Report from a meeting of the MUHC-ISAI's Partners' Advisory Council held in June, 2011. Among the participants were: Heather Chalmers, General Manager of Healthcare Systems, GE Healthcare Canada; Kathy Megyery, Vice-President, Strategy and Public Affairs, Sanofi; Cristina Rabasquinho, Director, Patient Access, Eastern Region, Merck; Joe Sardi, GE Healthcare; Marie-France Verdon, Strategic Account Manager, Roche; and Dale Weil, Senior Vice President, Integrated Healthcare Solutions and Pharmaceutical Solutions, McKesson Canada.
An important opportunity
It was recognized that the years leading up to the renewal of the Health Accord in 2014 provide an important opportunity to set Canadian health policy in a new, forward-facing direction. Participants at the meeting expressed frustration at health policy that seems to be developed while looking into a rearview mirror rather than acknowledging major changes in equipment, medicines and patient expectations in the Internet age. They also recognized the challenge of finding a way to move forward that both assures sustainability and supports innovation.
The status quo
As Canadians, we pay a lot for the health care we obtain and important components of health care, notably pharmaceuticals and long-term care, are left off the table. The Canada Health Act (CHA) prevents us from leveraging healthcare delivery options that are not focused on what a doctor provides in a hospital bed, despite the fact that most health care is now provided on either side of that bed: on one side, prevention, early diagnosis and chronic disease management; and on the other, rehabilitation, long-term care (with a growing emphasis on home care) and medical equipment.
Chronic disease prevention and management are recognized as the central healthcare challenges of the future. However, the regulatory and reimbursement frameworks that devolve from the CHA and drive provider behaviour do not support the products and services that can prevent and manage disease and therefore control healthcare costs. The result is that people with chronic diseases go to the wrong places to be treated by the wrong people — because that is where an outdated model directs them.
Our funding structure, with exclusive public financing of doctors and hospitals, and primarily private financing of drugs, long-term care, eye care and dentistry, is no longer relevant to the majority of healthcare needs.
What is more, government monopoly of both funding and delivery blocks competitive pressure to lower the cost of services and leaves rationing as the main cost-control strategy. In response to this, we see uncontrolled and unregulated privatization of health care, with provinces/territories pushing the limits of federal government tolerance and physicians and patients opting out of the public system. We see businesses and even government enrolling their top executives with private, often foreign healthcare providers.
Can policy catch up?
Political leaders have been loath up to now to challenge the health system because the status quo has a lot of friends, whereas change has many enemies. The political response remains reactive: Elected representatives cave in to pressure to provide access to a given service to an individual or group, but do not fundamentally change the system structures or processes that contribute to poor access.
Segmented provincial/territorial health budgets cannot provide a holistic view of what it costs to produce a desired health outcome. Each budget (e.g. physicians, hospitals, drugs, long-term care, home care, etc.) is fixed and therefore resistant to innovation, despite the potential positive impact on other budgets. Payments to physicians and hospitals do not correlate with patient outcomes in a system that is process-driven rather than results-driven.
We are likewise lacking models for the broad-scale adoption and funding of new technologies such as home telemonitoring that enable better integration of acute and community care settings and benefit both health-system efficiencies and clinical outcomes.
Technology is moving the locus of control over care from doctors and institutions to patients, and is changing how people interact with the system. However, our ability to exploit the Internet in models of care is seriously hampered by excessive concerns for privacy and security. As well, physician remuneration has not evolved to incorporate new technologies that could potentially make doctors more accessible to people through e-consultations and home health monitoring, and doctors often hang on to tasks that could be provided more efficiently and less expensively by other health professionals.
For example, email consultations could be an effective means of improving patient access to physicians. However, since there is no fee code for such a service, physicians cannot be compensated through government-funded mechanisms. Some physicians offer patients a set number of email communications for an annual fee despite their admitted uncertainty about not only the legality of doing so but also their professional liability. Similar constraints hinder the expansion of telehealth and home health care.
How to get off the treadmill?
Daring strategies are needed to develop and test new ways of financing and providing care. Current structures, regulations and policies impose important limitations on where money is spent to best improve health, on who provides care and on how relationships between stakeholders are structured. It is time to experiment with models that reflect new healthcare realities and encourage private participation in some areas of healthcare delivery in order to promote competition, encourage innovation, improve quality and lower costs. We need to reexamine what health services are publicly and privately financed in light of current needs and possibilities.
A number of specific ideas for moving beyond the current impasse were proposed:
1. Institute a federal programme similar to the Canada Foundation for Innovation or Canada Health Infoway* to support the piloting of healthcare delivery projects that may then prove worthy of expansion. These would allow us to assess the results of innovative methods of providing care and redesign health policy to promote successful models.
2. Experiment with expanding the public-private-partnership (PPP) approach beyond physical infrastructure to include managed equipment leasing. This would enable healthcare institutions to cultivate longer-term relationships with companies and develop new models of care. The single one-off competitive bidding process for each piece of equipment works against efficiencies and innovation.
3. Gain a better notion of the cost of specific components of care, but also dare to assign a price to different services. Price is what provides the incentive to do something more economically.
4. Encourage private delivery within universal public funding for relatively straightforward services such as MRI and CT diagnostics, ambulatory care and some cancer care to promote competition on cost and quality and relieve the burden on public institutions.
5. Experiment with alternatives to exclusionary innovation-resistant drug formularies, and consider listing agreements that bring value and better healthcare outcomes to Canadians. Promising models include listing with follow-up, to make companies more accountable for appropriate use of a new drug (at the risk of penalties) and provide some degree of budget predictability for government payers. For cancer drugs, conditional listing accompanied by commitment from the drug company to collect and analyze evidence from real-world use promises quicker initial approval. Work is needed to refine these models and make them practicable.
6. Encourage the federal government to keep increasing its share of healthcare funding; clearly spell out results provinces/territories need to achieve, but also allow provinces/territories to experiment with different delivery models and, potentially, some new funding sources, without penalty. This would enable some to take the lead on different initiatives and allow the others to learn what works and to emulate successful models.
*Programmes established to overcome impasses in health research and health information technology