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Back to Basics, 2013POPULATION HEALTH : Health Care Organization

Prepared by Doug Coyle

Epidemiology & Community Medicine

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MCC Objectives: Population health 78-4 Administration of effective

health programs at the population level

Rationale: • Knowing the organization of the health care and

public health systems in Canada as well as how to determine the most cost-effective interventions are becoming key elements of clinical practice.

• Physicians also must work well in multidisciplinary teams within the current system in order to achieve the maximum health benefit for all patients and residents. 03/2013

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MCC Objectives: Population health 78-4 Administration of effective

health programs at the population level

Terminal objectives: • Know and understand the pertinent history,

structure and operations of the Canadian health care system.

• Be familiar with economic evaluations such as cost-benefit / cost effectiveness analyses as well as issues involved with resource allocation.

• Describe the approaches to assessing quality of care and methods of quality improvement.

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MCC Objectives: Population health 78-4 Administration of effective

health programs at the population levelEnabling objectives (1)• Describe at a basic level:

– methods of regulation of the health professions and health care institutions;

– supply, distribution and projections of health human resources; – health resource allocation; – organization of the Public Health system; and – the role of complementary delivery systems such as voluntary

organizations and community health centres.

• Describe the role of regulated and non-regulated health care providers and demonstrate how to work effectively with them.

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MCC Objectives: Population health 78-4 Administration of effective

health programs at the population levelEnabling objectives (2)

• Outline the principles of and approaches to cost containment and

economic evaluation.

• Describe the main functions of public health related to population

health assessment, health surveillance, disease and injury

prevention, health promotion and health protection.

• Demonstrate an understanding of ethical issues involved in resource

allocation.

• Define the concepts of efficacy, effectiveness, efficiency, coverage

and compliance and discuss their relationship to the overall

effectiveness of a population health program. 03/2013

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MCC Objectives: Population health 78-4 Administration of effective

health programs at the population levelEnabling objectives (3)• Be able to recognize the need to adjust programs in order to meet the

needs of special populations such as new immigrants or persons at increased risk.

• Participate effectively in and with health organizations, ranging from individual clinical practices to provincial organizations, exerting a positive influence on clinical practice and policy-making.

• Define quality improvement and related terms: quality assurance, quality control, continuous quality improvement, quality management, total quality management; audit.

• Describe and understand the multiple dimensions of quality in health care, i.e. what can and should be improved.03/2013

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What Will We Cover?

• Organization of Health Care Delivery in Canada

• Elements of Health Economics

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1867 British North America Act Provincial gov. given regulatory power over hospitals, asylums etc.

1914-1917 Saskatchewan Moves towards paying retainers for physicians and the right to collect taxes to finance health care

1920 Creation of Federal Department of Health • Response to Spanish flu epidemic • Focus on public health, child health food and drug standards

1935 Provinces stop Federal gov. plan to provide social and health benefits

1947 Saskatchewan Introduces public insurance for hospital services

1957 Federal Hospital Insurance and Diagnostic Services Act (HIDS)

Provinces given 50% of funding from Federal gov to provide a service which is:

Publicly administered, comprehensive, universal, portable and accessible.

1961 All provinces participate in HIDS

1966 Medical Care Act Universal coverage for physician services

1977 Federal-Provincial Fiscal Arrangements and Established Programs Financing Act (EPFA)

Reduced requirements of federal government to match funding

1984 Canada Health Act

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Historical Progression in the Organization of Health Care

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Canada Health Act PrinciplesPublic administration Administered for non profit and

accountable to a provincial government

Comprehensive All medically necessary services provided by hospitals, medical practitioners

Universal All insured persons have equal coverage

Accessible Reasonable access without financial and other barriers

Portable Coverage between provinces

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Problems with the Canada Health Act

• Only partial coverage– Physician services in and out of hospital only– What is “medically necessary”– Only those “provided by hospitals”– Not all hospitals must provide all services

• Does not legislate which services must be provided– Only that federal government will not provide funding

if conditions not met• Impact of other legislation

– Canadian Charter of Rights and Freedom

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Events Post 1984

• 2001: Kirby & Romanow commissions– Attempts to reform the health care system– Focus on long term sustainability

• 2005: Chaoulli decision (Quebec)– Controversial interpretation of the CHA in regards to banning of

private clinics.

• 2012 Drummond report (Ontario)– Emphasis on home care

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Ways of organizing a health care system

• Publicly financed and provided– UK (?), Scandinavia

• Insurance based system for all– Tax based - Canada – Compulsory premiums - Japan

• Insurance based system for some– (former ?) US– Wouldn’t meet requirements of Canada Health Act

• Purely private– Mainly underdeveloped countries– Wouldn’t meet requirements of Canada Health Act

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Some Data

• 2012– total health care expenditures were $5,811/person or

about $200.5 billion– 11.6% of GDP– down from 2010 (SIM web link)

• 70.3% from public sector – 45% in the USA

• 48% spent on hospitals, 9% on drugs, 18% on MDs• Research shows that private-for-profit care is more

expensive (and potentially less effective)03/2013

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World Health Report, 2012 (data mostly from 2009)

Population(x 1,000)

% GDP on Health(2000)

% GDP on Health

(2009)% from

governmentPer capita

(US$)MD’s/10,000

Nurses/10,000

Afghan- istan

31,412 N/A 7.6 11.6 34 2.1 5.0

Canada 34,017 8.8 11.4 70.4 4,519 19.8 104.3

China 1,348,932 4.6 5.1 52.5 191 14.2 13.8

France 62,787 10.1 11.9 77.9 4,840 34.5 3.1

Japan 126,536 7.7 9.5 82.3 3,754 21.4 41.4

UK 62,036 7.0 9.8 84.1 3,440 27.4 101.3

USA 310,384 13.4 17.6 47.7 7,960 24.2 98.2

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Methods of paying doctors (SIM web link)

• Fee-for-service: unit is services. – Incentive to provide many services, especially procedures.

• Capitation: unit is patient. Fixed payment per patient.– Incentive to keep people healthy, but not to make yourself

accessible.– Incentive to recruit young, healthy people, not the ‘sick’

• Salary: unit is time. – Productivity depends on professionalism and institutional controls– Practice plans

• Combinations of above, e.g., "blended funding“– Family health networks (Ontario)

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Methods for paying hospitals• Line-by-line:

– separate payments for staff, supplies, etc. – Cumbersome, rigid.

• Global budget:– fixed payment to be used as hospital sees fit. – Fails to recognize differences in case mix.

• Case-Mix weighted: – payment for total cost of episode, greater for more

complicated cases. – Now used in Canada.

• New technology: OHTAC reviews requests. – If approved, government pays. – If declined, hospitals can pay for it from core budget.

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ORGANIZATIONS

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CMPA• “The role of the CMPA as a medical defence

association representing the interests of individual physicians.”

• Canadian Medical Protective Association is a co-operative– largely replaced commercial malpractice insurance.

• It advises physicians on threatened litigation (talk to them early), and pays legal fees and court settlements.

• Fees vary by region and specialty– $792-$39,828/year.

Local Health Integration Networks (LHINs)

• Champlain LHIN– Covers Renfrew, Lanark, Ottawa, Eastern Ontario – Funds

• 21 hospitals• 7 community health centres, • 61 long-term care homes, • the Champlain Community Care Access Centre, • and more than 100 Community Support Services including mental health

and addictions agencies

– Covers approximately 1.1 million people or 9 per cent the population of Ontario

– Plan, coordinate, integrate and partially manage care in the target region

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Physician Organizations (1)

• Medical Council of Canada– Maintains the Canadian Medical Registry– Does not grant licence to practice medicine– administers country-wide examinations of competency

• serve as the base for provincial registration and licencing

• College of Physicians and Surgeons of Ontario– Responsible for issuing license to practice medicine– Handles public complaints, professional discipline, etc.– Does not engage in lobbying on matters such as

salaries, working conditions.

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Physician Organizations (1a)

• Ontario license requirements– graduate of an accredited medical school

• or ‘acceptable unaccredited’ school

– meets standards of moral behaviour• mentally competent

• integrity, honesty and decency as applied to practice

• sufficient skill, knowledge and judgement

• communicates effectively and professionally

– Successful completion of MCCQE part 1 & 2

– Certification by either• the Royal College of Physicians & surgeons of Canada

• College of Family Physicians of Canada

– One year post grad training or clinical clerkship in Canada

– Canadian citizen or landed immigrant03/2013

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Physician Organizations (2)

• Royal College of Physicians and Surgeons of Canada.– Maintains standards for post-graduate training through-

out Canada.– Sets exams and issues fellowships for specialty training

• Ontario Medical Association– Professional association; lobbies on behalf of

physicians re: fees, working conditions, etc.

• College of Family Physicians of Canada– Organization certifying/promoting family practice

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Public Health Units/Medical Officer of Health

• Reports to municipal government.• Responsible for:

– Food/lodging sanitation– Infectious disease control and immunization– Health promotion, etc.– Family health programmes

• E.g. family planning, pre-natal and pre-school care, tobacco prevention, nutrition

– Occupational and environmental health surveillance.

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Public Health Units/Medical Officer of Health (2)

• Powers (related to a public health hazard) include:– ordering people to take any of these actions:

• Vacate home or close business• Regulate or prohibit sale, manufacture, etc. of any

item• Isolate people with communicable disease• Require people to be treated by MD• Require people to give blood samples

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Coroner

• Notify coroner of deaths in the following cases:– Due to violence, negligence, misconduct, etc.– During work at a construction or mining site.– During pregnancy– Sudden/unexpected– Due to disease not treated by qualified MD– Any cause other than disease– Under suspicious circumstance or by ‘unfair means’– Deaths in jails, foster homes, nursing homes, etc.

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DECISION MAKING

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Role of Federal Government

• General responsibility for international health, public

health, aboriginal health, etc.

• Funding– has the greatest taxing power

• Its provision of funding allows it to enforce the Canada

Health Act, despite its lack of constitutional authority...

• Reductions in federal contributions have reduced its

influence

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Role of Provincial Governments• Responsibility for health (and most other

expensive services) lies with the provinces • Provinces provide most of the funding for

health services• Therefore, they are the main decision-

makers– hospitals, – public health, etc.

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Decision Making in Ontario (1)

• Province decides– Which drugs funded through ODB– Block budgets to LHINs– Special payments for technologies– Physician fees– Other services covered

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Decision Making in Ontario (2)

• Drugs – Ontario covers prescriptions for approx 20% of

population• Welfare recipients• Over 65

– Decision on what drugs to fund influenced by Committee to Evaluate Drugs• Based on level of evidence• Cost effectiveness

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Major Decision Making Committees (Ontario)

• Ontario Health Technology Advisory Committee– Health technology funding to hospitals etc.

• Committee to Evaluate Drugs (CED)/ Canadian Expert Drug Advisory Committee– Drug funding through OPDP

• CED/ panCanadian Oncology Drug Review– Cancer drug funding

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Decision Making in Ontario (3)

• Role of LHINs• 14 in number

– regional offices of Ministry of Health & Long-term Care

• Plan, coordinate, integrate and partially manage care at the local level– oversee approximately $20.3 billion health care dollars.

• Members are appointed• political ‘hot potato’

– LHIN concept may change with change in government

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Decision Making in Ontario (4)

• Politics– Many decisions are politically motivated not

necessarily evidence based or efficient• HPV vaccine• Newborn screening• Preoperative use of EPO

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78.1: MEDICAL ECONOMICS (1)

• Define the socio-economic rationales, implications and consequences of medical care– Medical care has impact on costs to society;

both financial and other (non monetary) resources.

– This objective aims to raise awareness of these types of issues.

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MEDICAL ECONOMICS (2)

• Does effective medical care reduce health care spending?

• How do we value non-fiscal benefits such as quality of life, ‘health’, not being dead?

• Should resources be spent on health or other societal objectives?

• How do we value non-traditional expenditures, etc. which impact on health– Healthy Public Policy

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Year

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Principles of cost-containment• Three approaches to improve cost effectiveness of

health care delivery– Eliminate ineffective care– Reduce costs of effective care

• Substitute cheaper but equally effective care,– day surgery for hospital admission, – nurse practitioners for some primary care, – generic drugs

• Reduce unit costs– reduce salaries (risk of reduced effectiveness) or fees (but quantity

provided may increase)

– Adopt only new interventions that are cost effective

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Assessing Cost Effectiveness

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Types of economic analysis (SIM web link)

Form of Analysis Measurement of Costs

Measurement of benefits

Synthesis of Benefits and Costs

Cost minimization Dollars None Incremental cost

Cost Effectiveness Dollars Single Dimension of Effectiveness (e.g. life years gained)

Incremental cost effectiveness:- incremental cost per unit gained

Cost Utility Dollars Utility gained (e.g. QALYs)

Incremental cost effectiveness:- incremental cost per QALY gained

Cost Benefit Dollars Monetary values of benefits gained

Net benefit gained

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Economic Evaluation Example

Coyle D, Coyle K, Bettinger JS, Halperin SA, Vaudry W, Scheifele DW, Le Saux N. Cost effectiveness of infant vaccination for rotavirus in Canada. CJIDDM 2012;23 71- 77

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Acknowledgements

• The economic analysis was funded by a grant from the Public Health Agency of Canada to the Canadian Paediatric Society.

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Schematic of Model

No infection

Infection Previous infection

Dead

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Data Inputs (1)• Monthly probability of primary RV infection• Probability of death from RV per case of RV• Relative risk reduction for secondary infection versus primary

infection • Monthly probability of death from other causes• Distribution of RV infections without vaccination

– Not requiring medical management, GP visit, ED visit, Hospitalization

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Data Inputs (2)• Vaccine Efficacy

– Meta analysis• Vaccine uptake• Utility Values

– Child and caregiver with and without rotavirus• Vaccine Costs• Costs of Rotavirus cases

– Hospitalization, Emergency dept. visit, GP visit

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Unvaccinated Population

Vaccinated Population

Cost Effectiveness of Infant Vaccination for Rotavirus

No vaccination

Vaccination with Rotateq

Vaccination with Rotarix

Costs

Health Care System $69.29 $206.85 $199.41

Societal Perspective $351.89 $321.99 $304.28

QALYs 4.352 4.353 4.353

Incremental cost per QALY gained versus no vaccination

Health Care System $122,000 $108,000

Societal Perspective Dominant Dominant

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Conclusions

• From a societal perspective, a universal vaccination program against rotavirus will be both cost saving and more effective than no vaccination assuming there are limited additional costs of administration.

• From a health care system perspective, a program would not be considered cost effective at current vaccine costs– Reducing the costs of the vaccine by 50% would make

vaccination cost effective03/2013 51

Impact

• Based on the results of the analysis and a negotiated lower price:– Ontario MOHLTC covers RotarixTM

• Publicly Funded Immunization Schedules for Ontario to protect infants against diarrhea and vomiting caused by rotavirus infection.

– BC covers Rotarix

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Health System

Multiple Choice Questions

For discussion

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19) In 2010, which country spent the least on health care as a percentage of GDP (gross domestic product):

a) Canada

b) France

c) Finland

d) UK

e) USA

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20) The component of Canada's health care system that receives the highest percentage of the health care budget is:a) hospitals

b) physician fees

c) pharmaceuticals

d) laboratory services

e) administration

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22) Regarding health expenditure and health outcomes:a) the U.S. has the greatest health expenditure and

the lowest infant mortality rates

b) there is a positive association between national expenditure on health and GDP

c) increased national health expenditure always increases health status of a country

d) all of the above

e) none of the above

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Deaths/1000 live births

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Life expectancies

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52) Which of the following is not one of the five Terms and Conditions of Medicare?a) portability

b) flexibility

c) universality

d) comprehensive coverage

e) accessibility

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41) Which of the following statements about the Canada Health Act (1984) are FALSE:

a) it did not define all medically necessary hospital and physician services

b) the CHA replaced the Hospital Insurance and Diagnostic Services Act of 1957

c) the CHA banned all forms of extra billing

d) according to the CHA, provinces must meet all the terms and conditions of Medicare to qualify for federal transfer payments

e) they are all true03/2013

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21) The British North America Act (BNA):a) was mainly concerned with health legislation

b) granted exclusive powers over health care to the provinces, including power over marine hospitals

c) replaced the Canada Health Act

d) applied to British Columbia only

e) none of the above

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More MCQs

• Here are some more questions that students can use to test their own knowledge:

http://www.medicine.uottawa.ca/sim/data/Self-test_Qs_HC_System_e.htm

• The questions contain comments on the

answers, to illustrate why a given response is not correct

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