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. 






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?




Health Links

I asked for suggestions on a new topic and HealthLinks came up-surprise, surprise. It has been on the radar only since the fall of 2012 and its timing is of interest.  It is the current government driven effort in Ontario to create efficiency and coordination of care including services for high needs individuals and for primary care and ultimately to create more integration of care at many locations and institutions...dare I say it is an effort at creating "the seamless continuum of care". I have not heard a LHIN CEO refer to it as the SCC but perhaps that acronym was taken already. From the illustrations I have seen it seems like HealthLinks is intended to be rather circular which wouldn't be far from the reality of the health care world sucking everything into its vortex.

(Forgive me if I'm not up on my black hole science terminology exactly but I understand that it generally consumes or absorbs most things it encounters-a lot like health care transformation.)

HealthLinks is comprised of Health Links, groups of primary care doctors organizing themselves to coordinate with other necessary institutions and professionals that will exist across the provinces under the control of the regionally based Local Health Integration Networks. They are local. They involve health. They are being integrated. They will create networks. So voila! LHINs now officially have primary care physicians to manage which they did not before, at least not to the same degree. As one of the posters to this blog pointed out, the health IT to accomplish this isn't quite settled yet but it sure is expected to make for excellent coordination of care! We'll see.

The LHIN landscape is littered with acronyms and you can already see that I have not been able to avoid using at least two. When health care types get together they tend to use the acronyms like another language and this may be helpful for abreviating for speedier discussion....mind you, it doesn't seem to matter that we talk and write and report on health care for decades, much about the same things, with little overall improvement in reducing costs or improving care across the big health care board. It's the hurry up and wait approach.

I must admit that I am somewhat suspicious of the timing associated with HealthLinks arriving on the health care scene. I just can't get over the rather sudden emergence of this entity at a time when the Ontario Liberals, who perhaps had previously thought they would be tossed out of power in the fall, found themselves still at the helm with the potential of a spring election and needed to produce something tangible for health care...and quickly.

Out popped HealthLinks and millions of dollars to offer groups of family doctors for the creation of plans to coordinate the care for expensive users of the health care system and to be directly responsible to the LHINs for integration of patient care.

Is this another transformation effort that is politically motivated without any real evidence of improved outcomes for patients or cost-reduction?

If we look to another system-the National Health System in the UK- we can recognize a similar form of transformation that essentially paid patients to stay out of hospital. Health care teams would sit down with  patients using health care resources far beyond the norm and help figure out what would keep these patients using fewer resources. For some it was finding a helper to buy them groceries. For others it was finding a reliable health care contact beyond the ER (or A & E as ERs are called in the UK NHS). Last I checked this program had some success but if one looks at the issues facing the NHS overall, it is clear to see that it is struggling too.

We hear about the horrific reports of elderly patients ignored in UK NHS hospitals and left to die and of the Liverpool Care Pathway, perhaps initially a well-intentioned program to reduce futile care at the end of life, but which resulted in elderly people being denied  care and even water at the end of life. In some instances family members were not  consulted and patients were put on the Liverpool Care Pathway without family consent or even discussion.

To be clear:

I believe efficiency and integration and coordination of care can be helpful.

I believe that there are well-intentioned people who are trying hard to find solutions under the current umbrella of single payer health care.

However, it is quite likely that HealthLinks exists because of political need and not because it will bring down costs or reduce needs in health care.

I believe we need to have a deeper discussion about how to deliver health care in Ontario. While we can embrace efficiency finding, reduction of waste, and improved use of our providers in the public system these still won't be enough to provide the care that is needed in the future-not when so many forces are aligning to challenge the current system.

Unless we confront the serious challenges facing Ontario we will pay more to integrate care and still be unable to meet the needs of the coming decades and on the backs of a population that will not be able to fund the care it needs. Will HealthLinks make a difference? Maybe, maybe not..but it won't be enough-not nearly enough.



If Oprah was in Charge of Canadian Health Care

Oprah came to my city recently. Thousands upon thousands of people (mostly women) paid hundreds of dollars for a ticket to hear her speak--no singing, no dancing, no pyrotechnics --just someone influential speaking.

I'm going to be honest, I'm neutral on the Oprafication of North America. I think Oprah is a fine woman who has an intangible likability, is informed and intelligent and a highly influential speaker......and very wealthy.  I have even used some of her quotes for my own leadership presentations but what would happen to health care if we rely on positive messaging and hope to provide care? What HAS happened to Canadian health care already because of the reliance of politicians on saying what the public wants to hear instead of confronting the facts and real trends staring us in the face?

Now I'm not saying that we don't need hope. We do. It's just that it can't be instead of taking a realistic look at what is happening to Canadian health care now and what will happen to it in the future as changes in demographics, technology, science and economics loom large.

Oprah's inspiring messages give people hope but I am concerned that this kind of evangelical message of hope is also pervasive in health care and amongst communications advisers and PR types involved in health care decision-making and policy. How could they all be wrong?

Over and over again it is said that political messages must give hope but I firmly believe they must also clearly identify the problems that we need to address with  Plan A, a Plan B and even Plans C,D, and E. The public must be given the facts to understand what Canada is up against, especially Ontario and Quebec.

So, as I hear more political handlers and commentators talk about the message of hope that is necessary in communications I am struck by the stark reality that hope just does not deliver health care. It can make us feel better about the short-comings of the current system but it will not provide the changes that we need for the future.

Positive messages are comforting. They make us feel good. When it comes right down to it though, that feeling does not last in the face of shortages of hospital beds, inadequate long term care, patients denied timely care and drug shortages.

The comfort provided by positive messaging about health care is actually diminishing the ability to create necessary change. We need a bit of friction and grit to move forward. The slick and slippery messaging that smears itself over health care challenges by political handlers and advisers is not helping. We need to confront the challenges ahead and the public needs a clear understanding that the system we have created is no longer viable.

Lets embrace the patients, the providers and the people who work in all the various aspects of health care but change the system. We need a hybrid and we need it soon.





Flaherty's Federal Budget 2013

Jobs. Jobs. Jobs.

Better health for Canadians will be created by jobs and employment. This is where the much discussed and trendy "social determinants of health" -also discussed here on this blog-intersect with the economy. Better health for Canadians isn't about asking the Federal government to pour even more tax dollars into provincial health care sieves. It isn't about putting an MRI on every corner or funding health care for denied refugees. It is about making sure that there is an educated and skilled workforce that can participate in infrastructure building and in a developing knowledge-based economy.

When I talk about Canada's debt and deficit as well as Ontario's economic problem to some other physicians they do not seem to see the connection between standard of living and health or the economy and health.That is problematic because representative doctor groups do have a voice but it is sounding increasingly shrill as they miss the point about dealing with serious economic challenges and an aging demographic poised to drive down productivity and GDP.

Flaherty has been a good steward for Canada's economy and we are fortunate as Canadians to be doing relatively well compared to many other developed countries. I expect that this will be Jim Flaherty's last budget. He has done as well as could be hoped for given the fallout from 2008 and I hope the Federal government continues to resist the loud voices for a national pharmacare program and greater transfer payments to the provinces. Neither of these efforts will address the serious issues facing a slumped economy and both are money pits.

For the next generation's sake including my three children, I hope the voices of all the interest groups that perpetuate the monopoly status quo in health care with entrenchment of their own self-interests will be matched with common sense and pragmatism. At least then we might have a chance of moving forward.





Queue Jumping and Outsourcing in Canadian Health Care

When trying to sort out "where do we go from here", it is a helpful exercise to look back on the various trends that government health policy has emphasized as solutions for the challenges that hound Canadian health care. Take a few minutes to review:

Since the mid 90's we've seen MDs blamed as the cost drivers and saw their numbers cut in medical school only to result in continued escalation of overall health care costs and then a rapid influx of Internation Medical Graduates most recently and a doubling of medical students soon to begin practice (maybe not here). With provincial governments squeezed for cash across the country and a federal government equally strapped for cash now and for many years ahead it is not surprising to see new specialist graduates unable to find work. Sad but true despite Canada having less than average number of MDs per capita than most other developed nations.

We've seen the government and many government funded groups promote interdisciplinary care as the way forward to create quality care and as a way to stretch health human resources but I believe it hasn't made much difference and the costs significantly higher than Fee-For-Service. There are still hundreds of thousands of people in Ontario with no family doctor and across Canada the count is in the millions. There are reports of MDs in teams seeing less patients and working fewer hours and I wonder how this strategy of increasing the numbers of providers in health care will play out as the work force shrinks relative to dependents in the next 10-20 years. How do we fund more expensive health care teams with fewer tax payers and sluggish productivity especially when the outcomes aren't any better than what we had for fewer dollars?

There has been the eHealth spending to the tune of billions and billions of dollars in Canada but new reports seem to indicate errors associated with EMR are a reality only different from paper charts. I have no doubt that  developing Health IT provided jobs during a significant recession and I don't begrudge any government for providing them but let's be honest about it: EMRs will not save any tax dollars from the health care vortex. Are they necessary for the complexity in health care that is coming? Yes. Will they save money? No.

We've seen efforts at using a public air ambulance system to generate private dollars but with very questionable oversight from its Board the whole plan crashed and burned--leadership at its worst at many levels and it seems government not willing to be accountable for creating the entity and then letting it run wild.

Managing queues more efficiently and centralizing referral systems was going to reduce wait times and create efficiency. I hazard a guess that with multiple groups doing wait time analysis and studyng how to keep patients from accessing expensive care, the cost is likely in the billions and  we are still treading water with queues for various treatments and procedures.

Ontario comes out better than most provinces in terms of its wait times but the cost has been high and now as a have-not province, Ontario risks having its credit rating driven down so it will cost more to service its debt which means the same service will cost the province even more in the future. It would be ironic if Ontario's good-hearted money dumping to reduce wait times eventually makes them worse because it will cost more to provide the same service.

The ALC problem has nagged Ontario and other provinces for some time. Patients languishing in hospital beds when what they really need is long term care are now seeing action by hospitals and local health integration networks to move them out as quickly as possible. However, the supply of long term care beds and nursing home beds provided through government funding have not kept up. Elderly patients in the community who are frail and who have managed to avoid hospital so far are not a priority and it is only a matter of time before they end up needing acute care too. Despite this, hospital beds are being "closed" and unstaffed as hospitals are desperate to meet accountability agreements required by law. Nurses are laid off. Services are slashed in order to come in on budget and Ontario's Minister of Health Deb Matthews says "it's OK"...we'll move services to the community....only that isn't happening.

The queue jumping inquiry in Alberta serves to show us that despite relatively exhaustive efforts across Canada to reduce waits, it simply isn't working. With colonoscopy wait times measured in years in Alberta, "queue jumping" appears to have become fairly common. No surprises here because if you have a loved one that is suffering or at risk for nasty health problems, wouldn't you do what you could to help them if you knew someone who could help you? It happens all the time and it shouldn't become a witch-hunt to the tune of millions of dollars. Open up the system to those who are willing to pay for the service. Keep the medical specialists in the province to do the work they were trained to do. We all know there is plenty of patients needing care. If there were no queues and if there were reasonable wait times, there would be no substantial queues to jump. Let us be transparent and honest and allow people who can pay to pay.

Last but not least is the newest trend toward moving hospital services to the community. I've heard it all before. I've heard it for over 20 years and it does not happen. If it happens this time, nobody should expect it to be cheaper because all of the smaller facilities will have to have government support OR they will be set up by private groups who will then be paid by the government for public medical services provided. If hospital beds are cut at the same time as services are provided in the community how exactly will savings be achieved? Patients are more complex than in the past with growing ranks of elderly with dementia and chronic disease.  I predict that there will be no savings from moving services from hospitals to the communty.

Where do we go from here?

There must be a way of providing more care in Canada and especially in Ontario.

What would it look like?

How would funding for more care be created?

Should  insurance companies  be allowed to cover medically necessary services?

How would more options for care  be integrated into  our current system?

We need to have an honest and open and reasoned discussion about where we go from here--because queue jumping witch hunts, outsourcing care to the US, EMRs, and teams just aren't going to make health care more efficient or cost less.