1. The Second Stage of Medicare demands Community Engagement Nova Scotia Community Health Boards Conference Port Hawkesbury NS October 18, 2007 Michael M. Rachlis MD MSc FRCPC www.michaelrachlis.com

2. Outline What’s happening with the national health policy debate? What is the Second Stage of Medicare and how do we get there? Community engagement is essential for the fulfillment of the second stage of Medicare

3. There are three main views of Medicare but none are satisfying to Canadians

4. 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.

5. 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 50-50 cost sharing in 1977, and then hacked funding until 1997. 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.

6. 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 this sucker as fast as possible. Maybe a dumb, rich American will take it off our hands.

7. Canada’s Health Care System: A Diagnosis Medicare was the right road to take Costs are not out of control but neither is the system drastically underfunded The real problem is that Canada’s delivery system was designed for another time and important improvements were opposed, primarily by physicians As a result, we often get poor quality care There are solutions but they are being implemented slowly. We need to move faster on the 2 nd Stage of Medicare

8. Public Health Insurance was the right course for its time Canada & US had same system < 1960 Now 47 million US uninsured Canada spends less than the US but Canadians usually get more services Canadians live 2 1/2 years longer and Canada has a 30% lower infant mortality Medicare boosts Canadian business –Health care costs: 1.5% of Canadian manufacturers’ payroll and 9% of those in US

11. Health Care Costs are not out of Control but neither is the Health Care System Drastically Underfunded

13. S Woolhandler Int J H Serv 2004;34:65-78.

19. Outline What’s happening with the national health policy debate? What is the Second Stage of Medicare and how do we get there? Community engagement is essential for the fulfillment of the second stage of Medicare

20. Medicare – a compromise designed for another time Designed for acute care –Now the main problems are chronic illness Douglas’ original plans included a very different delivery system – the Second Stage of Medicare

21. 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.

22. We could prevent most chronic diseases > 80% of ischemic heart disease, lung cancer, chronic lung disease, and diabetes cases could theoretically be prevented with what we know now This would free up over 6000 hospital beds across Canada

23. 1945 -- Swift Current Region #1: The original visions Prepaid funding Services available on a universal basis, with little or no charge to users. Integrated coordination of health care delivery through the creation of local integrated health regions which fund a comprehensive package of services Group medical practice with doctors working in teams with nurses, social workers and other providers. In the original plans, the medical officer of health was the medical director. Democratic community governance

24. 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

25. What happened to the vision? Despite the Hall Commission, the feds only cover medical care Dr. John Hastings’s 1972 Report is mainly ignored, except in Quebec Canada inspires other countries’ policy –Lalonde Report, Ottawa charter of Health Promotion, Etc The Canada Health Act stops the bleeding –But it’s only temporary

26. 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” We can’t keep it secret anymore -- Poor quality care kills thousands

28. Houston, we have a quality problem (like other countries) One in 14 Canadian hospital patients suffers a complication while in hospital (Baker Norton Flintoft 2004) There are 9,000 to 24,000 deaths that occur in hospital every year which could be prevented (4-11% of all deaths)

29. Our health system doesn’t deal well 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 24% of asthmatics are properly controlled and 57% are poorly controlled Up to one in six seniors is re-admitted to hospital within 30 days of discharge

30. Do one-quarter of older Canadian women need to take Benzos? Benzos cause one-fifth of Quebec’s broken hips. Do we care what we’re paying for?

31. Canadian primary health care has problems, compared with other countries Canadian family physicians are the least likely to work in teams or have electronic records Canadian family physicians are the most likely to say they have difficulty managing chronic disease Canadian diabetics are the least likely to get adequate care

32. Trying to deliver health services without adequate primary health care is like pulling your goalie in the first period!

33. 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.”

34. We need to change the way we deliver care “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

35. “Only through the practice of preventive medicine will we keep the costs from becoming so excessive that the public will decide that Medicare is not in the best interests of the people of the country.” Tommy Douglas We need to focus on prevention

36. The Mission: In the Second Stage of Medicare we will continuously reduce: Unnecessary deaths, Unnecessary pain and suffering, Unwanted waiting Helplessness Waste Modified from Institute of Medicine 2001

37. The Second Stage’s Essence – delivering health services differently to keep people well

38. 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

39. Attributes of High Performing Health Systems Ontario Health Quality Council. April 2006. (www.ohqc.ca) 1.Safe 2.Effective 3.Patient-Centred 4.Accessible 5.Efficient 6.Equitable 7.Integrated 8.Appropriately resourced 9.Focused on Population Health

40. Second Stage of Medicare Principles Essential Principles – What we Want 1. Population Health Focus 2.Equitable 3.Patient-Centred 4.Effective 5.Accessible 6.Safe Instrumental Principles – How we get there 7. Efficient 8.Accountable 9.Appropriately resourced 10.Non-profit

41. 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

42. 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

43. 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

44. 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

45. 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

46. Effective The best science should ensure most appropriate care possible. Care is too often not based upon evidence It usually takes 15-20 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 people with diabetes

47. Accessible Patients should get timely care. Waits should be continuously reduced Advanced Access – same day service –Penticton, Toronto, Saskatchewan, Cape Breton 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

48. Safe People should not be harmed. We should continuously reduce adverse events. Safer Health Care Now (http://www.saferhealthcarenow.ca/)http://www.saferhealthcarenow.ca/ –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

49. Outline What’s happening with the national health policy debate? What is the Second Stage of Medicare and how do we get there? Community engagement is essential for the fulfillment of the second stage of Medicare

50. Second Stage of Medicare Principles Essential Principles – What we Want 1. Population Health Focus 2.Equitable 3.Patient-Centred 4.Effective 5.Accessible 6.Safe Instrumental Principles – How we get there 7. Efficient 8.Accountable 9.Appropriately resourced 10.Non-profit

51. Community Engagement works! Kahnewake fights diabetes South Riverdale gets the lead out Regent Park passes the course

52. Community Engagement needs work! Primary health care and public health need to plant seeds in communities –Pincher Creek community grants Senior levels of government need to provide fertilizer –Saskatchewan Human Services Integration Forum and Regional Intersectoral Councils

53. What Canadians want to hear? Medicare was the right road to take Costs are not out of control but neither is the system drastically underfunded. We need transition funding for innovation 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 – Medicare’s 2 nd Stage

54. For profit patient care tends to be more expensive and of poorer quality but the most effective argument is: “Fuhgetaboutit!”

55. Summary: Our health services are rife with problems because we failed to implement the Second Stage of Medicare The essence of the Second Stage of Medicare is re- organizing health services delivery to focus on prevention We need to implement the Second Stage of Medicare or we risk losing the First Community Participation is essential to Medicare’s Second Stage

56. “ Courage my Friends, ‘Tis Not Too Late to Make a Better World!”