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:

• 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.

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

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.