Brian Day Past President Canadian Medical Association Kananaskis February 16 th 2009 Coping with Change in Canada: Best and Emerging Practice

Global Budget or Block Funding Less Facilities Procedures Innovation Nurses Physicians Patients Less Facilities Procedures Innovation Nurses Physicians Patients Less Care

Patient Focused Funding PFF PFF PbR PbR P4P P4P ABF ABF SBF SBF EBP EBP Empowering the Patient Empowering the Patient

Orthopaedic Residents in Canada Approximately 50% leave for US “No jobs”

Fig. 1 The quality-improvement cycle. P4P must not become “Pay for Paperwork”

A Patient Focused System

Worst: sick patients waiting 6 days plus to see doctor Worst ranking: 4 hours plus in E.R. 65% Children wait a medically unacceptable period Last in use of information technology Last in use of interventional radiology

Health Care and the Economy

The Cost of Waiting

Four Targeted Areas $15 Billion January 2008 Wait Lists: an Unfunded Liability Paying for the Privilege of Waiting

“In total the economic burden was $51 billion…”

MEDIX GP Survey on Wait Lists Pre-PbR 66% - had patients admitted as emergencies 90% - consultations from delays 70% - significant problems from delayed treatment 1.5 million extra consultations 66% - had patients admitted as emergencies 90% - consultations from delays 70% - significant problems from delayed treatment 1.5 million extra consultations

Market conditions and competition Patient choice - quality and service Local control Bottom up instead of top down Wait lists gone, productivity up Carole Heatly England: the New NHS

The greatest change since 1948 Patients choose from 350 hospitals, including private Bunions to heart surgery Flexibility and convenience for patients Stimulates failing hospitals to improve Patients avoid MRSA hotspots or wait lists Patient Power and the New NHS Damien Fletcher, The Mirror, 31 st March 2008

Public Private Non Debate

Worksafe BC No Waits for Injured Workers Worksafe BC No Waits for Injured Workers Health Care Costs 1999 $204 million 2002 $187 million Health Care Costs 1999 $204 million 2002 $187 million Health costs constant at $200 million per year for the past 10 years

“A System Focus”

Data: Costing CMG HRG DRG and Performance

FOI Document Billings versus Costs

Total Indirect Costs (per sample $1000 direct surgical cost) BC Hospital A: Add $1220 BC Hospital B: Add $850 BC Hospital A: Add $1220 BC Hospital B: Add $850

BC Medicare 15-16% 1 U.S. Medicare and Medicaid 7-8% 2 1 Turchen, Matthews,2006 Measurement and Accuracy (Garbage in = Garbage Out) Independent audit Federal FOI to include CIHI Outcomes clearly defined Turchen 2008

Costing and Accountability Calgary Health Region (CHR) “CHR administration argues that accurate cost accounting would require a diversion of effort better expended elsewhere”

US Medicare:10 procedures, 4 Settings 2008

2008 NHS Tariff Examples Procedure NHS 2008 Tariff Cataract operation£786 Heart valve surgery£10,199 Heart bypass£8,080 Hip replacement£5,568 Hernia surgery£956 Knee replacement£6,182 Major breast surgery£2,386 Varicose vein removal£1,063

Economic Impact of Early Treatment Patients’ income Medical expense State revenue or payments Medical tourism income Patients’ income Medical expense State revenue or payments Medical tourism income

Medical Tourism $20 Billion 2006 $40 Billion 2007 $80 Billion 2008 U.S. Medical Tourists ¾ million million million 2012

Service - Based Funding The Health of Canadians – The Federal Role Final Report Volume Six Encourage efficiencies Keep or reinvest savings Create competition Specialized teams Centres of excellence Improve quality with increased volume Improve patient service Reduce inefficiencies Encourage efficiencies Keep or reinvest savings Create competition Specialized teams Centres of excellence Improve quality with increased volume Improve patient service Reduce inefficiencies “ “Kirby Report” Senator Michael Kirby

October October OECD: Competition in the Provision of Hospital Services OECD: Competition in the Provision of Hospital Services

Market mechanisms reduce government hospitals costs Close hospitals or change management for poor results Choice of provider Capacity is needed Rural hospitals benefit from benchmark competition With long waits, funds following patients increases output Centres of excellence may need entry constraints Market mechanisms reduce government hospitals costs Close hospitals or change management for poor results Choice of provider Capacity is needed Rural hospitals benefit from benchmark competition With long waits, funds following patients increases output Centres of excellence may need entry constraints Competition in the Provision of Hospital Services (OECD) Competition in the Provision of Hospital Services (OECD)

ONTARIO HOSPITAL ASSOCIATION January 2007

Patient Focused and Centred