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