District Health Authorities

We now have one health authority for most of the province while the IWK is treated as a separate entity.

 

My congratulations to the Liberal Government for following up on their election promise to eliminate the nine authorities and replace with one large body to coordinate the health care system in the province. That makes so much sense. In the long run this may save about $35M a year. The unfortunate part is that changes in transfer payment formulas implemented by the Harper government will offset that saving.

 

I think the IWK should not be treated differently but rather rolled into the larger system. They are a major piece of the puzzle and I can foresee the confusion that could arise. I also see the political (small 'p') logic of the move given that the board of the IWK is populated by high profile community (and political) people who are able to raise large amounts of money. I suspect that these people may have flexed their political muscle to maintain their current status.

 

I will be watching with the hope that reduction in the number of health authorities will result in the system becoming more efficient and more cost effective. I further believe that the resulting cash savings could and should be turned back into direct patient care.

 

The proof will be in the pudding!

 

Some specific examples of large scale savings that could result are:

1. A central lab - is now being implemented; with the introduction of robotics testing could be done in large volumes, rather than in more labour intensive satellite labs that we now have. (Urgent work should be done locally but less urgent and/or higher level testing could be done at the central lab.)
   Thus more cost effective and perhaps higher standards could be achieved. For example, often testing done in the satellite labs is not accepted by specialists in the larger facilities and must be repeated when the patient is referred to CDHA.)
2. Support services such as Human Resources, Accounting, Pharmacy, Purchasing/Stores and Laundry  could be centralized to some extent.
3. And I know there are many others.
   Please let me know if you have any insights or ideas.

Improved clinical services:
There are many services that could be improved with the streamlining that the establishment of a single health authority could bring. Oncology, orthopedics, diabetic care, prideHealth, and virtually every other service could gain some advantage through reorganization.

This would be a very painful transition that may take a few years to implement; and yes it may be costly – but the long term benefits...

1. from improved efficiency and

2. to get a better bang for our health care dollars

and the resulting cash savings could and should be turned back into direct patient care. The pain will be worth it.

 

The end result will be improved person centred care!

 

 

UD Apr. 2015

Physicians

 

How we pay our Physicians:
Currently we pay on a fee for service bases. There is a dollar amount attached for each thing they do. Each surgery, office visit, etc, etc – has a fee attached to it and the Doctor will submit a billing each month to receive reimbursement. By definition most doctors, regardless of where they work, is an independent business person whose income depends on how much they are willing to work and how many billings they can produce in that time. Typically a doctor will make $250,000 to $700,000 a year (Canadian average $320,000/year) depending on their specialty and the amount of time they are willing to put into their work.

History:
When Canadian Medicare was first being negotiated (in the 1950s) the founders decided that doctors should be paid a salary. That is the way it should have happened but the medical fraternity was so strong that they fought and won the retention of the ‘fee for service’ system of remuneration that was already in place. That system continues to the current time for most physicians. The forefathers of Medicare knew that the implication of this payment system would cause a problem to develop that could get out of control, and they were right.
Doctors are well paid! That leads to the questions:

• Why are there so many of us without a family physician?
• Why are the wait lists for medical procedures so long?
  (For example - up to 3years for orthopedics)

What is the alternative?
All doctors should be on salary! I am not suggesting that they should be paid less but the entire model of health care delivery should be changed in conjunction with the elimination of the fee for service method of reimbursement.

Yes, salaries should be established, based on fee for service billing levels over the last few years. At the same time workload expectations should be set based on the same billing period. A system for tracking and measuring work performed will also have to be established and physicians who under perform (that is, expectations not met) would have to be dealt with like any employee in the workplace. That would be one suggestion for how to transition.

Another suggestion would be to leave the current system in place for those who want to continue with it and to allow the transition for others who would prefer to work under the new salary system.  All new physicians would not have a choice; they would start with a salaried position.

The Delivery Model:
This change would promote a whole new system of delivery. We would encourage physicians to get involved with a collaborative care model. For example, they may work with a nurse practitioner, social worker, physiotherapist, dietitian, other doctors, etc. The patient would arrive at the clinic and have an initial assessment by a nurse or nurse practitioner and perhaps, if necessary, they would see the doctor for a more in-depth assessment. At that point the vitals (blood pressure, pulse, weight, etc) would have been taken and a quick summary of the reason for the visit would be recorded. The doctor’s time with the patient would be a lot more meaningful and efficient.
In that model the emphasis would change from treating illness to one of illness prevention, keeping the patient healthy.  In the long run we would have a healthier population and less demand on the system.
For example, how many people do you know who are over 60 years old and who do not take any prescribed medication? I suspect that they would be few. Under this model of care, a health team working together, caring for patients from a very young age could go a long way toward maintaining the health of each of their clients. Providing constant monitoring would result in early detection of problems by encouraging and facilitating healthy lifestyle choices, all of which would result in improving the health of the population; unlike in the current model where we are waiting until people get sick and then treating them. Does that really make sense?  I propose this health care system as opposed to our current sick care system.

What I am suggesting here is that one of the first steps to changing the way health care is delivered in this country is to change the way we pay doctors and then change what we expect from the whole system.
We have an example of this type of model now being tested in the Halifax area – it really can work! We just need the guts to step out of our comfort zone!

Work life balance:
This model would allow physicians to have a “life outside of work”, wherein many leisure activities and quality times with family and friends are more available. We must be more cognitive of our responsibility to take care of the care giver!

Other disciplines:
We should be doing more to recruit people to become nurse practitioners, midwives, operating room technicians, etc. These personnel could assume some of the duties now being performed by physicians and thus improve everyone’s productivity in terms of accomplishing the fundamental goal - 'to improve the health of the population.'

Conclusion:
This model could result in affordability in the long term while delivering more effective and efficient health care, unlike the system we now have. The reality is that if health care costs continue to grow at the current rate, it won’t be long before they outstrip our ability to pay.

I could go on but there is just not enough room here to do that. I would welcome the opportunity to chat with anyone about these ideas in an attempt to flush out the details.

 

 

Reviewed May, 2015

Programs

We now have countless programs in the health care system all of which, I am sure, were germinated from a very good, information based, decision making process. That is a motherhood statement that any reasonable person could accept.

My questions are:

1. When these programs were developed was there an evaluation process built into their Mission Statement/Terms of reference?
2. Has this evaluation ever been used?
3. Are the right people doing and reviewing the evaluations?
4. How objective has the process of evaluations been?

Unfortunately, in my opinion, the answers to these questions are not always positive.

We probably have programs that no longer serve the purposes for which they were initially designed and because ‘…that is how we always did things…’ they continue to chug on.

 

An example:
I hate to single out any particular one but I guess I should use an example to make the point. My view is from an outsider’s perspective and I do stand to be corrected in this particular case. What I am asking is that every program, small or large, be looked at with a critical and objective eye, and if possible, quantitative answers to the evaluation questions be developed, so that the need for its continuation can be appropriately determined. At the same time, if it is deemed to be a viable program, goals and objectives should be developed to guide future activities and to help with the next evaluation.
As an example I will chat about the Diabetic Day Care Program. That is a very good program that I suspect should continue. My question in this case is, should the program be expanded, as practitioners suggest?

The following questions might be included in an evaluation process:

• How many people in the catchment area have been identified as diabetic?
• Based on national data:
• What % of this population could we expect to be diabetic?
• What is a reasonable expectation for potential clients to actually access the service? (Penetration rate)
• How many people have accessed the service over the life of the program and of those how many have graduated (no longer need the services)?
• What is our experience?

In light of these questions, if we have a penetration rate that is reasonable at this point in history then maybe the entire program should not be concentrating on growth but rather serving newly diagnosed clients and providing a maintenance service for graduate clients. Perhaps more emphasis should be placed on prevention (obesity, diet, etc) and maybe that kind of service would be better delivered by the collaborative care clinics in the community. (See the last rant.)

 

Conclusion

I do not mean to downplay the importance of diabetic day care programs but rather point out that if we were to take a look at every one of the existing programs this way we would find many opportunities for savings.

 

Reviewed May 2015