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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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Wednesday
Jan132016

Palliative Care in Canada

Way back in the 1980s it dawned on me that as a soon-to-be family doctor it might be wise to know a thing or two about Palliative Care. It seemed reasonable that I should know how to alleviate the suffering of my patients from various end stage illnesses. So I took a two week elective.

The hospital I trained at in Alberta in 1986 happened to have a palliative program and I learned about  hypodermoclysis and the like. I also learned about the staggering ability of the human body even when it is failing to tolerate ever increasing amounts of narcotics.

It was a serious topic for an elective but the staffperson in charge of the unit was a bright soul and the patients were always grateful. Physicians at the hospital knew their loved ones would get good care there. Unfortunately, the program was shut down several years later....perhaps a victim of its own success or perhaps because of the optics of having the beds filled with mostly "MD relatives".

Over my medical career I discovered that my skills in this area were not needed. The hospitals had Palliative Care teams and patients did not die at home for the most part. If that was the wish of the family there were Palliative Care MDs who would provide this service. I never did use the hypodermoclysis procedure but I did use lots of empathy.

In any case, the resurgence in interest in Palliative Care is driven not only by demographics but also by the Right To Die movement along with the Supreme Court of Canada ruling on Physician Assisted Suicide.

As hospitals are overwhelmed with Alternate Level of Care patients, the concept of patients dying at home has taken on new zeal and while the Feds plead for more time to come up with some kind of legislation to solve the murky areas surrounding PAS I wonder if legislation will ever come to be just as there is currently no legislation for abortion.

I do believe that more access to robust palliative care can be a real solution to alleviating suffering of patients rather than resorting to Physician Assisted Suicide. More training of family doctors will be required and more funding for access will be needed.

It is worth noting that caring for patients in their homes is a relatively inefficient use of medical services. This access to care will require time and the skills of physicians. It will impact availability of health professionals for other areas of care. There will be trade-offs.

It is time to understand again what was understood thirty years ago. Palliative Care is an important part of compassionate care. Too bad it took so long.

 

 

 

Friday
Oct232015

Predictions for 2015 to 2019 in Ontario

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

What does it mean?

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

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

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

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

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

 

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

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

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

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

4. Increased immigration that is not necessarily contributing to GDP

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

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

7. Pressures arising from Hospital and Pharmaceutical demand

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

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

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

 

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

2.  Minister Hoskins will step down in a year.

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

4. Patients will continue to see wait times grow.

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

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

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

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

9. Assisted suicide morphs into Duty to Die

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

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

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

13. Hospitals are grid-locked

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

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

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

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

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

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

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

 

What do you think?

Have your say!

 

Thanks to all who lurk, linger, and enlighten!

 

 

 

 

 

 

 

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.