Westminster system characterized by:Head of State (Queen) with reserve powers, mostly ceremonial these daysHead of Government (PM or Premier), which must be supported a majority of MPPsExecutive power is concentrated in the Cabinet, which is appointed by the Premier and typically comprised of senior policymakers (i.e. Ministers) responsible for important portfolios. Legislative Assembly can reject a budget, pass a motion of no confidence, or defeat a confidence motion to trigger an election at any time before the Government’s 5-year term is reachedHead of Government can dissolve Parliament and call elections at any time
Contrast with Mixed-Member Proportional (MMP) voting system
Importance of confidence votes in minority government
Ontario Public Service: About 66,000 employees working in 27 Ministries and DirectoratesPolitical staff: Advise policymakers on the political ramifications of policy decisions
A look inside the machine…Left Side: Internal government services (IT, legal, corporate, management and investment)Right Side: Policy and programs development, implementation, oversight
Earnings made by ODSP recipients above a certain threshold are clawed back by the province at a rate of 50%Given the low advancement potential of individuals on ODSP and loss of potential income/valuable health benefits from holding down a full-time job, ODSP provides incentives for individuals not to find meaningful work
Week 2 - Ontario's Health System
Ontario’s Health Care System HLTH 405 / Canadian Health Policy Winter 2012 School of Kinesiology and Health Studies Course Instructor: Alex Mayer, MPA
RecapLast Week• Provincial vs. Federal responsibilities• Health Accords• The Canada Health Act: 5 criteria• ‚Narrow but Deep‛ Medicare coverage• ‚Similar but Distinct‛ provincial health insurance plans
In the News<• ‚Trims to health-care funding will help feds, but hurt provinces: Budget watchdog‛ - The Toronto Star (Jan 12)• ‚Hands off, please‛ – The Ottawa Citizen (Jan 13)• ‚Ottawa’s new health-care approach an opportunity for provinces‛ - The Globe and Mail (Jan 13)
iClicker Registration• If you have not done so already, please make sure to register your iClicker on the iClicker website by 11PM tonight. Use your Queensu E-mail address in full as your ‘Student ID’ Use the number on the back of your iClicker as your ‘Remote ID’• This will allow me to give you credit for your answers on Moodle.
Test Question<What is your favorite summer activity? A) Beach Volleyball B) Road Cycling C) Soccer D) Ultimate Frisbee
Ontario’s Health Care System Themes for today’s lecture: • How Government works • Health Policy Development Process • A look at Ontario’s health care governance • Ontario’s health care providers & programs • Health priorities for Ontario
Ontario Government• Ontario Government (like the rest of Canada) operates under a Westminster system
Ontario Government• Employs a ‘first-past-the-post’ (FPTP) electoral system to choose members to represent its ridings in the Legislature• Gives the successful party a disproportional amount of seats, relative to its total share of votes. • ‚Let’s the government govern‛
Ontario Government• Presently, Ontario is governed by a Liberal minority under Premier Dalton McGuinty• Last month, McGuinty laid out his government agenda (Speech from the Throne) and passed his first Confidence vote with support from the Ontario NDP• In March, another Confidence vote will take place when Finance Minister Dwight Duncan presents the McGuinty Government’s 2012 Budget
Question• What new health priority figured prominently in McGuinty’s 2011 electoral platform and Throne Speech? A) Improved home care services for seniors B) Shorter emergency room wait times C) Hiring more foreign doctors D) Creating a universal Pharmacare program
To summarize so far,• Ontario government follows Westminster Model o Concentrates executive power in the Cabinet• Politicians elected using First-Past-The-Post o Concentrates power in the hands of the dominant partySo who has the authority to set health policy inOntario? o The Premier charts government agenda, usually in consultation with the Finance Minister (i.e. New policy initiatives and program spending for the Budget) o Executive authority for day-to-day matters is delegated to the Minister of Health & Long-Term Care
Ministry of Health and Long-Term Care Minister Deputy Minister ADMs Directors
Ministry of Health and Long-Term CareWhat is a health policy analyst?- Expert researcher - Uses qualitative and quantitative evidence, economic analysis, political analysis to produce evidence-based health policies- Prepares briefs for Minister ‚For information‛ ‚For decision‛- Has two sacred responsibilities: ‚Speak truth to power‛ ‚Faithfully implement government policy‛ (whether you personally agree with it or not)
Case StudyWait times at emergency rooms are high, causing hospitalovercrowding, low patient satisfaction, and leading peoplewith injuries to leave without receiving care.Your job is to find ways the government can help to lowerwait times. (Reminder: You don’t control have any directcontrol over hospital operations.)How do you, as a policy analyst, approach the problem?
Steps in Policy Development1. Consult stakeholders and define theproblem. e.g. Are E.R. wait times a management problem? A resource ($$$) problem? A professional shortage problem? A perverse incentive problem? A population health problem? Consider many perspectives (economists, doctors, nurses, hospital admins, CCACs, LTCs).
Steps in Policy Development2. Read the scientific literature andunderstand the context. What is the scale of the problem? What are the potential causal and mediating variables? What is the historical context in which the problem is occurring?
Steps in Policy Development 3. Identify and elucidate the best policy options. What solutions have other jurisdictions developed? Have they been successful? What solutions are most likely to be successful in Ontario? Would laws need to be changed or modified? Would funds be required? What existing Ministry/agency/actor would we task with policy implementation?
Steps in Policy Development4. Analysis (Quantitative & Qualitative) If we implement Approach A, B or C, what is their relative impact on E.R. wait times? At what rate would morbidities/mortalities be prevented? What is the impact on patient satisfaction?
Steps in Policy Development5. Economic analysis (Optional) Cost-benefit: policy’s cost vs. expected benefits to society, in economic terms (typically presented as a ratio) Cost-effectiveness: Cost per unit of marginal benefit. e.g. How much $$$/hour of wait time reduction? How much $$$/complication avoided? How much $$$/Life- Year (LY) gained?
Steps in Policy Development 6. Political analysis & Considerations Who wins? Who loses? Will powerful interests be upset and take to the airwaves? What is an appropriate communications strategy to ensure support for the government’s policy? What other risks should government be aware of?
<And then stick all that in your briefing note. 2 pages max.
MOHLTC’s Evolving Role• MOHLTC used to be more ‘hands-on’ in deciding where health service funding goes (i.e. ‚central‛ decision- making)• In 2006, shift towards regionalization: Ontario’s LHINs are formed to take over responsibility for: o Public & Private Hospitals o Community Care Access Centres (CCACs) o Mental health and addictions services o Community Health Centres (CHCs) o Long-Term Care Homes (LTCs)
MOHLTC’s Evolving Role• Ministry of Health increasingly focused on policy, oversight and contract management• MOHLTC also retains responsibility for: o Health professionals and Family Health Teams (FHTs) o Ambulance services o Labs o Provincial programs (including ODB) o Independent Health Facilities (i.e. specialty clinics providing insured services) o Public Health Units
Local Health Integration Networks (LHINs)• 14 LHINs created in Ontario through the Local Health Systems Integration Act (2006)• Non-profit organizations that aim to make health care in the community< o More accessible, patient-centric and cost-effective through local service integration and consolidation o More responsive to local needs and priorities• Transfers to LHINs account for 2/3 of MOHLTC’s budget
Local Health Integration Networks (LHINs)Responsibilities:• Must enter into accountability agreements with MOHLTC to receive provincial $$$• Must develop a Service Plan to show how services will be integrated and how community health goals will be metPowers:• Can create region-specific bylaws• Cannot shut down hospitals or other service providers• Can integrate/relocate services to reduce duplication and improve coverage, when it is in the public interest
QuestionIn Ontario, health insurance through OHIPaccounts for ~70 cents of every dollar spenton health care (‚public financing‛). Is health care in Ontario publicly-delivered?
Ontario, like the rest of Canada, has a mixedpublic-private system: o Mostly public financing, mostly private delivery Important to understand the distinction between public vs. private financing and public vs. private health care delivery
Physicians• Prime example of public financing, private delivery • MDs ≠ government employees; they are private contractors and business owners (if they own a clinic)• Family physicians are primary care providers that play a ‘gatekeeping’ role in the health care system
Physicians• Historically derive large portion of their income from Fee-for-Service (FFS) payments • FFS incentivizes high level of productivity (More patients seen, more $$$ earned) • But does FFS provide appropriate incentives to provide high quality preventative care? • Concern that FFS leads to poor quality and waste: Shortened patient visits Do chronic illness patients really need to book an appointment with MD to refill a prescription?
Physicians• In the new Family Health Teams, physicians are paid using a ‚blended‛ capitation model • 60% salary from capitation: funding envelope based on patient roster size • Physicians earn a reduced fee (15% of regular fee schedule) for each service provided • Substantial bonuses ($) for delivering preventative services & meeting patient screening targets
Hospitals• 227 hospitals in Ontario• Most are private, not-for-profit (NFP)• Funded by MOHLTC by way of global funding budgets provided annually • based on historical expenditure trends • adjusted to reflect changes in expected service costs
Hospitals• Global funding budgets account for ~85% of hospital revenue. o Other 15%: Fundraising, fees for semi-private and private rooms, Worker’s Compensation payments• While most hospitals are operate independently (‚privately‛) as corporations, most are subject to the Public Hospitals Act and report their Plans annually to the MOHLTC. Some call them ‚semi-private‛.
Community Care ProvidersCommunity Care Access Centres (CCACs)• Arrange for long-term care home placements, home care services and in-school health support services• Can include MD, nursing, occupational therapy, speech therapy, dietician, homemaking and other services
Community Care ProvidersCommunity Health Centres (CHCs)Provides child and family health services such as:• Domestic violence interventions, addictions counseling, parenting education, anti-racism programs, and body image/healthy sexuality counseling
Community Care ProvidersFamily Health Teams (FHTs)Provides patients with high quality, patient-centered care:• Multiple primary health care professionals including family MDs, nurses, dieticians, pharmacists, etc., all working collaboratively under one roof.
Important ProgramsOntario Drug Benefit (ODB)• Provides ‚free‛ pharmaceutical drugs to seniors (age 65+) and ODSP/OW recipients• Also available to patients living in a LTC home or enrolled in the home care program• Ontario’s catastrophic drug insurance (Trillium Drug Benefit) limits copayment for pharmaceutical products to 3-4% of annual income
Important ProgramsOntario Disability Support Program (ODSP)• Provides employment and income supports to individuals who have a disability• Benefits include drug and dental coverage, as well as reimbursement for work-related expenses• Criticized on basis that it requires individuals to run down their assets before they can apply for support
Important ProgramsOntario Disability Support Program (ODSP)• Earnings made by ODSP recipients above a certain threshold are clawed back by the province at a rate of 50%• Given low advancement potential of ODSP recipients and loss of income/health benefits from holding down a full-time job, ODSP provides incentives for individuals not to find meaningful work (known as ‚poverty wall‛)
Health Priorities in Ontario• Aging at Home Strategy• eHealth• Pharmaceutical drug costs• Wait Times
RecapOntario’s Health Care System• How Government works• Health Policy Development Process• A look at Ontario’s health care governance• Ontario’s health care providers & programs• Health priorities for OntarioFill-In-The-Blank<• The Excellent Care for All Act is a critical piece of McGuinty’s health policy agenda. What does it involve? o Be the first to post the answer to the HLTH 405 Facebook Wall!