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. 






Health Reports: Bias or No Bias?

There is no shortage of organizations and institutions reporting information on the status of Canada's health care system. Journalists, CIHI, ICES, Statistics Canada, OECD, and The  Commonwealth Fund come to mind but there are many "institutes" and "centres" that gather data on how long patients are waiting, what they are waiting for and how provinces compare.

What's curious is the huge variation in the conclusions. Some say that aging of our population will not pose a problem. The same organizations report that public health care is fully sustainable.  We just need to be smarter about how we use resources. Big Data is going to be the saviour.

Other organizations use data to show that wait times are increasing and that the aging population will cause social entitlements to buckle, including pensions and public health care. Their conclusion is that the public system is unsustainable and that just about every option should be on the table including copayments and private options for medically necessary care. The message I hear from these organizations is that we need to look ahead and prepare for changing times.

Can the public sift through the barrage of information to find the truth?

Is there bias, unconscious or conscious, by journalists and left or right leaning organizations that report on health care?

Answer to the first question is that people judge the health care system by their own anecdotal experience. If things go well for them or their loved ones, they believe the system is just fine. They do not see what is happening to other patients in their own region or elsewhere. The reality is the vast majority of citizens are not waiting in queues. They simply do not know what the reality is for others.

Answer to the second question is that bias is quite likely. It's fairly clear that some groups start out with an end point that they want to prove using data. Unfortunately, the data can be selected and is not complete. I often use the analogy of health care as a balloon. If you squeeze one area, another will bulge-you just may not see it if all changes in the health care system cannot be simultaneously evaluated.

As I've said many times here, the unintended consequences of government health care decisions are not usually apparent at first. They occur over time with the result that the decision that prompted the change elsewhere is difficult to link. Health care is truly a complex system.

The Mowat Centre, a left leaning think tank initially created by Dalton McGuinty with five million dollars in provincial seed money, reports that the "doomsayers" about sustainability are wrong.

The Fraser Institute, a right leaning think tank, raises the issue of unsustainability and makes various recommendations for changes.

What are the risks of siding with one or the other?

If you subscribe to the "just work smarter all will be well" camp, there is a distinct possibility that this prediction will be wrong. It is not possible to know what the changes in a complex system will create. It is also impossible to predict sufficient efficiencies for the future that is unpredictable.

If you subscribe to the "act now to create more ways for patients to get care" camp, there is a  chance that the flexibility created will drive free-minded innovation and that the need for accurately predicting the outcomes of various programs will have less significant impact if the predictions are wrong.

Governments can regulate. They can fund provincial public health care systems, but there is danger in wishful thinking. Let us prepare for the worst case scenario. Let us be prepared.

On another note, I would like to thank you all for your contributions especially in the past few weeks. 

Cheers to you!








Defining the Problem in Health Care....with Vision

A number of current events have prompted this journal entry. We've recently heard from the Health Council of Canada, soon to be moth-balled, where Jack Kitts, chair of the Council's panel was quoted as saying:

"Most Canadians think that they have good health care; yet, the evidence suggests the system is not as good as they think it is."

The newest report from the HCC discusses how the health reforms that governments have taken in Canada have not created the transformation required. So good to hear some honesty about wait times and the failure of billions of tax dollars to make any significant change. Some of you may take this as negative but after so many years of being advised that to lead in health care we must take part in Groupthink it is a relief to see an  evidence based report that confronts reality.

And that made me reaffirm my thinking:

The happy thoughts and attempting to deliver "the right care, to the right people, at the right time, in the right places" might not be working the way the decision-makers intended.

Why is this?

With so many talented, dedicated people trying to innovate in health care, why are the changes not resulting in the improvements that were anticipated and why are there so many unintended consequences?

Quite possibly, it is because we have defined the wrong problem(s) to be solved.

I'm a keen reader of the Harvard Business Review Blog Network and an article by Bart Barthelemy and Candace Dalmagne-Rouge from September 13, 2013 caught my eye. Here are some snippets from "When You're Innovating, Resist Looking for Solutions" :

" soon as you start thinking of a solution, you unconsciously begin shutting off possibilities for getting a deeper understanding of the problem and therefore of finding a truly breakthrough solution....It's better to stay in what we call the "problem space" for as long as possible."

"So go deep. Look for underlying issues. What's the real obstacle you face? Once you've found it, go deeper still. What's the essence of that obstacle?"

"Search for different viewpoints."

"Don't be afraid to bring outsiders into the discussion."

"Staying in the problem space, in particular, can be difficult."

Over the past decade, decision-makers, consultants, politicians, bureaucrats, Ministers of Health and Deputy Ministers as well as organized physician representation have been focussed on efficiencies, doing "more with less", teams, ehealth, coordinating care, improving "value" (however that is defined) and big data. 

But what if the essence of the problem isn't really related to any of these things?

What if the areas mentioned above make the health care situation worse by moving tax dollars for health care to other endeavors that don't improve care or improve access or improve health?

Isn't the problem we are facing in health care really the inability of government to fund all of the medical services  required and demanded by a population that has grown to believe that government can provide for all of its needs?

If we want to find solutions in health care that improve access, maintain or improve quality, and decrease government costs to a sustainable level then we need to redefine the problem with long term vision.

According to a recent report from the Society of Actuaries and Canadian Institute of Actuaries released September 17, 2013, Canada's current health care system is not sustainable over a 25-year horizon. As reported by the Rock Hill Herald, the study predicts that provincial and territorial governments' annual spending on health care will increase by approximately 133% from 2012 to 2037 and the expenditures will be close to 86% of governments' own source revenues.

Key findings:

*Growth rates will make it almost impossible for provincial and territorial governments to service their debts and program other services such as education, social welfare and infrastructure."

*There are two key causes of growth in the proportion of the budget: real growth in health care expenditures largely due to the aging of the population and reduced growth in GDP as the working population grows much slower that in the past."

*The revised Canada Health Transfer formula anticipates the future share of the federal government will drop to 14% by 2037, further reducing the amount available to provincial and territorial governments for other program expenditures."

"This report's findings confirm that funding future health care expenditures will be challenging for provincial and territorial governments even if the CHT remains unchanged."-Gary Walters, member of the report's Project Oversight Group.

Which brings me to the article I first spotted in the Kelowna Daily Courier a few weeks ago regarding the plans of the Westbank First Nations to build a 100 bed private hospital. The first phase would include 10 operating rooms and full lab and diagnostic services. Tentatively called the "Lake Okanagan Wellness Clinic", it would use public funds to treat aboriginal people but would also treat Canadians paying out of pocket including joint replacement surgery and cosmetic surgery.

There are also plans to conduct research into diabetes and heart disease and "treat people long-distance using closed-circuit TV".

The National Post reported on this exciting health care development in the last few days and so far I have not heard any vociferous backlash from DoctorsforMedicare or Friends of Medicare or other loud union-backed groups that prefer to support creating and maintaining dependency on a health care system unable to meet the overall demand for care.

Perhaps by defining the problem in health care as an overwhelming dependency on an overburdened public health care system we can move to truly innovative solutions that create more opportunity for care, strengthen initiative and support truly vulnerable populations.

I am hopeful.

Once again, thank you for your support over the years and for your ongoing participation in this important health care dialogue. I truly value my contributors.

Thank you.


Big Data Consequences

Health Informatics and Data Analytics are burgeoning fields following on the footsteps of ehealth efforts. Big Data is now touted as the solution to solving health care costs by mining for numbers and patterns. Some influential people believe that the "Watsonization" of health care is also at hand whereby computers will diagnose the disease or advise on next steps.

I can't help think of how the car industry has evolved from mechanics to computer identification as to why the dashboard is flashing various lights....problem is that patients aren't cars or widgets with replaceable mother boards. They are a complex combination of emotional, psychological, physiological matter held together with bones and flesh. And our brains...way more than grey and white matter with some synapsing neurons and a few sulci.

As always the devil is in the details and at a time when clear communication and positive relationships are acknowledged as key to patient well being and patient satisfaction, efforts are in full swing to mine for data from health records or any other data that various networks and health systems can get their hands on.

Whether it is analysis of care coordination, readmissions or even medication compliance we should acknowledge upfront that numbers don't tell the whole story. Human behaviour is as complex as our physiology and when we combine the complexity of providers with the complexity of patients and the complexity of our environments we have something that even Big Data  cannot fully elucidate.

For providers it means a system of payment more focused on generating data that can be tied to funding either positive or more likely negative as economies fail to grow.

As provider funding is tied to data and generating patient indices or outcomes deemed "positive", expect a greater attempt by providers to choose more optimum practice locations or select patient populations. The law of unintended consequences will be in full swing.

When governments tie financial incentives to patient selection for various kinds of care including the murky "end of life care", we can expect Liverpool Care Pathway type events to occur.

Providers incented to select patients for end of life pathways and hospitals provided with funding to deny patients care is not a recipe for trust.

Who will the patient trust to give them medical advice on their care when the physician or nurse or other is conflicted in their attempt to preserve the system or limit care?

How do we ration based on evidence or quality or value when there are so many unknowns?

When do we determine that a patient should have an "end of life discussion"?

Why does any decision-maker in health care believe that Big Data can take the place of the relationships that humans seem to need so deeply?

When will the public and patients come to the realization of the risks inherent in the sharing of their personal data for government rationing efforts?

What does Big Data do to caring and compassion?

None of this is to say that evidence isn't important in creating understanding of medical science. Neither is it to say that we don't need statistics and facts.

It's just to say that as we create more complexity and try to comfort ourselves in data, we are mixing a recipe for more costs and not better outcomes either in patient satisfaction or in eventual quality of life.

As always, I'm grateful for your insights!




The Canada Health Transfer-Where Do We Go From Here?

Having observed the mainstream media with interest for the past 10 years or so, I have become aware that it generally has the attention span of a gnat. All a premier or highly seated politician needs to do is mention the word "election" and the media goes into reaction mode, running and twirling about at a frenetic pace trying to get the stories out and align their sources. Almost everything else of significance seems to fall by the wayside as the pursuit of power takes main stage.

Does it matter that the ball gets dropped on so many issues involving health care as the focus switches to power and politics? I think it does.

In Ontario, we have major long term care issues and hospital access being rationed more severely as dementia patients are moved out quickly to home rather than long term care despite the inability to have their needs met even with home care and loving family. We see a rise in interest in "end of life care" and euthanasia which may be timely "compassion" given the demographics but I suspect the interest is driven by an attempt to reduce health care spending rather than anything else.

In Ontario, Premier Wynne is out canvassing Ottawa South neighborhoods with the Provincial Liberal candidate in the next by-election. Meanwhile we have breathtaking news on deaths that could have been prevented had ORNGE not had the problems it had. We have the provincial ombudsman turning away 369 complaints related to systemic and individual problems in hospitals because only in Ontario are hospitals barred from ombudsman scrutiny. Apparently patient advocates are supposed to deal with this but they report to hospital management with no power to investigate or to report publicly.

There are health care and hospital issues that the public should be aware of but reporting them may not be  in the best interests of Ontario politicians.

So what does this have to do with the Canada Health Transfer or the Canada Health Accord? Lots.

In the past two to three decades, the provinces looked to the federal government to solve their health care spending problems. They called on the Feds to pony up more and more cash to solve what what was a provincial denial of the demographic, economic and scientific shift taking place. The health care programs that provincial governments had created while the federal tap was open were no longer sustainable as the federal government grappled with its own financial house in a post 2008 Great Recession era. Even with one eye open, the provinces should have seen the demographic challenges coming but only the short term eye was open...the long term eye was fully closed and the mouth too as provincial political and health leaders only told the public what it wanted to hear.

An aging demographic, growing pharmaceutical use, advances in science and technology and surges of nasty new germs and drug resistant bacteria are upon us.  In some magical thinking the provinces expected the federal government to keep sending more money to the provinces for their needs that should have been identified and dealt with over the past few decades. It's as though the provinces believe the feds have nothing else important to spend tax payers' dollars on. National security? Nah. Combatting terrorism? Nah. Cybersecurity? Nah. Immigration? Nah. Environmental issues? Nah. Economic stability? Nah.

It's not surprising then that the Canada Health Transfer payments will have a new funding formula as of 2014. Payments will be on a strict per capita basis beginning next year and in 2017-18, annual transfer payment increases will be linked to economic growth and not the 6% escalator since Paul Martin's "fix for a generation" in 2004. Paul Martin's fix didn't work including 41 billion tax payer dollars. Try something else.

It's not as though the federal government is discontinuing the transfers. It is continuing them, even increasing the amounts being sent to the provinces but to some critics this isn't enough. I am left to wonder if they want to bankrupt the nation and provinces to provide more and more health care that they are told Canadians "want" which given debt repayments will cost more and more ultimately delivering less and less.

Canadians need to understand this.

Premiers will be gathering for their Council of the Federation meeting in Niagra-on-the-Lake next week. Let's hope that each one of them can open both eyes and their mouths and utter some honesty about what it is going to take to address future health care needs. More provincial whining will not serve Ontarians or Canadians.

What do you suggest?



Unaccountable Health Care Consultants

An article with the headline "How Doctors are Bankrupting Health Care" appeared in the National Post recently. The article is disturbing on a number of levels, least of all that neither of the authors are medical doctors and appear to have little real life knowledge of the nuts and bolts of medical practice. I will explain why that matters.

Steven Lewis is a health policy analyst and Terrence Sullivan PhD is a behavioural scientist. Both have extensive experience in health policy and have been involved in various health care organizations...but they have never been physicians to my knowledge and it shows.

All too often in health care transformation in Ontario and in other parts of Canada, decisions are made based on incomplete analysis.  Physicians are frequently considered "stakeholders" and their input is seen to be self-serving. This is a mistake and has led to numerous decisions that have not been kind to public health care.

Health care is complex and the challenges facing all Canadians over the next 30 years will need many solutions. Beware of the health care consultants and experts that tell you they have the answer whether it be abolishing fee-for-service or creating health care teams or co-ordinating care. None of these solutions will be sufficient to meet the future health care needs on the back of an aging and less productive population.

The authors write that "the only way to permanently de-escalate health care spending is to do less with less". I disagree. It is entirely possible for the public in general to do more with more. More mobile health technologies that encourage health literacy and encourage inexpensive text messaging support have huge potential to improve the health of large numbers of people with the result of decreasing utilization. Unfortunately, the privacy laws and physician regulatory colleges are not keeping up with the changes in public acceptance of trade-offs in privacy for convenience. What role do regulators have in increasing health care costs? Substantial-because they limit the ability of patients to access decision-making information and support in a less expensive way.

The authors write: "The only way to contain health care spending is to change the deals we make with doctors". Wrong headed again. They blame fee-for-service as the cause for rising ulitization costs yet it is probably the most effective way of maximizing the use of our current pool of MDs. Looking at the number of patients seen by MDs working in other models such as Community Health Centres and Family Health Teams, studies show fewer patients seen per MD once MDs move to these models. This is an important consideration given the costs of training physicians as well as the ability for the pool of MDs to provide the necessary volume of services to an aging and growing population. For specialists as well, productivity is an important aspect of efficiency and despite an attempt to downplay the importance of productivity by suggesting that a doctor's activity and productivity are not identical, the ability of patients to get access even to be triaged or prioritized requires access to physicians which could be reduced if salaried positions take the place of fee-for-service. What is needed is a balance of different kinds of funding models and the freedom for physicians and patients to choose what model fits their needs best.

The authors state that "those with office-based community practices are neither formally part of, nore meaningfully accountable to health regions or their equivalents". This may be true but we need to ask how much tax payers are willing to pay for "accountability" wrapped up in various packages of costly bureaucratic entities of various kinds instead of front line care.

Is it better to have many layers of administration and consultants and monitoring and measuring than it is to have more front line providers accountable directly to the patients they serve?

Lewis and Sullivan go on to mention that physicians "can set up practice wherever they want". This isn't  an accurate statement. Many specialists require hopital related facilities such as operating rooms, hospital beds, and staff and many family physicians understand they must locate where the patients are.

Their statement that "Conscientious and engaged family doctors who spend time dealing with the challenges of complex geriatric cases earn lower incomes for doing so" may reflect that some models of care may be better suited to assist complex patients. It is not unusual for family doctors to spend more time with some patients and less with others. Overall, the hope is that it will balance out in a fee-for-service setting but admittedly, some practice settings may serve complex patients better than others. Does this mean that there should be a complete switch to a different model of care that these authors seem to prefer? No. There needs to be a variety of care available to suit the needs of different patients at different times in their lives.

Studies show that the most expensive models of primary care include Community Health Centres and Family Health Teams with no proven outcome improvements. Clearly, planners and policy types cannot completely understand the behavioural and genetic and environmental nuances that will affect overall health. Only a fraction of health can be directly linked to medical care and spending more public dollars on manipulating provider models that are unlikely to yield improved health outcomes or cost-savings are not in the public's best interests. It is also important to note that to improve access to hospital care and procedures, that changes to hospital funding are shifting away from global hospital funding to funding that follows the patient (similar to a fee-for-service program).

As for ordering tests, the authors state "One physician may order three times as many tests for her patients as her colleagues, neither is likely to know that this is the case and there are no consequences for doing so." This clearly shows the authors' lack of insight into real life medical care. First, depending on the type of patients and the illnesses those patients have, more tests may need to be ordered. No two practices are identical. Second, there are significant natual disincentives to ordering tests and making referrals. It requires time to fill out the form/write the letter/include pertinent clinical information or print the forms off electronically. It takes time to explain to the patient why the test is being ordered or the referral made. It takes time to sort out who the patient will see. It takes time to review the tests when results are back and to document the actions and speak with staff or make notes or send an electronic message to staff. It takes time for the staff to contact the patient to follow up or to direct the patient on next actions. In fee-for-service, all the actions above are to be covered by the fees from the one visit. The fact that the authors don't seem to value all of the additional unpaid activity on behalf of the patient is notable and reflects the reality that they have never practiced medicine.

I have saved the most outrageous comment from these authors for last:

"It is one thing to grant late-career doctors the right not to change; it is going too far to allow them to continue to hold their colleagues, government and the citizenry hostage to the obsolete constructs of the ancien regime."

This is, to put it simply, stunning ignorance. To suggest that "older-physicians" are somehow holding anything "hostage" is absurd. It is the hard working physicians of the past 20 years that have managed to hold the public health care system together amidst Rae Days, income caps and the short sighted slashing of hospitals, hospital beds and medical student positions in the 1990s resulting in the access problems the public has felt for the past 10-15 years. It is estimated it will take at least two new medical graduates to replace one of the "older physicians" these authors refer to.

As a physician for the past 25 years I have seen many changes in health care.  Mostly they are reactionary, designed to address some political need and mostly for some short term election requirement.

Do the consultants who propose them prosper? Yes.

Are the consultants who are paid to create the solutions held accountable for the results? No.

Do the doctors who make the health care system work and who care for patients persist in their service to the system despite articles like that of Sullivan and Lewis?