Waiting for Medicare’s Second Stage


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Slides from a talk at Ryerson University Health Service Management program's 1st Annual Symposium by Dr. Michael Rachlis.

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Waiting for Medicare’s Second Stage

  1. 1. Waiting for Medicare’s Second Stage Michael M Rachlis MD MSc FRCPC Ryerson University April 25, 2009 www.michaelrachlis.com
  2. 2. Outline <ul><li>Where are we now? </li></ul><ul><li>How did we get here? </li></ul><ul><li>We could fix almost all Medicare’s problems with innovation and quality </li></ul><ul><li>Catching Medicare’s Second Stage </li></ul>
  3. 3. Where are we now? Bay and Dundas
  4. 4. Medicare View #1: Globe and Mail <ul><ul><ul><li>We established Medicare when we were young, healthy, and altruistic. The economy was growing rapidly. It worked pretty well then. </li></ul></ul></ul><ul><ul><ul><li>Now we are old, sick, and the economy is stagnant. Medicare doesn't work very well. Wait lists go from the North Pole to the US border. Health care costs are going through the roof. The public sector is too inefficient to make it work. </li></ul></ul></ul><ul><ul><ul><li>We now have to ‘be cruel to be kind’. We should allow some privatization of finance and profitization of delivery to 'save' Medicare. </li></ul></ul></ul>
  5. 5. Medicare View #2: Toronto Star <ul><ul><ul><li>At the beginning, the federal government paid half the bills and everything worked pretty well. </li></ul></ul></ul><ul><ul><ul><li>The Federal government gave up 50-50 cost sharing in 1977, and then hacked funding until 1997. Medicare was starved. This led to service erosion, privatization of finance, and increased use of for profit delivery. </li></ul></ul></ul><ul><ul><ul><li>Now we need more public money, more enforcement of the Medicare legislation, and curbs on for profit delivery to save Medicare. </li></ul></ul></ul>
  6. 6. Medicare View #3: National Post <ul><ul><ul><li>Medicare was always a bad idea. </li></ul></ul></ul><ul><ul><ul><li>Health care costs are out of control. But a government run health system is like the Beverly Hillbillies trying to run IBM. Despite huge costs, services are terrible. </li></ul></ul></ul><ul><ul><ul><li>It’s not too late to do the right thing. Let’s privatize and profitize as fast as possible. Maybe a dumb, rich American will buy it. </li></ul></ul></ul>
  7. 7. What do Canadians want to hear? <ul><ul><ul><li>Medicare was the right road to take </li></ul></ul></ul><ul><ul><ul><li>Resources aren’t the problem. Costs are not out of control but neither is the system drastically underfunded </li></ul></ul></ul><ul><ul><ul><li>Medicare was designed for another time and was implemented as a compromise </li></ul></ul></ul><ul><ul><ul><li>There are public sector solutions for every one of Medicare’s problems </li></ul></ul></ul>
  8. 8. Medicare was the right road to take <ul><li>Canada & US had same health care system and the same health status until the mid-1950s </li></ul><ul><li>46 million uninsured Americans </li></ul><ul><li>We spend less than the US but usually get more </li></ul><ul><li>Now Canadians live 2 1/2 years longer and our infant mortality rate is 30% lower. </li></ul><ul><li>Medicare boosts Canadian business </li></ul><ul><ul><li>Health care costs: 1.5% of Canadian manufacturers’ payroll and 9% of those in US </li></ul></ul>
  9. 10. S Woolhandler Int J H Serv 2004;34:65-78 .
  10. 14. Canadian Medicare was designed for another time and was a compromise <ul><li>It was designed for acute illness and Canada’s acute care system compares well internationally </li></ul><ul><li>But now the main problems are chronic diseases and Canada does poorly with these and we wait too long. </li></ul><ul><li>Political compromise slowed the development of a more effective and efficient delivery system </li></ul>
  11. 15. Canada does a poor job managing chronic disease <ul><li>~50% of diabetics have gone > 1 yr without an eye exam or a check for proteinuria </li></ul><ul><li>One out of six older patients are readmitted to hospital within 60 days of discharge </li></ul>
  12. 16. We could prevent most chronic diseases <ul><li>> 80% of ischemic heart disease, lung cancer, chronic lung disease, and diabetes cases could theoretically be prevented with what we know now </li></ul><ul><li>This would free up over 6000 hospital beds across Canada </li></ul>
  13. 17. Swift Current Region Saskatchewan
  14. 18. The original vision for Medicare -- Swift Current, Saskatchewan 1945 <ul><li>Prepaid funding Services available on a universal basis, with little or no charge to users. </li></ul><ul><li>Integrated health care delivery with acute care, primary care, home care, and public health. </li></ul><ul><li>Group medical practice with doctors working in teams with nurses, social workers and other providers. Overall public health view of the system. </li></ul><ul><li>Democratic community governance of health care delivery by local boards. </li></ul>
  15. 19. What happened to the vision? <ul><li>Despite the Swift Current Region’s success, Saskatchewan MDs wanted independent practice paid on fee for service </li></ul><ul><ul><li>Doctors didn’t want to negotiate with a sub-provincial body </li></ul></ul><ul><li>1947 Saskatchewan Hospital Insurance </li></ul><ul><li>1957 Federal Hospital Insurance </li></ul><ul><li>1950s Saskatchewan considers the terms of physician insurance </li></ul>
  16. 20. What happened to the vision? 1962 SK Physicians’ Insurance – MDs strike
  17. 21. What happened to the vision? <ul><li>1964 Justice Emmett Hall recommends physicians insurance and coverage for home care, drugs, and children’s dental care. </li></ul><ul><ul><li>The federal government only covered hospital and medical care leaving coverage incomplete </li></ul></ul><ul><li>Dr. John Hastings’s 1972 Report recommends re-organizing the delivery system but it’s mainly ignored </li></ul><ul><ul><li>The models that were implemented, e.g. Sault Ste. Marie Group Health Centre and Saskatoon Community Clinic, prove to be fonts of innovation </li></ul></ul>
  18. 22. What happened to the vision? <ul><li>Canada inspires other countries’ health policies but not our own </li></ul><ul><ul><li>Lalonde Report, Ottawa Charter for Health Promotion </li></ul></ul><ul><li>1990s cutbacks harm a vulnerable system </li></ul><ul><li>Waits and delays worsen </li></ul><ul><li>The 2002 Romanow Federal government Commission can’t craft a new political consensus </li></ul><ul><li>The 2005 Supreme Court Chaoulli case re-opens the debate about private health care </li></ul>
  19. 23. The Canadian system has long waits for care
  20. 24. Germany, CAN, US
  21. 25. Good News! We could solve almost all our problems with innovation and quality!
  22. 26. Good News! We could access primary health care within 24 hrs “ Even if we did nothing else, and we should implement other reforms, if every family physician implemented Advanced Access , every Canadian could have a family doctor.” Penticton British Columbia’s Dr. Jeff Harries to the CMA meeting, “ Taming the Queue”. Ottawa. March 31, 2006
  23. 27. Good News! We could have elective specialty consultations within one week <ul><ul><li>The Hamilton Family Medicine Mental Health Program increased access for mental health patients by 1100% while decreasing psychiatry outpatients’ clinic referrals by 70%. </li></ul></ul><ul><ul><li>The program staff includes 150 family doctors, 80 mental health counsellors, and 17 psychiatrists and provides care to 300,000 patients </li></ul></ul>
  24. 28. Good News! We could have elective surgery within two months <ul><ul><li>In Toronto, Barrie, and other parts of Ontario arthritis patients are assessed within two weeks for joint replacements and have their surgery within two months </li></ul></ul>
  25. 29. Pooling referrals reduces waits
  26. 30. Waiting is just one sign of poor quality care
  27. 31. Canada Has Big Quality Problems – But so do all countries <ul><li>Misuse </li></ul><ul><ul><li>Canadian Adverse Events Study -- 9000 to 24,000 preventable hosp deaths/yr . (GR Baker et al. CMAJ 2004) </li></ul></ul><ul><ul><ul><li>5-10% of all deaths in developed countries </li></ul></ul></ul><ul><li>Overuse </li></ul><ul><ul><li>Medication and the elderly </li></ul></ul><ul><ul><li>10% of diagnostic imaging </li></ul></ul><ul><li>Under use </li></ul><ul><ul><li>Pain control </li></ul></ul><ul><ul><li>Waits and delays </li></ul></ul><ul><ul><li>Chronic disease management and prevention </li></ul></ul>
  28. 32. Attributes of High Performing Health Systems Ontario Health Quality Council . April 2006. (www.ohqc.ca) <ul><li>Safe </li></ul><ul><li>Effective </li></ul><ul><li>Patient-Centred </li></ul><ul><li>Accessible </li></ul><ul><li>Efficient </li></ul><ul><li>Equitable </li></ul><ul><li>Integrated </li></ul><ul><li>Appropriately resourced </li></ul><ul><li>Focused on Population Health </li></ul>
  29. 33. Do one-fifth of older Canadian women need to take Benzodiazepines? Do we care what we’re paying for?
  30. 34. [Green et al Soc Sci Med 2003; 57:553-60]
  31. 35. Disparities in health between different groups are responsible for 20% of health care costs Health Disparities Task Group of the Federal Provincial Territorial Advisory Committee on Population Health and Health Security. Health Disparities: Roles of the Health Sector. 2004 . http://www.phac-aspc.gc.ca/ph-sp/disparities/pdf06/disparities_discussion_paper_e.pdf
  32. 36. Going for gold: Re-engineering services for people <ul><li>Toronto’s Access Alliance Multicultural Community Health Centre’s > 100 Peer Outreach Workers have brought maternal and child services to > 10,000 Toronto refugee women and their children </li></ul>
  33. 37. Catching Medicare’s second stage
  34. 38. “ I am concerned about Medicare – not its fundamental principles- but with the problems we knew would arise. Those of us who talked about Medicare back in the 1940’s, the 1950’s and the 1960’s kept reminding the public there were two phases to Medicare. The first was to remove the financial barrier between those who provide health care services and those who need them. We pointed out repeatedly that this phase was the easiest of the problems we would confront.” Tommy Douglas 1979
  35. 39. “ The phase number two would be the much more difficult one and that was to alter our delivery system to reduce costs and put and emphasis on preventative medicine…. Canadians can be proud of Medicare, but what we have to apply ourselves to now is that we have not yet grappled seriously with the second phase.” Tommy Douglas 1979
  36. 40. The Second Stage of Medicare meets the Quality Agenda “ Are we providing the safest, most suitable care? Are we investing enough in prevention? Are we reducing inequalities in health? The answer to these questions is no, not yet. But we could. It is the Council’s belief that we already have strong evidence and enough experience to pursue a quality agenda.” Health Council of Canada 2006
  37. 41. “ Many attribute the quality problems to a lack of money. Evidence and analysis have convincingly refuted this claim. In health care, good quality often costs considerably less than poor quality.” Fyke Report 2001 (Saskatchewan)
  38. 42. Quality provides sustainability <ul><li>Alberta aftercare program for congestive heart failure patients leaving hospital reduced future hospital use by 60% with $2500 in overall net cost savings per participant. </li></ul><ul><li>New Westminster's Royal Columbian Hospital reduced post heart surgery pain complications by 80% and length of stay by 33%. </li></ul><ul><li>BC’s Reference Drug Program kept Vioxx as a second line drug and saved $23 million per year and dozens of lives. </li></ul>
  39. 43. For profit patient care tends to be more expensive and of poorer quality – see PJ Devereaux et al -- but the most effective argument is: “Fuhgetaboutit!”
  40. 44. Summary: <ul><li>Our health services are rife with problems because we forgot the 2 nd Stage of Medicare </li></ul><ul><li>We need to change health services delivery to focus on prevention </li></ul><ul><li>We need to implement the Second Stage of Medicare or we risk losing the First </li></ul><ul><li>The solutions become harder to implement the more we privatize funding and delivery </li></ul>
  41. 45. “ Courage my Friends, ‘Tis Not Too Late to Make a Better World!” TC Douglas (per Tennyson )