By Philippe Couillard, Howard Bergman, Anita Brown-Johnson, Michel Clair, Alain Robillard, Joe Sardi, Barry Stein, Helen Stevenson
At present, Canadian provinces and territories each approach the provision and coverage of medicines, long-term care and home care in their own way, according to their resources and priorities. At a roundtable discussion chaired by Philippe Couillard as part of the 2011 program of the MUHC-ISAI, participants from different sectors of health care were invited to explore the impact of keeping these services outside the Canada Health Act. They discussed how this affects health system effectiveness and equity, and examined the potential advantages and disadvantages of bringing medicines, long-term care and home care under the Medicare umbrella.
The Medicare model refers to the health goods and services that Canadians expect to receive through public insurance. The national basis for the model is the Canada Health Act (CHA), which stipulates that the provinces and territories must provide all Canadians with access to medically necessary care, provided by doctors or in hospitals, in order to receive transfer payments from the federal government. The provinces and territories have brought in additional plans for necessary care that does not fall into these two categories. These vary and are funded through a wide variety of taxation-based programmes, public insurance and private insurance. This leaves us with a bifurcated system in which doctors and hospitals are treated one way and drugs, home care and long-term care (as well as other services) are treated another way — what André Picard, in a discussion paper he wrote for the MUHC-ISAI this year, calls the “absolutes” and the “maybes.”
This separation is an important difference between the Canadian healthcare system and systems in other advanced countries, notably in Europe. Canada ranks sixth in the world in terms of total healthcare expenses per capita, but even with this amount of spending, governments in Canada cover a much smaller range of services than those in most other advanced countries. Most of our government funding is concentrated on what is done in hospitals by physicians. Western European countries tend to fund a much wider spectrum of services but allow more options in terms of alternative funding, particularly in services provided by physicians. Most systems in Europe fund visual aids, hearing aids, drugs and rehabilitation services. In Canada, these services were kept out of Medicare at the time the system was crafted and are not covered by the principles of the CHA.
This restricted scope of the CHA is becoming more important as the contrast increases between the relatively stable spending on hospitals and physicians and the pronounced increases in the cost of what Canada considers non-core, non-Medicare services.
What impact do Canada’s gaps in public coverage have on effectiveness and equity?
Dr. Howard Bergman helped develop the SIPA (Système de services intégrés pour personnes âgées en perte d’autonomie) programme of integrated care after seeing too many patients in hospital waiting for placement in long-term care or for home care, even though they could be cared for in a more appropriate setting at a lesser cost. He considers Canada’s healthcare system to be still poorly adapted to prevention, management of chronic disease, disability and aging. “What we see now for these populations,” he maintains, “is poor quality of care, dissatisfaction among patients and families, and frustration among clinicians. We also see increased costs from a disproportionate use of heavier, more expensive resources when we could do things with simpler resources and achieve a better quality of care.”
A key factor is a fragmentation of clinical responsibility. “We are generally very good at what we do within the four walls of our jurisdiction,” concedes Dr. Bergman, “but in many instances, and despite the fact that we are all very good professionals, when somebody leaves the four walls of our jurisdiction, there is a sigh of relief because that person is now someone else’s responsibility under someone else’s budget.”
Dr. Bergman points to the way clinical responsibility has been aligned with financial incentives in very successful reforms in the U.S., within the Veteran’s Administration (VA) system and Kaiser Permanente, and in the British National Health Service (NHS). He considers the development of primary medical and community care to be an essential and integral part of that alignment.
Dr. Anita Brown-Johnson has worked to facilitate the transition of care from hospital to community and from community to hospital for many years. She sees practical limitations to the principles of universality and comprehensiveness expressed in the CHA when it comes to providing the services people need to preserve functional capacity, whether that involves a hearing aid, a home blood pressure monitor, physiotherapy or home care.
Mr. Michel Clair, President since 2001 of the Sedna Health Group, a company that operates 2,000 long-term care beds and the equivalent of another few hundred in home care, sees enormous inequities in access to home care services, long-term care and assistance. “The state contributes for some but not for others, and it refuses coverage for or imposes conditions on nursing care or assistance services.” He also recognizes that the current paradigm — in which the public system for long-term care and home care services tells people where to go, details the conditions of access and places them — does not correspond with population expectations. “People want to have a real ability to choose the resources that best suit them and their natural caregivers,” he states, “and to count on government to ensure financial support as single payer, mainly for assistance and specialized professional services.”
There is also a problem in assuring access to general practitioners for long-term care residents. “In September 2011 in Montreal, the Director General of General Practice admitted that over 1,000 long-term care beds had no regular physician coverage,” Mr. Clair reported, “and this is an area that is covered by the CHA principles.
Mr. Joe Sardi, former General Manager and now a consultant with GE Healthcare, is convinced that the technology and information technology available today can help make the shift from hospital- to home-based care achievable. “But the policies and incentives in the system need to be adapted to enable care to be provided in a new way,” he insists. “If the system were in place to compensate and recognize the teamwork required to provide quality home care, there would be a much higher level of satisfaction, quality and access.”
GE and Intel formed a joint venture in 2011 to focus on home health. Their goal now is to show that significant cost savings can be achieved while improving the quality of care delivery. The companies are looking at how to establish a large demonstration project that can be used to justify the investments required by government to shift the location of care.
Drs. Bergman and Brown-Johnson feel that Québec’s drug insurance plan, a public-private partnership that ensures everyone in the province is covered by either an employer plan or the public plan, has worked well to resolve this access barrier for the vast majority. Older people can move from one care setting to another without losing coverage. “If they are at home, they are covered under Québec’s public drug plan,” agrees Mr. Clair, “and are ensured access to a very large spectrum of medicines.” There may be some issues when they enter long-term care institutions, he states, because medicines then become part of the global budget of these establishments, but budgetary limitations have not generally compromised access to medications for older people.
Coverage is not quite so even in other Canadian provinces and territories. Moreover, no plan, be it government-run or employer-based, is exempt from concerns with the rising cost of drugs. Ms. Helen Stevenson, President of the Reformulary Group and Former Assistant Deputy Minister of Health and Executive Officer of Ontario Public Drug Programs, is on the front lines of the affordability issue in drugs. “Drugs represent upwards of $26 billion a year, and affordability concerns are shared by federal and provincial plans, private insurers and the public,” she says. Assuring appropriate use is the key challenge to stewards of drug plans, she feels, and that requires decisions based on evidence of benefit, harm and cost.
The need to address high-cost drugs is becoming more pressing for private drug plans, as fewer are covered by provincial government plans and more are delivered outside of hospitals. Mr. Alain Robillard, a partner at Mercer, describes his day-to-day job as interacting with large organizations to try and put group benefit programs together to cover the non-Medicare health needs of their employees. Employers are currently facing challenges with regards to this coverage. “When we talked about group benefit programs 15 years ago,” recalls Mr. Robillard, “we would call them marginal benefits, and the cost hovered between 1% and 3% of payroll. Today, the cost of employee benefit plans can range from 6% to 10% of payroll.”
So employers have a new interest in implementing measures to reduce cost while maximizing coverage to keep their plans competitive with those offered by other employers. Mr. Robillard sees progress in provincial legislation to increase the use of generic drugs but an enormous challenge with the arrival of very high-cost specialty drugs. “We conducted a study with one of our multi-employer groups that covers some 40,000 employees,” he says, “and found that 12 drugs were responsible for 10% of the global spend. Another client has 60 employees, three of whom use more than $100,000 in drugs a year, and we are now in discussions with the insurer about their ongoing willingness to insure that group.” Drug coverage must remain affordable for the employers because if it is not, some may decide to reduce or even terminate their group benefit programmes.
Can we afford broader coverage?
According to Dr. Couillard, “The challenge we face is to correct the imbalance we created by massively concentrating funding on physicians and hospitals, to the detriment of other services that respond to new health challenges like Alzheimer’s disease and chronic illnesses.” The simple way to correct this, by lowering physician/hospital coverage and increasing government funding for other services, remains politically impossible. Neither are efficiency gains likely to achieve sufficient savings in the public system. “Clearly, some kind of new funding will be needed if we are to enlarge what we fund publicly in Canada,” says Dr. Couillard.
Looking at projects in Québec, the rest of Canada and internationally, Dr. Bergman suggests that broader coverage of home care and long-term care can remain affordable, but only if there are major changes in the way care is organized. “In the SIPA project,” he explains, “we achieved a shift from institutional care provided in hospitals and long-term care institutions, to community care. We decreased costs for the heaviest (meaning most care intensive) patients and for those living alone, without any overall increase in costs.”
In the Montreal area, Dr. Bergman reports that hospitals, the Agence de la Santé et des Services sociaux de Montréal and the Ministère de la Santé et des Services sociaux have started looking into what resources could be transferred from hospitals to provide care in more suitable locations like the community or home. He also describes the all-too-common paradox where a hospital located right beside a nursing home that is equipped with a ward for Alzheimer patients and patients with behavioural difficulties keeps patients on its wards because the nursing home ward is full. Somehow, the resources need to be shifted across the street to open up more beds.
Dr. Couillard points to payment reform — how we pay individual professionals and institutions — as a means of simultaneously rendering spending more efficient and widening coverage to deal with current priorities. Places like Kaiser Permanente or the British fundholding system go further than payment for performance, Dr. Bergman notes, with payment for population responsibility. Dr. Brown-Johnson feels that Québec’s primary care reform and ongoing reorganization of post-hospital care services (including long-term care), guided by the population-based health care services delivery model, is enabling a progressive shift to community-based care and home care, though not without growing pains.
Mr. Clair sees the resistance to change coming from different places. Many stakeholders think they have more to lose than they have to gain if there is change. “Many lobbies,” he says, “and it would be unfair to pick on any one union, are oriented toward answering their own needs first, and then the needs of the patient.”
It is important to make it attractive to healthcare professionals to work across the continuum of care. Dr. Brown-Johnson describes recent difficulties in one Québec program, which had to close beds temporarily due to lack of access to medical care. “The program introduced significant changes to physicians’ workload,” she explains, “bringing patients into long-term care facilities who require more intensive levels of care and services during the night, without adequate provisions to compensate physicians for that change in clinical activity. Payment reform is certainly part of the solution.”
Mr. Barry Stein, President of the Colorectal Cancer Association of Canada, believes that part of the skepticism about change comes because everyone knows the main motivator behind calls for change is cutting costs, not delivering better services more efficiently. “The cost agenda is at the heart of all our Minister and Deputy Minister meetings,” he says. “The Pan Canadian Oncology Drug Review (pCODR) started off as a way to cut costs, not become more effective.”
A variation on payment for performance is being experimented with in pharmaceuticals, according to Ms. Stevenson, and “essentially means paying for drugs when patients respond to them as expected, and not paying for them if patients do not respond.” This strategy has been used in Ontario for some of the more expensive drugs and biologics, where governments are less than certain about what they should be paying for.” The other strategy Ontario is trying to implement is payment reform reward for physicians for managing a person with diabetes from a to z. “The hope, says Ms. Stevenson, “is that it will increase physician accountability for a patient’s entire health and help to integrate their care.”
What would be the advantages and disadvantages of bringing drugs, home care and long-term care under the CHA umbrella?
Dr. Couillard recounts being taken off guard by a report produced by the Organization for Economic Cooperation and Development (OECD) in 2009 that described the part of the Canadian health system not covered by the CHA as a U.S.-style system, in which people have to navigate from one private provider to another, and both private insurance and economic means play a significant role in determining a person’s access to services and outcome.
While all participants at the roundtable feel than uneven coverage between CHA and non-CHA services harms the integration of care and best use of resources, there is little appetite for pushing to expand the CHA to include drugs, home care and long-term care. Participants do not consider that a change in legislation would be enough to reduce access barriers in these areas. “The prospect of expanding the CHA to cover other services and goods becomes highly theoretical,” says Mr. Clair, “when we must fight for access to basic services already covered under the CHA such as GPs, specialists and integrated services with nurse navigators.” To Mr. Clair, “if bringing long-term care and home care under the umbrella of the CHA leads to additional bureaucratization similar to what we see today with access to physicians, then that is not something we want. If it is a way to change the paradigm and see the government in a position to regulate service providers and guarantee access to services within a reasonable delay, then the change would be welcome.”
Mr. Stein feels that many of the changes desired by participants could be accomplished under the CHA as it is currently written, but states: “A little tweaking of the CHA could make a difference in freeing up resources and spurring changes that bring better access and continuity of care.”
Ms. Stevenson views the drug system as different from other health services because of the dynamic tension between government plan managers, who must consider the views of stakeholders from across the system, and manufacturers, who are balancing those views with an ultimate responsibility to their shareholders. “I would be worried,” she says, “that the progress we have made with respect to building clinical and cost-effectiveness evidence into decision-making around drugs might be compromised if all drugs were broadly considered medically necessary and brought under the CHA umbrella.”
With renewal of the Health Accord looming, participants also discussed why the National Pharmaceutical Strategy that was enthusiastically included in the 2004 agreement accomplished so little in the end. Dr. Couillard, who participated in those meetings as Minister of Health in Québec, recalls that there was very little appetite on the federal side to engage in the discussion after 2004. “It was always put to the side.” Ms. Stevenson, who was involved in those discussions in more recent years, recalls initiatives at the federal/provincial/territorial level that tried to bring some kind of national collaboration on the drug issue, be it for catastrophic coverage or through a national formulary. “That type of mechanism,” asserts Ms. Stevenson, “more than incorporation into the CHA, would enable us to better drive decisions through evidence and achieve better access.” She is now, as President of the Reformulary Group, working on behalf of private insurers to build a big national purchasing collaborative, which may be another way to drive the area forward.
Mr. Robillard agrees that the solution lies less with changing the CHA and more in a collaborative approach among provinces to address high-cost drugs, potentially through a global insurance system across Canada to pool and spread the risk. He anticipates problems in the future if high-cost drugs are left with the employers and insurance business. “We hope that the insurance industry, under pressure from employers or third-party payers, will push for a single national pooling mechanism for high-cost drugs,” he says. “But we need to react now before our drug insurance system becomes unaffordable to employers and their employees.”
Participants also dwelled on the need for innovation and excellence. Mr. Stein does not think we will bring about better programs for services like drugs, home care and long-term care just by including them under the Medicare funding mechanism. “What we need in Canada today is innovation to obtain the best resources that we can capture across this country and attain excellence.” He also sees examples of excellent programmes across the country in both Medicare and non-Medicare areas, including Québec’s drug programme, B.C.’s programme for access to cancer drugs, Ontario’s home care programme, etc.
“The real challenge,” maintains Mr. Clair, “is to align the financial incentives (how we allocate resources) and promote clinical integration and clinical responsibility across the spectrum of care. What we need is innovation, and for that we need to change the way we pay providers; put patients in the driver’s seat, giving them the capacity to make choices whenever possible; and have the financial support follow that choice.”
Mr. Sardi sees a role for the federal government in supporting pilot projects that experiment with different ways of funding and delivering the broad spectrum of healthcare services and show how the transition to home health care could work. Infoway and the Canada Foundation for Innovation are potentially useful models for this type of funding.
Who will lead?
There was a general agreement among participants that we cannot count on government to lead changes toward broader public coverage of non-CHA services. In 2000, the Commission led by Mr. Clair recommended the implementation of a new prepaid public insurance program for long-term care and home care services. he says. “But even though most of our recommendations were well received by public opinion,” he says, “that one was killed the day after it launched. All the newspapers and public opinion makers translated it as a new tax on old people that went against intergenerational equity.”
He now feels that at some level, it is not the government but the whole population that has to be held responsible for not wanting to pay for a solid, high-quality home care and long-term care program. “You cannot ask elected officials to go very much farther than the population is ready to push them,” he says.