A brief discussion about Ontario’s Bill 60. If you live in Ontario a must read.

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https://www.cdhowe.org/sites/default/files/2023-06/IM-Mulcair_2023_0605.pdf

Introduction

Canada's healthcare system is facing significant challenges that require innovative solutions and bold reforms. In this blog post, we will delve into the report titled "Roadmap for Reform: A Consensus View of Viable Options Ahead for Canada's Healthcare System" by the C.D. Howe Institute. We will explore the key insights, recommendations, and viable options presented in the report to address the pressing issues and ensure the sustainability and effectiveness of Canada's healthcare system.

Understanding the Challenges

Canada's healthcare system has been grappling with long wait times, access issues, funding constraints, and an aging population with complex healthcare needs. The report highlights the urgent need for reform and emphasizes the importance of addressing these challenges to maintain high-quality care and improve patient outcomes.

Key Recommendations for Reform

The C.D. Howe Institute report puts forward a set of actionable recommendations that can pave the way for meaningful healthcare reform. These recommendations encompass several key areas:

Funding and Governance

The report suggests transitioning from the current block funding model to a more flexible and outcome-based funding approach. This shift would enable healthcare providers to focus on delivering value-based care and prioritize efficient resource allocation. Additionally, enhancing governance structures and accountability mechanisms is crucial to ensure effective decision-making and alignment of goals across the healthcare system.

Primary Care and Team-Based Models

Recognizing the importance of primary care in delivering comprehensive and coordinated healthcare, the report emphasizes the need to expand team-based care models. This involves empowering healthcare professionals such as nurse practitioners and physician assistants to play a more significant role in primary care delivery. By leveraging their expertise, improving scope of practice, and fostering collaboration, the healthcare system can enhance access to timely and preventive care.

Digital Health and Innovation

The report highlights the transformative potential of digital health technologies and recommends investing in digital infrastructure and interoperability. Embracing telehealth, electronic health records, remote monitoring, and artificial intelligence can improve care coordination, enhance patient engagement, and drive efficiency gains. Emphasizing a culture of innovation and creating pathways for the adoption of new technologies is vital for advancing healthcare delivery.

Pharmacare and Drug Pricing

The report suggests implementing a national pharmacare program that balances access to essential medications with cost containment measures. By leveraging bulk purchasing power and implementing value-based pricing, Canada can ensure equitable access to necessary medications while optimizing healthcare spending.

Workforce Planning and Training

Addressing workforce shortages and ensuring adequate training and support for healthcare professionals is critical. The report recommends investing in healthcare workforce planning, including increased medical school enrolment, enhanced training for primary care providers, and promoting inter-professional collaboration.

Conclusion

Canada's healthcare system is at a crossroads, requiring decisive action and thoughtful reforms to overcome the existing challenges and build a sustainable future. The recommendations presented in the C.D. Howe Institute report provide a comprehensive roadmap for reforming the healthcare system.

By adopting an outcome-based funding model, expanding team-based care, embracing digital health technologies, implementing a national pharmacare program, and investing in workforce planning, Canada can transform its healthcare system to deliver better outcomes, improved access, and enhanced patient experiences.

However, implementing these reforms requires a collaborative effort from policymakers, healthcare providers, and the public. It necessitates open dialogue, consensus-building, and a shared commitment to the principles of universality, accessibility, and sustainability that underpin Canada's healthcare system.

To read the full article paste this url in your browser:
https://www.cdhowe.org/public-policy-research/roadmap-reform-consensus-view-viable-options-ahead-canadas-healthcare-system

Introduction

Canada's healthcare sector is facing significant challenges. The COVID-19 pandemic has exacerbated these issues, leading to a perceived crisis due to a shortage of workers. This shortage is attributed to workers falling ill, experiencing burnout, resigning, retiring early, or simply due to a lack of adequately trained workers in the first place. However, the solution isn't as simple as hiring more workers. The shortages are specific to certain occupations, and the quality of care needs as much attention as the quantity of workers.

Despite public perceptions, the supply of healthcare workers in Canada has been increasing significantly in most major occupations, even throughout the pandemic. However, demand has exceeded supply, with the job vacancy rate for healthcare jumping to 5.8 percent by the second quarter of 2022. Shortages are particularly acute for family physicians, psychiatrists, geriatric and other specialists dealing with conditions affecting the elderly.

The stresses associated with COVID-19 have pushed parts of the health sector beyond their capacity. Many workers, particularly nurses and personal support workers, have opted for less stressful and/or better-compensated employment elsewhere in healthcare. Earnings in healthcare have grown at an annualized pace of 2.4 over a two-year period ended in July 2022, compared to 4.1 percent for all industries.

The report makes several recommendations to address these issues. These include establishing a governance structure at the provincial/federal level to better collect data and make policy changes, consolidating fragmented data from provinces and federal agencies, accelerating the development and expansion of Integrated Care Systems, expanding the scopes of practice of health professionals/providers, promoting training and accreditation of students in less popular generalist programs, and reviewing the curricula and experiential content of training programs.

Conclusion

The COVID-19 pandemic may have a silver lining if it awakens the public, politicians, and policymakers to the long-standing need for changes to Canada's healthcare system. The challenges faced by the healthcare workforce are complex and multifaceted, but with careful planning and strategic policy changes, it is possible to navigate a way out of these shortages and strengthen the country's cherished health system.

To read the full report paste this url into your browser: https://www.cdhowe.org/public-policy-research/troubles-canadas-health-workforce-why-where-and-way-out-shortages

In a recent report by the C.D. Howe Institute, a spotlight has been cast on the escalating costs of end-of-life care in Canada. The commentary, titled "Expensive Endings: Reining in the High Cost of End-of-Life Care in Canada," provides an in-depth analysis of the current state of end-of-life care and offers recommendations to manage these rising costs.

The report begins by highlighting the significant portion of healthcare spending that is dedicated to end-of-life care. It is estimated that 10 percent of public healthcare spending in Canada is allocated to patients in their last year of life. This amounts to approximately $14 billion annually. The authors, Rosalie Wyonch and William B.P. Robson, argue that this high expenditure is not necessarily reflective of the quality of care provided.

The authors point out that the current healthcare system is not designed to meet the unique needs of patients at the end of their lives. The system is primarily geared towards acute care, with a focus on curing diseases rather than providing comfort and quality of life in the final stages. This results in a high number of hospitalizations and intensive care unit (ICU) admissions for end-of-life patients, which are both costly and often not in the best interest of the patients.

The report also highlights the lack of access to palliative care services across the country. Despite the proven benefits of palliative care in improving patient outcomes and reducing healthcare costs, only 15 percent of Canadians have access to these services. This lack of access is particularly pronounced in rural and remote areas.

In light of these findings, the authors propose several recommendations to improve end-of-life care and manage costs. They suggest that the healthcare system should shift its focus from acute care to a more holistic approach that prioritizes the needs and preferences of end-of-life patients. This includes increasing access to palliative care services and promoting advance care planning.

The authors also recommend the use of data and technology to improve end-of-life care. They suggest that data on patient outcomes and costs should be collected and analyzed to inform policy decisions. Additionally, they propose the use of telemedicine to provide palliative care services, particularly in rural and remote areas.

In conclusion, the report emphasizes the need for a fundamental shift in the way end-of-life care is provided in Canada. By focusing on the needs and preferences of patients, increasing access to palliative care, and leveraging data and technology, it is possible to improve the quality of end-of-life care while managing costs.

This is detailed report that requires more than just a summary. Paste the url in your browser to link to the full report: https://www.cdhowe.org/sites/default/files/2021-10/Commentary_608.pdf

The C.D Howe Institute released a working paper on August 10, 2021, titled "Best in Health: Creating a Comprehensive Health Information Ecosystem". The paper, authored by Don Drummond, Duncan Sinclair, and Chris Simpson, provides a comprehensive analysis of the current state of health information systems in Canada and offers a roadmap for creating a more integrated and effective health information ecosystem.

Current State of Health Information Systems

The paper begins by acknowledging the importance of health information in improving patient care, enhancing health system performance, and informing health policy decisions. However, it also highlights the fragmented nature of health information systems in Canada. The authors argue that the lack of integration and interoperability between different health information systems hampers the ability to leverage data effectively for decision-making and patient care.

The authors point out that the current health information systems are characterized by data silos, where information is stored in isolated databases that do not communicate with each other. This fragmentation results in incomplete and disjointed patient records, making it difficult for healthcare providers to access comprehensive patient information when it is needed.

The Vision for a Comprehensive Health Information Ecosystem

The authors envision a comprehensive health information ecosystem that overcomes these challenges. This ecosystem would be characterized by seamless integration and interoperability between different health information systems, allowing for the free flow of information. It would provide healthcare providers with complete and up-to-date patient records, enabling them to make informed decisions about patient care.

The envisioned ecosystem would also support health system performance measurement and improvement. By integrating data from different sources, it would provide a more holistic view of health system performance, enabling policymakers and administrators to identify areas of strength and weakness and make informed decisions about resource allocation and system improvement.

Roadmap for Creating the Ecosystem

The authors propose a roadmap for creating the envisioned health information ecosystem. The roadmap includes the following key steps:

1.Establishing a National Health Information Strategy: The authors recommend the development of a national health information strategy that outlines the vision, goals, and objectives for the health information ecosystem. This strategy would provide a framework for coordinating efforts across different levels of government and sectors of the health system.

2. Developing Standards for Data Collection and Sharing: The authors emphasize the importance of developing standards for data collection and sharing to ensure data quality and interoperability. These standards would facilitate the integration of data from different sources and enable the creation of comprehensive patient records.

3. Investing in Health Information Infrastructure: The authors argue that significant investment is needed to upgrade health information infrastructure to support data integration and interoperability. This includes investment in technologies such as electronic health records and health information exchanges.

4. Promoting Data Literacy and Capacity: The authors highlight the need to build data literacy and capacity among healthcare providers and administrators. This includes training in data analysis and interpretation, as well as the ethical and legal aspects of data use.

5. Ensuring Data Privacy and Security: The authors stress the importance of ensuring data privacy and security in the health information ecosystem. This includes implementing robust data protection measures and educating healthcare providers and patients about data privacy rights and responsibilities.

The authors conclude by emphasizing the urgency of creating a comprehensive health information ecosystem. They argue that such an ecosystem is critical for improving patient care, enhancing health system performance, and informing health policy decisions. They call on policymakers, healthcare providers, and other stakeholders to work together to realize this vision.

In summary, the C.D Howe Institute's working paper provides a compelling case for the creation of a comprehensive health information ecosystem in Canada. It offers a clear vision and a practical roadmap for achieving this goal, making it a valuable resource for anyone interested in health information systems and health policy.

Paste the url in your browser to link to the full report.

This was a very prescient report written in May 2018 before Covid and while acted upon to some degree by some provinces much of what was recommended has not been implemented.

In the face of a rapidly evolving digital landscape, the healthcare sector is poised for a significant transformation. A recent report by Dr. R. Sacha Bhatia and William Falk, published by the C.D. Howe Institute, explores the potential of virtualization in modernizing Canada's healthcare system.

The report highlights the increasing interest in digital health services among Canadians, with a tripling of access to online services such as e-booking, e-prescribing, and electronic results of laboratory tests between 2014 and 2016. Despite this, the current regulatory and payment policies do not support the modernization of healthcare services. The authors argue that this lack of support risks losing the potential transformational benefits of virtual care.

The report suggests using the "Quadruple Aim" framework devised by the Institute for Healthcare Improvement (IHI) to examine virtual care and digital opportunities. This framework focuses on four key areas: improved population health, satisfied patients, satisfied providers, and reduced care cost.

The authors propose ten practical steps towards the virtualization of health services in Canada. These include making it compulsory for every healthcare provider to have a secure email address and including virtual-care services as part of hospital on-call responsibilities.

The report also emphasizes the importance of considering health equity when modifying payment mechanisms to facilitate the use of virtual care. It argues that virtual care can be delivered within a single-payer healthcare system, but access to technology, concurrent with health and technology literacy, could exacerbate already existing inequitable access within our health system.

In conclusion, the report argues that virtual care can be a transformational force for improved patient care, ensuring the sustainability of our health system, and creating economic opportunities for Canadians. However, to realize these benefits, health systems must adapt to the changing landscape and modernize their practices.

For a more comprehensive understanding of the report, you can access the full document by pasting this url in your browser: https://www.cdhowe.org/sites/default/files/attachments/research_papers/mixed/E-Brief%20277.pdf

Here is a summary of this 32 page report:

Introduction

Healthcare systems around the world are grappling with the challenges of providing universal access, maintaining quality, and controlling costs. Canada's single-payer system, while successful in many ways, faces calls for reform to address inefficiencies and adapt to changing needs. This post explores the possibility of introducing a multi-payer model inspired by countries like the Netherlands, focusing on how managed competition can promote efficiency without compromising universal insurance and equitable cost-sharing.

The Canadian Healthcare System: A Need for Reform

Canada's Medicare system has remained largely unchanged for over 50 years, despite significant advancements in medical technology. While ensuring universal access, it often struggles with efficiency, adaptability, and cost control. Comparisons with other countries reveal that Canada's healthcare costs are similar or even higher than peer nations like the UK and Australia.

The paper argues for considering a model with competing payers, preserving universal access and equitable cost-sharing. This doesn't mean abandoning universal healthcare; instead, it suggests introducing competition among insurance providers to drive efficiency and responsiveness to patient needs. The changing demographics in Canada, an aging population, and the increasing prevalence of chronic conditions are putting additional pressure on the healthcare system, highlighting the need for a more flexible and resilient system.

Universal Healthcare: The Multi-payer Option

Universal healthcare doesn't have to be synonymous with a single-payer system. A multi-payer system, where multiple insurance providers compete to offer coverage, can also achieve universal coverage and equity. This choice allows consumers to find a plan that best fits their needs, fostering competition among insurers to provide better services and more innovative care models.

The success of a multi-payer system in achieving universal coverage depends on careful design and regulation. Measures such as open enrolment periods, risk-adjusted vouchers, and compulsory insurance can prevent adverse selection and ensure universality. Transparency and information availability are also crucial, empowering consumers to make informed choices. The multi-payer option allows for greater adaptability to changing circumstances, leading to a more dynamic and responsive healthcare system.

The Netherlands: A Model to Consider

The Netherlands' healthcare system stands out as a compelling example of how managed competition can work effectively within universal healthcare. It's based on a multi-payer model, where private insurance companies compete to offer basic health insurance packages, with careful regulation to ensure universality, equity, and efficiency.

The concept of managed competition drives innovation and efficiency, while risk equalization ensures that insurers do not shy away from covering individuals with higher healthcare needs. Income-related subsidies make health insurance affordable for everyone, promoting equity. Quality and patient choice are emphasized, with transparency in quality metrics allowing consumers to make informed choices. The central role of primary care and emphasis on prevention further contribute to the system's success.

Conclusion

The exploration of healthcare reform through the lens of multi-payer systems, drawing inspiration from the Netherlands, offers fresh insights into how universal healthcare can be achieved in innovative ways. Canada's healthcare system, though robust, faces challenges that could be addressed through careful consideration of managed competition and choice.

The Dutch model demonstrates that a competitive healthcare system can thrive without compromising universality and equity. It serves as a valuable reference point for countries considering healthcare reform, showing that with thoughtful design and a focus on the public interest, a balance between competition, quality, and accessibility is attainable.

The ongoing debate on healthcare reform is complex and multifaceted. However, the exploration of alternative models, learning from international examples, and embracing innovation can pave the way for a more responsive, efficient, and equitable healthcare system for the future.

For a more comprehensive understanding of the report, you can access the full document by pasting this url in your browser:

https://www.cdhowe.org/sites/default/files/2022-05/Commentary_621.pdf

My Take

Another well written and thorough report from the C.D. Howe institute, but I disagree. While the notion of having multiple insurers compete to provide insurance coverage to Canadians would be the means of driving efficiency in our healthcare system is interesting, it is pure fantasy in reality. The argument is that the combination of ”managed competition” by the government(s) and the option to choose competing health plans would drive efficiency in the system would simply not achieve the efficiencies the paper suggests. It hasn’t in the USA and it won’t in Canada. One of the principal reasons is the lack of competition in smaller markets, which really means only competition within Canada’s 41 CMA’s and none in the rest of Canada. To overcome this the paper suggests, “better government policies to promote what is known as “managed” competition, or even direct regulation of fee and prices.”

That is just wishful thinking when provincial governments cannot even get medical associations to “rebalance” fees to make them more equitable among specialists. Who cares if the child psychiatrist only makes 55% what a radiologist or ophthalmologist makes. If provincial governments can’t make those adjustments in what reality do we believe we can make this seismic a change to our healthcare system even if it is phased in gradually.

I know we are always warned about looking at the US system because it is broken, but that system reveals much. But before I get to the US system of healthcare let’s look at a few basic facts. The Netherlands has a population of 17.62M people and a land mass of 41,850 sq km with a population density of 424.13 people per sq km. Canada has a population of 39M people, a land mass of 9.985M sq km and a population density of 4.2 per sq km.

For all intents and purposes the Netherlands has NO remote or rural areas, Canada has nothing but remote and rural areas. Despite any level of “managed competition” there would be at least two classes of healthcare in Canada. One for large urban areas and one far inferior system for remote areas, with smaller “closer-in” remote areas falling somewhere in between. This fact alone makes the Dutch model an inoperable choice.

But back to the US system just for a minute. The paper suggests that the “managed care revolution” in the 1990s in the US was a great success, but history has shown that was not the case. While HMO’s introduced “capitation” into the US healthcare model its implementation was not wide spread and still is NOT the dominant model for reimbursement in the US insurance system - I know I lived there for 30 years and used the most successful HMO in the US, Kasier Permanente. While capitation incentivized providers to focus on preventive care and cost-effective treatments there were numerous “levels” of coverage and co-pays that were involved. This equates to a multi-level system of coverage and out-of-pocket charges, not universality.

Despite the fact that Kasier Permanente, in my humble opinion, delivers the best healthcare in the USA, until recently it was basically a regional player in the US healthcare system. Sadly, capitation and Kaiser were not the “disruptive innovation” Clayton Christensen was hoping for to revolutionize the US healthcare system.

While the Dutch model of healthcare, with its multi-payer system and managed competition, offers intriguing possibilities for enhancing the Canadian system, transitioning from a single-payer system to a multi-payer model would be a complex and significant shift for Canada. Our Canadian healthcare system is deeply entrenched in our country's social fabric, and any changes would require careful consideration of the following factors:

1. Political Landscape: Healthcare is a provincial responsibility in Canada, and coordination among provinces and the federal government would be essential for any significant reform. And if past history is prologue, political consensus might be challenging to achieve, given the diverse interests and priorities across regions.

2. Public Support: The Canadian public's attachment to Medicare as a symbol of social solidarity would likely influence the debate on reform. Given the current political climate we live in, and our governments lack of effectiveness on dealing with Canada’s healthcare crisis, earning public understanding and support for changes would be challenging to say the least.

3. Equity Considerations: Preserving the principles of universality and equity that underpin the Canadian system would be a paramount concern. The Dutch model's success in maintaining equity through risk equalization and income-related subsidies offers valuable lessons but would be difficult to achieve given Canada’s geographical challenges.

4. Implementation Challenges: Transitioning to a new model would require careful planning, piloting, and phased implementation. Consideration of the existing healthcare infrastructure, workforce, and regulatory environment would be essential to avoid unintended consequences.

5. Learning from Others: While the Dutch model provides inspiration, it's not a one-size-fits-all solution. Examining other international examples and engaging in dialogue with experts, stakeholders, and the public could help shape a uniquely Canadian approach to reform.

As I mentioned in Blog Post Four, there are no “game-changers” when is comes to healthcare reform. Small incremental improvements will be order of the day, and even they will be challenging. While this proposal seems intriguing it is simply too big a change to make. The author is absolutely correct when he says “the Canadian healthcare system’s resistance to reform has assumed almost legendary status.” What more needs to be said?

Let me know your thoughts, pro or con as only informed debate will solve this very challenging problem.