Last month, I had the privilege of presenting on the subject of Comparative Health Systems at the Physician Hospitals of America conference in New Orleans. I’ve been an armchair student of international health policy for many years, but this was the first occasion that I had to present on the subject.
The challenge of presenting on health policy to an audience currently undergoing some of the grandest health system change in history was somewhat overwhelming, particularly to an audience of doctors and senior healthcare administrators.
My co-presenter, Dr. Nigel Murray, and I chose to look at Sweden, UK, New Zealand and Canada. We looked at very specific aspects as it related to the health reform initiatives under way in the US, including insurance coverage systems, public/private delivery, government intervention, and medical malpractice compensation systems in each of these countries.
The irony of having two Canadians presenting to this audience was not lost on me. Canada is the only OECD country to have a fully universal, publicly funded system. It is also the only country not to have undergone any major health reform in 25 years. And here we were, talking about comparative health systems and how they have evolved to meet the demands of their populations.
I would not do the reader justice to try to summarize the comparative health delivery systems here in a blog; suffice to say that while there are no “perfect” systems, Sweden, the UK, New Zealand and now the US have all entered the era of health reform. Each system has, or is, undertaking reform in an iterative process, enacting changes and not fearing the need for further change.
Which leads to the purpose of this posting. When President Obama initiated reform in the US, he took a bold step towards dramatic system change. Coverage, compensation schemes, the regulation of providers, and addressing the shortage of medical professionals are all on the table. The principles he put forward for this change will be the foundation for the greatest change in the history of the US. He’s staking his career on it.
Back in Canada, our 25 year old Canada Health Act continues to bump along. At the time that it was brought into legislation, tying the hands of all provincial governments to publicly funded and publicly delivered care (although that is subject to interpretation), no one could have envisioned the challenges and advances that would take place in healthcare. And now we have provincial governments faced with short term financial pressures looking to cut funding to population services – the largest of which is healthcare.
Canada needs to look at serious health reform. Politicians at both the provincial and federal levels need to have the courage and insight to create large-scale reforms of the Canadian system. It won’t be popular – as President Obama has certainly learned – and it may not even be right the first time. However, as our systems approach 50% of all provincial government spending, we are on the path to bankruptcy. We need to look at how other systems have reformed, what it has produced in terms of successes, failures, and sustainability. This steep learning curve should not be lead by bureaucrats who are married to the current system and rebuke change; we need learned people who can put their ideologies aside and understand the sense of urgency required.
Now that would be something worth holding an election over.
Friday, October 16, 2009
Monday, May 25, 2009
What the Hospital Report Card: British Columbia 2009 Means to You
Last week, the Fraser Institute released its second Hospital Report Card (http://www.hospitalreportcards.ca/ ), with glaring improvements in that this year’s report actually includes the names of hospital facilities. The Fraser Institute battled with the Province and CIHI under the Freedom of Information Act to achieve this, and it should be noted that this is a Canadian first in the disclosure of hospital-related outcomes data.
“This is the first time this level of transparency and accountability in the hospital sector has been available to citizens of any province in Canada. Indeed, British Columbia can now be considered a leading in providing transparency and accountability with respect to publicly funded care being delivered in the province’s hospitals.” – Fraser Institute Report, Hospital Report Card: British Columbia 2009.
The Report uses a peer-reviewed methodology largely based upon an American model for outcomes measurement. Comprising 2.5 million records, the Report assesses 39 quality and safety indicators across 95 public hospitals in BC over a six year period. The results have been risk adjusted for the fact that tertiary hospitals tend to manage higher acuity (sicker) patients, and perform more complex procedures.
The Report Card is searchable by facility, municipality, indicator, and mortality rates. There are many interesting observations to be made, amongst them:
“This is the first time this level of transparency and accountability in the hospital sector has been available to citizens of any province in Canada. Indeed, British Columbia can now be considered a leading in providing transparency and accountability with respect to publicly funded care being delivered in the province’s hospitals.” – Fraser Institute Report, Hospital Report Card: British Columbia 2009.
The Report uses a peer-reviewed methodology largely based upon an American model for outcomes measurement. Comprising 2.5 million records, the Report assesses 39 quality and safety indicators across 95 public hospitals in BC over a six year period. The results have been risk adjusted for the fact that tertiary hospitals tend to manage higher acuity (sicker) patients, and perform more complex procedures.
The Report Card is searchable by facility, municipality, indicator, and mortality rates. There are many interesting observations to be made, amongst them:
- Tertiary hospitals are not the only ones with good healthcare. In fact, Fraser Health’s Eagle Ridge Hospital ranked number one in the Hospital Mortality Index (the higher the ranking, the better), and Vernon Jubilee Hospital ranked third. Lion’s Gate was second, and Vancouver General fourth. Surprisingly though, hospitals with a wide range of services and specialties, such as Surrey Memorial Hospital, ranked 21 out of 26.
- The risk adjusted post-operative infection rate for elective procedures in public hospitals varies greatly and speaks to issues in individual facilities. Across the province, the infection rate is 6.2 per thousand (0.0062%). Ten hospitals in BC ranked higher, with the hospital in Quesnel ranking last with a risk adjusted infection rate of over 30 cases per thousand.
- Some hospitals are in need of serious review. Death in low mortality diagnostic related groups (DRG) occurs across the province at 1.4 cases per thousand. This indicates that the death rate among patients that are considered unlikely to die in the hospital. Four hospitals in 2006/7 reported rates over 8.4 per thousand, and one, McBride and District Hospital, reports 41.7 deaths per thousand (it should be noted that this is a smaller hospital and the data may be projected over 1000 patients and easily impacted by just a few cases). 39 hospitals scored 100, and had no deaths in low mortality DRGs.
- Not all hospitals use the same techniques. 82.18% of gallbladders in BC were removed using a laparoscopic technique, which as a minimally invasive procedure, results in shorter recovery, pain and complications. 42 hospitals in BC perform gallbladder surgery (normally done by a general surgeon), however if you lived in Prince George, Squamish, or Fort St. John, you were nearly half as likely to have your gallbladder removed using this technique.
While this Report is produced in a very user friendly manner, it has a few shortcomings. Firstly, the list of procedures measured is both short (only five) and somewhat of an odd selection. Two of the procedures listed (esophageal resection and pancreatic resection surgery), are so uncommon that under 100 total procedures are performed across the province each year. How can we measure a hospital’s performance using this indicator when some hospital performed just 9 in the year? The other shortcoming – and this is no reflection upon the Fraser Institute - is that BC patients lack portability in their healthcare options. While technically their insurance is portable, it is a challenge to have a Prince George GP refer you to a Victoria General surgeon for your specific procedure, never mind a logistical nightmare of consults, pre-operative, surgical and post-operative appointments.
I’d also like to see more information on volumes of procedures. If I actually had the opportunity to decide where to receive my care, the volume of procedures/treatments performed for my given medical need would certainly help me to determine where to receive care. Practice makes perfect.
The Fraser Institute claims that this report was designed to assist British Columbia patients in making informed decisions about their care. Beyond that, though, this Report provides a first look for Health Authorities and the Ministry of Health, at meaningful, methodical, risk adjusted data. It gives the hospitals and health authorities something to work with in terms of measuring outcomes, not just throughput. It gives the public something tangible against which to hold these public bodies accountable.
The Report Card may not be everything to everyone, but it is a giant leap for British Columbians in terms of the measurement of health system performance.
Tuesday, May 19, 2009
Consumer driven healthcare in Canada
“Single-payer systems control health care costs primarily by rationing services to the 20 percent of the people who account for 80 percent of the costs. The political calculus is cruel but irresistible: 80 percent of the people, the healthy ones, will love their system, while some of the sick, a mere 20 percent, will not” (Regina Herzlinger, 2009).[1]
The single-payer Canadian healthcare system is largely seen as a supply-side economy with an insatiable demand. System capacity is largely based upon the availability of government funds; system quality is controlled by provincial and federal government regulations; system access is determined by a combination of legislation and funding.
Nowhere in the equation do you see discussion of demand and demand-side management. I speculate that consumer demand will be the new buzz word in Canadian healthcare in 2009.
Perhaps some focus on consumer driven demand is appropriate in a marketplace that has stretched its capacity and efficiencies to the absolute extremes. We have studied, planned, implemented, tinkered, and studied some more, a plethora of ways in which to prudently manage the supply of health services. We’ve even gone so far as to expand the scope of practice of para-professionals in healthcare, most recently granting naturopaths certain privileges that were previously reserved for MDs.
However, we haven’t found even a close balance between supply and demand, and continue to see this see-saw out of balance.
In her same article, Herzlinger, a Harvard Professor in the School of Health Policy, suggests that giving control to the consumer will drive pricing, access and quality. She argues that the health care market would best be served by creating a more perfect market where funded demand is met by accessible supply, and competition will improve price, access and quality.
Applied to the Canadian scenario, what if we are to allocate to every Canadian, their share of health dollars and give them the opportunity to use them. They would have to choose their provider – based upon decision factors that they found important including location, quality, price, access and outcomes – and take their health dollars with them. Providers, including hospitals and medical professionals, would have to price their services at an effective price point so as to attract consumers. The market for services, would ultimately drive supply, price and quality. Insurance products for catastrophic illness or injury would be compulsory in some form, so as to ensure coverage.
The concept of shifting control to the demand side of the equation has another benefit – the potential for demand reduction. When the consumer is in control of the health dollars, they are also accountable for how they use them. Perhaps this accountability will expand to better efforts by consumers in health promotion and protection and ultimately, in disease prevention measures.
Alas, shifting the paradigm to demand-driven health care from the current supply system is not likely to happen in Canada in the immediate future. South of the border, this may become the reality, and will be worth watching.
[1] Herzlinger, R. “Can the United States provide health care for all?” What Matters, McKinsey & Company May 18, 2009. Found at http://whatmatters.mckinseydigital.com/health_care/can-the-united-states-provide-health-care-for-all
The single-payer Canadian healthcare system is largely seen as a supply-side economy with an insatiable demand. System capacity is largely based upon the availability of government funds; system quality is controlled by provincial and federal government regulations; system access is determined by a combination of legislation and funding.
Nowhere in the equation do you see discussion of demand and demand-side management. I speculate that consumer demand will be the new buzz word in Canadian healthcare in 2009.
Perhaps some focus on consumer driven demand is appropriate in a marketplace that has stretched its capacity and efficiencies to the absolute extremes. We have studied, planned, implemented, tinkered, and studied some more, a plethora of ways in which to prudently manage the supply of health services. We’ve even gone so far as to expand the scope of practice of para-professionals in healthcare, most recently granting naturopaths certain privileges that were previously reserved for MDs.
However, we haven’t found even a close balance between supply and demand, and continue to see this see-saw out of balance.
In her same article, Herzlinger, a Harvard Professor in the School of Health Policy, suggests that giving control to the consumer will drive pricing, access and quality. She argues that the health care market would best be served by creating a more perfect market where funded demand is met by accessible supply, and competition will improve price, access and quality.
Applied to the Canadian scenario, what if we are to allocate to every Canadian, their share of health dollars and give them the opportunity to use them. They would have to choose their provider – based upon decision factors that they found important including location, quality, price, access and outcomes – and take their health dollars with them. Providers, including hospitals and medical professionals, would have to price their services at an effective price point so as to attract consumers. The market for services, would ultimately drive supply, price and quality. Insurance products for catastrophic illness or injury would be compulsory in some form, so as to ensure coverage.
The concept of shifting control to the demand side of the equation has another benefit – the potential for demand reduction. When the consumer is in control of the health dollars, they are also accountable for how they use them. Perhaps this accountability will expand to better efforts by consumers in health promotion and protection and ultimately, in disease prevention measures.
Alas, shifting the paradigm to demand-driven health care from the current supply system is not likely to happen in Canada in the immediate future. South of the border, this may become the reality, and will be worth watching.
[1] Herzlinger, R. “Can the United States provide health care for all?” What Matters, McKinsey & Company May 18, 2009. Found at http://whatmatters.mckinseydigital.com/health_care/can-the-united-states-provide-health-care-for-all
Wednesday, May 13, 2009
Healthcare and Politics
Healthcare in Canada - like education, highways, and social services – is all about (capital “P”) Politics. If you don’t believe this, take a moment to consider the political run of four healthcare people in the recent British Columbia election. Two doctors, a nurse/lawyer, and a health care administrator ran as BC Liberal candidates in the provincial election this month. Three succeeded in winning a seat in the hallowed halls of Victoria.
I’m most familiar with the two doctors who ran. Margaret MacDiarmid, a general practitioner and former President of the BC Medical Association, won in Vancouver-Fairview. Following her stint at the BCMA, Margaret came to realize that working with the bigger picture had a greater chance of improving the health status of the communities she worked in, than working 10 hour days seeing patients. She came to understand the imperfect relationship that exists between doctors, patients, and the health system, and saw a way to create improvements. She’ll tackle each issue with her diplomacy, intellect, and listening skills.
Moira Stilwell, a nuclear medicine specialists (radiology), is the head of the department of nuclear medicine at three Lower Mainland hospitals and also has a public hospital practice, and won her seat in Vancouver-Langara. She’s been part of the Canadian Breast Cancer Foundation Board for many years, and has also worked on a screening mammography strategy to increase the screening rates in the public system. She looked at the issues from a systems and strategy perspective, and didn’t stop when it was suggested that they just tell women to go….she worked to find the influencers in the process, and then developed literature for these, the family doctors, to refer patients on their first visit after their 40th birthday. She too believes that she can create a bigger impact upon the population by working in policy, than she can in diagnosing and treating individual cancer patients.
These are two outstanding women, and the province is fortunate to have politicians of this caliber in the Legislature. Both women will take a pay cut to enter Politics, and will leave behind the patients for which they were trained to care. To have such insight into the ways they can use their talents to improve the health status of a larger population for the “greater good,” takes a bold character and intellect.
I predict that these two will take Victoria by storm, and help to bring a capital “H” to Healthcare in Politics.
I’m most familiar with the two doctors who ran. Margaret MacDiarmid, a general practitioner and former President of the BC Medical Association, won in Vancouver-Fairview. Following her stint at the BCMA, Margaret came to realize that working with the bigger picture had a greater chance of improving the health status of the communities she worked in, than working 10 hour days seeing patients. She came to understand the imperfect relationship that exists between doctors, patients, and the health system, and saw a way to create improvements. She’ll tackle each issue with her diplomacy, intellect, and listening skills.
Moira Stilwell, a nuclear medicine specialists (radiology), is the head of the department of nuclear medicine at three Lower Mainland hospitals and also has a public hospital practice, and won her seat in Vancouver-Langara. She’s been part of the Canadian Breast Cancer Foundation Board for many years, and has also worked on a screening mammography strategy to increase the screening rates in the public system. She looked at the issues from a systems and strategy perspective, and didn’t stop when it was suggested that they just tell women to go….she worked to find the influencers in the process, and then developed literature for these, the family doctors, to refer patients on their first visit after their 40th birthday. She too believes that she can create a bigger impact upon the population by working in policy, than she can in diagnosing and treating individual cancer patients.
These are two outstanding women, and the province is fortunate to have politicians of this caliber in the Legislature. Both women will take a pay cut to enter Politics, and will leave behind the patients for which they were trained to care. To have such insight into the ways they can use their talents to improve the health status of a larger population for the “greater good,” takes a bold character and intellect.
I predict that these two will take Victoria by storm, and help to bring a capital “H” to Healthcare in Politics.
Monday, April 27, 2009
BC Continues to Improve Measured Health System Performance
April 27, 2009
The Canadian Institute for Health Information (CIHI), a federally funded clearing house of health data, has just released its 2009 Wait Times Table by province. The report looks at five surgical areas along with MRI and CT wait times, and evaluates them by province against benchmarks established at the 2004 Health Ministers conference.
Since 2005, BC has shown measurable improvements in all five categories: radiation cancer treatment, coronary artery bypass surgery, hip replacement, knee replacement and cataract surgery. The target agreed to at the Health Ministers Conference is that 75% of the procedures should meet the benchmark. In 2008, BC achieved this in four of the five categories, and only marginally missed the targets in knee replacements.
Here is a sample of the data:
Procedure: Cancer Treatment – Radiation
Benchmark: Treatment within 4 weeks of being ready to treat
% achieving benchmark: 95%
Procedure: Coronary Artery Bypass Surgery
Benchmark: Surgery within 26 weeks
% achieving benchmark: 91%
Procedure: Hip Replacement
Benchmark: Surgery within 26 weeks
% achieving benchmark: 78%
Procedure: Knee Replacement
Benchmark: Surgery within 26 weeks
% achieving benchmark: 71%
Procedure: Cataract Surgery
Benchmark: Surgery within 16 weeks
% achieving benchmark: 78%
The full report may be found at http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=PG_2010_E&cw_topic=2010&cw_rel=AR_1909_E
In fact, only one province, Ontario, betters BC in the number of categories that meet the established benchmarks. It should be noted that BC and Ontario have different reporting and measurement systems.
BC has strategically managed its healthcare resources by placing priorities on commonly performed procedures. The challenge however, is in balancing these scarce resources with the increasing demand on the system. The aging population will continue to increase demand for these procedures. The BC government has pledged an additional $4.8billion in funding for the public healthcare system between now and 2012 in an effort to meet this, and other, growing demands and wait lists.
It is clear that the best way to meet a limited supply (of funded and resourced surgical time), is to reduce demand. With a growing population and aging populace this going to prove a greater challenge in the years to come. We need to continue to look at alternatives to traditional funding and delivery systems for healthcare; increasing our health literacy rates to improve the health of the population; and reassess what the public healthcare system “basket of services” will look like in the future.
BC has excelled in its management of wait times for these nationwide benchmarks, and succeeded through its diligence. The Province needs to stay on track to manage both supply and demand for this generation and those that follow.
The Canadian Institute for Health Information (CIHI), a federally funded clearing house of health data, has just released its 2009 Wait Times Table by province. The report looks at five surgical areas along with MRI and CT wait times, and evaluates them by province against benchmarks established at the 2004 Health Ministers conference.
Since 2005, BC has shown measurable improvements in all five categories: radiation cancer treatment, coronary artery bypass surgery, hip replacement, knee replacement and cataract surgery. The target agreed to at the Health Ministers Conference is that 75% of the procedures should meet the benchmark. In 2008, BC achieved this in four of the five categories, and only marginally missed the targets in knee replacements.
Here is a sample of the data:
Procedure: Cancer Treatment – Radiation
Benchmark: Treatment within 4 weeks of being ready to treat
% achieving benchmark: 95%
Procedure: Coronary Artery Bypass Surgery
Benchmark: Surgery within 26 weeks
% achieving benchmark: 91%
Procedure: Hip Replacement
Benchmark: Surgery within 26 weeks
% achieving benchmark: 78%
Procedure: Knee Replacement
Benchmark: Surgery within 26 weeks
% achieving benchmark: 71%
Procedure: Cataract Surgery
Benchmark: Surgery within 16 weeks
% achieving benchmark: 78%
The full report may be found at http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=PG_2010_E&cw_topic=2010&cw_rel=AR_1909_E
In fact, only one province, Ontario, betters BC in the number of categories that meet the established benchmarks. It should be noted that BC and Ontario have different reporting and measurement systems.
BC has strategically managed its healthcare resources by placing priorities on commonly performed procedures. The challenge however, is in balancing these scarce resources with the increasing demand on the system. The aging population will continue to increase demand for these procedures. The BC government has pledged an additional $4.8billion in funding for the public healthcare system between now and 2012 in an effort to meet this, and other, growing demands and wait lists.
It is clear that the best way to meet a limited supply (of funded and resourced surgical time), is to reduce demand. With a growing population and aging populace this going to prove a greater challenge in the years to come. We need to continue to look at alternatives to traditional funding and delivery systems for healthcare; increasing our health literacy rates to improve the health of the population; and reassess what the public healthcare system “basket of services” will look like in the future.
BC has excelled in its management of wait times for these nationwide benchmarks, and succeeded through its diligence. The Province needs to stay on track to manage both supply and demand for this generation and those that follow.
Thursday, April 16, 2009
BC Politics - Who's offering what in healthcare
As we approach the provincial election on May 12th, we need to look at the issues and platforms relating to healthcare. While the economy and public safety are polling at the top of the list, healthcare remains in the top three in terms of "most important issue facing BC" according to a recent Angus Reid Strategies survey.
The NDP platform on healthcare is spelled out on its website (www.bcndp.ca) , although detail is sparse:
- More nurses and health professionals
- Improved seniors care with 3000 new long-term care beds and independent seniors advocate
- Shorter waitlists and plan to clear backlogged emergency rooms
There is no discussion of how this will be done; nor is there any discussion on how much this will cost, or what percentage of the provincial budget would be allocated to healthcare.
The Liberal platform is laid out in far greater detail, supported by video "platforms" on specific issues in healthcare separated into two categories: innovation and investment. Health Minister Abbott is seen on the Liberal website identifying the issues and addressing the challenges with solutions (see http://www.bcliberals.com/platform/premiers_message/#vidPlatform). In all, the Liberals will commit an additional $4.8 billion to healthcare by the end of 2012.
What stands out in these two platforms is the strategy by which both parties intend to address healthcare - the largest and fastest growing government expenditure. The NDP plan appears to demonstrate a "through more money at the problem" approach. The Liberal plan is more strategic, looking for innovative ways to address the issues. They've already demonstrated some of this in their management of emergency room overcrowding - which included expanding capacity for inpatients in order to be able to admit patients requiring further care; expanded capacity for short stay in several ERs in the Lower Mainland; and an innovative approach in providing department funding based upon the ER staff's ability to provide time-measured, appropriate care for patients.
Frankly, the Liberal and NDP platforms are not even comparable in their promise. There is nothing to the NDP platform on healthcare. The Liberals have created a strategy and long term plan that is fact based and already proven.
Tuesday, March 31, 2009
What to include in a bundle of health care
Virginia Postrel, now a writer from The Atlantic Monthly, made a lasting impression in one of her articles from a prior publication. At a time when inflationary pressures in healthcare are running at 3 times the national inflation rate, and demand continues to grow, it is only too apparent that there are no easy fixes to any healthcare system. How we define health care is imperative to finding the solution.
Health care isn't a single good, nor, like food, is it easily defined in terms of a minimum to sustain life. Studying other countries' supposedly universal systems only demonstrates how fraught the concept of "health care" is: one bundle of services in British Columbia and a less-generous one in Nova Scotia, one in England and another in Scotland, one in New Zealand before the election and another afterwards. Arguably the U.S. already has universal care, in the sense that everyone can get some care-if only from an emergency room-for some things, and that citizens (a critical word in this context) without money are covered by Medicaid. The real issue is how you define "health care." What gets included is a matter not only of medicine and economics but of culture and politics.
Health care isn't a single good, nor, like food, is it easily defined in terms of a minimum to sustain life. Studying other countries' supposedly universal systems only demonstrates how fraught the concept of "health care" is: one bundle of services in British Columbia and a less-generous one in Nova Scotia, one in England and another in Scotland, one in New Zealand before the election and another afterwards. Arguably the U.S. already has universal care, in the sense that everyone can get some care-if only from an emergency room-for some things, and that citizens (a critical word in this context) without money are covered by Medicaid. The real issue is how you define "health care." What gets included is a matter not only of medicine and economics but of culture and politics.
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