Dr michael rachlis_20_avril_2012

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  • 1. Dollars and Sense: Medicare is Sustainable if we do our work differentlyMichael M Rachlis MD MSc FRCPC LLD Quebec Medical Association April 20, 2012 www.michaelrachlis.ca

2. Current received wisdom Health Care costs are wildly out of control My fellow baby boomers and I will reallydeep six Medicare as we get older The only alternatives are to either hackservices, go private, or better yet do both We need an adult conversation aboutwhom gets tossed out of the life raft2 3. 3 4. Whats my story? Whats the diagnosis Health Care costs are not out of control The aging population wont break the bank Most of health cares problems are due to antiquated,processes of care What are the solutions We need to complete Tommy Douglass vision for theSecond Stage of Medicare -- a patient-friendlydelivery system focussed on keeping people healthy How do we get there? What are the roles for health care providers What is the role of the medical profession4 5. Total health care expenditures as % of GDP1412QCCAN10 8 6 4 2 0 19811986 1991 19962001 20062011 f / p5Data from: http://secure.cihi.ca/cihiweb/products/NHEX_Trends_Report_2010_final_ENG_web.pdf 6. Total health care expenditures as % of GDP16 QCON14 MBAB12 CAN10 8 6 4 2 0 19811986 1991 19962001 20062011 f / p6Data from: http://secure.cihi.ca/cihiweb/products/NHEX_Trends_Report_2010_final_ENG_web.pdf 7. Canadian Provincial Govt health careExpenditures as share of Provincial GDP9%8%7% % 6%GDP 5%4%3%2%1%0% 19811983 19851987 19891991 19931995 19971999 20012003 20052007 20092011 f 7Data from: http://secure.cihi.ca/cihiweb/products/NHEX_Trends_Report_2010_final_ENG_web.pdf 8. Provincial Govt health care expenditures as % of Provincial GDP 10%9%8%7%6%5%4% ON MBAB3% QC CAN2%1%0%1981 19861991 19962001 2006 2011 fData from: http://secure.cihi.ca/cihiweb/products/NHEX_Trends_Report_2010_final_ENG_web.pdf8 9. The sustainability of Medicare in Canada Health slowly increased its share of Canadian GDP from 2000 to 2008 Healths share of GDP rose dramatically in 2009 because the economy collapsed. In 2010 and 2011, governments controlled costs, the economy grew again, and health decreased its share of GDP This downward trend of health costs as a share of GDP will likely continue for the next 3-5 years Public health care spending in 2011 was 0.6% higher than its previous peak in 1992 (8% in relative terms) vs. private sector cost rise of 0.9% (35% in relative terms) 9 10. Canadian Provincial Government HC Expas share of program spending 45% 40% 35% 30% 25% 20% 15% 10%5%0% 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010f/phttps://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC1671 10 11. Provincial Govt health care expenditures as share of program spending 50% 45% 40% 35% 30% 25%ON MB AB 20%QC CAN 15% 10%5%0% 1975 1980 1985 1990 1995 2000 2005 2010 f/p 11Data from: http://secure.cihi.ca/cihiweb/products/NHEX_Trends_Report_2010_final_ENG_web.pdf 12. Canadian Provincial Governmentprogram spending as share of GDP 25% 20% 15% 10% 5% 0% 2001200719811983 1985 1987 1989 199119931995 199719992003 2005 200912Data from: https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC1671 13. Provincial Government programspending as share of GDP 30% 25% % 20%GDP 15% 10%CanadaQuebec Ontario 5% Alberta Man. 0%200120071981198319851987198919911993199519971999200320052009 13Data from: https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC1671 14. Life Exectancy (both sexes)90807060 CANQC50 ON403020100 1927 1937 1947 1957 1967 1977 1987 1997 200714 15. Provincial Govt health care expenditures and Canadian Govt outlays as share of GDP 60% 50% 40% 30%Canada Prov Govt Health Exp 20%Canadian Government outlays 10% 0%19851989198119831987199119931995199719992001200320052007200915Data from: https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC1671 16. Canadian and US Govt Outlays as % of GDP 60 50 40% GDP 30 20 100 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 16Data from: : https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC1671 and http://www.fin.gc.ca/frt-trf/2011/frt-trf-11-eng.asp 17. The shrinking Canadian public sector Overall Canadian government revenues have fallen by 5.8% of GDP from 2000 to 2010, the equivalent of $94 Billion in lost revenue Just half of this, 47 Billion, could eliminate all 2012Canadian government deficits OR fund first dollaruniversal pharmacare, long term care and home careAND regulated child care for all parents who want itAND free university tuition AND build 15,000 units ofaffordable housing units AND the new fighter jets17 18. Percent of GDP devoted to Health Care 20 18 16 Average 14 12% of 10GDP86420BelgiumFranceLuxemSwedenItaly IcelandNZ Denmark Germany Nether AustriaCanadaUK SpainUS FinlandNorway Switz IrelandAll data from 2009. Source: OECDE Health Data 2011.18http://www.oecd.org/document/16/0,3746,en_2649_37407_2085200_1_1_1_37407,00.html 19. The aging population wont kill Medicare Canada is aging and health costs increase with age But Aging of the population per se has had and will have only a moderate impact on health expenditures Aging is like a glacier not a tsunami. We have lots of time to prepare and adapt our health system before we get swamped! The elderly are healthier than ever High performing health systems can hold costs whileenhancing quality of care for the frail elderly19 20. Annual impact of Aging on health costs 2001-20101,6%1,4%1,2%1,0%0,8%0,6%0,4%0,2%0,0%From Mackenzie and Rachlis 2010 21. Annual impact of Aging on health costs 2010-20362,5%2,0%1,5%1,0%0,5%0,0%From Mackenzie and Rachlis 201021 22. The Compression of MorbidityJF Fries. Millbank Memorial Fund Quarterly. 1983. 23. American prevalence of disabled elderly 1984 - 2004Year 19841989 199419992004Disability No73.8% 75.2% 76.8% 78.8%81.0%DisabilityLight or 15.9% 14.8% 13.9% 13.3%11.8% Moderate Severe10.0%9.2%7.9%10.3% 7.2%Requiring > 2.5 hrspersonal care daily Manton et al. PNAS. 2006:103(48):18734-9 24. Our results, supporting thehypothesis of morbiditycompression, indicate that youngercohorts of elderly persons are livinglonger in better health.K Manton et al. Journal of Gerontology: SOCIAL SCIENCES2008, Vol. 63B, No. 5, S269S281 25. Dependency of the elderly in wealthy countries2005-20102025-2030 2045-2050Old Age Dependency 0.280.41 Ratios 0.53(OADRs) Prospective Old Age 0.190.23 Dependency Ratios0.27(POADRs)Adult Disability Dependency Ratios 0.110.12 0.12 (ADDRs)W Sanderson. Science. 2010;329:1287-8. Canada was not included 26. It is not the aging of our populationthat threatens to precipitate a financialcrisis in health care, but a failure toexamine and make appropriate changesto our health care system, especiallypatterns of utilization. Dr. William Dalziel. CMAJ. 1996;115:1584-6 27. Most of health cares problems aredue to antiquated, processes of care 27 28. After-Hours Care and Emergency Room UseDifficulty getting after-hours care Used emergency room in past twowithout going to the emergency room yearsPercent28Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. 29. Waited Less Than a Month to See SpecialistPercentBase: Saw or needed to see a specialist in the past two years.29Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries. 30. Spine surgeons in Ontario: Awasted precious resource Only 10% of patients referred to a spinesurgeon actually need surgery $24 million in unnecessary MRI scans(http://www.theglobeandmail.com/news/opinions/editorials/spine-surgery-can-become-much-more-efficient/article2023173)30 31. Traditional Joint Replacement Referral Process Spaghetti junction! 32. There are affordable solutions to all of Medicares apparentlyintractable problems: The Second Stage of Medicare 32 33. We need to change the way we deliverservicesRemoving the financial barriers betweenthe provider of health care and therecipient is a minor matter, a matter oflaw, a matter of taxation. The realproblem is how do we reorganize thehealth delivery system. We have a healthdelivery system that is lamentably out ofdate. Tommy Douglas 1982 34. Catching Medicares second stage I am concerned about Medicare not its fundamental principles -- but with the problems we knew would arise. Those of us who talked about Medicare back in the 1940s, the 1950s and the 1960s kept reminding the public there were two phases to Medicare. The first was to remove the financial barrier between those who provide health care services and those who need them. We pointed out repeatedly that this phase was the easiest of the problems we would confront. Tommy Douglas 1979 35. The phase number two would be the muchmore difficult one and that was to alter ourdelivery system to reduce costs and put andemphasis on preventative medicine.Canadians can be proud of Medicare, butwhat we have to apply ourselves to now isthat we have not yet grappled seriously withthe second phase. Tommy Douglas 1979 36. The Second Stage ofMedicare is deliveringhealth services differently to keep people well 37. Health Promotion intervention for BC frail eldersOutcome Living in theResident of a LTC at 3 yrs community facility or deadGroupHealth75.3%24.7%Promotion(61) (20) Group (N=81) Control58.7% 42.3%Group(98)(69) (N=167) (P = 0.04) N Hall et al. Canadian Journal on Aging. 1992;11(1):72-91 38. Step right up!Get your ELIXIR ofHealth Promotion!Reduce your risk of dyingor ending up in a nursinghome by over40%!Increase your chances ofstaying in your ownhome by nearly30%! 39. Per Person Average overall costs of health care forcontinuing care patients in areas with/without cutsto social and preventive home care (Hollander 2001)Year PriorFirst Year Second Third Year to CutsAfter Cuts Year After CutsAfter Cuts Areas with$5,052 $6,683$9,654$11,903cuts Areas $4,535 $5,963$6,771 $7,808withoutcuts http://www.hollanderanalytical