1. April 1, 20101 Back to Basics, 2010 POPULATION HEALTH (3A): Health Care Organization and Vital Stats N Birkett, MD Epidemiology & Community Medicine Based on slides prepared by Dr. R. Spasoff

2. April 1, 20102 THE PLAN(2) First class –mainly lectures Other classes –About 2 hours of lectures –Review MCQs for 60 minutes A 10 minute break about half-way through You can interrupt for questions, etc. if things aren’t clear.

3. April 1, 20103 THE PLAN (5) Session 3 (April 1) –Organization of Health Care Delivery in Canada –Elements of Health Economics –Vital Statistics –Overview of Communicable Disease control, epidemics, etc.

4. April 1, 20104 COMMUNICATIONS!!! C 2 LEO

5. April 1, 20105 Organization of Health Care (0) Provincial governments are responsible for Health Care. 1962: First universal medical care insurance 1965: Hall commission recommended federal leadership on medical insurance 1966: Medical Care Act (federal) established medical insurance with 50% funding from federal government 1977: EPFA reducing federal role; led to extra billing debate 1984: Canada Health Act 2001: Kirby & Romanow commissions 2005: Chaoulli decision (Quebec) –Controversial interpretation of the CHA in regards to banning of private clinics.

6. April 1, 20106 Organization of Health Care (0A) Canada Health Act established five principles –Public administration –Comprehensiveness –Universality –Portability –Accessibility Bans ‘extra-billing’

7. April 1, 20107 Organization of Health Care (0B) 2003: total health care expenditures were $3,839/person or about $135billion, 10% of GDP 73% from public sector (45% in the USA) 32% spent on hospitals, 16% on drugs,14% on MD’s and 12% on other HCP’s Research shows that private-for-profit care is more expensive and less effective

8. April 1, 20108 Methods of paying doctors (I&PH link)I&PH link Fee-for-service: unit is services. Incentive to provide many services, especially procedures. Capitation: unit is patient. Fixed payment per patient. Incentive to keep people healthy, but not to make yourself accessible. Salary: unit is time. Productivity depends on professionalism and institutional controls –Practice plans Combinations of above, e.g., "blended funding“ –Family networks (Ontario) ( I&PH link) I&PH link

9. April 1, 20109 Methods for paying hospitals Line-by-line: separate payments for staff, supplies, etc. Cumbersome, rigid. Global budget: fixed payment to be used as hospital sees fit. Fails to recognize differences in case mix. Case-Mix weighted: payment for total cost of episode, greater for more complicated cases. Now used in Canada. New technology: OHTAC reviews requests. If approved, government pays. If declined, hospitals can pay for it from core budget.

10. April 1, 201010 How good is the Canadian health care system? The World Health Report 2000 (from WHO) placed Canada 30 th to 35 th in the world, slightly above US but well below most of western Europe Implies that we should be healthier, given our high levels of income and education Methods used by the Report have been highly criticized

11. April 1, 201011 Organization of Health Care (1) Student & Resident Issues “The role of student and resident associations in promoting protecting their members’ interests.” Student organizations will be familiar to you PAIRO (Professional Assoc of Interns and Residents of Ontario) has been extremely effective in negotiating salaries, working conditions, educational programs

12. April 1, 201012 Organization of Health Care (2) CMPA “The role of the CMPA as a medical defence association representing the interests of individual physicians.” Canadian Medical Protective Association is a co- operative, replacing commercial malpractice insurance. It advises physicians on threatened litigation (talk to them early), and pays legal fees and court settlements. Fees vary by region and specialty ($500-$75,000/year).

13. April 1, 201013 Organization of Health Care (3) Interprovincial Issues “The portability of the medical degree.” –Degrees are portable across North America “The transferability of provincial medical licences.” –Traditionally, provincial Colleges of Physicians and Surgeons set own requirements (with input from provincial governments) As part of attempts to improve intra-provincial trade, recent legal changes have established a common lisencing standard –Pass LMCC –Family med or Royal College fellowship

14. April 1, 201014 Organization of Health Care (3b) Certification vs. licensing –Medical College of Canada Certifies MD’s (LMCC) –Royal College of Physicians and Surgeons of Canada Certifies specialists –College of Family Physicians of Canada Certifies family physicians –College of Physicians and Surgeons of Ontario Issues a licence to practice to MD’s.

15. April 1, 201015 Organization of Health Care (4a) Physician Organizations Medical Council of Canada –Maintains the Canadian Medical Registry –Does not grant licence to practice medicine College of Physicians and Surgeons of Ontario –Responsible for issuing license to practice medicine –Handles public complaints, professional discipline, etc. –Does not engage in lobbying on matters such as salaries, working conditions.

16. April 1, 201016 Organization of Health Care (4b) Physician Organizations Royal College of Physicians and Surgeons of Canada. –Maintains standards for post-graduate training through- out Canada. –Sets exams and issues fellowships for specialty training Ontario Medical Association –Professional association; lobbies on behalf of physicians re: fees, working conditions, etc. College of Family Physicians of Canada –Organization certifying/promoting family practice

17. April 1, 201017 Organization of Health Care (5) Medical Officer of Health Reports to municipal government. Responsible for: –Food/lodging sanitation –Infectious disease control and immunization –Health promotion, etc. –Family health programmes E.g. family planning, pre-natal and pre-school care, Tobacco prevention, nutrition –Occupational and environmental health surveillance.

18. April 1, 201018 Organization of Health Care (6) Medical Officer of Health Powers include ordering people, due to a public health hazard, to take any of these actions: –Vacate home or close business; –Regulate or prohibit sale, manufacture, etc. of any item –Isolate people with communicable disease –Require people to be treated by MD –Require people to give blood samples

19. April 1, 201019 The Coroner Notify coroner of deaths in the following cases: –Due to violence, negligence, misconduct, etc. –During work at a construction or mining site. –During pregnancy –Sudden/unexpected –Due to disease not treated by qualified MD –Any cause other than disease –Under suspicious circumstance or by ‘unfair means’ –Deaths in jails, foster homes, nursing homes, etc.

20. April 1, 201020 78.1: MEDICAL ECONOMICS (1) Define the socio-economic rationales, implications and consequences of medical care Medical care costs society financial and other resources. This objective aims to raise awareness of these types of issues.

21. April 1, 201021 MEDICAL ECONOMICS (2) Is there a net financial benefit from medical care? How do we value non-fiscal benefits such as quality of life, ‘health’, not being dead? Should resources be spent on health or other societal objectives? How do we value non-traditional expenditures, etc which impact on health (Healthy Public Policy).

22. April 1, 201022 Principles of cost-containment Eliminate ineffective care Reduce costs of effective care –Substitute cheaper but equally effective care, day surgery for hospital admission, nurse practitioners for some primary care, generic drugs –Reduce unit costs reduce salaries (risk of reduced effectiveness) or fees (but quantity provided may increase)

23. April 1, 201023 Types of economic analysis [Costs always expressed in dollars] Cost-minimization: assume equal outcomes Cost-benefit: outcomes in dollars *Cost-effectiveness: outcomes in natural units (deaths, days of care or disability, etc.) *Cost-utility: outcomes in QALYs (quality- adjusted life years)

24. April 1, 201024 78.1: VITAL STATISTICS INFORMATION What are the key causes of illness or death in Canada? Common things are common – using epidemiology can help you run a better clinical practicekey causes of illness or death How have disease incidence and mortality change in Canada in the past 20 years? –Little good information on disease incidence except for cancer (cancer registries)

25. April 1, 201025 13/7/200825 # deaths in Canada from 1979-2004; men and women.

26. April 1, 201026 13/7/200826 Mortality RATES in Canada from 1979-2004; men and women.

27. April 1, 201027 VITAL STATISTICS VITAL STATISTICS (2) Leading causes of death –‘Cardiovascular disease’: 37% Heart disease: 20% ‘Other circulatory disease’: 10% ‘Stroke’ 7% –‘Cancer’: 28% Lung cancer: 9% (M); 6% (W) Breast cancer: 4% (W) Prostate cancer: 4% (M) –Respiratory Disease: 10% –Injuries: 6% –Diabetes: 3% –Alzheimer’s: 1%

28. April 1, 201028 CANCER: 30.3% Circ Disease: 27.6% †† † † Pneumonia & influenza grouped with respiratory disease. Would increase infectious % to about 3.4%.

29. April 1, 201029 CANCER: 29.8% Circ Disease: 29.0% † † † Pneumonia & influenza grouped with respiratory disease. Would increase infectious % to about 3.5%.

30. April 1, 201030 CANCER: 31.6% Circ Disease: 27.3% † † † Pneumonia & influenza grouped with respiratory disease. Would increase infectious % to about 3.3%.

31. April 1, 201031 Sex ratio (M/F) in Canada from 1979-2004.

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39. Vital Stats (3) In the USA, it is estimated that 86,000 people are sent to ER every year after a fall caused by a cat or dog! –Mainly minor injuries but 10% are fractures, internal bleeding, etc. –Cats mainly trip people by walking under your feet. –Dogs (the main source of injuries!) causes trips, push people over or pull them over on walks. Watch out!!

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41. April 1, 201041 Overall trends in mortality from Cancer 1976-2005: rates and numbers

42. April 1, 201042 Overall trends in mortality 1976-2005: rates and numbers

43. April 1, 201043 Cancer and Age Age-Specific Incidence Rates for All Cancers by Sex, Canada, 2003 Surveillance Division, CCDPC, Public Health Agency of Canada

44. April 1, 201044 Cancer and Age Age-Specific Mortality Rates for All Cancers by Sex, Canada, 2003 Surveillance Division, CCDPC, Public Health Agency of Canada

45. April 1, 201045 Time trends in incidence - Males Age-Standardized Incidence Rates (ASIR) for Selected Cancer Sites, Males, Canada, 1978-2007 Surveillance and Risk Assessment Division, CCDPC, Public Health Agency of Canada Estimated

46. April 1, 201046 Time trends in mortality - Males Age-Standardized Incidence Rates (ASIR) for Selected Cancer Sites, Males, Canada, 1978-2007 Surveillance and Risk Assessment Division, CCDPC, Public Health Agency of Canada Estimated

47. April 1, 201047 Time trends in incidence - Females Age-Standardized Incidence Rates (ASIR) for Selected Cancer Sites, Females, Canada, 1978-2007 Surveillance and Risk Assessment Division, CCDPC, Public Health Agency of Canada Estimated

48. April 1, 201048 Time trends in mortality - Females Age-Standardized Incidence Rates (ASIR) for Selected Cancer Sites, females, Canada, 1978-2007 Surveillance and Risk Assessment Division, CCDPC, Public Health Agency of Canada Estimated

49. April 1, 201049 Population Pyramids Canada, 1901-2001 Newfoundland 1951-2001 Ontario 1951-2001 Nunavut, 1991-2001