So You Want Universal Health

Care, Eh?

James E Calvin Jr MD MBA FRCPC FACC FACP

Chair Chief of Medicine

Western University

for

Goals

• Describe what it is like to work in a Canadian Health Care System (Ontario) in a relatable way

• Describe its principles

• Describe briefly how it is managed (COVID)

• Describe the good, bad and the ugly as I See IT

• Suggest what changes might be necessary to make such a system work in the US

This Photo by Unknown Author is licensed under CC

My Story

• American born

• Canadian educated

• Canadian and US trained

• Worked in Canada 8 y (CCU Director, Research Scholar)

• Moved to US in 1991(CCU Director, Associate Professor)

• Chair of Cardiology at CCH ’98-’01

• Cardiology Chief at RUMC ’02-’12

• Professor and Chair/Chief, Medicine, U.W.O, 2013-

• CMO and Exec VP, 2018

• President CAPM 2017-2019

People: Why We Act Like

CanadiansPeace, Order and Strong Government

“In Canada you are reminded of the government every day. It parades itself before you. It is not content to be the servant, but will be the master.”

Henry David Thoreau , 1866

Once a Loyalist

“Historically, a Canadian is an American who rejects the revolution”

Northrup Frye , 1953

An Important Difference

Egalitarianism vs Pursuit of Happiness

Pierre Berton, “Why We Act Like Canadians”

Principles of the Canada Health Act

(Federal Government)

• Public Administration – Macro-managed (seems like)

• Comprehensiveness ***

• Universality ****

• Portability ****

• Accessibility **

In Ontario,

the Health Plan (OHIP) Covers:

• Visits to doctors

• Hospital visits and stays

• Hospitalized procedures including abortions

• Eligible dental surgery in hospital

• Eligible optometry

• Podiatry

• Ambulance services

• Travel for health services

Ministry of Health &

Long- Term Care• Wait Times

• Adult CT 72% done within prescribed time

• Expected wait time of 28 d occurs on the average of 37 d

• Expected wait time of 10 d occurs on the average of 16 d

• Breast Cancer Surgery• Target within 84 d occurs in

99%

• Target within 28 d occurs in 99%

• Target within 14 d occurs in 80 %

• Long-Term Care Capacity continues to be a big problem

• Perfect Storm• Increased Costs

• Technology

• Drug therapies

• Fixed or reduced hospital revenue

• Hospital payments based on volumes experienced 2 y before

• Volumes mandated• Do less, paid less

• Do more , cost is yours

• More complex patient mix• Older, more comorbidity

Perceived Differences: Universal Health Care vs. Multiple Insurer System

PROs

• Cheaper to run overall:

• Smaller administrative cost

• All are insured

• Macro management (less need to regulate and control)

• Freedom of choice for patient; autonomy for MD (incorporation)

• Doctors are paid well by the health plan not by the institution

CONs

• Funding too closely linked to economic health of country or province and to change of governments

• Rigid – single platform

• But too many stakeholders

• Limited research funding especially for salary support

• Academic institutions face large deficits

Canadian Health Care System:

OverviewMD Education

• Basically the same

• Tuition much cheaper in Canada

• Length of specialty training is similar; post-doc common (largely in NA)

Billing

• Canadian system is straightforward – both FFS and AFP

• Codes/documentation is simpler

• Billing Cycle is shorter

• Macro-managed – MOH pays on time; few denials, rules driven by government

Attitudes

• Public satisfaction falling

• MDs’ satisfaction is variable

Compensation for Physicians

• Fee for Service

• Alternate Funding Plan

• Repair for academic doctors

• Take home pay is good

• Incorporation• Corporate tax rate is low

• Tax credit for research

• Poor research salary support

• Department imposes tithe to support research and education

• This is independent of hospital funding

Ok! So Where is the Pay-off?

• Depends on perspective

• Medicine is the same

inside the box

• Constraints and mindset

are different

The Medicine I learned in

medical school, residency

and fellowship

Inside

Can We Make Money To Support The Academic

Mission : Yes, At The Physician Level

Plan for Use of the Funds

▪ DOM continues to generate a surplus; assuming this continues:

▪ Recruitment plan has been modeled to allow recruitment of researchers over the next 10 years providing minimum of 3 y of start up and secure salary support through to promotion so long as:

❖we ensure sufficient additional annual investment in the development fund. This amount is modeled annually

▪ Recruitment plan is flexible enough that in the event that financial circumstances change then the recruitment plans can be revised

Development Fund and Breakeven Analysis

-

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

2020 2021 2022 2023 2024 2025 2026 2027 2028

$$

Years

Development Fund Break-Even Point

Total Expenses

Development Fund (no profit)

Development Fund - AnnualProfit of $500K

Development Fund - AnnualProfit of $750K

Development Fund - AnnualProfit of $1 MM

So What About The System : Comparing

Universal Health Care Systems-You Might Not

Choose Canadian System

Health Care Problems Are

Usually Complex

• Large numbers of interacting elements

• Interactions are non-linear

• Systems are dynamic

• Systems have a history

• Agents and system constrain one another

• Hindsight does not correlate with foresight

Leadership Styles In Canada

• Model is primarily managerial

• Provinces follow the Federal rules

• Regions and hospitals do what the province mandates

• Physician colleges regulate physicians

• Strategic leadership/ visionary leadership is primarily at departmental or faculty level

• Movement towards salaried physicians would hinder innovation

Types of SystemsSimple

• Sense• Categorize• Respond

Complicated• Sense• Analyze• Respond

ComplexProbeSenseRespond

Chaotic• Act• Sense• Respond

Diagnose Problem

System 1

System 2

System 2

Response To Coronavirus-We

Thought We Were Pretty Good

Covid Cases-Wave 1-3, Outbreak

Wave 1: Supply Chain

Outbreak

Wave 2

Organization: When It Hits the FanLevel Role Status

Federal Government Supply Chain-PPE, VaccinesReporting, Modeling, border closing

We don’t manufacture vaccines. We depend on others. Thus, a very slow roll out

Provincial Government Patient movement/bed control(ICU)Restrict hospials to 85 % occupancyVaccine distributionLockdowns/Stay at home ordersICU beds

Supply chain sparse at the beginningThird wave has resulted in patients being transferred to other citiesSecond shots delayed in an attempt to get herd immunity

Ontario Health Team Regional coordination of Beds This is directed by a central command post

County Health Unit DirectivesDeclare outbreaksquarantines

Vaccination delivery

Very difficult to have two way conversation at the Department levelControlled cohorting within hospitals

Hospital Manpower-RN , AHP,cohortingInstitutional organizationBed and movement controlDrug acquisition

Bed expansion for third wave has created great strain

Portfolio/Program Day to day operations Relatively smooth organization of meetingsRedeployment of AHP

Department MD scheduling/ coverageTestingVaccination lists

Redeployment of physiciansManaging training programs

COVID-19 Case Status Access and Flow Bed Status Staff Status

Confirmed Cases (past 24hr) OccupancyAs of Midnight

Critical Care Beds AvailableCCIS as of 9am

Staff not available to

workAs of today

866

Staff returned to work

from March 18, 2020

1444Confirmed Admitted Cases Inpatient Ward Beds Available

As of Midnight

Number of staff sickAs of today

106

Staff home COVID-19

relatedAs of yesterday

760

ED Visits/RegistrationsAs of midnight

Staff Overtime Hours WorkedAs of 7am for prior day

Current validated # not available today.Bi-weekly results will be provided.

Staff Tested COVID-19 +As of 2:00 pm prior day

36 Total tested positive to date

23 of the total positive staff remain off work

Tests Pending Cases ED Admissions (Non COVID-19:COVID-19)

% of staff available to

work

91%

Staff redeployedAs of yesterday

382

ED admitted patients waitingAs of 7am

DAILY SNAPSHOT for April 27, 2020

WardCritical

Care

Lab conf’d tested

Deaths (New: Total to

Date)

27 11 335 0:14

N-COVID-19 COVID-19

Med Surg UH 67.3% aa%

Med Surg VH 64.3% aa%

Adult ICU UH 66.7% bb%

Adult ICU VH 60.0% bb%

Adult MH 59.1% cc%

Children’s Hospital

38.8% dd%

CH ICU 79.3% TBD

VH UH CH

142 97 47

VH UH CH

23:x 20:y 6:z

VH MH VH UH CH

0 2 0 0

As of 3pm As of 12amAs of 3pmAs of 3pm

11

16

0

5

6

0

UH Inpatient

VH Inpatient

CH Inpatient

UH Critical Care

VH Critical Care

CH Critical Care

16

2

0

0

15

3

UH Inpatient

UH Critical Care

CH Inpatient

CH Critical Care

VH Inpatient

VH Critical Care

154

4716

1145

Cardiac

Surgery

Oncology

Victoria Hospital

357

3433

102

Cardiac

Medicine

Epilepsy

University Hospital

742

C&A MH

Children's Hospital

941254

CSRUMSICUCCTCNICUPCCU

Daily Management-Early On

Covid Cases-Wave 1-3, Outbreak

Wave 3- Almost Out Of Control

Later

Occupancies went down to under 85 %

Managing Surgery During a Pandemic

Our Strategies For COVID

• Reduce Spread• PPE supply chain

• Staff/ Deployment

• Testing

• Vaccination

• Reduce surgery and ambulatory face to face

• Covid ambulatory care with remote monitoring

(over 1900 patients seen,~60 % need home monitoring)

• Bed Capacity Management• 85 % capacity- govt mandate

• Decrease elective surgery

• Regional approach/provincial and interprovincial

• Re-allocation

ImplicationsResident rotationsCancel examsCancel electivesWaiting lists/ ramp up$’s,$’s

COVID CHAOS

• Poor data- create data

• Inadequate supply chain – ration or find new suppliers

• Need to create capacity• Stop elective surgery sooner

• Transform ambulatory care to digital/electronic• Triage Covid+ from Covid- and uncertain cases

• ED to Cohort wards and teams

• Sufficient testing- this took way too much time.

• Aren’t vaccines supposed to protect? Sadie’s story

• Avoid Peter P.

Lessons Learned

• Don’t Get Cocky

• Supply Chain, Supply Chain, Supply Chain

• Faith in Vaccines needs to be guarded

• Control has to be balanced between front

line and centrally

• Politicians mean well but….

Six Aims for Quality Improvement

Health Care should be:

1. Safe

2. Effective

3. Patient Centered

4. Timely

5. Efficient

6. Equitable

Outcomes

• Safe• Effective• Efficient• Personalized• Timely

• Equitable

Crossing the quality chasm: a new health system for the 21st century/Committee on Quality Health Care in America, National Academy Press, Washington, DC, 2001; pp 1-323.

Redesign Imperative: Six Challenges

• Redesign care processes – a lot to do

• Effective use of information technologies – behind US

• Knowledge and skills management

• Development of effective teams – collaboration between hospitals and MD’s

• Coordination of care across patient conditions, services, and settings over time

• Use of performance and outcome measurement for continuous quality improvement and accountability – needs a lot of work

Care System

Supportive

payment and

regulatory

environment

Organizations that

facilitate the work

of patient-

centered teams

High

performing

patient-

centered teams

Things To Make the Canadian

Health Care System Better

• Re-explore alignment of physicians with hospitals

• Enhance Dyadic leadership models- Needs to be a full partnership

• Improve financing of System User fees

Private tier

• Invest in Health Service Research to set appropriate standard of

care that is patient centered

• Monitor and reward true quality

• Enhance system’s flexibility, ingenuity, and innovation

• Invest (including private sector) in better systems of care

How To Make A Canadian-Style Health

Care System Palatable To Americans?

1. Emphasize patient’s freedom of choice of physician

2. Emphasize portability of care

3. Transfer present administrative cost savings into enhancing

existing services and reducing variations in care(need data)

4. Administer by states through regional, county councils

5. De-emphasize control by political parties and politicians.

6. Maintain some degree of privatization to support innovation, capital

expansion and infrastructure maintenance and upgrading

7. Control costs including drugs and technology, reduce waste

8. Ensure timely best practices by providers

9. Be selective about scope of services provided by the system

10. Create large Networks to support innovation and capital expansion

End of Presentation

So You Want Universal Health Care, Eh?James E Calvin Jr MD MBA

FRCPC FACC FACP

Questions?