Dr michael rachlis_20_avril_2012

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Dr michael rachlis_20_avril_2012

  1. 1. Dollars and Sense: Medicare is Sustainable if we do our work differently Michael M Rachlis MD MSc FRCPC LLD Quebec Medical Association April 20, 2012 www.michaelrachlis.ca
  2. 2. Current received wisdom• Health Care costs are wildly out of control• My fellow baby boomers and I will really deep six Medicare as we get older• The only alternatives are to either hack services, go private, or better yet do both• We need an “adult conversation” about whom gets tossed out of the life raft 2
  3. 3. 3
  4. 4. What’s my story? • What’s the diagnosis – Health Care costs are not “out of control” – The aging population won’t break the bank – Most of health care’s problems are due to antiquated, processes of care • What are the solutions – We need to complete Tommy Douglass vision for the Second Stage of Medicare -- a patient-friendly delivery system focussed on keeping people healthy • How do we get there? – What are the roles for health care providers – What is the role of the medical profession 4
  5. 5. Total health care expenditures as % of GDP 14 12 QC CAN 10 8 6 4 2 0 1981 1986 1991 1996 2001 2006 2011 f / p 5Data from: http://secure.cihi.ca/cihiweb/products/NHEX_Trends_Report_2010_final_ENG_web.pdf
  6. 6. Total health care expenditures as % of GDP 16 QC ON 14 MB AB 12 CAN 10 8 6 4 2 0 1981 1986 1991 1996 2001 2006 2011 f / p 6Data from: http://secure.cihi.ca/cihiweb/products/NHEX_Trends_Report_2010_final_ENG_web.pdf
  7. 7. Canadian Provincial Govt health care Expenditures as share of Provincial GDP 9% 8% 7% % 6% GDP 5% 4% 3% 2% 1% 0% 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 f 7Data from: http://secure.cihi.ca/cihiweb/products/NHEX_Trends_Report_2010_final_ENG_web.pdf
  8. 8. Provincial Govt health care expenditures as % of Provincial GDP 10% 9% 8% 7% 6% 5% 4% ON MB AB 3% QC CAN 2% 1% 0% 1981 1986 1991 1996 2001 2006 2011 fData from: http://secure.cihi.ca/cihiweb/products/NHEX_Trends_Report_2010_final_ENG_web.pdf 8
  9. 9. The sustainability of Medicare in Canada • Health slowly increased its share of Canadian GDP from 2000 to 2008 • Health’s share of GDP rose dramatically in 2009 because the economy collapsed. • In 2010 and 2011, governments controlled costs, the economy grew again, and health decreased its share of GDP • This downward trend of health costs as a share of GDP will likely continue for the next 3-5 years • Public health care spending in 2011 was 0.6% higher than its previous peak in 1992 (8% in relative terms) vs. private sector cost rise of 0.9% (35% in relative terms) 9
  10. 10. Canadian Provincial Government HC Exp as share of program spending 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 f/phttps://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC1671 10
  11. 11. Provincial Govt health care expenditures as share of program spending 50% 45% 40% 35% 30% 25% ON MB AB 20% QC CAN 15% 10% 5% 0% 1975 1980 1985 1990 1995 2000 2005 2010 f/p 11Data from: http://secure.cihi.ca/cihiweb/products/NHEX_Trends_Report_2010_final_ENG_web.pdf
  12. 12. Canadian Provincial Government program spending as share of GDP 25% 20% 15% 10% 5% 0% 2001 2007 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2003 2005 2009 12Data from: https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC1671
  13. 13. Provincial Government program spending as share of GDP 30% 25% % 20%GDP 15% 10% Canada Quebec Ontario 5% Alberta Man. 0% 2001 2007 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2003 2005 2009 13Data from: https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC1671
  14. 14. Life Exectancy (both sexes)90807060 CAN QC50 ON403020100 1927 1937 1947 1957 1967 1977 1987 1997 2007 14
  15. 15. Provincial Govt health care expenditures and Canadian Gov’t outlays as share of GDP 60% 50% 40% 30% Canada Prov Govt Health Exp 20% Canadian Government outlays 10% 0% 1985 1989 1981 1983 1987 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 15Data from: https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC1671
  16. 16. Canadian and US Govt Outlays as % of GDP 60 50 40 % GDP 30 20 10 0 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 16Data from: : https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC1671 and http://www.fin.gc.ca/frt-trf/2011/frt-trf-11-eng.asp
  17. 17. The shrinking Canadian public sector • Overall Canadian government revenues have fallen by 5.8% of GDP from 2000 to 2010, the equivalent of $94 Billion in lost revenue – Just half of this, 47 Billion, could eliminate all 2012 Canadian government deficits OR fund first dollar universal pharmacare, long term care and home care AND regulated child care for all parents who want it AND free university tuition AND build 15,000 units of affordable housing units AND the new fighter jets 17
  18. 18. Percent of GDP devoted to Health Care 20 18 16 Average 14 12 % of 10 GDP 8 6 4 2 0 Belgium France Luxem Sweden Italy Iceland NZ Denmark Germany Nether Austria Canada UK Spain US Finland Norway Switz IrelandAll data from 2009. Source: OECDE Health Data 2011. 18http://www.oecd.org/document/16/0,3746,en_2649_37407_2085200_1_1_1_37407,00.html
  19. 19. The aging population won’t kill Medicare • Canada is aging and health costs increase with age • But Aging of the population per se has had and will have only a moderate impact on health expenditures • Aging is like a glacier not a tsunami. We have lots of time to prepare and adapt our health system before we get swamped! – The elderly are healthier than ever – High performing health systems can hold costs while enhancing quality of care for the frail elderly 19
  20. 20. Annual impact of Aging on health costs 2001-20101,6%1,4%1,2%1,0%0,8%0,6%0,4%0,2%0,0% From Mackenzie and Rachlis 2010
  21. 21. Annual impact of Aging on health costs 2010-20362,5%2,0%1,5%1,0%0,5%0,0% From Mackenzie and Rachlis 2010 21
  22. 22. The Compression of Morbidity JF Fries. Millbank Memorial Fund Quarterly. 1983.
  23. 23. American prevalence of disabled elderly 1984 - 2004 Year 1984 1989 1994 1999 2004Disability No 73.8% 75.2% 76.8% 78.8% 81.0% Disability Light or 15.9% 14.8% 13.9% 13.3% 11.8% Moderate Severe 10.0% 9.2% 7.9% 10.3% 7.2%Requiring > 2.5 hrspersonal care daily Manton et al. PNAS. 2006:103(48):18734-9
  24. 24. “Our results, supporting thehypothesis of morbiditycompression, indicate that youngercohorts of elderly persons are livinglonger in better health.”K Manton et al. Journal of Gerontology: SOCIAL SCIENCES2008, Vol. 63B, No. 5, S269–S281
  25. 25. Dependency of the elderly in wealthy countries 2005-2010 2025-2030 2045-2050Old Age Dependency 0.28 0.41 Ratios 0.53 (OADRs) Prospective Old Age 0.19 0.23 Dependency Ratios 0.27 (POADRs) Adult Disability Dependency Ratios 0.11 0.12 0.12 (ADDRs) W Sanderson. Science. 2010;329:1287-8. Canada was not included
  26. 26. “It is not the aging of our populationthat threatens to precipitate a financialcrisis in health care, but a failure toexamine and make appropriate changesto our health care system, especiallypatterns of utilization.” Dr. William Dalziel. CMAJ. 1996;115:1584-6
  27. 27. Most of health care’s problems aredue to antiquated, processes of care 27
  28. 28. After-Hours Care and Emergency Room Use Difficulty getting after-hours care Used emergency room in past two without going to the emergency room yearsPercent 28Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
  29. 29. Waited Less Than a Month to See Specialist PercentBase: Saw or needed to see a specialist in the past two years. 29Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
  30. 30. Spine surgeons in Ontario: Awasted precious resource • Only 10% of patients referred to a spine surgeon actually need surgery • $24 million in unnecessary MRI scans(http://www.theglobeandmail.com/news/opinions/editorials/spine-surgery-can-become-much-more-efficient/article2023173) 30
  31. 31. Traditional Joint Replacement Referral Process Spaghetti junction!
  32. 32. There are affordable solutions to all of Medicare’s apparentlyintractable problems: The Second Stage of Medicare 32
  33. 33. We need to change the way we deliverservices“Removing the financial barriers betweenthe provider of health care and therecipient is a minor matter, a matter oflaw, a matter of taxation. The realproblem is how do we reorganize thehealth delivery system. We have a healthdelivery system that is lamentably out ofdate.” Tommy Douglas 1982
  34. 34. Catching Medicare’s second stage “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. 35. “The phase number two would be the muchmore difficult one and that was to alter ourdelivery system to reduce costs and put andemphasis on preventative medicine….Canadians can be proud of Medicare, butwhat we have to apply ourselves to now isthat we have not yet grappled seriously withthe second phase.” Tommy Douglas 1979
  36. 36. The Second Stage of Medicare is deliveringhealth services differently to keep people well
  37. 37. Health Promotion intervention for BC frail elders Outcome Living in the Resident of a LTC at 3 yrs community facility or dead Group Health 75.3% 24.7% Promotion (61) (20) Group (N=81) Control 58.7% 42.3% Group (98) (69) (N=167) (P = 0.04) N Hall et al. Canadian Journal on Aging. 1992;11(1):72-91
  38. 38. Step right up!Get your ELIXIR ofHealth Promotion!Reduce your risk of dyingor ending up in a nursinghome by over40%!Increase your chances ofstaying in your ownhome by nearly30%!
  39. 39. Per Person Average overall costs of health care forcontinuing care patients in areas with/without cutsto social and preventive home care (Hollander 2001) Year Prior First Year Second Third Year to Cuts After Cuts Year After Cuts After Cuts Areas with $5,052 $6,683 $9,654 $11,903 cuts Areas $4,535 $5,963 $6,771 $7,808 without cuts http://www.hollanderanalytical.com/Hollander/Reports_files/preventivehomecarereport.pdf
  40. 40. With current resources Canadians could:• Have elective surgery within two months• Have elective specialty input within one week• Have same day access to our regular family doctor or someone on the doctor’s team 40
  41. 41. Toronto Arthroplasty ModelReferring Central Assessment Surgeon Surgery Post-OpPhysician Intake Advanced Consult Discharge Practice Follow-Up Physio Holland Centre Holland Mt. Sinai Holland Centre Centre and St. Michael’s Toronto St. Joseph’s Western Toronto East General Toronto Western
  42. 42. Good News in Hamilton and Winnipeg!We could have elective specialty consultationswithin 7 days– The Hamilton Family Medicine Mental Health Program increased access for mental health patients by 1100% AND decreased psychiatry outpatients’ clinic referrals by 70%.– The program staff includes 22 psychiatrists, 129 family physicians, 114 Nurses and Nurse Practitioners, 20 Registered Dietitians, 77 Mental Health Counsellors, 7 pharmacists and provides care to 250,000 patients
  43. 43. Good News in Cambridge, Cape Breton,Penticton, etc! We could access primary healthcare within 24 hrs In Cambridge, Dr. Janet Samolczyk aims to see her patients WHEN they want to be seen including within 24 hours
  44. 44. There is substantial evidencethat for profit patient care tends to cost more and is of poorer quality -- but the most salient argument is Tony Soprano’s: “Fuhgetaboutit!” We don’t need it.
  45. 45. How do we get to the Second Stage of Medicare? 45
  46. 46. How do we get to the SecondStage of Medicare? • Get your values right • Focus on the health of the population • Follow the 10 commandments for quality • Create quality workplaces for providers • New roles for health care providers • A new role for doctors and the medical profession
  47. 47. Attributes of High Performing HealthSystems Ontario Health Quality Council.April 2006. (www.ohqc.ca) 1. Safe 2. Effective 3. Patient-Centred 4. Accessible 5. Efficient 6. Equitable 7. Integrated 8. Appropriately resourced 9. Focused on Population Health
  48. 48. Population Health and the IHI Triple Aim“The health system should work to preventsickness and improve the health of the peopleof Ontario.”Health Quality Ontario
  49. 49. The Institute for Health Improvement’s Triple Aim1. Enhance the Care experience for patients2. Improve the health of the population3. Control overall health care costs http://www.ihi.org/IHI/Programs/StrategicInitiatives/TripleAim.htm
  50. 50. Canadian disparities inhealth between differentgroups are responsible for20% 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
  51. 51. Toronto Diabetes Prevalence Rates by Neighbourhood 2001From: R Glazier. Neighbourhood environments and resources for healthy living http://www.ices.on.ca/file/TDA_Chp2.pdf Age and sex adjusted Diabetes prevalence rates 2.8 – 4.0 4.1 – 5.0 5.1 – 6.0 6.1 – 6.5 6.5 – 7.6
  52. 52. Crossing the Quality Chasm: Ten Rules toHeal the Health Care System (www.iom.edu)1. Care should be based upon continuous healing relationshipsinstead of mainly in-person visits.2. Care should be customized for individual patients’ needs andvalues instead of being dictated by professionals.3. Care should be under the control of patients notprofessionals.4. Knowledge about care should be shared freely betweenpatients and providers and between different providers. Thistransfer should take maximal advantage of leading-edgeinformation technology. Patients should have unrestrictedaccess to their records.5. Clinicians should make decisions on the basis of the bestscientific evidence. Care should not vary illogically from clinicianto clinician or from place to place.
  53. 53. Crossing the Quality Chasm:Ten Rules to Heal the Health Care System6. Safety is the responsibility of the whole system not individualproviders.7. The content of care is made transparent instead of being held insecret. The health system should give as much information as isrequired to patients and families to enable them to fullyparticipate in clinical decisions, including where to seek care.8. Patients’ needs should be, as much as possible, anticipated andnot treated in a reactive fashion.9. The health care system should continually decrease waste(goods, services, and time) instead of focusing on cost reduction.10. Providers should cooperate and work in high-functioning teamsinstead of attempting to work in isolation. Concern for patientsshould drive cooperation among providers and drive outcompetition based upon professional and organizational rivalries.
  54. 54. Quality workplaces forproviders • Happier staff = healthier patients • Happier staff = lower turnover • Healthier patients = lower costs • Lower turnover = lower costs
  55. 55. New roles for health care providers • Patient and family centred care means big changes in roles for providers and patients, especially for chronic disease • Providers now need to be more like supportive coaches than deliverers of the revealed truth 55
  56. 56. Ontario’s Chronic Disease Prevention & Management Framework INDIVIDUALS Healthy AND FAMILIES Personal Public Policy Skills & Self- HEALTH CARE Supportive Management ORGANIZATIONS Support Environments Information Delivery Systems Community Provider System Design Action Decision Support Productive interactions and relationships Informed, Activated communities & activated prepared, proactive Prepared, proactive individuals Practice teams Community partners & families Improved clinical, functional and population health outcomes: http://www.health.gov.on.ca/english/providers/program/cdpm/pdf/framework_full.pdf
  57. 57. New roles for health care providers • Transfer of Accountability at the bedside – Nothing with me without me! • The Eden Alternative in Long Term care – Human relationships are the key to quality of life 57
  58. 58. New roles for physicians • Follow the CANMEDS roles – Medical Expert – Communicator – Collaborator – Manager – Health Advocate – Scholar – Professional 58
  59. 59. New roles for physicians • Embrace patient/family centred care • Our identity as doctors must flow from our service to patients instead of vice versa • Follow the patient! – Winnipeg HIV/AIDS care – Hamilton shared care psychiatry 59
  60. 60. “Deputy ministers last 18 months, Ministers last 2-3 years, CEOs rarely last 4years. I’ve been here for 15 years and I will be here forever. I can’t make change but I can block it!” Dr. Richard Steyn, Thoracic surgeon Birmingham UK 60
  61. 61. High performing health organizationsand physician engagement: There areonly two models. 1. A disciplined medical group that co- manages with the board E.g. The Kaiser Permanente system in the US, the Sault Ste. Marie Group Health Centre 2. Doctors as salaried employees E.g. The Mayo clinic, the Cleveland Clinic, and the Saskatoon Community Clinic 61
  62. 62. Summary: • Health Care costs are not out of control • The aging population won’t break the bank • Medicare was and is good public policy • Our health system’s problems reflect our failure to implement Tommy Douglas’s Second Stage of Medicare • There are affordable solutions to all of our apparently intractable problems • Health care providers, especially doctors, need to do their work differently to ensure Medicare’s sustainability 62

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