service integration the canadian way presentation to the king’s fund study tour september 17 th,...
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Service Integration The Canadian Way
Presentation to the King’s Fund Study Tour
September 17th, 2007
Cathy Fooks
President and CEO
The Change Foundation
Presentation Overview
• Structure of Canadian health system
• Regionalization in Canada
• Ontario version of integration
• Implications for patient outcomes
• Predictions for the future
Structure of Canadian Health System
• Health care delivered by provinces and territories with some federal funding
• Amount of federal funding negotiated and subject of much argument
• The Canada Health Act gives funding authority and covers physician care and services delivered in hospital. Different ways that private care is dealt with across jurisdictions.
• Everything else is up to p/ts thus significant variation across the country
Structure of Canadian Health Care System
• Physicians are largely in private practice, on a fee for service basis – gradually changing to more group practice based on capitation and program funding
• Drugs are privately covered, often through employment benefits with some public funding for elderly or low income individuals
• Very little quality oversight, public reporting of outcomes
• Very little experience with purchasing service, contracting or commissioning
Expenditure per capita by source of funding, 2004
2727
2210
2350
1940
2176
1832
803
472
313
582
389
2572
483
342
354
370
28
0 1000 2000 3000 4000 5000 6000 7000
US
Canada
Germany
Australia
UK
Japan
public
out of pocket
private
System Design
“Canada has a series of disconnected parts, a hodge-podge patchwork, health care industry comprised of hospitals, doctors offices, group practices, community agencies, private sector organizations, public health departments and so on.”
Toward a Model of Integrated Care, 2000
Leatt et al.
Reform Reviews in All Provinces
• Common themes – need for:
– Primary care reform– Regionalization– Reigning in of drug expenditures– Increased spending in home care/community– A focus on non medical determinants of health
Move to Regionalize – mid 1990s
• Everywhere but Ontario
• Ontario had at the time District Health Councils – Ministerially appointed local individuals to provide advice to the Minister
• Health Services Restructuring Commission – legal authority to mandate merger/closure of hospitals – saw some amalgamation at governance level but most physical plants were kept and/or redeveloped
Timing
• Initial efforts at reform coincided with multi year reductions in the federal transfers (which have subsequently been increased up to previous levels)
• Choices for provinces to cut, cover the federal portion or reorganize
• Ontario chose to cover, the rest of the country reorganized
Lessons from the Initial Regionalization Experience
1a) Had to fiddle with the numbers –• BC went from 9 to 5• Alberta went from 17 to 9• Saskatchewan went from 32 to 12• Nova Scotia went from four regional boards to 9 district
authorities
1b) still need provincial authority to tertiary care (eg, cancer, transplants)
Current Numbers Against Population
Jurisdiction # of Regions Population, April 2007 BC 5 regions and
1 provincial authority 4,352,800
Alberta 9 regions and provincial cancer board
3,455060
Saskatchewan 12 regions and provincial cancer agency
990,210
Manitoba 11 regions and provincial cancer agency
1,182,920
Ontario 14 LHINs and provincial cancer agency and provincial cardiac care network
12,753,700
Quebec 18 regions and 95 local service networks
7,687,060
Nova Scotia 9 districts 932,970 New Brunswick 7 regions 748,880 PEI No regions, 5
community hospital boards
138,800
N & L 6 regions with 15 health boards
506,550
NWT 8 health and social service regions
41,795
Nunavut No regions 31,220 The Yukon No regions 30,880
Lessons from the Initial Experience
2) Experimented with Public Participation – quick decision to dump it
• Saskatchewan elected 2/3rds of its Boards but moved to wholly appointed Boards
• Quebec had elected Boards by representative assemblies but moved to wholly appointed Boards
• Alberta had directly elected Boards but moved to wholly appointed
• Some form of advisory council or committee created in some jurisdictions
Lessons from the Initial Experience
3) Lack of clarity around roles and responsibilities
• Survey done by the Centre for the Analysis of Regionalization and Health (2003) found that:– Majority of respondents found that division of responsibility
was unclear– CEOs felt that residents had a tendency to bypass the
Boards and present issues to the province– Boards felt they had less authority than they should– Ministry felt the RHAs were not restricted in their authority
and that special interests had too much influence in decisions
Made in Ontario
• Ministry of Health and Long Term Care is steward• LHINS- regional planning and eventual resource allocation
(although Ministry has already set three year budgets)• CCACs – purchase for home care and LTC• Providers – maintaining separate governance for now• Physicians outside any accountability system other than
professional self regulation and some performance targets with financial incentives for family health teams
LHINS and Regions: Key Differences (S. Lewis, 2007)
Feature LHINS RHAs
Hold budget for community care, hospitals, LTC
√
√
Boards appointed by MOH √ √
Boards/CEO have clear authority over services in their area
? √
Mandate to manage programs and services directly
X √
Responsible for MDs and drugs X X
Fewer local boards with reduced power
X √
Critical Differences
LHINS RHAs Purchasers, funders within Ministry allocation
Purchasers, funders and managers of services within negotiated budget
Employ only their own central staff Major regional employer Exercise authority through accountability and service agreements
Direct authority as employer and service agreements with affiliates
Agreements with independent providers boards
Very few independent provider boards
Physician Report Use of Multi Disciplinary Teams and Non-Physician Clinicians, 2006
29
32
49
32
81
30
39
22
56
38
70
51
0 10 20 30 40 50 60 70 80 90
US
Canada
Germany
Australia
UK
New Zealand
% use multidisciplinary teams % use non-MD clinicians
Primary Care MDs Use of Information Technology, 2006
28
23
42
79
89
92
37
26
81
68
92
80
0 10 20 30 40 50 60 70 80 90 100
US
Canada
Germany
Australia
UK
NZ
% MDs using electronic record % of primary care practices generating list of pts by diagnosis
Quality Measures, 2006
50
27
70
26
70
41
37
46
22
39
65
49
0 10 20 30 40 50 60 70 80
US
Canada
Germany
Australia
UK
NZ
% MDs set formal targets for clincial performance % MDs reporting problems due to poorly coordinated care
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