Transcript 100303 Rachlis Southey PHC

First Things First! Primary health care is the key
to managing wait lists, chronic disease, and
modernizing Medicare for the 21st Century
Michael M Rachlis MD MSc FRCPC
Southey SK March 3, 2010
www.michaelrachlis.com
Outline
• Where are we now?
• How did we get here?
• We could fix almost all Medicare’s
problems with innovation and quality –
the Second Stage of Medicare
• Primary health care reform is the key to
health reform
Where are we now?
Southey
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
• Medicare was designed for another time and
was implemented as a compromise
• Canadians overwhelming support public
sector solutions to Medicare's problems
• And, there are public sector solutions –
Tommy Douglas’s 2nd Stage of Medicare
Medicare was the right road
Canada vs. the US: No contest!
• All Canadians are covered but 47 million
Americans are uninsured, and tens of millions
more are under-insured
• Canada spends much less than the US
• Canadians get only slightly fewer services overall
• Canadian outcomes are as good or better
• Canadians live 3 years longer than Americans
and our infant mortality rate is 20% lower.
• Single payer insurance boosts Canadian business
– Health care costs are 1.5% of Canadian
manufacturers’ payrolls vs. 9% in the US
Health Spending as share of GDP
18
16
% of GDP
14
12
10
8
6
4
2
0
From: http://www.oecd.org/document/30/0,3343,en_2649_34631_12968734_1_1_1_1,00.html
S Woolhandler Int J H Serv 2004;34:65-78.
Canadian health care outcomes on average
are as good, or better than those in the US
• Guyatt et al 2007 published an overview of
individual studies comparing US and
Canadian health care. They concluded that
overall Canadian care was as good or
superior to US care.
• See:
http://www.openmedicine.ca/article/view/8/1
What do Canadians want to hear?
• Medicare was the right road to take
• Resources aren’t the problem
• Medicare was designed for another time and
was implemented as a compromise
• Canadians overwhelming support public
sector solutions to Medicare's problems
• And, there are public sector solutions –
Tommy Douglas’s 2nd Stage of Medicare
Canadian Health Exp as % of GDP (NHEX 2008)
12
8
6
4
2
Total HC as % of GDP
Prov/Terr HC as % of GDP
0
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
% of GDP
10
Canadian Health Exp as % of GDP (NHEX 2009)
14
12
8
6
4
2
Total HC as % of GDP
Prov/Terr HC as % of GDP
0
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
% of GDP
10
From: http://secure.cihi.ca/cihiweb/products/National_health_expenditure_trends_1975_to_2009_en.pdf
Government Outlays as a share of GDP
60
% of GDP
50
40
30
20
10
0
From: http://www.fin.gc.ca/frt-trf/2009/frt09_e.pdf
What do Canadians want to hear?
• Medicare was the right road to take
• Resources aren’t the problem.
• Medicare was designed for another time
and was implemented as a compromise
• Canadians overwhelming support public
sector solutions to Medicare's problems
• And, there are public sector solutions – the
2nd Stage of Medicare
Canadian Medicare was designed for
another time and was a compromise
1. Medicare was designed for acute illness
and Canada’s acute care system compares
well internationally
2. But now the main problems are chronic
diseases and Canada does poorly with
these and with waits and delays.
3. Political compromise has slowed the
development of better delivery models
since the 1960s and the implementation of
the “quality agenda” more recently
Chronic disease: Big problems
• 60% of people with diabetes have gone more
than a year without an eye exam.
• More than 50% of type 2 diabetics are not at
recommended blood glucose targets.
• Less than 50% of type 2 diabetics are tested
for A1c levels, blood pressure, cholesterol, or
kidney function.
Ontario Quality Improvement and Innovation Partnership 2009
Practices with Advanced Electronic
Health Information Capacity
100
92
91
89
75
66
%
54
50
49
36
26
19
25
15
14
FR
CAN
0
NZ
AUS
UK
ITA
NET
SWE
GER
US
NOR
21
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Practice Routinely Receives and Reviews
Data on Patient Outcomes
100
89
71
75
68
65
%
50
43
41
40
25
25
24
17
12
0
UK
SWE
NZ
NET
US
GER
ITA
NOR
AUS
CAN
FR
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians
22
Time Spent Reporting or Meeting
Regulations is a Major Problem
100
75
67
%
50
25
15
19
20
NET
NOR
26
27
29
AUS
US
NZ
32
UK
49
50
SWE
ITA
38
0
CAN
FR
GER
23
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians
We could prevent most chronic diseases
• > 80% of ischemic heart disease,
lung cancer, chronic lung disease,
and diabetes cases could
theoretically be prevented with
what we know now
• This would free up over 6000
hospital beds across Canada
% Long Waiting Times
K Davis.
Commonwealth
Fund April 2006
(Germany, Canada, USA)
Elective surgery
wait > 4 months
Specialist wait
times > 4 weeks
ER wait > 2 hr
PHC appt > 5 d
0%
20%
40%
60%
Canada Has Big Quality Problems -- mainly
similar to those of other countries
• Misuse
– 5-10% of deaths in developed countries are
preventable hospital deaths
• Overuse
– Medication and the elderly
• Under use
– Chronic disease management and prevention
– Cervical and breast cancer screening
Do one-fifth of older Canadian women
need to take sedatives?
Do we care what we’re paying for?
Fig. 3: Standardized Diabetes Prevalence Rates,
Winnipeg, 1998, by Health Region
N
Diabetes Prev., Cases/1000
37.7 - 42.3
42.3 - 47.9
47.9 - 55.3
55.3 - 63.4
63.4 - 78.8
4
W
E
S
0
[Green et al Soc Sci Med 2003; 57:553-60]
4
8
Miles
We don’t have equal access to health
•
•
•
•
•
Men live 5 years less than women
Women have more chronic, non-fatal conditions
Aboriginal men live 7 years less than other 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 shortest lives
Disparities in health
between different groups
are responsible for 20% of
health care costs
Health Disparities Task Group of the Federal
Provincial Territorial Advisory Committee on
Population Health and Health Security. Health
Disparities: Roles of the Health Sector. 2004.
http://www.phac-aspc.gc.ca/phsp/disparities/pdf06/disparities_discussion_paper_
e.pdf
Quality workplaces for
providers
•
•
•
•
Happier staff = healthier patients
Happier staff = lower turnover
Healthier patients = lower costs
Lower turnover = lower costs
Saskatchewan
Swift Current Region
The original vision for Medicare -- Swift
Current, Saskatchewan 1945
• 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 other providers. Overall public health
view of the system.
• Democratic community governance of health care
delivery by local boards.
What happened to the vision?
• Despite the Swift Current Region’s
success, Saskatchewan MDs didn’t want
to bargain with anyone but the province
• Saskatchewan MD strike of 1962
What happened to the vision?
• The federal government only covered hospital and
medical care leaving coverage incomplete
• Despite the 1972 Hastings’s Report recommendations
for re-organizing the system around prevention, new
models of care are slow to develop
• 1990s cutbacks harm a vulnerable system
• Waits and delays worsen
• There’s less national vision every day
• Notwithstanding, reforms are being implemented in
some places and have made significant improvement
in outcomes and efficiency
What do Canadians want to hear?
• Medicare was the right road to take
• Resources aren’t the problem.
• Medicare was designed for another time and
was implemented as a compromise
• Canadians overwhelming support public
sector solutions to Medicare's problems
• And, there are public sector solutions –
Tommy Douglas’s 2nd Stage of Medicare
Do you support public solutions to
make our public healthcare stronger?
Unsure
Oppose
Somewhat oppose
Somewhat support
Support
0
20
40
http://medicare.ca/wp-content/uploads/2009/08/nanos.pdf
%
60
80
What do Canadians want to hear?
• Medicare was the right road to take
• Resources aren’t the problem.
• Medicare was designed for another time and
was implemented as a compromise
• Canadians overwhelming support public
sector solutions to Medicare's problems
• And, there are public sector solutions –
Tommy Douglas’s 2nd Stage of Medicare
Medicare’s problems are due to
the failure to re-tool an ineffective
and inefficient delivery system
20 litres/100 km
5 litres/100km
Good News! We could improve
care for chronic disease
• The Sault Ste Marie
Group Health Centre
has had an electronic
record since 1997 and
uses it to continuously
improve the care of
over 5000 patients with
diabetes.
Good News! We could access
primary health care within 24 hrs
“Even if we did nothing else,
and we should implement
other reforms, if every family
physician implemented
Advanced Access, every
Canadian could have a family
doctor.”
Penticton British Columbia’s Dr. Jeff
Harries to the CMA meeting, “ Taming the
Queue”. Ottawa. March 31, 2006
Good News! We could have elective
specialty consultations within one week
– The Hamilton Family Medicine Mental
Health Program increased access for
mental health patients by 1100%
while decreasing psychiatry
outpatients’ clinic referrals by 70%.
– The program staff includes 150 family
doctors, 80 mental health counsellors,
and 17 psychiatrists and provides care
to 300,000 patients
Good News! We could have
elective surgery within two months
– In Toronto, Barrie, and
other parts of Ontario
arthritis patients are
assessed within two
weeks for joint
replacements and have
their surgery within
two months
Going for gold: Re-engineering
services to immigrants in Toronto
• Access Alliance works with immigrant and
refugee communities to identify women who
are leaders and hires them as community
health workers (CHWs)
• They are given 3 months of paid training and
3 year contracts
• The CHWs run educational workshops and
facilitate well children and well women care
• CHWs have brought services to more than
12,000 women and their children
• 85% of CHWs get jobs in health or social
services after their contracts are over
45
Going for Platinum: Population
Health Planning in Saskatoon,
Saskatchewan
Saskatoon neighbourhood analysis boundaries,
excluding industrial and development areas, 2005
Legend
Affluent neighbourhoods
Rest of Saskatoon
Low income neighbourhoods
Source: Saskatoon Health Region, Public Health Sevices
Catching Medicare’s second stage
“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
Canada’s health policy is in evolution
from a 19th century passive insurance
program for 18th century professional
practice to a public health program
based upon high performing, patientcentred, team-based care
First things first! Primary health
care reform is the key to health
reform
Why is integrated primary health
care so important?
• Canada has problems with access, chronic
disease management and prevention, and
population health
• Primary health care is the key for access,
chronic disease management and
prevention, and population health
• Primary health care = sustainability
A population health strategy focuses on factors
that enhance the health and well-being of the
overall population. It views health as an asset that
is a resource for everyday living, not simply the
absence of disease. Population health concerns
itself with the living and working conditions that
enable and support people in making healthy
choices, and the services that promote and
maintain health.
From Strategies for Population Health 1994
FPT Advisory Committee on Population Health
Primary health care and population health
• Can the health system engage with
communities?
• South Riverdale gets the lead out
• Regent Park’s Pathways to Education reduced
its high school dropout rate from 56% to 14%
• Montreal PHC dealt with its Ice Storm
• Ottawa PHC dealt with influenza
• Saskatoon CC and the downtown Westside
55
What are the barriers to better
primary health care linkages?
• Definitions do matter
– They reflect different visions and values
for Medicare and health care delivery.
– Is health care largely a public good or is
it largely a private commodity?
• Integration of physicians
– Physician payment
“PHC is essential health care made universally accessible
to the community by means acceptable to them, through
their full participation and at a cost that the community
and the country can afford....it is the first level of contact
of individuals, the family and community within the
national health system … and constitutes the first
element of a continuing health care process...PHC
addresses the main health problems in the community,
providing promotive, preventive, curative, supportive
and rehabilitative services accordingly.“
(World Health Organization 1978)
“Primary health care represents the first point
of contact for individuals with the health care
system, and is the key to efficient, timely, quality
family and community care based on continuity
and coordination, early detection and action,
and better information on needs and
outcomes.”
First Ministers’ Accords; 2000, 2003, 2004
Declaration of Montevideo 2005
(http://www.paho.org/english/gov/cd/CD46-decl-e.pdf)
• Approved by all countries in Pan American
Health Organization
• PHC should be integrated into health
systems
– Not implemented as a separate program
• Commitment to social inclusion and equity
• Recommendations to strengthen
community participation and oversight of
PHC
What are the facilitators for primary
health care reform?
• Engagement of the rest of the
health care system including
public health
• Engagement of communities
What are the facilitators for primary
health care reform?
• Engagement with MDs
– At all levels
– Quality Improvement initiatives
– Family physician divisions?
• Physician payment reform
– Salary
– Capitation
– Blended systems
Trying to deliver health services without
adequate primary health care is like pulling
your goalie in the first period!
“Only through the practice of preventive
medicine will we keep the costs from
becoming so excessive that the public
will decide that Medicare is not in the
best interests of the people of the
country.”
Tommy Douglas
Summary:
• Canada’s health system out-performs the US but
our health services are rife with problems
because we forgot the 2nd Stage of Medicare
• We could fix almost all Medicare’s problems with
innovation– the 2nd Stage of Medicare
• We need to implement the 2nd Stage of Medicare
or we risk losing the First
• Primary health care reform is the key to health
reform and the 2nd stage of Medicare
Courage my
Friends, it is
Not Too Late to
Make a Better
World!
Tommy Douglas