John N. Lavis, MD, PhD

1
28 June 2005
Health Policy Update from CanadaPrimary Care
Reform andTimely Access to High-Quality Care
AcademyHealth Annual Research Meeting Boston, MA,
USA

• John N. Lavis, MD, PhD
• Associate Professor and
• Canada Research Chair in Knowledge Transfer and
  Uptake
• McMaster University

2
Overview

• Policy context and climate
• Two current policy issues
• Primary care reform
• Timely access to high-quality care (or waiting
  lists)
• Conclusions

3
Policy Context and Climate

• British North America Act
• Health care is a provincial responsibility
• Canada has 14 different healthcare systems
• 10 provincial healthcare systems
• 3 territorial healthcare systems
• 1 federal healthcare system for First Nations
  and soldiers

4
Policy Context and Climate (2)

• Canada Health Act (and preceding legislation)
• Federal government has a role to play in
  healthcare as an overseer and partial source of
  finance
• Politics of blame avoidance, which makes for a
  lot of finger-pointing and noise

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Policy Context and Climate (3)

• Canada Health Act (and preceding legislation)
• Private delivery / public payment bargain (the
  core bargain)
• Private practice physicians deliver care with
  first-dollar, one-tier public (fee-for-service)
  payment
• Private not-for-profit hospitals deliver care
  with first-dollar, one-tier public payment
• Same debates play out over and over
• Change the way primary health care is delivered?
• Continue to provide one-tier public payment?

6
Primary Care Reform

• Changes in the framing of the policy issue
• Until about five years ago, the issue was cast as
  a search for big-bang primary care reform, and
  this proved challenging given
• Delivery is in the private domain and
  fee-for-service payment is entrenched
• Medical associations often sit at the policy
  table
• Research does not support a single model
• Since then, the issue has been re-cast as a
  search for incremental reforms with a plurality
  of approaches

7
Primary Care Reform (2)

• Problems in the organization delivery of
  primary care
• Lack of continuity of care for patients
• Lack of involvement of other healthcare providers
• Focus on acute or episodic care, not chronic
  diseases such as diabetes, heart disease or
  hypertension
• And from the perspective of physicians
• Many family physicians are reducing (or
  considering reducing) their workload
• Less than 30 of medical students are choosing
  family medicine as a career

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Primary Care Reform (3)

• Priorities for action (with examples of
  strategies used)
• Improved continuity and coordination of care
  (24/7 access and multidisciplinary teams)
• Early detection and action (disease prevention,
  chronic disease management)
• Better information (electronic health records,
  telehealth technologies)
• Incentives to change practice (innovative funding
  models, involvement of non-medical staff)

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Primary Care Reform (4)

• Strategies being used
• Mixed remuneration methods
• Incentives or requirements for
• Rostering patients
• Providing certain types of services (e.g.,
  immunizations)
• Hiring or working with other types of providers

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Primary Care Reform (5)

• Strategies being used (2)
• Incentives or requirements for
• Making organizational changes (e.g., working in
  groups/networks, providing 24/7 coverage,
  adopting an electronic health record)
• Engaging in continuing medical education
• Additional support provided centrally (e.g.,
  telephone health advisory service)
• Limits placed on patient choice (e.g., notify MD
  if seeking care elsewhere unless its an
  emergency)

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Primary Care Reform (6)

• Provincial efforts to move forward on primary
  care reform have been supported by some degree of
  national consensus about action
• General commitment to one primary care goal in
  the First Ministers Accord in 2003
• By 2011, 50 of Canadians will have 24/7 access
  to an appropriate healthcare provider
• Some initiatives involve shifting the point of
  first contact to nurses or nurse practitioners
• Most initiatives involve supporting physicians

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Primary Care Reform (7)

• Where to from here?
• Options for bringing about change
• Offer alternatives to all new physicians (and
  experienced physicians who are ready for a
  change)
• Entice a broad range of physicians into generous
  contracts and then use the contracts as a tool to
  bring about other changes and/or to bring some
  uniformity to the models being used

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Timely Access to High-Quality Care

• Changes in the framing of the policy issue
• Until very recently, the issue was cast as a
  delivery issue (i.e., long waiting lists) that
  needed to be addressed, and this proved
  challenging given delivery is primarily in the
  private domain
• Supreme Court recently re-cast the issue as a
  financing issue (i.e., ban on two-tier public
  payment) that needed to be addressed, at least in
  Quebec, and this is proving challenging given
  financing is primarily in the public domain and
  governed by a highly visible core bargain

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Timely Access to High-Quality Care (2)

• Problems with long waiting times
• Waiting can cause harm
• Waiting can be unfair (e.g., remote and rural
  regions, populations with special needs, and
  areas where providers and services are in short
  supply)
• Waiting can undermine confidence in the system

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Timely Access to High-Quality Care (3)

• Potential causes of long waiting times
• Lack of coordination
• Lack of accountability
• Clinical judgements vary
• New technology has increased demand and lowered
  threshold for treatment
• Emergency cases bump non-emergency cases
• Lack of capacity

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Timely Access to High-Quality Care (4)

• Actions being taken to address long waiting times
• Enhance capacity
• Study waiting times (e.g., standardize measures,
  evaluate outcomes)
• Post waiting times (e.g., BC, ON, QC)
• Set benchmarks regarding waiting times
• Manage waiting lists (e.g., Cardiac Care Network)
• Define need for care with precision and fairness
• Manage flow of patients

17
Timely Access to High-Quality Care (5)

• Provincial efforts to address long waiting times
  have been galvanized by a national consensus
  about action
• General commitment to timely access in the First
  Ministers Accord in 2003
• Specific commitments in the Ten Year Action Plan
  released in September 2004
• Meaningful reductions in waiting times for
  diagnostic imaging, cancer care, cardiac care,
  cataract procedures, and joint replacements
• Comparable indicators, benchmarks, and multi-year
  targets, all of which will be reported publicly

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Timely Access to High-Quality Care (6)

• And then, on 9 June 2005, Canadas Supreme Court
  re-cast the issue as a financing issue (i.e., ban
  on two-tier public payment) that needed to be
  addressed, at least in Quebec
• 4 to 3 decision struck down Quebecs ban on
  private health insurance, saying the public
  system failed to deliver timely care, which
  imperils patients Charter right to security of
  the person
• 3 to 3 vote about the decisions applicability to
  other provinces, so the citizens of other
  provinces would need to pursue a similar court
  challenge (if their government did not
  proactively end the ban)

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Timely Access to High-Quality Care (7)

• Where to from here?
• Quebec has asked the Supreme Court for a stay of
  between six months and two years to consider the
  implications
• Options
• (Re) Introduce a two-tier system of medically
  necessary hospital and physician care, as Canada
  has in all other parts of its healthcare system
• Move rapidly to set benchmarks and achieve them
• Both, with likely result that the private tier is
  small

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Conclusions

• Changes to the core bargain have been difficult
• Private practice physicians deliver care with
  first-dollar, one-tier public (fee-for-service)
  payment
• Private not-for-profit hospitals deliver care
  with first-dollar, one-tier public payment
• Primary care reform continues to bang up against
  it
• Timely access to high-quality care may have
  needed a Supreme Court decision to trigger
  meaningful action

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References

• Primary care reform
• Hutchison BG, Abelson J, Lavis JN. Primary care
  reform in Canada So much innovation, so little
  change. Health Affairs May/June
  200120(3)116-131.
• Both policy issues
• Health Council of Canada (2005). Report to
  Canadians. Ottawa Health Council of Canada.
• http//hcc-ccs.com/index.aspx

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Contact Information

• John N. Lavis
• lavisj_at_mcmaster.ca
• Program in Policy Decision-Making, McMaster
  University
• www.researchtopolicy.ca