High Performance Health Systems How Do We Get There from Here? - PowerPoint PPT Presentation

High Performance Health Systems – How Do We Get There from Here? National Healthcare Leadership Conference Toronto June 12, 2007 Michael M. Rachlis MD MSc FRCPC www.michaelrachlis.com

Outline • Canada’s health system has big quality problems but not big cost problems • How did we get this way? • How do we move forward?

Houston, our hospitals have quality problems (like other countries) • One in 14 Canadian hospital patients suffers a complication while in hospital (Baker Norton Flintoft 2004) • There are 9,000 to 24,000 deaths that occur in hospital every year which could be prevented (4-11% of all deaths)

K Davis. % Long Waiting Times Commonwealth Fund April 2006 Elective surgery wait > 4 months Specialist wait times > 4 weeks ER wait > 2 hr > 5 d to PHC appointment 0% 10% 20% 30% 40% 50% 60%

Commonwealth Fund Rankings AUS CA DEU NZ UK US High Med Low Overall Rank 2007 3.5 5 2 3.5 1 6 Quality of Care 4 6 2.5 2.5 1 5 Right care 5 6 3 4 2 1 Safe care 4 5 1 3 2 6 3 6 4 2 1 5 Coordinated care 3 6 2 1 4 5 Patient-centered care 3 5 1 2 4 6 Access Efficiency 4 5 3 2 1 6 Equity 2 5 4 3 1 6 Healthy Lives 1 3 2 4.5 4.5 6 US$/Capita (PPP) $2876 $3165 $3005 $2083 $2546 $6102 K. Davis et al Commonwealth Fund pub no 1027 May 2007

Trying to deliver health services without adequate primary health care is like pulling your goalie in the first period!

There are inequalities in health and health care • Men live 6 years less than women • Women have more chronic, non-fatal conditions • Aboriginal men live 7 years less than non-Aboriginal men • Poor men live 5 years less than rich men • Infant mortality is 70% higher in poor neighbourhoods than rich neighbourhoods • Northern Canadians have the lowest life expectancy • 20% of health care costs are related to disparities • There are inequalities in access to health care by income in all developed countries

US and Canada HC $ as % of GDP 18 16 14 Percent of GDP 12 10 8 CAN 6 4 US 2 0 1960 1980 1990 1992 1994 1996 1998 2000 2002 2004

Provincial Health Spending as GDP % http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=media_01nov2006_e 8 7 6 5 % GDP 4 3 2 1 0 f 2 4 6 8 0 2 4 6 8 0 2 4 8 8 8 8 9 9 9 9 9 0 0 0 6 9 9 9 9 9 9 9 9 9 0 0 0 0 1 1 1 1 1 1 1 1 1 2 2 2 0 – – – – – – – – – – – – 2 1 3 5 7 9 1 3 5 7 9 1 3 – 8 8 8 8 8 9 9 9 9 9 0 0 5 9 9 9 9 9 9 9 9 9 9 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 0 2

Canadian Gov't Budget Expenditures http://www.fin.gc.ca/toce/2006/frt06_e.html 50 45 40 35 % of GDP 30 25 20 15 Federal Provincial 10 Total 5 0 1984-85 1986-87 1988-89 1990-91 1992-93 1994-95 1996-97 1998-99 2000-01 2002-03 2004-05

Outline • Canada’s health system has big quality problems but not big cost problems • How did we get this way? • How do we move forward?

“I am concerned about Medicare – not its fundamental principles- but with the problems we knew would arise. Those of us who talked about Medicare back in the 1940’s, the 1950’s and the 1960’s kept reminding the public there were two phases to Medicare. The first was to remove the financial barrier between those who provide health care services and those who need them. We pointed out repeatedly that this phase was the easiest of the problems we would confront.” Tommy Douglas 1979

“The phase number two would be the much more difficult one and that was to alter our delivery system to reduce costs and put and emphasis on preventative medicine…. Canadians can be proud of Medicare, but what we have to apply ourselves to now is that we have not yet grappled seriously with the second phase.” Tommy Douglas 1979

The Second Stage of Medicare is delivering health services differently to keep people well

1945 -- Swift Current, Saskatchewan • Prepaid funding Services available on a universal basis, with little or no charge to users. • Integrated health care delivery through the creation of local integrated health regions. • Group medical practice with doctors working in teams with nurses, social workers and other providers. The chief public health officer was one of the lead managers • Democratic community governance of health care delivery by local boards.

What happened to the vision? • Despite Swift Current Region’s success, Saskatchewan MDs wanted independent practice paid on fee for service • Saskatchewan MD strike of 1962

What happened to the vision? • Despite the Hall Commission, the feds only cover medical care so we never finish Medicare’s 1 st stage – The provinces develop patchwork a quilt of coverage • Dr. John Hastings’s 1972 Report recommends re- organizing the delivery system but it’s mainly ignored • Canada inspires other countries’ policies but not ours – Lalonde Report, Ottawa Charter of Health Promotion, etc • The Canada Health Act stops the bleeding – But it’s only temporary

What happened to the vision? • 1990s cutbacks harm a vulnerable system • Waits and delays worsen – More specialties and special units – Can’t admit people for “investigations” • The 2002 Romanow Commission isn’t able to establish a new political consensus • The 2004 Fed/Prov/Terr Health Accord provides lots of money but little direction • The 2005 Chaoulli case opens the door to more private health care – more politically than legally

Outline • Canada’s health system has big quality problems but not big cost problems • How did we get this way? • How do we move forward?

Before we board the bus let’s decide where we’re going 1. Is health care primarily a commercial good or a public service? 2. Should most health care be available according to need and financed according to ability to pay?

The Second Stage of Medicare meets the Quality Agenda “Are we providing the safest, most suitable care? Are we investing enough in prevention? Are we reducing inequalities in health? The answer to these questions is no, not yet. But we could. It is the Council’s belief that we already have strong evidence and enough experience to pursue a quality agenda.” Health Council of Canada 2006

Attributes of High Performing Health Systems Ontario Health Quality Council 2006 1. Safe 2. Effective 3. Patient-Centred 4. Accessible 5. Efficient 6. Equitable 7. Integrated 8. Appropriately resourced 9. Focused on Population Health

There are solutions! • Primary health care access today – Patients are seen the day they want to be seen at the Saskatoon, and Toronto CHCs and private practices in Ontario, Nova Scotia, and BC – Saskatchewan Health Quality Council has worked with 25% of the province’s primary health care practices to improve access and chronic disease management

There are solutions! • Specialty services integrated with primary health care – Hamilton Shared Care Mental Health The Hamilton HSO Mental Health Program increased access for mental health patients by 1100% while decreasing referrals to the psychiatry outpatients’ clinic by 70%.

There are solutions! • Elective surgery within one month – The Alberta Bone and Joint Institute reduced waits for joint replacements from 19 months to 11 weeks all the way from family doctor referral to surgery

Going for gold: Re-engineering services for people • Access Alliance Multicultural Community Health Centre Peer Outreach Workers have brought maternal and child services to 10,000 Toronto refugee women and their children

Health care reaches platinum! • The health system cooperates with other sectors to maximize population health – Saskatchewan Human Services Integration Forum – Saskatoon Regional Intersectoral Council – A community approach to poverty keyed by the health sector in Sherbrooke Quebec – Sandy Lake and Kahnawake Diabetes Prevention Projects

Facilitating Solutions • Comprehensive coverage to complete the First Stage of Medicare • Integrated funding • True primary health care reform • Electronic health records • ��� resources for training for staff and boards

For profit patient care tends to be more expensive and of poorer quality – see PJ Devereaux et al -- but the most effective argument is: “Fuhgetaboutit!”

Summary: • Our health services are rife with problems because we forgot the 2 nd Stage of Medicare • We need to change health services delivery to focus on prevention • We need to implement the Second Stage of Medicare or we risk losing the First • The solutions become harder to implement the more we privatize funding and delivery

“ Courage my Friends, ‘Tis Not Too Late to Make a Better World!” TC Douglas (per Tennyson)