FOUR FEDERAL INITIATIVES TO IMPROVE AFFORDABILITY, PRODUCTIVITY AND ACCOUNTABILITY
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FOUR FEDERAL INITIATIVES
TO IMPROVE AFFORDABILITY,
PRODUCTIVITY AND
ACCOUNTABILITY
FRANCESCA GROSSO AND MICHAEL DECTER
INTRODUCTION BACKGROUND: CHANGES ALREADY MADE Francesca Grosso is a
Maintaining a high quality healthcare system Beginning in the early 1990s, the federal Principal at Grosso McCarthy,
in the current era of slower economic growth government made significant changes and a consulting firm specializing
and greater healthcare demand will be a huge invested substantial sums in the areas of in health care strategy and
challenge for Canada. The task of addressing health information, health research and policy. Francesca served as
and managing this challenge falls largely to health informatics. Director of Policy to the Ontario
public sector decision makers (since the public Minister of Health and Long
sector currently provides 70% of Canadian // Health information The Canadian Term Care from 2001 – 2003.
health services financing). Such decision Institute for Health Information (CIHI), Prior to this she was Vice
makers must cope with the combined effects was first proposed in the early 1990s by President of Healthcare at
of two key factors: (i) an aging population then federal Deputy Minister of Health Environics Research Group.
and higher dependency ratios but also (ii) the Margaret Catley-Carlson to consolidate, Francesca worked with Michael
vast number of new healthcare interventions, rationalize and improve the collection Decter to establish the Health
both diagnostic and in treatment, and of health information. Prior to this, Council of Canada and has been
the seemingly boundless public appetite four separate taxpayer-funded bodies involved in the establishment
for these. It is not aging per se that is the were engaged in the collection of of several other federal health-
problem but aging in the context of increased information: Statistics Canada, Health care agencies. She co-authored,
healthcare options. Canada, the Hospital Medical Records with Michael Decter, the 2006
The Government of Canada has an Institute (HMRI) in Ontario and MIS book, Navigating Canada’s
important leadership role to play in ensuring in the rest of Canada. The information Health Care: A User Guide to the
a sustainable, high quality healthcare system they provided was often up to three Canadian Health Care System.
into Canada’s future. This paper describes or four years out of date. HMRI and
four key initiatives that would help it build MIS were therefore merged into CIHI.
on past successes and provide more dynamic Health Canada transferred much of its
and substantive leadership at this critical health statistics activity to the new orga-
time. Each initiative has the potential to drive nization and a strong bond was built
both an improvement in delivery and an between CIHI and Statistics Canada as
increase in the affordability of healthcare. the Chief Statistician serves as Vice Chair
THE CANADA WE WANT IN 2020SECURING THE HEALTH SYSTEM FOR THE FUTURE
of the CIHI Board. CIHI’s budget – These key investments have positioned
which is drawn from both federal and Canada to be much more effective in applying
provincial sources – has increased evidence both at the point of patient care and
from about $10 million a year to over in the management of healthcare services.
$40 million. The Institute now stands But are these initiatives bearing fruit? Is the
as an important cornerstone of health sizable federal investment that has already
information in Canada. With significant been made making a difference to Canadian
analytical capacity, it provides critical healthcare?
data on issues such as hospital admis-
sions, discharges and lengths of stay in WHAT NEEDS TO BE DONE
a timely manner. Despite all the investments, many health
funding decisions are still driven by vested
// Health research In 2000 Dr Henry Friesen, interests advocating for their particular
Chair of Canada’s federally-funded causes, rather than by hard evidence as to
Medical Research Council (MRC), the efficacy of treatment. Individual patient
convinced the federal government to cases land on the front page of our daily
transform the organization into the newspapers and cause public opinion
Canadian Institutes of Health Research and politicians to swing in favour of new
(CIHR). The aim was to move away treatments. Public fears rather than medical
Michael Decter is a from a research agenda driven largely evidence drive many decisions. As an example,
Harvard-trained economist by the MRC and its staff, to one with all available data supports the view that we
and leading Canadian expert broader linkages to the health system are over-medicated, yet payments to phar-
on health systems. He as a whole. This important federally- macists for reviewing patient medications
served as Deputy Minister led initiative has resulted in both an are only gradually being introduced.
of Health for Ontario and increase in and a diversification of In order to capitalize on existing
as Cabinet Secretary in the federal health research dollars. Funds investments and achieve an effective and
Government of Manitoba. now flow to thirteen virtual health affordable health system for the future, the
He has published several research institutes which are much Government of Canada must move to put in
books on healthcare and has better linked to clinical decisions and place an evidence-based set of strategies: it
held many senior positions health policy. At the same time the needs to provide very specific leadership, in
in health management and Canadian Health Services Research partnership with the provinces and territories,
health-focused organizations, Foundation, (CHSRF) was established to achieve concrete goals in health services
including being the Founding to link the health information and performance. Below we outline four key
Chair of the Health Council of research areas. Its mandate is to “pro- initiatives that we believe would help it do so.
Canada. He currently serves as mote the use of evidence to strengthen
President and Chief Executive health service delivery in Canada”. 1 Improve accountability
Officer of the investment to drive quality improvement
management firm, LDIC Inc. // Health informatics Canada Health One of the key thrusts of the 2004 Healthcare
Michael was awarded The Infoway was created to lead the devel- Accord was an improvement in accountabil-
Order of Canada in 2004. opment of electronic health records. ity. However this fell short due to a failure of
Although the provinces worked with the political will and problems with the detail of
federal government on this initiative the accountability. What we have ended up
and are represented on its governing with instead is too much measurement and
board, the $2.1 billion in financing too little management.
provided to date has all come from What were supposed to be “comparable
federal coffers. indicators”, on issues such as waiting times,
became different indicators in different
provinces. Such obfuscation has meant that
it is hard to hold the provinces to account.
While the differences in indicators are slight, What we have ended up with
they are sufficient to preclude any sensible
national comparison or overview. is too much measurement and
Consider the analogy of the labour force
survey. This provides both public and private too little management
sector decision makers with a great deal of
information on how the economy is doing 2 Tackle safety in health delivery
and on unemployment rates province-by- The Baker Norton study, jointly commis-
province, within various age groups and sioned by CIHI and CIHR and released in
across gender lines. Such information enables 2004, documented huge safety issues in the
targeting of remedial efforts: the labour force Canadian healthcare system. These take
survey provides an effective framework for an enormous toll both in terms of human
decision making about employment and suffering and financial cost to the system.
economic policy. If provinces were to set The authors calculated that between 9,000
different measures for unemployment (as and 23,000 Canadians die unnecessarily each
they do for healthcare) then most of this year, as a result of avoidable errors within
value would be lost. the health system. Since then, others have
Another problem has been the massive looked at the burden that avoidable injuries
number of indicators developed. When it pose to the healthcare system. It is estimated
comes to healthcare indicators, more is not by Baker and Norton that the equivalent
better: what is required is a simple set of easily of nine hospitals, each with 200 beds, are
understood indicators that measure quality, utilized just for “repair” work.
timeliness, affordability and access. The Baker Norton report led to the creation
The federal government needs to show of the Patient Safety Institute (PSI) head-
courage and leadership in the next round quartered in Edmonton and funded by the
of health negotiations with the provinces federal government. Despite the excellent
and insist on a limited set of relevant efforts of this organization, the safety problem
indicators across the country. The aim in Canadian healthcare (and in the healthcare
should be to make the system more account- systems of other nations) remains both large
able (but accountable to the public – who and intractable. A much more forceful national
can draw their own conclusions about effort is required to solve it.
performance – as opposed to the provinces Other jurisdictions, including American
being more accountable to the federal states such as Minnesota, have been grap-
government). Canadians have much to gain pling with this problem. They have used
and nothing to lose from having a more legislation and a number of other tools, such as
accountable healthcare system. mandatory public reporting of adverse events,
Fortunately we already have the health to address it. Meanwhile, Canada has stuck
services data gathering and analysis capacity with a largely voluntary approach, relying
in place, through the institutions mentioned on the PSI and somewhat strengthened health
above, as well as a host of provincial health facility and health services accreditation
services organizations (such as the Institute through Accreditation Canada (even this is
for Clinical Evaluative Sciences in Ontario) voluntary in some parts of the country). The
that can contribute. What is needed now is PSI’s budget is a paltry $10 million a year
political will. against a total Canadian healthcare budget
of over $140 billion.
THE CANADA WE WANT IN 2020SECURING THE HEALTH SYSTEM FOR THE FUTURE
Contrast this with the enormous man- The First Nations and Inuit Health
datory efforts undertaken in civil aviation. Envelope was introduced by the federal gov-
Each plane crash in Canada is thoroughly ernment in 1994. At that time it totaled more
investigated to determine the cause and than $1.1 billion for all health programs;
indicate remedial actions. Pilots are tested and today it amounts to about $2 billion per
recertified frequently. Healthcare providers, annum. The continuing huge difference in
by contrast, can often practice for an entire health outcomes between First Nations/
career without formal recertification or Inuit and other Canadians begs the question:
assessment of their competency. The health- is this money being well spent?
care system tends to run on the basis that The federal government has made some
regulatory colleges, run overwhelmingly by progress in shifting responsibility and dollars
the healthcare professionals themselves, will to aboriginal organizations and provincial
deal with outlier behaviour. There is no focus governments, but a much more rapid transfer
on systemic aspects of the lack of safety in is needed. Fortunately there are some models
healthcare. of successful practice from which to learn.
// In BC, a tripartite agreement between
The safety problem in the federal government, the province
and aboriginal authorities has resulted
Canadian healthcare remains in placing $318 million in the hands of
a new BC First Nations Health Council.
both large and intractable This has given tribal councils greater
power to solve issues within their own
One way for the federal government to communities, rather than having to
change this would be for it to commission a abide by decisions made in Ottawa or
smaller-scale Baker Norton review, looking by an ineffective system of regional
at specific indicators across the country, on offices run from Ottawa.
an annual basis. This would keep the safety
issue front and centre. Other ways of address- // In 2006 the federal government provid-
ing the problem include increasing the PSI’s ed $3.1 million to a partnership struck
funding and insisting on mandatory review between Saint Elizabeth Health Care,
and accreditation of hospitals and staff. It an NGO with expertise in nursing care,
would be nice to think that hospital stays and the Assembly of Manitoba Chiefs.
could be made as safe as flying. The aim was to map ways to manage
diabetic foot ulcers and avoid amputa-
3 Transfer healthcare delivery tions. The parameters were realistic
for First Nations and Inuit and included there being no commit-
Statistics Canada reported in 2000 that ment to increase healthcare staffing
life expectancy for aboriginal people was levels in areas that cannot attract such
markedly shorter than the Canadian average: resources under normal conditions.
7.4 years shorter for men and 5.2 years for The pilot project built capacity and
women. In addition, aboriginal communities care pathways that assisted health care
saw increased rates in: infant mortality (22% staff to utilize prevention strategies,
higher); tuberculosis (6.2 times higher); undertake early detection, and then
diabetes (almost 20% higher); and foot provide treatment and quick access
amputations as a result of diabetic foot ulcers to specialists as required. The result
(18 – 22% higher). These are dismal statistics. was embraced by the Assembly of
Manitoba Chiefs and local communi- // break down the barriers that prevent
ties and has since been expanded. individuals practicing in the care
setting of their choice;
// In Ontario, Aboriginal Health Access // provide professionals with cost
Centres – aboriginal community-led, pri- effective, attractive alternatives
mary health care organizations – have, to higher pay.
since 1994, brought tens of thousands
of aboriginal community members into All three problems could be at least
the circle of care and support. partially addressed by reform of the pension
system for healthcare workers.
These examples make sense. Provinces A lack of pension portability is the main
and NGOs have expertise in implementing reason why healthcare workers are unwilling
health care delivery and aboriginal com- to move out of an acute-care setting into a
munities understand their own needs. The community-care setting. A community-care
federal government, not really an expert in setting is not only less costly for the funding
either, provides the financing. government, it can also provide a less stressful
It should therefore move ahead to: work environment and a better quality of
// dismantle the inefficient and life for healthcare professionals. Many such
ineffective First Nations and Inuit professionals are willing to accept somewhat
Health Branch (FNHIB) and regional lower wages in return for these benefits, but
health bureaucracy; the sticking point is that hospital employees
// shift dollars into more agreements such cannot take with them their generous defined
as the tripartite one outlined above; benefit (DB) pensions. Likewise, community-
// promote health among First Nations care organizations (which are also provincially
youth; and funded) find it hard to attract qualified workers
// contract out to NGOs for specialized in the first place because of their lower
services such as the non-insured pension offerings.
Health Benefits Program, currently
run by Health Canada (the manage-
ment of which could be akin to the A lack of pension portability
Veterans Affairs drug administration
or health delivery for the Canadian is the main reason why healthcare
Armed Forces).
workers are unwilling to move out
4 Stabilize human resources of an acute-care setting into a
in the health system
Canada’s health system has numerous
human resources problems that undermine community-care setting
its effectiveness. These include quality con-
cerns, chronic shortages and a poor distri- Extending DB plans to other parts of the
bution of health professionals. In order to health system (beyond acute care settings)
address these, the federal government should would cost money, albeit not a great deal
support the provinces to: of money. In Ontario, for example the
// encourage professionals to leave Healthcare of Ontario Pension Plan estimated
practice before their skills deteriorate; that it would cost just $20 million to bring
most of the community sector in line with the
hospital sector on the issue of DB pension
THE CANADA WE WANT IN 2020SECURING THE HEALTH SYSTEM FOR THE FUTURE
premiums. At least some of this increase in CONCLUSIONS
the pension envelope could be funded by the The federal government has a crucial role
federal government. to play in achieving sustainable and high
quality healthcare services in Canada.
With a focused and strategic approach the
Negotiations should have Government of Canada can assist provinces
in modernizing Canadian health services. It
very specific goals in place for can also realize a return on the significant
investments it has made over two decades
performance, for productivity, in improved health information, health
informatics, health research and evidence
for safety and for affordability gathering.
Negotiations for renewed health funding
The biggest direct contribution the federal for the provinces post the expiry of the
government could make to reforming health- current Health Accord in 2014 should have
care pensions would be to enable physicians very specific goals in place for performance,
to belong to DB pension plans. This would for productivity, for safety and for affordabil-
help keep costs in check as many physicians ity. These should be set out in advance by
would consider trading pay increases for the the Government of Canada. There will, as
ability to belong to a DB plan. The actual move always, be howls of jurisdictional protest
would be funded not by the taxpayer, but from the provincial premiers but if the
by participating physicians through their federal government sticks to specific and
medical corporations. However, effecting such public performance goals, Canadians will be
a switch would require changes in Canada better off.
Revenue Agency (CRA) legislation. While the
required changes are of some complexity,
they are certainly not insurmountable.1 A sim-
ilar legislative change was made in 2002 when
the federal government revised the law to
enable doctors to create medical corporations
that would benefit from similar tax regimes
to other small businesses. This move helped
physicians immeasurably and provided
the provinces with significant leverage in
negotiations with medical associations.
1
Under CRA rules
employers can be pension
plan sponsors provided
they have workers who
qualify as employees.
Medical corporations do
not meet CRA rules for
inclusion because their
physician employees,
also shareholders, are not
classified as employees.
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