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A prescription for health care reform: think integration & collaboration

This morning the CCPA released a new report (co-authored by yours truly) that looks at the thorny issue of health care reform in BC (and Canada) and identifies some practical, evidence-based strategies that have been successful in improving quality of care and controlling costs in other jurisdictions.

The papers comes out at a time when all Canadian provinces face significant pressure to reduce the rate of growth of health spending while continuing to improve access and quality of care but when there is no agreement on the specific changes needed to ensure that public healthcare dollars are more efficiently utilized. As a result, individual provinces are experimenting with a variety of reforms. In BC, the two major policy options being introduced are an activity based funding (ABF) model for hospital surgical procedures; and an integrated model for caring for people with chronic conditions and complex needs in the community. Though both of these are formally priorities of the Ministry of Health, ABF is receiving the vast majority of the financial resources and technical expertise.

Our paper raises serious concerns that the current preoccupation with reforming hospital funding is simply too narrow to effectively address BC’s most pressing health care challenges, many of which have roots outside the hospitals (in our inadequately funded community care system). This is why we titled our report Beyond the Hospital Walls: Activity Based Funding Versus Integrated Health Care Reform.

The current focus on ABF is a reflection of the conventional, hospital-centric model of health care that our system was built on. While this worked well to meet the health care needs of Canadians in the 1960s, it’s outdated in the 21st century when chronic disease management — which is better handled in the community, not the hospital — is increasingly becoming a pressing concern.

But what’s worse is that ABF is not just a distraction from the real problems in our health care system: it may actually reinforce the silos and fragmentation within the health care system, hindering efforts to improve overall system integration and coherence (this stand in the way of priority #2). This is why jurisdictions where ABF has been in place for a number of years are increasingly looking to move away from it towards funding mechanisms that incentivize integration across the system (among hospitals, family doctors and community care services like long term care and home support).

The paper outlines a strategy for health care reform that is timely, practical and evidence-based, and that will address the root causes of problems in our health care system.

Our review of the international evidence on health systems reform suggests that the best performing systems are the ones that have developed mechanisms to collaborate and share accountability across services and providers. The key to their success is understanding the patient experience across the continuum of diverse health services the patient needs at any one time. High performing health systems are organized in a way that allows providers to be jointly accountable for providing cost-effective care in whichever venue is medically appropriate – the patients’ home, the family doctor’s office or the hospital. There are many examples of how this can be done, both internationally and from our own backyard (Northern Health Authority is a leader in this area). All that’s needed is for the BC government to show leadership, look at the evidence, and actually implement the initiatives that have proven successful province-wide.

We hope that Canada’s Premiers’, who are currently meeting to discuss health care in Victoria, find a way to avoid getting bogged down into narrow issues like hospital funding reform and engage in a broader discussion of how to improve quality, increase access and ensure the cost effectiveness of the overall health care system.

Originally posted on

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Comment from Anthony
Time: January 17, 2012, 9:28 am

I’m quite sure that the very sensible proposals outlined in Ivanova’s report will help save a few dollars–integration among health care providers is a good idea, and would be effective if implemented on a broad scale.

However, Canada’s health care system is burdened by one overarching problem: the drug patent system, which costs Canadians roughly $30 billion a year. Economically speaking, it is inefficient and wasteful–not to mention harmful when it comes to the development of lifesaving, but unprofitable, medication.

Before we speak about “reforming” the health care system–meaning, of course, finding “efficiencies” by, amongst other things, reducing surgeries, closing ERs, amalgamating hospitals, privatizing long-term care, and encouraging more for-profit clinics–we might speak first about reforming, in the best sense of that word, the drug patent system.

As a site dedicated to economic analysis, I would expect that this issue would be a priority.

Comment from Iglika Ivanova
Time: January 18, 2012, 12:01 am

Anthony, you’re absolutely right that we need to tackle the issue of drugs, how they’re developed & priced. They are (along with technology) the highest growing cost of health care in this country.

That said, I want to be very clear that the healthcare reforms we need go beyond simply controlling costs. We’ve got to do better in terms of quality of care, particularly as it relates to timely access, appropriate interventions (w/ evidence-based quality standards), and monitoring & reporting on patients’ clinical outcomes.

Even if we had affordable drugs for everyone tomorrow, this wouldn’t do anything about the people waiting months to see a specialist, to get diagnostic imaging or an elective surgery. It also won’t put an end to patients being treated in hospital hallways because over one tenth of the hospital beds are taken up by patients who no longer need hospital care, but there’s nowhere else for them to go (not enough palliative or long term care beds, etc). The rate of preventable hospitalization of people with diabetes and other chronic diseases will continue to be much higher than best practices tell us it should be.

The integration initiatives we recommend are key to bringing our system in line with the needs of the population. This will ensure that people have access to the support they need to stay as healthy as they can be in their homes and in their communities on a daily basis, not just when they’re sick enough to be hospitalized.

The bottom line is that health care is a complex system, made up of many parts, and successful reform will require work at multiple levels simultaneously. And, if we’re serious about improving the health of Canadians, then health care is but a small part of the equation. Dealing with poverty, income inequality and the social determinants of health will have to become one of our priorities.

Comment from Dori
Time: February 10, 2012, 8:24 am

You say “All that’s needed is for the BC government to show leadership, look at the evidence, and actually implement the initiatives that have proven successful province-wide.”

The BC government HAS shown leadership in the goals that IT values, i.e. privatizing health care. Their different (unconscious) assumptions about the world produce a different morality than the one we hold dear. The “evidence” we see would be invisible to them because of confirmation bias. (see Drew Westen, George Lakoff). I think the realities about how we humans reason needs to become part of these discussions.

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