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View Daryl Kramp Profile
CPC (ON)
Okay, fine. Thank you very much.
Slipping across now to, I guess it's a hobby horse, but it's also critical for all of us, there isn't a member of Parliament, certainly around this table, and most Canadians, who don't share a concern with regard to health care in Canada. There are many, many options out there. In many cases we live in a falsehood that we have nothing but the best in the world when in reality we have many jurisdictions that can claim to provide better health care for less money. There is no doubt there is room for improvement. There is a way that we have to look at how we're going to do that, how we can improve health care services while certainly controlling the cost.
I think we're well aware that this government in particular, over the past number of years, has put the escalator clause at 6% per year to 2016-17, with the recognition that health care in its present direction is just not sustainable.
I can recall being involved earlier when health care took about 23% or 24% of the provincial budget in Ontario. Now it's upwards of 48%. It certainly is not sustainable going forward. There has to be some acknowledgement that we have to have some significant changes.
I've been at round tables. I've listened to medical professionals all over and they, quite frankly, are in concurrence with this, so everybody's looking for that solution.
I'm pleased to say that most of the provinces are actually heeding this. My understanding is that their expenditures are going up in the range of 3% to 4% even while we're contributing 6%. Of course, that escalator will slow in 2017 and on. I understand that we are still committed to a base of 3% plus inflationary measures in there.
Going forward, is what I've said here a true assessment of the reality of the situation? This is what I'm being led to believe by all the professional people I'm dealing with, both in my riding and around the country, but I'd like to have the official version on behalf of Finance.
Benoît Robidoux
View Benoît Robidoux Profile
Benoît Robidoux
2013-03-05 15:59
In a nutshell, we tend to fully agree with what you've said. You are right on the facts. Effectively, the data we have this year for provinces is that they are in the range of 3% to 4% rate of growth in spending on health care. Their spending has been going down quite significantly in recent years. They will receive 6% up to 2016-17. After that, they will receive a minimum of 2%, or the rate of growth in nominal GDP. That could be more in the range of, in normal years, 4% to 4.5%. Therefore, that is what they would receive.
Effectively, although it's fairly complicated to control the costs of health care on the ground, the only solution over a long period, like we have analyzed in these documents of 50 years and 30 years, is to control such a big element of spending. The only way is to control it and make sure that it is not growing faster than GDP, which is your base of taxation.
The only other solution is to increase taxation without limit, or to reduce spending elsewhere, like in education and so on, which are also big elements on the provincial side, again without much limit. This is fairly technical in these kinds of projections, but this is in fact the dire reality of all of these people. There's not much of a way out. You need to control it over time.
Jason Sutherland
View Jason Sutherland Profile
Jason Sutherland
2013-02-28 15:42
Thank you.
I'd like to take the first couple of minutes to introduce myself. I'm a faculty member at the Centre for Health Services and Policy Research at the University of British Columbia in Vancouver, where my specialty lies in evaluating the organization, delivery, and funding of health care systems. I'm a Scholar of the Michael Smith Foundation for Health Research and I'm also Canada's Harkness Fellow in health policy.
I'm currently studying the health reforms that President Obama has enacted in the United States in Medicare. I'm working in Washington, D.C., as a foreign scholar for the next 10 months.
I welcome your questions in both English and French.
The international results are in. Canada again ranks last in the ranking of the top 11 industrialized countries in terms of access to many kinds of hospital-based care and specialized care, with substantial waits for hospital care and to see a specialist. I think the persistence of these trends is demonstrating that we are clearly performing very poorly on some aspects of the health care delivery system.
Recent data also shows that Canadian governments are spending over $60 billion a year on health care in the provinces, with another $30 billion each on drugs and physician care, based on 2012 statistics provided by the Canadian Institute for Health Information. Where does this put us internationally? We're definitely in the top percentile for spending per capita among nations. This draws a really harsh light on the paradox between our very poor access to specialized care and our very high expenditures.
Given these findings and the persistence of these findings, we should be paying much more attention to how we spend these massive amounts on health care. The way we pay for our health care provides incentives for providers of health care to act in certain ways and engage in certain behaviours. For example, global budgets, which are the way that we fund most health care providers, reward cost minimization and rationing of health care.
What are the results of the behaviours that we're currently paying for? There are many examples of inefficiencies, ineffective care, and unsafe practices in health care. Two significant ones certainly spring first to mind.
First, from time of referral, the time to see a specialist often exceeds more than 12 months. In other words, from the referral from your general practitioner to a surgical consultation, the median time exceeds a year. That's a long time if you're in agony, or your quality of life is suffering, or you're debilitated.
Second, this is very shocking but is not news to many of you who work in the health care industry: every single day there are thousands of patients who are in hospital beds and are ready to be discharged safely, but there's no place for them to go. They even have a name for them: “alternative level of care”. It's a very prevalent problem in our Canadian hospitals. This use of hospital beds is inefficient and unsafe for patients and has detrimental effects on the hospital staff who care for them. It's also associated with the clogging of our emergency departments, something I've written about extensively.
We should, I believe, expect more from our health care system and strive for a high-performing health care system on cost efficiency, access, higher quality, and safe care. In my forthcoming report on the use of funding methods to change the delivery of care, I advocate using policies that have been proven effective in other countries in improving access, especially to surgical care. I also advocate that we curtail policies that ration resources and restrict access to care and lengthen wait-lists.
To do so, we should create incentives for the health care system as to what we think we want from it. For example, if our policy imperative is to improve access, then we should use a funding mechanism that rewards access to hospital-based care. This is known as activity-based funding and is the predominant form for funding hospitals across the industrialized world. There are also many strategies that other countries have developed for mitigating the risks of rising expenditures from these kinds of methods.
Similarly, we can develop, design, and implement incentives for community care providers to pull waiting patients from the hospitals when it is safe to do so; I refer back to my comment that every day in hospitals there are thousands of patients who are waiting to go home. By doing so, we'll improve our access to hospital-based care for those thousands of patients waiting for their elective surgeries and hopefully improve the clogging of our emergency departments.
Now I want to highlight the two provinces that are trying to figure out how to use these innovations to try to achieve their policy aims of improving access.
First off, British Columbia is starting implementation and experimentation with activity-based funding for elective procedures, as a small proportion of overall hospital funding, to increase the volume of elective surgery and improve access and decrease wait-lists. An evaluation is ongoing of the effectiveness of these policies, but they're widely implemented in many other countries.
On the other hand, Ontario is using a new policy initiative for certain chronic conditions, tying funding to best practices of care. That is, they are funding, they are creating incentives, to reward providers to provide the evidence-based care that patients with those conditions have. This is known as QBP, for quality-based procedures.
A third example originates in the United States. I'm currently studying it. It employs innovative strategies for addressing the seams between the silos in the delivery systems. That might be between post-acute-care providers or between the hospital and home. Known as bundled payments, the incentives are based on reducing avoidable or unnecessary care. Research has demonstrated its feasibility in some Canadian provinces already.
So what's missing from these policies in order to execute innovations to address the limitations in our current health care system? Well, much work needs to be done. Our national health information agency has to adapt and provide the plumbing for these innovations to be successful. I think this is an achievable goal in the short term.
In the medium term, I believe one agency should also specialize in identifying innovative and successful health delivery strategies that work in regions or in provinces and in disseminating that information elsewhere. Currently there's not a clearing house for good ideas, and I think that would be a useful role to be played in the medium term.
In the long term, I believe there's a very prominent role to be played by collecting patient-reported outcomes and patient-reported experience measures so that we can tie patients' experiences and their outcomes with how to direct care and resources to those who need it the most, and waiting patients.
With that, I conclude. I'd like to thank the committee for the opportunity to present my views on the state of innovation in the health care system in Canada.
View Libby Davies Profile
NDP (BC)
For your patients who go there, how are they covered? You're in Ontario, right? Are they covered through OHIP, the insurance plan in Ontario? How does that work?
Emad Guirguis
View Emad Guirguis Profile
Emad Guirguis
2013-02-28 15:51
That's actually an excellent question.
Lakeview is funded completely outside the taxpayer's purse. We funded the centre ourselves. We did not ask the provincial or federal government for any funding for the centre.
In terms of the procedures that are performed there, we are total advocates for the Canada Health Act. We believe the population has access to insurable services and everyone should have equal access. So right off the bat we're proponents of the Canada Health Act.
That said, we have performed both OHIP-covered procedures, or public-covered procedures, and private procedures. If a service is insured by the provincial government, then we do not charge any extra for that procedure—for example, inguinal hernia repair, thyroid surgery, breast cancer surgery—whereas if it's not covered by the government purses, if you will, then the patients or third-party insurers would fund that procedure.
Emad Guirguis
View Emad Guirguis Profile
Emad Guirguis
2013-02-28 15:52
Exactly. Of course, the challenge from an operational point of view is that if a procedure is covered by the provincial government, such as a hernia, for example, we can only bill the province for the procedural fee alone, so that the owners ourselves would have to absorb all the other costs: the nursing costs, the anesthesia costs, and the facility costs. It becomes very difficult to perform publicly funded procedures in an out-of-hospital facility.
However, the provinces.... For example, Ontario has said that it would like to see more procedures that are publicly funded procedures funded in out-of-hospital facilities. We really believe strongly that this is the way of the future. You extract out procedures that can be done safely as outpatient procedures and have them funded properly in an out-of-hospital facility.
Jason Sutherland
View Jason Sutherland Profile
Jason Sutherland
2013-02-28 15:55
First off, specifically with regard to activity-based funding, I think the promise of that mechanism is certainly aimed at improving access to surgically based care. There are limitations to it that are associated with the often increasing physician- and hospital-based costs with regard to an increasing volume of care. If you're willing to go with a policy imperative of improving access, this proves to be an effective mechanism for doing that. Given that many countries have tried this, it's well known what the side effects are and how to guard against those side effects.
However, I would point back to the federal wait-times strategy as one effective mechanism that actually opened the door for activity-based funding at different levels in Canada. Many provinces use that as a contracting mechanism to bulk-purchase additional surgical care from their hospitals or from their health authority's or health region's hospitals. I think that was very effective in improving access for elective care, and I think it's certainly one mechanism that could be logically extended into many other conditions beyond the Cinderella services.
View Libby Davies Profile
NDP (BC)
Is there anything else that we should be considering for the federal government to do in terms of advocating for more of a national perspective on these different types of funding models? Is it targeting funds to particular outcomes and saying that if you want this extra money you have to show that your outcome is whatever you base it on?
Jason Sutherland
View Jason Sutherland Profile
Jason Sutherland
2013-02-28 15:57
Well, I think the federal wait-times strategy was a very innovative method for trying to get this contracting with activity-based funding down, because now the provinces are very familiar with the mechanism. At the same time, it opens the door for perceived inequities between different kinds of surgeries if you're not in the Cinderella services of the five conditions. For example, hernia repairs may get pushed out for additional hips and knees, because the marginal revenue goes to those patients.
View Hedy Fry Profile
Lib. (BC)
Thank you very much, Madam Chair.
I want to start with a question on the obesity piece. I know that in fact not every province funds the innovative surgery you do with a lap band. Is there a guideline that says you have to be over a certain weight, that your BMI has to be over a certain number in order for it to be fundable, or is it never fundable?
Emad Guirguis
View Emad Guirguis Profile
Emad Guirguis
2013-02-28 16:06
The lap band has variable funding across Canada. Alberta funds the lap band. Quebec funds the lap band. The challenge, though, is the amount of funding required to fund a procedure like the lap band, because it really is a chronic condition. It requires very intense follow-up and care.
The gastric bypass and another surgical procedure called the gastric sleeve are publicly funded in all provinces.
View Hedy Fry Profile
Lib. (BC)
Thank you.
Dr. Sutherland, I think what you're talking about is really extraordinarily important for us as we look at how we spend appropriately. I know that many of us who have been in the health care field for the longest time have always felt that hospitals are rewarded for spending badly, because the next year they get a bigger budget, as opposed to what you're suggesting, which is activity-based funding.
Is activity-based funding in this project that's going to go on in B.C.—and we're looking at this as a best practice—going to be based on everything, or only on the five areas for bringing down wait times? Is it open to any kind of activity funding?
Jason Sutherland
View Jason Sutherland Profile
Jason Sutherland
2013-02-28 16:07
If we're going to limit the discussion to the experience in B.C., there are several different initiatives within their patient-focused funding there. One of them is the activity-based funding. Another of them is called the procedural care program, which does bulk contracting with hospitals for incremental surgical volume.
Activity-based funding is across the board, so it weights all hospital activity equally. However, it's for only a small portion of the health authorities' or hospitals' activity. It's about 17% of the health authorities' or hospitals' funding. It applies to only the largest hospitals since they feel that the hospitals can achieve economies of scale without jeopardizing access in smaller communities. It's not across the board, and it probably should not be applied across the board for everyone. They've sensibly, as have many other countries, restricted it to the largest ones.
Jason Sutherland
View Jason Sutherland Profile
Jason Sutherland
2013-02-28 16:08
The British Columbia experiment with activity-based funding is essentially intended to provide more care. It is about decreasing length of stays and decreasing wait-lists. There are no outcome measures in terms of patient-reported outcome measures or patient outcomes, although we are looking at readmission rates and mortality rates to see if we detect changes.
The program in Ontario, the quality-based procedures initiative, is a very new initiative. It is essentially pulling together clinical panels of expert clinicians in every field, identifying for that condition what the best practices should be and how to line up the funding behind them, and then matching the funding cross-continuum to that. They currently are just compiling their clinical panels. Some of them have met, including those on chronic heart failure, congestive heart failure, hip fractures, knee replacements.
So a number of them have already met, and they are developing these guidelines. They intend to match the funding, but it has not actually been implemented to the degree that they've been able to delineate what the best practices are. They are doing so now.
View Djaouida Sellah Profile
NDP (QC)
Thank you, Madam Chair.
My thanks to our two guests for coming here to shed a little more light on the issue for us.
My question is for Mr. Sutherland.
I listened carefully to your presentation. You said that Canada was the last of 11 developed countries in terms of access to specialized care. You also talked about the pay-for-performance funding policy, whereby payment is used as an incentive to health care providers to achieve a certain benchmark.
In your view, could pay-for-performance funding be effective in promoting innovation in health care systems? Could you also give us an example of how this works in Canada or elsewhere, please?
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