Transcript Stitches in Time - Michael Rachlis

Sustaining Medicare into the
Future: The Problem is quality
and the Solution is Innovation
St. Thomas University
May 13, 2008 Fredericton NB
Michael M. Rachlis MD MSc FRCPC
www.michaelrachlis.com
Outline
• There are three main public analyses of
Medicare but none reflect Canadians true
feelings about Medicare
• The problem is not public funding, too little
money, or too much money
• The main problem is poor quality of care
which is related to the pre-Medicare way we
organize service delivery
• Good News about Canada’s health System!
There are three main
views of Medicare but
none are satisfying to
Canadians
Medicare View #1: Globe and Mail
• We established Medicare when we were young, healthy,
and altruistic. The economy was growing rapidly. It
worked pretty well then.
• Now we are old, sick, and the economy is stagnant.
Medicare doesn't work very well. Wait lists go from the
North Pole to the US border. Health care costs are going
through the roof. The public sector is too inefficient to
make it work.
• We now have to ‘be cruel to be kind’. We should allow
some privatization of finance and profitization of
delivery to 'save' Medicare.
Medicare View #2: Toronto Star
• At the beginning, the federal government paid half
the bills and everything worked pretty well.
• The Federal government gave up 50-50 cost
sharing in 1977, and then hacked funding until
1997. Medicare was starved. This led to service
erosion, privatization of finance, and increased use
of for profit delivery.
• Now we need more public money, more
enforcement of the Medicare legislation, and curbs
on for profit delivery to save Medicare.
Medicare View #3: National Post
• Medicare was always a bad idea.
• Health care costs are out of control. But a
government run health system is like the
Beverly Hillbillies trying to run IBM.
Despite huge costs, services are terrible.
• It’s not too late to do the right thing. Let’s
privatize and profitize as fast as possible.
Maybe a dumb, rich American will buy it.
What do Canadians want to hear?
• Medicare was the right road to take
• Resources aren’t the problem. Costs are
not out of control but neither is the system
drastically underfunded
• Medicare was designed for another time
and was implemented as a compromise
• There are public sector solutions for every
one of Medicare’s problems
Outline
• There are three main public analyses of
Medicare but none reflect Canadians true
feelings about Medicare
• The problem is not public funding, too little
money, or too much money
• The main problem is poor quality of care
which is related to the pre-Medicare way we
organize service delivery
• Good News about Canada’s health system!
Medicare was the right road to take
• Canada & US had same health care
system and the same health status until the
mid-1950s
• Now there are 47 million US uninsured
• We spend less than the US but we usually
get more services
19
60
19
64
19
68
19
72
19
76
19
80
19
84
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88
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92
19
96
20
00
20
04
% GDP
Canada and US % GDP $ on HC
18
16
14
12
10
8
6
2
Canada
4
US
0
Admininstration as % of Total HC Exp
35%
30%
25%
20%
15%
10%
5%
0%
US
CAN
S Woolhandler Int J H Serv 2004;34:65-78.
Medicare was the right road to take
• Now Canadians live 2 1/2 years longer
and our infant mortality rate is 30% lower.
• Medicare boosts Canadian business
– Health care costs: 1.5% of Canadian
manufacturers’ payroll and 9% of those
in US
Health Care Costs are
not out of Control but
neither is the Health Care
System Drastically
Underfunded
19
60
19
64
19
68
19
72
19
76
19
80
19
84
19
88
19
92
19
96
20
00
20
04
% GDP
Canada and US % GDP $ on HC
18
16
14
12
10
8
6
2
Canada
4
US
0
8
7
6
5
4
3
2
1
0
19
75
19
78
19
81
19
84
19
87
19
90
19
93
19
96
19
99
20
02
20
05
% GDP
Provincial HC Spending as % GDP
CIHI NHEX 1975-2007
Provincial HC Exp as % of GDP
20
05
20
02
19
99
Ontario
QC
BC
19
96
19
90
19
87
19
84
Canada
NB
AB
19
93
10
9
8
7
6
5
4
3
2
1
0
19
81
% GDP
(From CIHI NHEX 2007 http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=AR_31_E&cw_topic=31)
Canadian Government Expenditures
From http://www.fin.gc.ca/toce/2007/frt07_e.html
40
30
20
Federal
10
Provincial
Total
06
05
-
04
20
03
-
02
20
01
-
00
20
99
-
98
19
97
-
96
19
95
-
94
19
93
-
92
19
91
-
90
19
89
-
88
19
87
-
19
85
-
86
0
19
Percent of GDP
50
General Gov't Outlays
From: http://www.fin.gc.ca/frt/2007/frt07_e.pdf
50
40
30
20
10
Canada
US
0
19
73
19
76
19
79
19
82
19
85
19
88
19
91
19
94
19
97
20
00
20
03
20
06
Percent of GDP
60
Outline
• There are three main public analyses of
Medicare but none reflect Canadians true
feelings about Medicare
• The problem is not public funding, too little
money, or too much money
• The main problem is poor quality of care
which is related to the pre-Medicare way we
organize service delivery
• Good News about Canada’s health system!
Canada Has Big Quality Problems -But No Bigger Than Other countries
• Misuse
– Canadian Adverse Events Study
• 9000 to 24,000 preventable hosp deaths/yr
• (GR Baker et al. CMAJ 2004;170:1678-1686)
• Overuse
– Medication and the elderly
– 10% of diagnostic imaging
• Under use
– Chronic disease management and prevention
– Cervical and breast cancer screening
Do one-quarter of older Canadian
women need to take Benzodiazepines?
Do we care what we’re paying for?
The Canadian system has
long waits for care
K Davis.
Commonwealth Fund
April 2006
% Long Waiting Times
Germany,
CAN, US
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%
Chronic diseases have
a major impact
• Chronic diseases account for 70% of
all deaths.
• Chronic diseases account for more
than 60% of health care costs.
Canada deals poorly with
chronic diseases
• < 30% of Canadians hypertensives have their
blood pressure properly controlled
• 60% of diabetics have gone > 1 yr without an
eye exam or a check for proteinuria
• 60% of asthmatics are not properly controlled
• Up to one in six seniors is re-admitted to
hospital within 30 days of discharge
Trying to deliver health services without
adequate primary health care is like pulling
your goalie in the first period!
1945 -- Swift Current, Saskatchewan
• Prepaid funding Services available on a universal
basis, with little or no charge to users.
• Integrated health care delivery with acute care,
primary care, home care, and public health.
• Group medical practice with doctors working in
teams with nurses, social workers and other
providers.
• 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’s recommendations for
homecare and pharmacare, the federal legislation only
covers medical care
• Dr. John Hastings’s 1972 Report recommends reorganizing the delivery system but it’s mainly ignored
– The models that were implemented, e.g. Sault Ste. Marie
Group Health Centre and Saskatoon Community Clinic,
prove to be fonts of innovation
• 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
There is good news about
Canada’s health system
“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 the
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
Are we finally ready for the
Second Stage of Medicare?
• Stage One: Provide financial support
for care when people get sick.
• Stage Two: The “more difficult task” --“keeping people well.”
The Second Stage’s
Essence – delivering
health services differently
to keep people well
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. April 2006. (www.ohqc.ca)
1.
2.
3.
4.
5.
6.
7.
8.
9.
Safe
Effective
Patient-Centred
Accessible
Efficient
Equitable
Integrated
Appropriately resourced
Focused on Population Health
Population Health Focus We should
continuously improve the health of the population.
• Our health system was largely designed to
treat acute illness and federal legislation
only requires the provinces to cover
hospitals and physicians services.
• The key strategy is intersectoral action
which requires changes in the organization
of government, e.g. Saskatchewan Human
Services Integration Forum
Equitable We should continuously reduce
disparities in health
• Men live 6 years less than women
• Women have more chronic, non-fatal conditions than men
• Aboriginal men live seven 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
A 3-pronged attack on disparities
•
•
•
Improving the accessibility of the health system
through outreach, location, physical design, opening
hours, and other policies. Vancouver Coastal Health
Improving the patient-centredness of the system by
providing culturally competent care, interpretation
services, and assisting patients and families surmount
social and economic barriers to care. London
Intercommunity Health Centre
Cooperating with other sectors to improve population
health. Saskatoon Health Region
Patient-Centred care respects individuality,
ethnicity, dignity, privacy, and information and the
patient’s family. Patients should control their own care
• The average patient requires 90 seconds to
explain a problem but the average doctor
interrupts the average client in only about
20 seconds
• Patients are capable of fully-informed
decision-making in less than 10% of
physician visits
Patient-Centred respects individuality,
ethnicity, dignity, privacy, and information and the
patient’s family. Patients should control their own care
• Saskatoon’s Sherbrooke Community Centre
– The Eden Alternative creates paradise
– “I used to cry every time I left him. I don’t cry
anymore.”
• Centre for Addictions and Mental Health
– Leadership in diversity
Effective The best science should
ensure most appropriate care possible.
• Care is too often not based upon evidence
• It often takes 15-20 years after an innovation’s
development before it becomes routine practice.
• Sault Ste. Marie Group Health Centre
– Electronic health records
– 50% reduction in readmissions of heart failure patients
– Diabetes and Vascular Intervention Project
• Tracking 5000 diabetics
Accessible Patients should get timely care.
Waits should be continuously reduced
• Advanced Access – same day service
– Penticton, Toronto, Saskatchewan
• Hamilton shared Care Mental Health
– 145 GPs, 80 counsellors, 17 psychiatrists
– 1100% ↑ in patients seen for mental health
– 70%↓ in referrals to psychiatrists
• Alberta Bone and Joint Pilot Project
– Reduced wait times for hip and knee
replacements from 19 months to 11 weeks
Safe People should not be harmed. We
should continuously reduce adverse events.
• Safer Health Care Now
(http://www.saferhealthcarenow.ca/)
– 600 safety improvement teams in over 180
health care organizations
– NS South Shore District Health Authority had
no ventilator associated pneumonias in 14
months
• Pharmacists in primary health care
Why do we need the
Second Stage of
Medicare now?
Why do we need the Second
Stage of Medicare now?
• Aging of the population and chronic disease
put extra pressures on an inefficient system
• The workforce is getting older and sicker
– Family doctors are exiting comprehensive care
– Nurses and other health workers face burnout
• We need to improve the sustainability of the
system
“Many attribute the quality problems
to a lack of money. Evidence and
analysis have convincingly refuted
this claim. In health care, good
quality often costs considerably less
than poor quality.”
Fyke Report 2001 (Saskatchewan)
Quality provides sustainability
• Alberta aftercare program for congestive heart
failure patients leaving hospital reduced future
hospital use by 60% with $2500 in overall net
cost savings per participant.
• New Westminster's Royal Columbian Hospital
reduced post heart surgery pain complications by
80% and length of stay by 33%.
• BC’s Reference Drug Program kept Vioxx as a
second line drug and saved $23 million per year
and dozens of lives.
Quality provides sustainability
• Quality workplaces improve the health of
workers and patients
• Quality workplaces could be worth a one
year’s graduating class of nurses
Facilitating the Second Stage
• Pay providers fair and equitable compensation so they
can meet their patients’ needs wherever they may be
• Implement electronic health records ASAP
• Increase training budgets
– The Saskatchewan Health Quality Council’s Chronic
Disease Collaborative has improved primary health care
for more than a third of the province
• A network of public health oriented PHC centres
– Could the federal government support this?
• Supportive housing
• And other social policies
What Canadians want to hear?
• Medicare was the right road to take
• Resources aren’t the major problem. Costs are
not out of control but neither is the system
drastically underfunded. We need transition
funding
• Medicare was designed for another time and
was implemented as a compromise
– If Douglas had had his way in the 1940s and 1950s
Medicare would have many fewer problems today
• There are public sector solutions for every one
of Medicare’s problems – The Second Stage of
Medicare
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!”
Tony Soprano
Summary
• There are three main public analyses of
Medicare but none reflect Canadians true
feelings about Medicare
• The problem is not public funding, too little
money, or too much money
• The main problem is poor quality of care
which is related to the pre-Medicare way we
organize service delivery
• There is oodles of Good News about Canada’s
health system! Let’s get it out!
Courage my
Friends, ‘Tis Not
Too Late to Make
a Better World!
Tommy Douglas