Questions related to the case summary What is criteria? Vertical integration vs. horizontal integration

Principles of Medicare Public administration Comprehensiveness Universality Accessibility portability

Our health care system defines us as communities, as a society, and as a nation. What Canadians are prepared to do, and more importantly, what we are not prepared to do for each other when we are sick, vulnerable, and most in need, says a great deal about Canada, our basic values, and the values that we want to hand on to future generations of Canadians. Margaret Somerville, LLB Founding Director, The McGill Center for Medicine, Ethics and Law McGill University, Montreal, Quebec

95% hospitals are non-profit entities –Run by community boards of trustees, voluntary organizations or municipalities. –Accountable to the communities they serve, not to the provincial bureaucracy

Rely extensively on primary care physicians –Account for 51% of all active physicians in Canada –Paid on fee-for-services basis –Act as “gatekeeper” of the Canadian health care system

Objectives Understand the context of the reform of the Canadian health care system Analyze the causes of the problems in the Canadian health care system Identify possible solutions

Current problems of the Canadian health care system Emergency overcrowding Doctor shortage –One in four Ontario doctors will retire in four years –By 2020, 30% of Ontario’s population will be over the age of 55. Waiting time –Access to health care providers, diagnostic tests, specialty treatment, hospital beds

Waiting time examples: –Six months to obtain a hip replacement –Five months to get a CAT scan –Some patients wait more than a year for cardiac surgery –Some cancer patients go to the States for treatment –2/3 Canadian physicians are finding it difficult to get appropriate resources such as diagnostic tests, referrals or operating room time for their patients.

The current situation Aging population (30% of Ontario population over 55) Physicians shortage family physicians have heavy work loads Funding constraints

Projecting the future health care OldNew Acute carecontinuum of care Treating illnessmaintaining and promoting wellness Individual patientsdefined population Provider similardifferentiation Inpatient admissionpeople health Fill bedsprovide timely care Separate org.Integrated system Run organizationoversee a market Managers as depart.headsoperate across organizations Coordinate servicespursue quality improvement

Causes Less funding for hospitals, resulting in –Lay off employees (e.g., nurses) –over-crowdedness –Longer waiting time –Decreasing quality of the health care

Causes (contd.) Payment system (how patients pay for the health care services and how physicians get paid) –Physicians Focus on volume, thus longer waiting time Reluctant to refer to specialists Duplicated services –Patients Don’t care about costs Solely rely on physicians Lack of knowledge on the common diseases

Causes (contd.) Structure –Task-oriented rather than customer-oriented Patients on their own Long waiting time Difficult to give the right care to patients at the right place and right time –Lack of integration among sectors Duplicated services Quality of care

Causes (contd.) Structure –Physician as “gatekeeper” Shortage of doctors becomes a bottleneck Longer waiting time for specialists Heavier work load

Causes (contd.) Philosophy – Cure disease rather than prevention and promotion –Patient rather than customer

Criteria Reduce costs Reduce physicians’ work loads Enhance the quality of the health care Not violate five principles Stakeholders are willing to accept Shift to prevention

Perspectives Quality in health care can be reflected through the perspectives of its different stakeholders: the patient (client, resident), the provider, the funder, and society. From the patients’ perspective, quality is defined in terms of how well their needs and expectations for care and service are met. For the providers, quality includes clinical effectiveness in terms of the correctness of the diagnosis and the appropriateness and efficacy of the treatment and care provided. From the system's perspective, quality is concerned with the efficiency of the services provided and the cost effectiveness, management and use of resources to achieve desired health outcomes. Finally, to society, quality is often measured in terms of value for money and benefits to the community at large.

What does quality mean? In general, quality reflects the extent to which health services meet the specified goals and standards of the accepted norm for good care and health service. Quality in health care is judged by three key areas, namely structure, process, and outcomes. Structure comprises the necessary resources to conduct the task (e.g. the resources to deliver the care, the physical resources, facilities, organization, standards, policies). Process is the act of doing the task (inputs-tasks-outputs, i.e. the care itself), and outcomes are the result (e.g. effective care, patient satisfaction, efficient use of resources).

The enhanced continuity of care A stepped up focus on prevention and healthy living 24-hour access to health advice through a dedicated telephone helpline Improved communication though increased use of information technology

Solution of Dr. Jim MacLean

IHS Fully connected through the use of information and communication technologies that use universal standards for shared information systems – a system that is fully connected.

What are the current situation? There are 57,243 practicing physicians in Canada –19,398 in solo practice –35,658 in group practice in 17,829 group offices –1,997 teaching or in administrative positions

There are about 229,813 nurses About 18,300 community and 4,000 hospital pharmacists and 7000 pharmacies 845 hospitals 6,129 long-term care institutions 1,798 labs 2,660 imaging locations

Fewer than 5% of physician’s offices have Internet-capable PCs.

What are the challenges? Funding required –Total initial start-up cost $ 4.1 billion –After implementation, operating costs $830 million

What have been done so far? Primary care reform Physicians –High level of satisfaction except those in Chatman –No change in their practice patterns –Some found unable to offset the extra costs of information technology –Found difficult in providing on-all coverage (since they can’t bill for the telephone advice) –Unrealistic expectations from the government –Information technology acquisition process (lengthy, resource-intensive, inefficient, and fragmented)

Final thought If survival of the Canadian Healthcare System is desired by Canadians it must be managed differently than in the past. Continuous Quality improvement is a management philosophy that offers promise to save our system through the reduction of inefficiencies and inappropriate variation as identified by line healthcare professionals and support staff. The spark and direction to begin the implementation of Continuous Quality Improvement must come from medical, nursing and administrative leaders who will be required to set the stage, create the culture and provide a vision of a preferred future. R.H. Wensel, MD, FRCP(C) Health Care Consultant Edmonton, Alberta