Page created by Clarence Benson

     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 2020

                                     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 2020

          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 2020

                                 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.

    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.

You can also read