Medicare is as sustainable as we want it to be

Michael M Rachlis MD MSc FRCPC LLD (Hon)University of Toronto February 7, 2013

www.michaelrachlis.ca

Current received wisdom

• Health Care costs are wildly out of control• My fellow baby boomers and I will really

deep six Medicare as we get older• The only alternatives are to either cut real

services or use more private care and finance.

• We need an “adult conversation” to reduce our expectations and make us see the need for private involvement

What’s my story?

• Health Care costs are not “out of control”• The aging population won’t break the bank• Medicare was and is good public policy• Healthcare uses antiquated processes of delivery• The two key solutions are:– Complete the First Stage of Medicare– Implement the Second Stage of Medicare

Health Care costs are not out of control

But Health care hasn’t been starved either

19751978

19811984

19871990

19931996

19992002

20052008

2011 f / p

0

2

4

6

8

10

12

14Public Private Total

Canadian Health Care Costs as % of GDP

% GDP

Data from Canadian Institute for Health Information NHEX 2012

198119831985198719891991199319951997199920012003200520072009

2011 f / p

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

ONCAN

Provincial Government HC Exp as % of GDP

% GDP

Data from Canadian Institute for Health Information NHEX 2012

198119831985198719891991199319951997199920012003200520072009

2011 f / p

0%

2%

4%

6%

8%

10%

12%NS ON

AB CAN

Provincial Government HC Exp as % of GDP

% GDP

Data from Canadian Institute for Health Information NHEX 2012

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

2009

2011

f / p

0%5%

10%15%20%25%30%35%40%45%50%

ON CAN

%ProgExp

Data from Canadian Institute for Health Information NHEX 2012

Provincial Government HC Expas share of Program Spending

19811983

19851987

19891991

19931995

19971999

20012003

20052007

2009

2011 f/p

0%

5%

10%

15%

20%

25%

Provincial Government Program Exp as % of GDP

% GDP

Data from Canadian Institute for Health Information NHEX 2012

1981

1983

1985

1987

1989

1991

1993

1995

1997

19

99

2001

20

03

2005

20

07

2009

20

11

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%Prov Fed Total

Canadian government Program Spending

% GDP

Data from: http://www.fin.gc.ca/frt-trf/2012/frt-trf-12-eng.asp

19811983

19851987

19891991

19931995

19971999

20012003

20052007

2009

2011 f/p

0%

5%

10%

15%

20%

25%

30%

35%NS ONAB CAN

Prov Gov Program Exp as % of GDP

% GDP

Data from Canadian Institute for Health Information NHEX 2012

1990–911992–931994–951996–971998–992000–012002–032004–052006–072008–092010–112012–13

- 200 400 600 800

1,000 1,200 1,400 1,600 1,800 2,000

ON GDP CAN GDP

Ontario and Canadian GDP

GDP$Bil

Data from Canadian Institute for Health Information NHEX 2012

1970197319761979198219851988199119941997 2000 2003 2006 2009

05

101520253035404550

CANUSG7 Avg

% GDP

Data from: Data from: http://www.fin.gc.ca/frt-trf/2012/frt-trf-12-eng.asp

Revenues as % of GDP

19911993

19951997

19992001

20032005

20072009

2011 0

10

20

30

40

50

60

Govt outlays as % GDP

% GDP

Data from: http://www.fin.gc.ca/frt-trf/2012/frt-trf-12-eng.asp

?

AUTBEL

CANDEN FIN FR

AGER ICE IRE ITA

KORNET NZ

NORSP

ASW

ESW

IUK

USA02468

101214161820

% GDP

Average

Health Care as % of GDP (2010 Data)

Data from: http://www.oecd.org/els/healthpoliciesanddata/oecdhealthdata2012-frequentlyrequesteddata.htmAll OECD countries included with 2010 data and GDP per capita > $30K US PPP (from http://en.wikipedia.org/wiki/List_of_OECD_countries_by_GDP_per_capita )

The aging population won’t kill Medicare

• Canada is aging and health costs increase with age• But aging of the population per se has had and will

have only a moderate impact on health expenditures

• Aging is like a glacier not a tsunami. We have lots of time to prepare and adapt our health system before we get swamped!– The elderly are healthier than ever– High performing health systems can hold costs while

enhancing quality of care for the frail elderly

Health costs are related to illness and Canadian seniors are

healthier than ever

19

Year

Disability

1984 1989 1994 1999 2004

NoDisability

73.8% 75.2% 76.8% 78.8% 81.0%

Light or Moderate

15.9% 14.8% 13.9% 13.3% 11.8%

SevereRequiring > 2.5 hrs personal care daily

10.3% 10.0% 9.2% 7.9% 7.2%

American prevalence of disabled elderly 1984 - 2004

Manton et al. PNAS. 2006:103(48):18734-9

2005-2010 2025-2030 2045-2050

Old Age Dependency Ratios

(OADRs)

0.28 0.41 0.53

Prospective Old Age Dependency Ratios

(POADRs)

0.19 0.23 0.27

Adult Disability Dependency Ratios

(ADDRs)0.11 0.12 0.12

Dependency of the elderly in wealthy countries

W Sanderson. Science. 2010;329:1287-8. Canada was not included

CANADA

NL PEI NS NB PQ ON MB SA AB BC YT NWT NT0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

From Mackenzie and Rachlis 2010

Annual impact of Aging on health costs 2010-2036

“It is not the aging of our population that threatens to precipitate a financial crisis in health care, but a failure to examine and make appropriate changes to our health care system, especially patterns of utilization.”

Dr. William Dalziel. CMAJ. 1996;115:1584-6

Most of health care’s problems are due to antiquated, processes of care

After-Hours Care and Emergency Room Use

Percent

Difficulty getting after-hours care without going to the emergency room

Used emergency room in past two years

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

Waited Less Than a Month to See SpecialistPercent

Base: Saw or needed to see a specialist in the past two years.Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

Spine surgeons in Ontario: A wasted precious resource

• Only 10% of patients referred to a spine surgeon actually need surgery

• $24 million in unnecessary MRI scans

(http://www.theglobeandmail.com/news/opinions/editorials/spine-surgery-can-become-much-more-efficient/article2023173)

The three solutions are:

• Complete the First Stage of Medicare• Implement the Second Stage of

Medicare• Develop a healthier population

financed by fair taxation

Complete the First Stage of Medicare

• Medicare’s founders intended public coverage for pharmaceuticals, long term care, home care, and dental care

• Mainly private finance and for profit delivery for these sectors means higher costs, poorer quality, and needless suffering

• This would prevent cost shifting and “passive privatization”

There are affordable solutions to the delivery system’s apparently

intractable problems: The Second Stage of Medicare

We need to change the way we deliver services“Removing the financial barriers between the provider of health care and the recipient is a minor matter, a matter of law, a matter of taxation. The real problem is how do we reorganize the health delivery system. We have a health delivery system that is lamentably out of date.”

Tommy Douglas 1982

“I am concerned about Medicare – not its fundamental principles -- but with the problems we knew would arise. Those of us who talked about Medicare back in the 1940’s, the 1950’s and the 1960’s kept reminding the public there were two phases to Medicare. The first was to remove the financial barrier between those who provide health care services and those who need them. We pointed out repeatedly that this phase was the easiest of the problems we would confront.” Tommy Douglas 1979

Catching Medicare’s second stage

“The phase number two would be the much more difficult one and that was to alter our delivery system to reduce costs and put the emphasis on preventative medicine…. Canadians can be proud of Medicare, but what we have to apply ourselves to now is that we have not yet grappled seriously with the second phase.”

Tommy Douglas 1979

The Second Stage of Medicare is delivering

health services differently to keep people well

With few if any new resources, Canada’s health system could provide:

• Elective surgery within two months• Elective specialized care within one week• Same day access to one on our regular primary

health care providers – NOT a walk in clinic or ER!• A healthier population!

These improvements should be implemented in such a way that:• Empowers patients and families in their own

healthcare, in program planning, and in policy development and implementation

• Ensures that health care providers are available where patients need care

• Enhances the quality of worklife of providers• Strengthens communities• And, Improves Canada’s overall health status

and quality of life

Toronto Arthroplasty ModelCentral Intake

AssessmentAdvanced Practice Physio

SurgeonConsult

Surgery Post-Op Discharge Follow-Up

Referring Physician

Holland Centre

andToronto Western

Holland Centre

Holland Centre

Mt. Sinai

St. Michael’s

St. Joseph’s

Toronto East General

Toronto Western

Good News in Hamilton, Winnipeg, Nova Scotia, etc! We could have elective specialty input into patients’ care within 7 days

– The Hamilton Family Medicine Mental Health Program increased access for mental health patients by 1100% AND decreased psychiatry outpatients’ clinic referrals by 70%.

– The program staff includes 22 psychiatrists, 129 family physicians, 114 Nurses and Nurse Practitioners, 20 Registered Dietitians, 77 Mental Health Counsellors, 7 pharmacists and provides care to 250,000 patients

Good News in Cambridge, Cape Breton, Penticton, etc! We could access primary health care within 24 hrs

In Cambridge, Dr. Janet Samolczyk aims to see her patients WHEN they want to be seen including within 24 hours

New models of care for the elderly and those with serious chronic illness, show great potential for

improved quality

Step right up!Get your ELIXIR of Health Promotion! Reduce your risk of dying or ending up in a nursing home by over

40%!Increase your chances of staying in your own home by nearly

30%!N Hall et al. Canadian Journal on Aging. 1992;11(1):72-91

42

Get your community

services corrective right here!

They will reduce your health costs by

50% in 3 years!

http://www.hollanderanalytical.com/Hollander/Reports_files/preventivehomecarereport.pdf

Going for gold: Re-engineering services to immigrants in Toronto• Access Alliance works with immigrant and

refugee communities to identify women who are leaders and hires them as community health workers (CHWs)

• They are given 3 months of paid training and 3 year contracts

• The CHWs run educational workshops and facilitate well children and well women care

• CHWs have brought services to more than 12,000 women and their children

• 85% of CHWs get jobs in health or social services after their contracts are over

43

Denmark: A country of best practices

• 1987 moratorium on building new nursing home beds– Accompanied by giving all benefits of long term

care to home care clients– Scandinavian public responsibility for housing– Increased construction of supportive housing

• 1998 country-wide policy of home visits/assessments for people > 75– Provide health promotion and system linkages

Denmark: A country of best practices

• Denmark has 17.1% population > 65 while Canada has 15.9% > 65

• Total Health spending as share of GDP is about the same in Denmark (11.1%) as in Canada (11.4%) 2010 OECD data

• Public funding: Denmark 85% Canada 71%– Denmark has better public coverage for home

care, drugs, and appliances and devices

There is substantial evidence that for profit patient care tends

to cost more and is of poorer quality -- but the most salient argument is Tony Soprano’s:

“Fuhgetaboutit!”

We don’t need it.

Summary:

• Health Care costs are not “out of control”• The aging population won’t break the bank• Medicare was and is good public policy• Healthcare uses antiquated processes of delivery• The two key solutions are:– Complete the First Stage of Medicare– Implement the Second Stage of Medicare

Courage my Friends, it is

Not Too Late to Make a Better

World!

Tommy Douglas(paraphrasing

Tennyson)