost of eHealth in Ontario and Canada to understand how programs that start out with predicted costs begin to balloon and cost many billions more than anticipated without even being completed.

Creating an ongoing National Pharmacare program that creates dependency but that can then have no end is a recipe for creating costs that are not affordable despite what some economists and well meaning physicians say. Once it is created, there can be no going back. Unlike the  Long Gun Registry, closing down a pharmacare program and cutting off medication to patients that have grown to expect it is a very different situation.

Look also to Quebec's experience with its publicly funded pharma program. Despite touting its universal public drug coverage for its citizens, Quebec has robbed its medical system to cover its pharmaceuticals. While the shift is not transparently done, it is at least clear that Quebec has difficulty affording access to quality medical care as its citizens swarm Ontario hospitals and MDs for access to care. There are always trade offs.

Other programs in Quebec were expected to save dollars by creating public coverage but did not. Several years ago a CMAJ article suggested cost savings from a publicly funded In-Vitro Fertilization program and yet cost savings did not materialize. In fact, the popularity of this program soared and costs with it so much so that recently Quebec women were encouraged to go about pregnancy "the natural way" with focus for at least three years!

The accuracy of predictions by the CMAJ and some well-meaning medical doctors is suspect. One Toronto-based MD wrote a few years ago that maintaining Canada's single payer system was no problem, our rising GDP was going to save the day. This is a sober reminder that not all of what we believe is predictable is truly predictable. It is a cautionary example of how a more cautious and thoughtful approach to health care is required so that politicians do not promise what cannot be delivered despite the best of intentions. Creating a dependency on entities that cannot be sustained is irresponsible.

Dr Danielle Martin, one of the authors of the study claims that it is with "certainty" that specific claims of cost savings can be made. I caution Dr Martin that in a world that is increasingly unpredictable, speaking in certainties may sound confident but can also be ultimately misleading.

However, there are many other issues with the report that should be identified.

The authors of this study may defend their report citing that savings can be had in a National Pharmacare program through the following mechanisms:

1. Increased use of Generic medications

2. Lower Generic prices generated through bulk purchasing

3. Lower Brand Name prices through economies of scale in price negotiations.

These premises are flawed.

Consider the drug shortages that have resulted in part from governments favouring generic drugs. The pharmaceutical industry is in upheaval responding to new realities in different ways by altering its assembly lines and looking to rebalance profitability. Only people with little insight into complex systems would believe that prices can be driven down through bulk purchases without some resulting compensatory response.

Look at recent concerns over generic drug manufacturer quality issues to understand where this kind of bulk buying will lead us. A National Pharmacare program that relies on "best prices" has potential to also rely on lower quality products without the choice that patients currently have. It also has the potential to reduce access to brand name medications which in turn creates changes in the pharmaceutical industry that are unpredictable. What effect on production will occur? What shortages will result? It's anybody's guess.

One of the other major flaws with this report is that it uses past information to predict the future. This may seem like a standard approach to health economists or to people who do not study major scientific and medical changes such as Genomics or Epigenetics but anticipating future developments is important to understanding the viability of any potential National Pharmacare program. Although specifics may not be predictable, it is clear to see that on the horizon there are many new life altering and life saving drugs. It is arguable that this is the very reason why a National Pharmacare program is needed but until economic conditions have improved, assuring the viability and sustainability of such a program is dubious at best despite the claims of cost savings in the CMAJ study.

It must be noted that many more expensive medications for rare diseases are in the pharmaceutical pipeline. Expensive immunologics and biologics are being developed and have promise for many people. Adding these to many new and expensive medications for cancer as a chronic disease and medications for age related diseases such as macular degeneration, it will be difficult to avoid the lobbying for coverage of more and more medications.

Once again, we will have created a program that creates dependency on public funding and it will distort access to medication as private options become limited or are passed up by patients. A National Pharmacare program that identifies medications it will include based on cost savings will have repercussions when patients are denied coverage due to cost and who have not purchased private coverage, much the way the public health care system fails patients who were led to depend on it and then who are denied access to the care or procedure based on excessive cost to government.

It is not uncommon for patients who have been denied public coverage of a medication for their cancer to have it funded through their private drug plan. A National Pharmacare program has potential to create an expectation by patients that their pharmaceutical needs will be met. This is as unfair as what has been created in our government funded health care system. Funded care may exist, but it may not exist for you despite the fact that you have paid into the system.

Now is not the time for a National Pharmacare program. The CMAJ study makes assumptions that future pharmaceutical demand can be assessed in a snap shot of today and of previous years. This is simply not the case. The affordability of universal public coverage of prescription drugs is currently not possible despite the best efforts of well-meaning individuals to present it as such. Once there is a Hybrid system for medically necessary care in Canada, this discussion could be revisited.

 

 

Thursday
Feb052015

Bending the Cost Curve Can Be Deceptive

This journal entry was prompted by a discussion on the cost savings efforts being put forth for end of life care. There has been concern voiced by various groups about futile care and how valuable health care resources are used in our dying days. Bending the cost curve at the end of life is seen as a way of improving use of health care dollars and quite a lot of effort has been put into pushing an agenda of "advanced care planning".

I am certainly supportive of palliative care efforts and supporting patients and their families in the process of dying. However, it has crossed my mind that these discussions were not had before now to any significant degree. While there has been the occasional Supreme Court case every twenty years or so regarding physician assisted suicide, there has never, to my knowledge, been so many efforts to advance end of life planning.

Rising costs to the health care system of government funded services near the end of life are one reason for the new found angst over "bending the cost curve" but is it true that encouraging limiting interventions and treatments in final years of life will save our single payer system from it's own success?

I don't think it will.

The reality is that dying is quite inexpensive....people have been doing it for a very long time at zero dollars.

Here's why all the fuss over costs at the end of life will make little difference to the sustainability of single payer care:

Longevity is increasing at approximately 3 months per year. As we get better at prevention, people live longer lives.

If you don't die from dysentery, diarrhea, pneumonia or child hood diseases, you grow up.

If you grow up and don't die from infectious diseases or war or trauma, you live to older age.

If you live to older age, the likelihood of having heart disease and cancer rises.

If you survive your cancer, diabetes, heart valve problem or quadruple bypass you then go on to have a 1 in 2 chance of dementia for which nobody has any good treatment right now and likely won't for a very long time. It turns out that our brains are complicated.

So all the efforts we provide in terms of prevention, or being "proactive" as Dr Hoskins likes to say, end up pushing up longevity. All the diseases we manage to stave off are replaced by others.

And I'm not trying to be negative about this. I'm simply pointing out the reality that the better we get at providing all the prevention and quality care, the longer we live and the more things there are to provide and screen for.

There will be no true bending of the cost curve other than by distorting it over a much longer timeframe or by rationing using indices created by government. If you fall outside the standard line that gov't draws, you are out of luck. In the current health care arrangement of "single payer only medical care", you have no options should your needs not fit the standard or vote-determined priorities.

We've said all this before but it is worth repeating because bending the cost curve isn't going to happen in any significant way. We might appear to be reducing costs at the end of life but that won't make up for all the screening and interventions that will need to occur in the last DECADES of life due to advances in genomic understanding and epigenetics as well as other technological advances.

The only way out is a Hybrid system. The "prevention" and "proactive" stuff isn't going to save single payer.

Now, let's get on with forging the way forward with a Hybrid system.

What legislation needs to be eliminated, changed first?

How should the innovation beyond gov't single payer be supported?

Who should support it?

When should it be started ?

What do you think? What are your suggestions?