Brian DayPast President

Canadian Medical Association

KananaskisFebruary 16th 2009

Coping with Change in Canada:Best and Emerging Practice

Global Budget or Block Funding Global Budget or Block Funding

Less

Facilities Procedures Innovation Nurses Physicians Patients

Less

Facilities Procedures Innovation Nurses Physicians Patients

Less Care

Patient Focused Funding

• PFFPFF• PbRPbR• P4PP4P• ABF ABF • SBFSBF• EBPEBP

Empowering the PatientEmpowering the Patient

Orthopaedic Residents in Canada

Approximately 50% leave for US

“No jobs”

Fig. 1 The quality-improvement cycle.

P4P must not become

“Pay for Paperwork”

A Patient Focused System

10%

36%

13%

3%

15%

23%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Per

cen

t o

f R

esp

on

den

ts

Australia

Canada

Germany

New Zealand

United Kingdom

United States Worst: sick patients waiting 6 Worst: sick patients waiting 6 days plus to see doctordays plus to see doctor

Worst ranking:4 hours plus in E.R.

65% Children wait a medically 65% Children wait a medically unacceptable periodunacceptable period

Last in use of informationLast in use of informationtechnologytechnology

Last in use of interventionalLast in use of interventionalradiologyradiology

Health Care and theEconomy

The Cost of Waiting

Four Targeted Areas $15 Billion January 2008 Wait Lists: an Unfunded Liability

Paying for the Privilege of Waiting

“In total the economic burden was $51 billion…”

MEDIX GP Survey on Wait Lists Pre-PbR

MEDIX GP Survey on Wait Lists Pre-PbR

• 66% - had patients admitted as emergencies• 90% - consultations from delays• 70% - significant problems from delayed treatment• 1.5 million extra consultations

• 66% - had patients admitted as emergencies• 90% - consultations from delays• 70% - significant problems from delayed treatment• 1.5 million extra consultations

Market conditions and competition

Patient choice - quality and service

Local control

Bottom up instead of top down

Wait lists gone, productivity up

Carole Heatly

England:

the New NHS

• The greatest change since 1948 • Patients choose from 350 hospitals, including private

• Bunions to heart surgery

• Flexibility and convenience for patients

• Stimulates failing hospitals to improve

• Patients avoid MRSA hotspots or wait lists

Patient Power and the New NHSDamien Fletcher , The Mirror, 31st March 2008

Public Private Non Debate

Worksafe BCWorksafe BCNo Waits for Injured WorkersNo Waits for Injured Workers

Worksafe BCWorksafe BCNo Waits for Injured WorkersNo Waits for Injured Workers

Health Care Costs1999 $204 million2002 $187 million

Health Care Costs1999 $204 million2002 $187 million

Health costs constant at $200 million per year for the past 10 years

Health costs constant at $200 million per year for the past 10 years

“A System Focus”

Data: Costing CMG HRG DRG

and Performance

FOI Document Billings versus Costs

Total Indirect Costs (per sample $1000 direct surgical

cost)

Total Indirect Costs (per sample $1000 direct surgical

cost)

BC Hospital A: Add $1220

BC Hospital B: Add $850

BC Hospital A: Add $1220

BC Hospital B: Add $850

BC Medicare 15-16%1

U.S. Medicare and Medicaid 7-8%2

1Turchen, 20082 Matthews,2006

Measurement and Accuracy(Garbage in = Garbage Out)

Independent auditFederal FOI to include CIHIOutcomes clearly defined

Turchen 2008

Costing and Accountability Calgary Health Region (CHR) Costing and Accountability Calgary Health Region (CHR)

“CHR administration argues that accurate cost accounting would require a diversion of effort better expended elsewhere”

“CHR administration argues that accurate cost accounting would require a diversion of effort better expended elsewhere”

US Medicare:10 procedures, 4 Settings 2008

2008 NHS Tariff Examples

Procedure NHS 2008 Tariff Cataract operation £786

Heart valve surgery £10,199

Heart bypass £8,080

Hip replacement £5,568

Hernia surgery £956

Knee replacement £6,182

Major breast surgery £2,386

Varicose vein removal £1,063

Economic Impact of Early TreatmentEconomic Impact

of Early Treatment• Patients’ income• Medical expense• State revenue or payments• Medical tourism income

• Patients’ income• Medical expense• State revenue or payments• Medical tourism income

Medical Tourism$20 Billion 2006$40 Billion 2007

$80 Billion 2008

U.S. Medical Tourists

¾ million 2008 6 million 201012 million 2012

Service - Based Funding The Health of Canadians – The Federal Role

Final Report Volume Six

Service - Based Funding The Health of Canadians – The Federal Role

Final Report Volume Six

• Encourage efficiencies• Keep or reinvest savings• Create competition • Specialized teams• Centres of excellence • Improve quality with increased volume • Improve patient service • Reduce inefficiencies

• Encourage efficiencies• Keep or reinvest savings• Create competition • Specialized teams• Centres of excellence • Improve quality with increased volume • Improve patient service • Reduce inefficiencies “ “Kirby Report”

Senator Michael Kirby

October 27 2006

October 27 2006

OECD: Competition in the Provision of Hospital ServicesOECD: Competition in the Provision of Hospital Services

• Market mechanisms reduce government hospitals costs• Close hospitals or change management for poor results• Choice of provider• Capacity is needed• Rural hospitals benefit from benchmark competition• With long waits, funds following patients increases output• Centres of excellence may need entry constraints

• Market mechanisms reduce government hospitals costs• Close hospitals or change management for poor results• Choice of provider• Capacity is needed• Rural hospitals benefit from benchmark competition• With long waits, funds following patients increases output• Centres of excellence may need entry constraints

Competition in the Provision of Hospital Services

(OECD)

Competition in the Provision of Hospital Services

(OECD)

ONTARIO HOSPITAL ASSOCIATION

January 2007

Patient Focused and Centred