Post on 15-Apr-2017
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What is Primary Care? A Canadian PerspectivePatient and Clinician Engagement, NAPCRG PreCon Dr. David M. Kaplan MD, MSc, CCFPPrimary Care Physician LHIN LeadCentral Local Health Integration NetworkAssociate Professor, Family & Community Medicine
October 24th, 2015Cancun, Mexico
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Conflicts of InterestNone to declare
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DisclaimerViews are my own and not necessarily the views of the Regional Health Authority for which I work
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Canada & Health CareDesign of Health Care in Canada
What is Primary Care?What should we be doing in Primary Care
What Primary Care Can Look LikeForward Looking to Primary Care Renewal in Ontario
How does Primary Care Compare?Health Systems outcomes across North America
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Canada and Health Care“universal health care is almost universally loved with 94% of Canadians calling it an important source of collective pride”
Brain's "Malleability"
Spending on Health,Education and Welfare
0 3 10 70Age
The Mismatch Between Opportunity and Investment
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Canada is slightly larger than the United States … but has only 11 percent as many people
8http://www.zonu.com/images/0X0/2009-11-08-10947/North-America-at-night.jpg
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Geography
http://www12.statcan.gc.ca/census-recensement/2006/as-sa/97-550/vignettes/img/map-2006-pop-density-canada-sz01-en.gif
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Institutionalism Health Care Policy is Constricted by the Constitution Act
Federal Government
Provincial Governments
‣ Section 91(11) assigns responsibility for:
‣ “quarantine, and‣ the establishment and
maintenance of marine hospitals”
‣ Section 92(7) assigns responsibility for:
‣ most other hospitals to the provinces
‣ Provinces have broad powers to make laws regulating:
‣ “property and civil rights”‣ “generally all matters of a
merely local or private nature”
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History of Public Funding of Canadian Health System
1947 1957 1966 1984 2003/2004 2013
Public Hospital Carecame at the provincial level in Saskatchewan in 1947 followed by Alberta in 1950
Hospital Insurance and Diagnostic Services ActFirst implementation of nationalized public health care
Medical Care ActUniversal Health Care
First Ministers’ Accord on Health Care / Canada Health TransferPriority areas: primary health care, home care, catastrophic drug coverage, access to diagnostics, IT and an EMR
Canada Health ActAmalgamated the 1966 Medical Care Act and the 1957 Hospital Insurance and Diagnostic Services Act
Canada Health Transfer UpdateNow a direct transfer of cash from the federal government to the provinces.
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A Canadian Health Care System?Canada has 15 different health care systems
PlusAboriginal HealthcareVeteran health care
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Health Spending as Share of GDP in 2013OECD Health Statistics, 2015
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Health Care FinancingPrivate Insurance
CANADA UNITED STATES
‣ ~67% buy complementary coverage for noncovered benefits (e.g., private rooms in hospitals, drugs, dental care, optometry)
‣ Canadians cannot purchase insurance for services that are funded by the provincial government
‣ Primary private insurance covers ~56% of population (employer-based and individual); supplementary for Medicare
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Canada & Health CareDesign of Health Care in Canada
What is Primary Care?What should we be doing in Primary Care
What Primary Care Can Look LikeForward Looking to Primary Care Renewal in Ontario
How does Primary Care Compare?Health Systems outcomes across North America
1234
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Primary Health Care is generally understood to be the first contact a patient
has with the health system.
.
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What is Primary Health Care?
‣ universal (accessible to all)‣ linked to prevention and promotion of population health‣ scientifically sound and socially acceptable care
‣ community participation
‣ affordable and sustainable care‣ network of health facilities as part of a referral system‣ a philosophy based on self reliance, self responsibility,
people's empowerment‣ an inter-sectoral approach (linked to socio economic
development)
World Health Organization (2002)
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Gatekeeping Role of Primary Care
CANADA UNITED STATES
‣ Gatekeeping:‣ mainly through financial
incentives varying across provinces (e.g., in Ontario, specialists receive lower fees for patients not referred)
‣ Registration with Primary Care: Not generally, but yes for some capitation models
‣ Gatekeeping:‣ Only in some insurance
models‣ Registration with Primary
Care: no
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“the foundation on which the transformation of Ontario’s health care system is built.”
Ministry of Health and Long-term Care Ontario , 2004
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2500xEach day in Ontario, there are over 2,500 times more primary care visits than there are hip and knee replacements
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Four Principles of Family Medicine‣ The Family Physician is a Skilled
Clinician‣ Family Medicine is a Community-based
Discipline‣ The family physician is a resource to a
defined practice population‣ The patient-physician relationship is
central to the role of the family physician
The College of Family Physicians of Canada
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Models of Primary Care
‣ Solo Physician‣ Group Practice
• Mostly cost sharing‣ Team-based Care‣ Nurse Practioner –
Led Clinics
Primary Health Care Delivery Models
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Payment Models in Primary Care
‣ Salary‣ Fee for Service‣ ‘Enhanced’ Fee for
Service‣ Blended Capitation
Methods of Family Physician Reimbursement
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Canada & Health CareDesign of Health Care in Canada
What is Primary Care?What should we be doing in Primary Care
What Primary Care Can Look LikeForward Looking to Primary Care Renewal in Ontario
How does Primary Care Compare?Health Systems outcomes across North America
1234
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Why is Canada Lagging Behind?
‣ Health is in Provincial Jurisdiction• Provincial Governments are the Insurance
Companies • Federal Government is a funding partner • Government is a dominant but passive payer
‣ Governments Historically “Just Pay & Trust”
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Why is Canada Lagging Behind?
‣ No one likes to change! • Assumption is change will be bad • Change is especially difficult when economics
(income) will/may be affected. ‣ Provincial governments negotiate
changes with medical associations.‣ Environment of fear & lack of trust!
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Why is Canada Lagging Behind?‣ The Canadian Medical model can not be
accurately compared because of:• data quality• lack of common indicators• common definitions• common coding• common standards
‣ When Canada is compared we fare poorly
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Canada & Health CareDesign of Health Care in Canada
What is Primary Care?What should we be doing in Primary Care
What Primary Care Can Look LikeForward Looking to Primary Care Renewal in Ontario
How does Primary Care Compare?Health Systems outcomes across North America
1234
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“How can we better help you look after your patients?"
Change how Acute care interacts with Primary Care
HealthLinks
Population Health
Lower percapita cost
Better patientand familyexperience
‣ Improved patient and provider satisfaction
‣ Improved patient outcomes
‣ Increased efficiencies (reduced waste)
‣ Improved Transitions in Care
‣ Increased Communication
‣ Collaborative Quality Improvement projects
‣ Activities can be directed by community and population needs
Prescription for Future Success in Primary Care
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CONFLICT TRUECOLLABORATION
ESCALATION GROUPTHINK
High
LowLow High
Willi
ngne
ss a
nd Fr
eedo
m to
Di
sagr
ee
Mutual Trust and Respect
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Primary Care Hubs
PrimaryCareHub
IdentifySystem Players
Fragmented SystemMove from a fragmented system into a fully integrated model
With fully engaged clinicians – start with a coalition of the willing
Primary care hubs are the first step towards integration
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Primary Care Hub100/100/100
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Why join a primary care hub?‣ Access to inter-professional providers• Even for those not practicing in inter-disciplinary teams!
‣ Access to coordinated Quality Improvement activities
• Avoids duplication of work (surveys, data analysis, etc)
• Makes it easy for many providers to participate
‣ Opportunities for back-office integration, administrative support and data sharing
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Why join a primary care hub?
‣ Ability to share on-call services with a larger pool of providers/groups
‣ Opportunity to engage existing leaders in the community and work across sectors • (i.e. with hospitals, home care, Long-term care, public health,
community agencies)
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In exchange, a hub with provide:
‣ Provide data• To be used in Quality of Care activities
‣ Participate in system planning‣ Operate as system stewards in their
community ‣ Work with regional health authorities to
establish and monitor targets
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Outcome MeasuresBased on Health Quality Ontario Measures 2013
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Physician Speak Accountability Terms
‣ Patient Experience‣ Care coordination/safety‣ Preventative health‣ Care of at-risk populations (CDM) ‣ “We are committed to look after a
population of patients if they choose to engage us or not”
change the culture: “we are used to serving the providers”
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Primary Care Evaluation- We are at a critical time in Canada as
the traditional medical/sickness model shifted slightly to a model focusing on wellness, involving teams of health care providers
- Patients, physicians, allied health professionals and policy makers are seeking to continue reform the delivery of health care to make it both more consumer friendly and cost effective.
- We have an opportunity to model these team based approaches and research them at the same time.
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Primary Care Evaluation
‣ Do changes in payment methods / delivery methods improve clinical practice outcomes, retain physicians and provide incentive for medical students to train in family medicine?
‣ We need to challenge these reforms and provide the academic rigour to ensure best practices are reviewed, researched, documented and shared so that all the people of Canada can benefit
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“I have been impressed with the urgency of doing. Knowing is not enough; we must apply. Being willing is not enough; we must do.”Leonardo da Vinci (1452-
1519)
Thank YouDavid M. Kaplan MD, MSc, CCFPAssociate Professor, Family & Community Medicine, Joint Centre for Bioethics, University of TorontoPrimary Care Physician LHIN Lead, Central LHINStaff Physician, North York General
david@davidkaplanmd.com