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

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 cost sharing in 1977, and then hacked funding until 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

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

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: ) 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

Germany, CAN, US

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!

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 re- organizing 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 ( 1.Safe 2.Effective 3.Patient-Centred 4.Accessible 5.Efficient 6.Equitable 7.Integrated 8.Appropriately resourced 9.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 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 ( –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?

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