Dollars and Sense: Medicare is Sustainable if we do our work differently Michael M Rachlis MD MSc FRCPC LLD Quebec Medical Association April 20,

Current received wisdom Health Care costs are wildly out of control My fellow baby boomers and I will really deep six Medicare as we get older The only alternatives are to either hack services, go private, or better yet do both We need an “adult conversation” about whom gets tossed out of the life raft 2

3

What’s my story? What’s the diagnosis – Health Care costs are not “out of control” – The aging population won’t break the bank – Most of health care’s problems are due to antiquated, processes of care What are the solutions – We need to complete Tommy Douglas's vision for the Second Stage of Medicare -- a patient-friendly delivery system focussed on keeping people healthy How do we get there? – What are the roles for health care providers – What is the role of the medical profession 4

5

6

7

8

The sustainability of Medicare in Canada Health slowly increased its share of Canadian GDP from 2000 to 2008 Health’s share of GDP rose dramatically in 2009 because the economy collapsed. In 2010 and 2011, governments controlled costs, the economy grew again, and health decreased its share of GDP This downward trend of health costs as a share of GDP will likely continue for the next 3-5 years Public health care spending in 2011 was 0.6% higher than its previous peak in 1992 (8% in relative terms) vs. private sector cost rise of 0.9% (35% in relative terms) 9

10

11

12

13

14

15

16

The shrinking Canadian public sector Overall Canadian government revenues have fallen by 5.8% of GDP from 2000 to 2010, the equivalent of $94 Billion in lost revenue – Just half of this, 47 Billion, could eliminate all 2012 Canadian government deficits OR fund first dollar universal pharmacare, long term care and home care AND regulated child care for all parents who want it AND free university tuition AND build 15,000 units of affordable housing units AND the new fighter jets 17

18

The aging population won’t kill Medicare Canada is aging and health costs increase with age But Aging of the population per se has had and will have only a moderate impact on health expenditures Aging is like a glacier not a tsunami. We have lots of time to prepare and adapt our health system before we get swamped! – The elderly are healthier than ever – High performing health systems can hold costs while enhancing quality of care for the frail elderly 19

From Mackenzie and Rachlis 2010 Annual impact of Aging on health costs

From Mackenzie and Rachlis 2010 Annual impact of Aging on health costs

The Compression of Morbidity JF Fries. Millbank Memorial Fund Quarterly

Year Disability No Disability 73.8%75.2%76.8%78.8%81.0% Light or Moderate 15.9%14.8%13.9%13.3%11.8% Severe Requiring > 2.5 hrs personal care daily 10.3% 10.0%9.2%7.9% 7.2% American prevalence of disabled elderly Manton et al. PNAS. 2006:103(48):

K Manton et al. Journal of Gerontology: SOCIAL SCIENCES 2008, Vol. 63B, No. 5, S269–S281 “Our results, supporting the hypothesis of morbidity compression, indicate that younger cohorts of elderly persons are living longer in better health.”

Old Age Dependency Ratios (OADRs) Prospective Old Age Dependency Ratios (POADRs) Adult Disability Dependency Ratios (ADDRs) Dependency of the elderly in wealthy countries W Sanderson. Science. 2010;329: Canada was not included

“It is not the aging of our population that threatens to precipitate a financial crisis in health care, but a failure to examine and make appropriate changes to our health care system, especially patterns of utilization.” Dr. William Dalziel. CMAJ. 1996;115:1584-6

Most of health care’s problems are due to antiquated, processes of care 27

28 After-Hours Care and Emergency Room Use Percent Difficulty getting after-hours care without going to the emergency room Used emergency room in past two years Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

29 Waited Less Than a Month to See Specialist Percent Base: Saw or needed to see a specialist in the past two years. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

Spine surgeons in Ontario: A wasted precious resource Only 10% of patients referred to a spine surgeon actually need surgery $24 million in unnecessary MRI scans 30 (

Traditional Joint Replacement Referral Process Spaghetti junction!

There are affordable solutions to all of Medicare’s apparently intractable problems: The Second Stage of Medicare 32

We need to change the way we deliver services “Removing the financial barriers between the provider of health care and the recipient is a minor matter, a matter of law, a matter of taxation. The real problem is how do we reorganize the health delivery system. We have a health delivery system that is lamentably out of date.” Tommy Douglas 1982

“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 Catching Medicare’s second stage

“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

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

Outcome at 3 yrs Group Living in the community Resident of a LTC facility or dead Health Promotion Group (N=81) 75.3% (61) 24.7% (20) Control Group (N=167) 58.7% (98) 42.3% (69) Health Promotion intervention for BC frail elders (P = 0.04) N Hall et al. Canadian Journal on Aging. 1992;11(1):72-91

Step right up! Get your ELIXIR of Health Promotion! Reduce your risk of dying or ending up in a nursing home by over 40%! Increase your chances of staying in your own home by nearly 30%!

Per Person Average overall costs of health care for continuing care patients in areas with/without cuts to social and preventive home care (Hollander 2001) Year Prior to Cuts First Year After Cuts Second Year After Cuts Third Year After Cuts Areas with cuts $5,052$6,683$9,654 $11,903 Areas without cuts $4,535$5,963$6,771 $7,808

With current resources Canadians could: Have elective surgery within two months Have elective specialty input within one week Have same day access to our regular family doctor or someone on the doctor’s team 40

Toronto Arthroplasty Model Central Intake Assessment Advanced Practice Physio Surgeon Consult Surgery Post-Op Discharge Follow-Up Referring Physician Holland Centre and Toronto Western Holland Centre Mt. Sinai St. Michael’s St. Joseph’s Toronto East General Toronto Western

Good News in Hamilton and Winnipeg! We could have elective specialty consultations within 7 days – The Hamilton Family Medicine Mental Health Program increased access for mental health patients by 1100% AND decreased psychiatry outpatients’ clinic referrals by 70%. – The program staff includes 22 psychiatrists, 129 family physicians, 114 Nurses and Nurse Practitioners, 20 Registered Dietitians, 77 Mental Health Counsellors, 7 pharmacists and provides care to 250,000 patients

Good News in Cambridge, Cape Breton, Penticton, etc! We could access primary health care within 24 hrs In Cambridge, Dr. Janet Samolczyk aims to see her patients WHEN they want to be seen including within 24 hours

There is substantial evidence that for profit patient care tends to cost more and is of poorer quality -- but the most salient argument is Tony Soprano’s: “Fuhgetaboutit!” We don’t need it.

How do we get to the Second Stage of Medicare? 45

How do we get to the Second Stage of Medicare? Get your values right Focus on the health of the population Follow the 10 commandments for quality Create quality workplaces for providers New roles for health care providers A new role for doctors and the medical profession

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 and the IHI Triple Aim “The health system should work to prevent sickness and improve the health of the people of Ontario.” Health Quality Ontario

The Institute for Health Improvement’s Triple Aim 1.Enhance the Care experience for patients 2.Improve the health of the population 3.Control overall health care costs

Canadian 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 sp/disparities/pdf06/disparities_discussion_paper_e.pdfhttp:// sp/disparities/pdf06/disparities_discussion_paper_e.pdf

2.8 – – – – – 7.6 Age and sex adjusted Diabetes prevalence rates Toronto Diabetes Prevalence Rates by Neighbourhood 2001 From: R Glazier. Neighbourhood environments and resources for healthy living

Crossing the Quality Chasm: Ten Rules to Heal the Health Care System ( 1. Care should be based upon continuous healing relationships instead of mainly in-person visits. 2. Care should be customized for individual patients’ needs and values instead of being dictated by professionals. 3. Care should be under the control of patients not professionals. 4. Knowledge about care should be shared freely between patients and providers and between different providers. This transfer should take maximal advantage of leading-edge information technology. Patients should have unrestricted access to their records. 5. Clinicians should make decisions on the basis of the best scientific evidence. Care should not vary illogically from clinician to clinician or from place to place.

Crossing the Quality Chasm: Ten Rules to Heal the Health Care System 6. Safety is the responsibility of the whole system not individual providers. 7. The content of care is made transparent instead of being held in secret. The health system should give as much information as is required to patients and families to enable them to fully participate in clinical decisions, including where to seek care. 8. Patients’ needs should be, as much as possible, anticipated and not treated in a reactive fashion. 9. The health care system should continually decrease waste (goods, services, and time) instead of focusing on cost reduction. 10. Providers should cooperate and work in high-functioning teams instead of attempting to work in isolation. Concern for patients should drive cooperation among providers and drive out competition based upon professional and organizational rivalries.

Quality workplaces for providers Happier staff = healthier patients Happier staff = lower turnover Healthier patients = lower costs Lower turnover = lower costs

New roles for health care providers Patient and family centred care means big changes in roles for providers and patients, especially for chronic disease Providers now need to be more like supportive coaches than deliverers of the revealed truth 55

INDIVIDUALS AND FAMILIES Improved clinical, functional and population health outcomes HEALTH CARE ORGANIZATIONS Informed, activated individuals & families Prepared, proactive Practice teams Activated communities & prepared, proactive Community partners Healthy Public Policy Supportive Environments Community Action Delivery System Design Provider Decision Support Information Systems Ontario’s Chronic Disease Prevention & Management Framework Productive interactions and relationships Personal Skills & Self- Management Support :

New roles for health care providers Transfer of Accountability at the bedside – Nothing about me without me! The Eden Alternative in Long Term care – Human relationships are the key to quality of life 57

New roles for physicians Follow the CANMEDS roles – Medical Expert – Communicator – Collaborator – Manager – Health Advocate – Scholar – Professional 58

New roles for physicians Embrace patient/family centred care Our identity as doctors must flow from our service to patients instead of vice versa Follow the patient! – Winnipeg HIV/AIDS care – Hamilton shared care psychiatry 59

“Deputy ministers last 18 months, Ministers last 2-3 years, CEOs rarely last 4 years. I’ve been here for 15 years and I will be here forever. I can’t make change but I can block it!” Dr. Richard Steyn, Thoracic surgeon Birmingham UK 60

High performing health organizations and physician engagement: There are only two models. 1.A disciplined medical group that co- manages with the board E.g. The Kaiser Permanente system in the US, the Sault Ste. Marie Group Health Centre 2.Doctors as salaried employees E.g. The Mayo clinic, the Cleveland Clinic, and the Saskatoon Community Clinic 61

Summary: Health Care costs are not out of control The aging population won’t break the bank Medicare was and is good public policy Our health system’s problems reflect our failure to implement Tommy Douglas’s Second Stage of Medicare There are affordable solutions to all of our apparently intractable problems Health care providers, especially doctors, need to do their work differently to ensure Medicare’s sustainability 62

Courage my Friends, it is Not Too Late to Make a Better World! Tommy Douglas (paraphrasing Tennyson) 63