Program in Policy Decision-Making McMaster University John N. Lavis, MD, PhD Associate Professor and Canada Research Chair in Knowledge Transfer and Uptake McMaster University 28 June 2005 Health Policy Update from Canada: Primary Care Reform and Timely Access to High-Quality Care AcademyHealth Annual Research Meeting Boston, MA, USA

2 Policy context and climate Two current policy issues Primary care reform Timely access to high-quality care (or waiting lists) Conclusions Overview

3 British North America Act Health care is a provincial responsibility Canada has 14 different healthcare systems -10 provincial healthcare systems -3 territorial healthcare systems -1 “federal” healthcare system for First Nations and soldiers Policy Context and Climate

4 Canada Health Act (and preceding legislation) Federal government has a role to play in healthcare as an overseer and partial source of finance Politics of blame avoidance, which makes for a lot of finger-pointing and noise Policy Context and Climate (2)

5 Canada Health Act (and preceding legislation) Private delivery / public payment bargain (the “core bargain”) Private practice physicians deliver care with first- dollar, one-tier public (fee-for-service) payment Private not-for-profit hospitals deliver care with first-dollar, one-tier public payment Same debates play out over and over -Change the way primary health care is delivered? -Continue to provide one-tier public payment? Policy Context and Climate (3)

6 Primary Care Reform Changes in the framing of the policy issue Until about five years ago, the issue was cast as a search for big-bang primary care reform, and this proved challenging given -Delivery is in the private domain and fee-for- service payment is entrenched -Medical associations often sit at the policy table -Research does not support a single model Since then, the issue has been re-cast as a search for incremental reforms with a plurality of approaches

7 Primary Care Reform (2) Problems in the organization & delivery of primary care Lack of continuity of care for patients Lack of involvement of other healthcare providers Focus on acute or episodic care, not chronic diseases such as diabetes, heart disease or hypertension And from the perspective of physicians Many family physicians are reducing (or considering reducing) their workload Less than 30% of medical students are choosing family medicine as a career

8 Primary Care Reform (3) Priorities for action (with examples of strategies used) Improved continuity and coordination of care (24/7 access and multidisciplinary teams) Early detection and action (disease prevention, chronic disease management) Better information (electronic health records, telehealth technologies) Incentives to change practice (innovative funding models, involvement of non-medical staff)

9 Primary Care Reform (4) Strategies being used Mixed remuneration methods Incentives or requirements for -Rostering patients -Providing certain types of services (e.g., immunizations) -Hiring or working with other types of providers

10 Primary Care Reform (5) Strategies being used (2) Incentives or requirements for -Making organizational changes (e.g., working in groups/networks, providing 24/7 coverage, adopting an electronic health record) -Engaging in continuing medical education Additional support provided centrally (e.g., telephone health advisory service) Limits placed on patient choice (e.g., notify MD if seeking care elsewhere unless it’s an emergency)

11 Primary Care Reform (6) Provincial efforts to move forward on primary care reform have been supported by some degree of national consensus about action General commitment to one primary care goal in the First Ministers’ Accord in By 2011, 50% of Canadians will have 24/7 access to an appropriate healthcare provider -Some initiatives involve shifting the point of first contact to nurses or nurse practitioners -Most initiatives involve supporting physicians

12 Primary Care Reform (7) Where to from here? Options for bringing about change -Offer alternatives to all new physicians (and experienced physicians who are ready for a change) -Entice a broad range of physicians into generous contracts and then use the contracts as a tool to bring about other changes and/or to bring some uniformity to the models being used

13 Timely Access to High-Quality Care Changes in the framing of the policy issue Until very recently, the issue was cast as a delivery issue (i.e., long waiting lists) that needed to be addressed, and this proved challenging given delivery is primarily in the private domain Supreme Court recently re-cast the issue as a financing issue (i.e., ban on two-tier public payment) that needed to be addressed, at least in Quebec, and this is proving challenging given financing is primarily in the public domain and governed by a highly visible core bargain

14 Timely Access to High-Quality Care (2) Problems with long waiting times Waiting can cause harm Waiting can be unfair (e.g., remote and rural regions, populations with special needs, and areas where providers and services are in short supply) Waiting can undermine confidence in the system

15 Timely Access to High-Quality Care (3) Potential causes of long waiting times Lack of coordination Lack of accountability Clinical judgements vary New technology has increased demand and lowered threshold for treatment Emergency cases bump non-emergency cases Lack of capacity

16 Timely Access to High-Quality Care (4) Actions being taken to address long waiting times Enhance capacity Study waiting times (e.g., standardize measures, evaluate outcomes) Post waiting times (e.g., BC, ON, QC) Set benchmarks regarding waiting times Manage waiting lists (e.g., Cardiac Care Network) -Define need for care with precision and fairness -Manage flow of patients

17 Timely Access to High-Quality Care (5) Provincial efforts to address long waiting times have been galvanized by a national consensus about action General commitment to timely access in the First Ministers’ Accord in 2003 Specific commitments in the Ten Year Action Plan released in September Meaningful reductions in waiting times for diagnostic imaging, cancer care, cardiac care, cataract procedures, and joint replacements -Comparable indicators, benchmarks, and multi- year targets, all of which will be reported publicly

18 Timely Access to High-Quality Care (6) And then, on 9 June 2005, Canada’s Supreme Court re- cast the issue as a financing issue (i.e., ban on two-tier public payment) that needed to be addressed, at least in Quebec 4 to 3 decision struck down Quebec’s ban on private health insurance, saying the public system failed to deliver timely care, which imperils patients’ Charter right to “security of the person” 3 to 3 vote about the decision’s applicability to other provinces, so the citizens of other provinces would need to pursue a similar court challenge (if their government did not proactively end the ban)

19 Timely Access to High-Quality Care (7) Where to from here? Quebec has asked the Supreme Court for a stay of between six months and two years to consider the implications Options -(Re) Introduce a two-tier system of “medically necessary” hospital and physician care, as Canada has in all other parts of its healthcare system -Move rapidly to set benchmarks and achieve them -Both, with likely result that the private tier is small

20 Conclusions Changes to the core bargain have been difficult Private practice physicians deliver care with first- dollar, one-tier public (fee-for-service) payment Private not-for-profit hospitals deliver care with first- dollar, one-tier public payment Primary care reform continues to bang up against it Timely access to high-quality care may have needed a Supreme Court decision to trigger meaningful action

21 References Primary care reform Hutchison BG, Abelson J, Lavis JN. Primary care reform in Canada: So much innovation, so little change. Health Affairs May/June 2001;20(3): Both policy issues Health Council of Canada (2005). Report to Canadians. Ottawa: Health Council of Canada. -

22 Contact Information John N. Lavis Program in Policy Decision-Making, McMaster University