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Beyond Decision Support
Rationing Rationalizing and Renewing Radiology in the New Era of Canadian Health Care
Greg Butler MD FRCPC FACRMay 2013
Planning is Everything
Plumber of the Year
Who put that door there?
Every problem has a solution
Hi traffic washroom
Long arms are sometimes an asset
DisclosureChairReal Time Medical Inc.
CHANGE IS COMING…AGAINThe successful metamorphosis of radiology as
a profession will stand on two successful strategies:
1. Radiologists will embrace and lead in methods of cost containment and quality within the PUBLICLY funded system
2. Radiologists will lead a move into a parallel PRIVATE world where patient access and satisfaction ALONG WITH QUALITY are the primary goals
QUALITY WILL BE THE GIVENQUALITY IS HERE. QUALITY IS NOT ENOUGHQuality will ensure that patients receive what
they needQuality will not always give patients what
they want
QUALITY AND THE FALL TOWARDS MEDIOCRITY
We risk a preoccupation with mandated quality and accountability at the expense of compassion and accessibility
Outcomes and evidence based analysis will trump patient and physician expectations
Radiologist professionalism will decline as self identity as “employees” increases
Cab Driver Back to PakistanNot happy with Canadian Educational systemWants better for his kids
Time For Transformative Change*Senate Committee has recently re examined the 2004
Health accord and concludes (among many other things)
1. System change has stalled. Canada no longer looked upon as a model of innovation in health care (currently rated 30 among OECD countries by WHO)
2. Funding is adequate 3. The system has suffered from remarkably low levels
of innovation. Innovation based transformation is essential.
* With thanks to Senator Kelvin Ogilvie, Chair
Federal funding after 2014 will increase at 6%
per year until 2016-2017, after which it will increase by a three year moving average of GDP, not less than 3%
This will not likely keep up with the expectations of the public
GDP vs Health Care costsHealth care costs are rising at an annual rate
of 6.7% while the GDP rises at <1.5%The Aging population contributes to about 1%
of the health care cost riseHealth care is utilizing an increasing
proportion of budgets in all provinces“The wall” is here.
Radiology Costs are on the Federal Radar Screen
Diagnostic Imaging Meeting February 2012
The Canadian Institute for Health Information and the Institute for Health Economics
BOTTOM LINE: DATA ON DI IN CANADA IS LIMITED AND NOT YET SUITABLE FOR ANALYSIS
It is coming….
WHERE IS THE INNOVATION NEEDED IN RADIOLOGY?Difficult to innovate in an environment over
which we have little control
RADIOLOGY STRATEGIES FOR SUSTAINABILITY OF OUR CURRENT SYSTEM
COST CONTAINMENT IN PUBLIC SPENDING ON IMAGING1. Effective utilization control2. Improved efficiency and elimination of
waste3. ?Will these prevent fee reductions?
INCREASE THE ROLE AND OUR ENDORSEMENT OF PUBLIC/PRIVATE COLLABORATION
UTILIZATION CONTROLDistinction between essential and non essential
services extremely difficult.Decision support with application of guidelines does
reduce utilization * (23% decrease for MRI spine, MRI for headache, and CT for sinusitis).
But how aggressive can guidelines get?Will evidence become a threshold for public pay?The Manitoba Project
*Blackmore et al JACR 2011
Aggressive Utilization ControlThe validity of many imaging procedures has not
been demonstrated with evidence, but only with expert opinion
Expert opinion may be directed at the older objectives of peace of mind, diagnostic confidence, medical legal avoidance, patient expectations
What if we eliminated public pay for all imaging that is not validated with hard evidence?
E.g.. What is the evidence to support the average chest Xray?
OK…We need to innovateWe need to offer more to patients than the
current system canWe will have reached the Quality destination
in the next few years.
Seriously…We have to consider the Private AlternativePublic vs private one of the longest, most
passionate, and confusing debates in Canadian history
Leadership and government has waffled, and inconsistent in enforcement, and policy statements
Generations convinced that our existing way of providing health care is a sacred trust that speaks to our patriotism as Canadians.
Public Private PartnershipPrivate funding of insured services has been
forbidden by the Canada Health Act as a means of the Federal Government preventing federal transfers from subsidizing private delivery of services
Considerable ambiguity among providers and the public of the meaning of private.
Further AmbiguityProvincial policy adds to the complexity and
confusion of the intent of the CHAFor example:
“Private” (non institutional) imaging facilities in Ontario are funded (T fees)
Private imaging facilities in other provinces are technically forbidden, but allowed
Some facilities charge only technical fees to the patients, while others charge the full amount.
Physicians working in private facilities may be opted in or opted out.
Disincentives for MDs to go PrivateIn 3 Provinces (NB,NS,ONT) MDs cannot
charge beyond the fee scheduleIf opted out, cannot do any services for public
reimbursementPatients cannot recover fees from the public
system (NS)
Restrictions on Full PrivateCanada Health Act does not forbid entirely
private facility, provided no public money is used in its operation.
Some provinces (e.g. Nova Scotia) forbid billing above professional tariff (e.g. no technical fee)
Some provinces (e.g. NB and Saskatchewan) forbid MDs working these clinics from doing any publicly funded services.
Government Objections to PrivateWill allow “Queue Jumping”.. (pts get faster
access to diagnosis, and then jump ahead in the public system for treatment)
If too many providers opt out, the public system will suffer (the “thin edge of the wedge argument”)
Kickbacks for referralSelf Referral
Technical Barriers to Privatization in ImagingIntegration of flow of information between
public and private repositoriesWhat killed our clinic ultrasound projectAchieving public administration and
accountability over private facilities
Advantages of PrivateEfficiencyAdding total $$ to the system through
discretionary spendingIndustry standards and competitive
consequencesRADIOLOGIST CONTROL ALLOWS THE
ADDITION OF THE IMPROVED ACCESS, AND TURNAROUND PATIENTS WILL DESIRE,WHILE RETAINING QUALITY, APPROPRIATENESS AND PUBLIC ACCOUNTABILITY
Success in the Private WorldPublic demand and government scrutiny will
ensure and demand highest quality servicesLower quality providers will not surviveCompetition in the private sector will depend
on the best combination of “value add” quality items, particularly accessibility, at the lowest price.
Forgo your trip to Florida this season. Pay for insurance that will provide rapid and pleasurable imaging and therapeutic experience
CONCLUSION: PUBLIC HEALTHCAREPublicly funded services limited to providing
radiology services at the lowest cost and highest quality affordable.
Radiology leadership will gain traction when providing cost saving strategies like more aggressive utilization controls and evidence based practices.
Commoditization of radiology services to the public system will likely occur
CONCLUSION:PRIVATE HEALTHCAREThe new opportunities will be on the private sideWe must pursue opportunities to influence
legislation barriers (national and provincial)ENHANCED ACCESS AND SUPERIOR PATIENT
EXPERIENCERADIOLOGIST CONTROLLED POLICY AND
STAFFINGBusiness level EfficienciesPositioned as an aid not a threat to, principles
of a strong public system
What Kind of System do Canadians Want?Do we know what we want?What we do know…We want sustainability,
accessibility, value AND the experience of our preference.
Recent Environics poll (Globe and Mail, Jan 2013) states that 55% of Canadians believe that “inefficient management” is the culprit as to why our health care system has stalled. 55% also said they approved of a private health care system to improve access to health care.
A blended public/private system is what we both need and want.
