Prescription for Excellence: How Innovation is Saving Medicare

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Prescription for Excellence How Innovation is
Saving Medicare

• The Third Age Centre
• May 12, 2008 Fredericton NB
• Michael M. Rachlis MD MSc FRCPC
• www.michaelrachlis.com

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Outline

• There are three main public analyses of Medicare
  but none reflect Canadians true feelings about
  Medicare
• The problem is not public funding, too little
  money, or too much money
• The main problem is poor quality of care which is
  related to the pre-Medicare way we organize
  service delivery
• Good News about Canadas System!

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There are three main views of Medicare but none
are satisfying to Canadians
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Medicare View 1 Globe and Mail

• We established Medicare when we were young,
  healthy, and altruistic. The economy was growing
  rapidly. It worked pretty well then.
• 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.
• We now have to be cruel to be kind. We should
  allow some privatization of finance and
  profitization of delivery to 'save' Medicare.

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Medicare View 2 Toronto Star

• At the beginning, the federal government paid
  half the bills and everything worked pretty well.
• 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.
• Now we need more public money, more enforcement
  of the Medicare legislation, and curbs on for
  profit delivery to save Medicare.

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Medicare View 3 National Post

• Medicare was always a bad idea.
• 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.
• Its not too late to do the right thing. Lets
  privatize and profitize as fast as possible.
  Maybe a dumb, rich American will buy it.

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Outline

• There are three main public analyses of Medicare
  but none reflect Canadians true feelings about
  Medicare
• The problem is not public funding, too little
  money, or too much money
• The main problem is poor quality of care which is
  related to the pre-Medicare way we organize
  service delivery
• Good News about Canadas System!

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What do Canadians want to hear?

• Medicare was the right road to take
• Resources arent the problem. Costs are not out
  of control but neither is the system drastically
  underfunded
• Medicare was designed for another time and was
  implemented as a compromise
• There are public sector solutions for every one
  of Medicares problems

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Medicare was the right road to take

• Canada US had same health care system and the
  same health status until the mid-1950s
• Now there are 47 million US uninsured
• We spend less than the US but we usually get more
  services
• Now Canadians live 2 1/2 years longer and our
  infant mortality rate is 30 lower.
• Medicare boosts Canadian business
• Health care costs 1.5 of Canadian
  manufacturers payroll and 9 of those in US

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S Woolhandler Int J H Serv 20043465-78.
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Health Care Costs are not out of Control but
neither is the Health Care System Drastically
Underfunded
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Outline

• There are three main public analyses of Medicare
  but none reflect Canadians true feelings about
  Medicare
• The problem is not public funding, too little
  money, or too much money
• The main problem is poor quality of care which is
  related to the pre-Medicare way we organize
  service delivery
• Good News about Canadas System!

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Canada Has Big Quality Problems -- But No Bigger
Than Other countries

• Misuse
• Canadian Adverse Events Study
• 9000 to 24,000 preventable hosp deaths/yr
• (GR Baker et al. CMAJ 20041701678-1686)
• Overuse
• Medication and the elderly
• 10 of diagnostic imaging
• Under use
• Chronic disease management and prevention
• Cervical and breast cancer screening

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Do one-quarter of older Canadian women need to
take Benzodiazepines?

• Do we care what were paying for?

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The Canadian system has long waits for care
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Germany, CAN, US
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Chronic diseases have a major impact

• Chronic diseases account for 70 of all deaths.
• Chronic diseases account for more than 60 of
  health care costs.

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Canada deals poorly with chronic diseases

• lt 30 of Canadians hypertensives have their blood
  pressure properly controlled
• 60 of diabetics have gone gt 1 yr without an eye
  exam or a check for proteinuria
• 60 of asthmatics are not properly controlled
• Up to one in six seniors is re-admitted to
  hospital within 30 days of discharge

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Trying to deliver health services without
adequate primary health care is like pulling your
goalie in the first period!
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1945 -- Swift Current, Saskatchewan

• Prepaid funding Services available on a
  universal basis, with little or no charge to
  users.
• Integrated health care delivery with acute care,
  primary care, home care, and public health.
• Group medical practice with doctors working in
  teams with nurses, social workers and other
  providers.
• Democratic community governance of health care
  delivery by local boards.

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What happened to the vision?

• Despite Swift Current Regions success,
  Saskatchewan MDs wanted independent practice paid
  on fee for service
• Saskatchewan MD strike of 1962

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What happened to the vision?

• Despite the Hall Commission, the feds only cover
  medical care
• The provinces develop patchwork a quilt of
  coverage
• Dr. John Hastingss 1972 Report recommends
  re-organizing the delivery system but its mainly
  ignored
• The models that were implemented, e.g. Sault Ste.
  Marie Group Health Centre and Saskatoon Community
  Clinic, prove to be fonts of innovation
• Canada inspires other countries policies but not
  ours
• Lalonde Report, Ottawa Charter of Health
  Promotion, etc
• The Canada Health Act stops the bleeding
• But its only temporary

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What happened to the vision?

• 1990s cutbacks harm a vulnerable system
• Waits and delays worsen
• More specialties and special units
• Cant admit people for investigations
• The 2002 Romanow Commission isnt able to
  establish a new political consensus
• The 2004 Fed/Prov/Terr Health Accord provides
  lots of money but little direction
• The 2005 Chaoulli case opens the door to more
  private health care

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Are we ready for Tommy Douglass Second Stage of
Medicare?
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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 1940s, the 1950s and the
1960s 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
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The phase number two would be the much more
difficult one and that was to alter our delivery
system to reduce costs and put the 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
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Are we finally ready for the Second Stage of
Medicare?

• Stage One Provide financial support for care
  when people get sick.
• Stage Two The more difficult task ---keeping
  people well.

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The Second Stages Essence delivering health
services differently to keep people well
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Second Stage of Medicare Principles

• Essential Principles What we Want1. Population
  Health Focus 2. Equitable3. Patient-Centred
• 4. Effective5. Accessible6. Safe
• Instrumental Principles How we get
  there7. Efficient8. Accountable9. Appropriately
  resourced
• 10. Non-profit

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Accessible Patients should get timely care. Waits
should be continuously reduced

• Advanced Access same day service
• Penticton, Toronto, Saskatchewan
• Hamilton shared Care Mental Health
• 145 GPs, 80 counsellors, 17 psychiatrists
• 1100 ? in patients seen for mental health
• 70? in referrals to psychiatrists
• Alberta Bone and Joint Pilot Project
• Reduced wait times for hip and knee replacements
  from 19 months to 11 weeks

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Why do we need the Second Stage of Medicare now?

• Aging of the population and chronic disease put
  extra pressures on an inefficient system
• The workforce is getting older and sicker
• Family doctors are exiting comprehensive care
• Nurses and other health workers face burnout
• We need to improve the sustainability of the
  system

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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)

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Quality provides sustainability

• 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.
• New Westminster's Royal Columbian Hospital
  reduced post heart surgery pain complications by
  80 and length of stay by 33.
• BCs Reference Drug Program kept Vioxx as a
  second line drug and saved 23 million per year
  and dozens of lives.

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Quality provides sustainability

• Quality workplaces improve the health of workers
  and patients
• Quality workplaces could be worth a one years
  graduating class of nurses

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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!
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Summary

• Medicare was the right road to take
• Resources arent the major problem. Costs are not
  out of control but neither is the system
  drastically underfunded. We need transition
  funding
• Medicare was designed for another time and was
  implemented as a compromise
• If Douglas had had his way in the 1940s and 1950s
  Medicare would have many fewer problems today
• There are public sector solutions for every one
  of Medicares problems The Second Stage of
  Medicare

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Courage my Friends, Tis Not Too Late to Make a
Better World! Tommy Douglas