Hi all,

I posted a note a few weeks back about health care reform in the US and was asked to post about my experiences with the Canadian system.  Due to a job change and a large move, I haven't had a chance to follow-up on the request to talk about the Canadian experience yet, and in order to stimulate some discussion, I thought I'd post it as a new thread.

 Writing on the Canadian health care system could take a up a whole book, and others have done that already, so I'm going to try to hit a few of the pros and cons to the way the system operates here.  I've worked in Canadian health care for more than ten years (I'm fairly early on in my career with many years to go).  I've worked as a paramedic, a mid-level health services manager, and as an executive for a large regional health authority.  I've also worked in the pharmaceutical industry in sales, marketing, and government relations, so my perspective is a bit of an unusual one, so like any opinion, consider the source.  :)

Generally, Canadians view health care services as a birthright.  It was born in Saskatchewan (Canadian province) with the Premier at the time, a guy named Tommy Douglas.  Douglas' view was that people shouldn't lose their farm (literally) because they got sick, so the provincial government began covering hospital services through a provincial insurance program.  Over time, this caught on and was expanded to all provinces, and was consolidated through the Canada Health Act, a piece of federal legislation that ensures that health care is comprehensive, accessible, portable, universal, and publicly administered.  The idea was that people should have care that comprehensive, was not limited by geography, was available to everyone, and was administered on behalf of the public.  Douglas was recently voted "The Greatest Canadian" by the public a few years back, so that gives you an idea how important health care is to Canadians.

So, what works?

Believe it or not, a lot of stuff works really well in the Canadian system.  We do a very good job managing urgent and emergent patients who have very immediate needs.  If your case requires immediate intervention, you will get immediate intervention.  Cancer patients are very well managed with very good outcomes.  Patients generally have pretty ready access to primary care, though the more rural the area, the more difficult it is to find a physician.  We have good hospitals that do a lot of research and offer cutting edge services.  We have highly qualified physicians, surgeons, and nurses, who are recruited around the world for their skills.  There are many academic medical centres that do great research and train physicians from around the world.  Our health outcomes are pretty good across the board, and we have far more vertically integrated health care systems in Canada, where all services, be they public health, acute care services, residential care, and increasingly, primary care services, are offered under the auspices of one organization whose role is to get all of these parts of the orchestra playing the same tune from the same songbook.  Not easy, but some substantial advantages.  I also think we do primary care really well - philosphically, I really like the idea of having a family physician who sees patients over a lifetime and who can help to coordinate care among specialists.  I think the lack of same in the US is a real challenge for you to overcome.  Also, health care in Canada is free for everyone.  Whether you're rich or poor, you get the care you need, when you need it, and everyone goes into the same line where they are prioritized by who the sickest person is.

What doesn't work?

Well, this is where people go a bit haywire in the media about how the Canadian system really operates.  The Canadian system basically runs on the triage principle - if you need immediate care and the resources associated, you get it, because we (as a system) focus our needs there.  What this means is that if you need a surgical procedure (particularly hip and knee replacements, as well as cataract surgery) that is deemed to be a lower priority relative to cardiac, respiratory, or cancer procedures, you're going to have to wait.  As well, the incidence of catracts and large joint arthritis is such that demand for these services are greater than the allocated supply, so you end up waiting a long time.  Governments have finally got a handle on this concept and have been investing additional resources to increase resources for these targeted areas.  This has helped a lot, but it's far from perfect. 

One of the other challenges we have is around the adoption of technology in the health care system.  One of the stats that is frequently trotted out is how many more MRIs are in use in the United States than in Canada - Canada is slower to adopt these technologies because government, as the single payer, wants to know *exactly* what they're getting for the extra cash.  The government can very much act like an insurance company, but different, in that instead of refusing the MRI study at the time of the procedure as an insurance company might, the government pre-empts the dicussion by not allowing the hospital to have the equipment in the first place.  The hospital also couldn't buy the machine itself because it couldn't charge anyone for its use when that services is deemed 'medically necessary'.

There are also aren't the incentives in the Canadian system to promote innovative approaches to health care.  For example, if I'm running a surgical program funding would come in two forms:  one was global funding, where I'd get an envelope and they'd say go meet the surgical needs of the community for the next year, or I'd get case-based funding, where I'd get paid x amount per case.  In both circumstances, I only had access to x amount of dollars each year.  I had no ability to generate revenue to increase my capacity to meet varying needs, nor were their incentives to do more because there would be no payoff for being more innovative.  Instead of being measured on my ability to meet the needs of the community, I got measured based on whether I hit my budget targets (first and foremost), and then evaluated on whether or not the community was up in arms, and then somewhere down the road, would be outcomes and patient satisfaction (that never really came up), though it was my main focus.  In contrast, if I was running the same program in the US, the more patients I moved through, and the better the outcomes, the more efficient, and therefore, more profitable, we could be.  Surgical services really lends itself to the US style of health care, I think.  Politics is also a major problem for Canadian health services managers - government, because they foot the bill, wants health organizations to do what is politically expedient.  Sometimes that's what's good for the communities, sometimes, it isn't, but almost always, it's what the voice of the public is telling the politicians they want.  In that sense, it's representative of the desires of the community, though they don't feel the cost directly because they don't get a bill when they leave the hospital. 

Another big challenge for Canada is the use of IT and how it relates to patient safety and measuring outcomes.  The few outcome measures we have say we're doing a good job, generally, but we don't have the detailed case-level outcomes data that would help us manage the system better.  The information is there, but it's generally hidden and inaccessible.  We also spend way too much money for the outcomes we get - other countries are spending less money and getting the same or better outcomes, so there appears to be room for improvement.

This has ended up being quite long, but hopefully it's of some interest.  I'm happy to answer any questions (remember, just my somewhat-informed opinion).

SCH

A well developed marketing  plan will include all of the following except:

1. Staffing considerations

2. Competitive analysis

3. quality of care considerations

4. pricing considerations

 

Answer: 3. Quality of care considerations is not a tool used in the development of marketing plans. However, quality of care is of concern to helathcare administrators.

There has been a lot of talk about healthcare reform in the media and thorugh every day conversations.  How will healthcare reform affect your hospital or  your work environment?

Which of the following performance constraints should be considered when setting budget expectations for CSSs?

a. Profit requirement, benchmarks, forecasts

b. Competition, forecasts, PDCA cycles

c. Benchmarks, negotiated agreements, lean processes

d. Negotiated agreements, historic constraints, urgent patient needs

Correct answer: (a) Profit requirement, benchmarks, forecasts (Page 309 Griffith and White Text) - Text also adds competition, forecasts, historic constraints and negotiated agreements to the list of constraints.

 

 

In the book Understanding the U. S. Healthcare Services System by Barton, there are a number of forces influencing changes in the U. S. health services delivery system.  The forces include:

• The raised level of consciousness that employers and payers are experiencing about the costs of providing employee health insurance
• The perverse incentives that fee-for-service care establishes
• The effects on utilization of self-referral, doctor-shopping, and open access to specialists
• The need for both private and public payers to better predict total health expenditures
• The need for accountability of health expenditures within a society
• The belief that optimal rather than maximal use of limited resources is more appropriate
• The need to increase efficiency in the system, including the appropriate use of inpatient and outpatient services and the reduction of overcapacity. 

 I am sure there are several more forces that are just as important that have developed over the past few years.  How do you think the impact on the current Administration will change these forces overall. 

In the book Understanding the U. S. Healthcare Services System by Barton, there are three dimensions of hospital organization that are important to gain an understanding of the health services system.  Which of the following is not a dimension mentioned in the literature?

 

1. How an individual hospital is organized to perform its functions
2. How hospitals may be linked into systems
3. How the hospital gains community involvement and positive interaction through the governing board.
4. The hospital’s relationship to other health services functions and facilities in its community

Answer:  c.  How the hospital gains community involvement and positive interaction through the governing board.

A Clinical Support System (CSS) such as a Health Promotion Center focuses efforts on preventive care. Education of the public is necessary about poor life style behaviors. Educating young people about the dangers of poor dietary habits, smoking, sexual behaviors, alcohol abuse, drug abuse, and violent acts continues to be an important area to focus. Those that need to provide education at the local level include hospitals, physicians, nurses, other healthcare providers, schools, and law officials.

Reducing healthcare consumption, by people taking responsibility for their own life style behaviors, will decease overall healthcare spending. Preventive care is the best solution in reducing healthcare spending, because decreasing the potential of developing chronic illness and lessening the amount of violent behavior will result in less demand for healthcare.

Costs of Chronic Disease

The United States cannot effectively address escalating health care costs without addressing the problem of chronic diseases: 

• More than 90 million Americans live with chronic illnesses. 
• Chronic diseases account for 70% of all deaths in the United States. 
• The medical care costs of people with chronic diseases account for more than 75% of the nation’s $1.4 trillion medical care costs. 
• Chronic diseases account for one-third of the years of potential life lost before age 65. 
• Hospitalizations for pregnancy-related complications occurring before delivery account for more than $1 billion annually.
• The direct and indirect costs of diabetes are nearly $132 billion a year. 
• Each year, arthritis results in estimated medical care costs of more than $22 billion, and estimated total costs (medical care and lost productivity) of almost $82 billion. 
• The estimated direct and indirect costs associated with smoking exceed $75 billion annually. 
• In 2001, approximately $300 billion was spent on all cardiovascular diseases. Over $129 in lost productivity was due to cardiovascular disease. 
• The direct medical costs associated with physical inactivity was nearly $76.6 billion in 2000. 
• Nearly $68 billion is spent on dental services each year. (CDC, 2005)

Cost-Effectiveness of Prevention: Benefits Associated with Healthy Behaviors.

• For every $1 spent on water fluoridation, $38 is saved in dental restorative treatment costs. 
• For a cost ranging from $1,108 to $4,542 for smoking cessation programs, one quality-adjusted year of life is saved. Smoking cessation interventions have been called the gold standard of cost-effective interventions. 
• The direct medical costs associated with physical inactivity were $29 billion in 1987 and nearly $76.6 billion in 2000. Engaging in regular physical activity is associated with taking less medication and having fewer hospitalizations and physician visits. 
• For each $1 spent on the Safer Choice Program (a school-based HIV, other STD, and pregnancy prevention program), about $2.65 is saved on medical and social costs. 
• For every $1 spent on preconception care programs for women with diabetes, $1.86 can be saved by preventing birth defects among their offspring. 
• According to one Northern California study, for every $1 spent on the Arthritis Self-Help Program, $3.42 was saved in physician visits and hospital costs. 
• A mammogram every 2 years for women aged 50–69 costs only about $9,000 per year of life saved. This cost compares favorably with other widely used clinical preventive services. 
• For the cost of 100 Papanicolaou tests for low-income elderly women, about $5,907 and 3.7 years of life are saved. 
• After controlling for physical limitation and major socioeconomic factors, more than 12% of annual medical costs of the inactive persons with arthritis is associated with physical inactivity. Physical activity interventions may be a cost-effective strategy for reducing the burden of arthritis. (CDC, 2005)

The broad consider of health concept is increasing being used by employers and managed care organizations who face financial pressures to reduce their medical costs. Employers’ use of health risk appraisal questionnaires is a recognition that their employee’ health can be improved, less expensively, by changes in their lifestyle behavior. Incentives given to their employees to stop smoking, reduce their weight, and exercise enable employers to retain a skilled workforce, while reducing medical expenditures. The emphasis by managed care organizations on reducing per capita medical costs is leading several of them to identify high-risk groups who can benefit form early preventive measures to reduce costly medical treatments. (Heshmat, 2001, p. 93)

The incentives to adhere to healthy lifestyle behaviors is better and improved health and less cost to the consumers, healthcare providers, and third-party payers,

 

CDC. (2005). Chronic disease overview. Retrieved January 15, 2005, from http://www.cdc.gov/nccdp

Heshmat, S. (2001). An overview of managerial economics in the health care system. Albany, NY: Delmar

 

 

Barriers to clinical support services include all  the following areas except:

A.    High cost

B.   Low technical quality

C.  High customer satisfaction

D.  Doctor ignorance that leads to inapropriate use

 

Answer:  C (page 299)

 

If you are familiar with a healthcare system outside of the US, please consider sharing your thoughts and insights about reforms and/or programs that have helped improve access and quality, reduce health disparities, and/or make the system less costly.  If this posting is of interest, Sean Hardiman added a post on 10/15, that you would enjoy reading.