The Role of the Federal Government in Health and Healthcare American Society of Neurosurgeons Hon....

The Role of the Federal Government in Health and Healthcare

American Society of Neurosurgeons Hon. Carolyn Bennett, M.D., M.P.

St. Andrews-by-the-Sea, New BrunswickJune 9, 2014


An Accidental Tourist in Politics

Hon. Carolyn Bennett, M.D., M.P.

Patient as Partner

Doctor MultidisciplinaryHospital Community

Social Determinants of Health

Non Quo Sed Quo Modo


Sir Michael Marmot


“The worst thing for a physician is to help someone get well and then send them straight back into the situation that made them sick in the first place”

- Sir Michael Marmot, Chair, WHO Commission on the Social Determinants of Health


Canadian Institute of Advanced Research


25% health attributable to health care system

15% biology and genetics

10% physical environment

50% social and economic environments

HEALTH VS HEALTH CARE


The Goal of Medicare


Sharing risk• getting people the health care they

need when they need it

• Solidarity

Keeping people well not just patching them up once they get sick


Health of Canadians


Health Care delivery - Provincial • Except Federal Government is the 5th

biggest provider • First peoples, military, veterans, RCMP,

corrections

Health of Canadians – shared• Health promotion, disease prevention• Social determinants of health• Regulator• Research


The Tyranny of the Acute


As long as citizens think of the sickness care system whenever they hear the word ‘health’ we are not going to be able to reorient health systems.


Sustainability = Prevention + Quality


PREVENTIONDecrease the demand side

QUALITYIncrease the cost effectiveness on the supply side


Health Goals for Canada


As a nation, we aspire to a Canada in which every person is as healthy as they can be:

• physically• mentally • emotionally • spiritually



Social Determinants of Health

vs

Choose Health(modifiable risks)


Citizens as Partners



Canada Health Act Principles


Universality: The plan must entitle 100% of the insured population (i.e. eligible residents) to insured health services on uniform terms and conditions

Comprehensiveness: The plan must insure all medically necessary services provided by hospitals and physicians

Accessibility: The plan must provide, on uniform terms and conditions, reasonable access to insured hospital and physician services without barriers

Portability: Residents are entitled to a certain level of coverage when they are in another province within Canada (or when they travel within Canada or abroad)

Subject to negotiation among provinces

Public administration: The health insurance plan of a province must be administered and operated on a non-profit basis by a public authority accountable to the provincial government

This says nothing about delivery, which can be (and often is) private

Provinces are free to ignore these principles, but may have federal dollars withheld under the Canada Health Transfer


Public Health 101




Do you think we should have a:

A) strong fence at the top of the cliff

B) state of the art fleet of ambulances and paramedics waiting at the bottom

???



Would you prefer:

A) Clean air

B) Enough puffers and respirators

???



Would you prefer that that wait-times were reduced by:

A) A falls program to reduce preventable hip fractures

B) Private orthopedic hospitals and more surgeons

???



Governments should boast about:

A) How much they spent on the sickness care system

B) The health of their citizens, leaving no one behind

???


Health vs. Healthcare


My first rotation as a final year med studentNight after night – subdural haematomas

Has public policy changed the lives of neurosurgeons?

Seatbelts, helmets, airbags?


The Citizen and the Constitution


The U.S.A.

• Life

• Liberty

• The pursuit of Happiness

Canada

• Peace

• Order

• Good Government



U.S.A:• Health care = a market commodity

• Medicare and Medicaid

CANADA:• Health care = a universal common good

for all citizens of all ages, all conditions• All universities are public and heavily

subsidized by both levels of government


OECD Data, Health Incomes, 2011


Measure Canada U.S.

Life expectancy at birth (2011)

81.1 78.7

Pot. Years of life lost <69 (per 100,000) (2011)

3926 (males)2505

(females)

5814 (males)3447

(females)

Infant mortality per 1,000 live births (2011)

4.9 6.7


Infant Mortality



Healthcare Costs as a Portion of GDP




The Moral-Hazard MythThe bad idea behind our failed health-care system.

Malcolm Gladwell, The New YorkerAugust, 29, 2005

Do you think that people whose genes predispose them to depression or cancer, or whose poverty complicates asthma or diabetes, or who get hit by a drunk driver, or who have to keep their mouths closed because their teeth are rotting ought to bear a greater share of the costs of their health care than those of us who are lucky enough to escape such misfortunes?

The moral-hazard argument makes sense, however, only if we consume health care in the same way that we consume other consumer goods, and to economists like John Nyman this assumption is plainly absurd.

We go to the doctor grudgingly, only because we’re sick “Moral hazard is overblown,” the Princeton economist Uwe Reinhardt says. “You always hear that the demand for health care is unlimited. This is just not true. People who are very well insured, who are very rich, do you see them check into the hospital because it’s free? Do people really like to go to the doctor? Do they check into the hospital instead of playing golf?”



One implication:Canada does not have `Socialized Medicine`

It has a system of public financing of certain categories of health services

These services are delivered by private (albeit often not-for-profit) providers

This system of publicly-financed hospital and medical insurance is referred to as “Medicare”

Dr. Raisa Deber, PhDUniversity of Toronto



Who Pays for Health Care, 2011

Total HealthExpenditure 2.7 Trillion $187 Billion

Per capita $8508.00 $4,665.80

% GDP 17.7 11.2

% publicly 47.8% 70.4% paid Seniors, disabled, poor, veterans tax, no ext-billing

% privately 52.2% 29.6% paid employer/personal insurance drugs, dental, vision, home

Uninsured/ 16.1% universal coverage forUnderinsured 52% doctors and hospitals

U.S. Canada


Woolander and Himmelstein


NEJM: ‘for profit hospitals are 25% more expensive (admin costs)

JAMA 1999: ‘for profit’ HMO’s rated lower on all 14 quality indicators as measured by the National Committee for Quality Assurance

Johns Hopkins study dialysis patientsFor-profit clinics 20% greater mortalityFor-profit clinics 26% less referral for transplantation


Profit… as a motivation


results in

PROFIT

QUALITY OR COST


Alberta Bone & Joint Health Institute (non-profit)


• A time of urgent need • Model tested on hip and knee replacements • Putting patients at the centre • Delivering health care in a multi-disciplinary team environment • Encouraging patient choice with innovative compensation models • Aligning efforts across health regions • Diverting services to single-purpose focused facilities from overcrowded

hospitals • Making all publicly funded health services evidence-based • Improving efficiency and asset utilization, and reducing demand on

taxpayers • Ensuring the public health care system is sustainable • A satisfying journey through the health care system

Significant improvement in patient and health care provider satisfaction, driven by A decline of approximately 80% in consultation waiting time A decline of 90% in surgery waiting time A decline of 30% in hospital stay Faster recovery and enhanced patient engagement, accountability and education

More efficient utilization of scarce - and expensive - health care resources including major gains in the number of surgeries per day per operating room


Achieving Health Reform’s Ultimate Goal


How Successful Health Systems Keep Costs Low and Quality HighU.S. Senate Committee on Aging Sept 30, 2009

1. INSURANCE COMPANIES

30% of US costs – almost a third – go to insurance companies.

These insurers set premiums, design packages, assess risk, review claims and decide who to reimburse for how much.

But they don’t deliver health care.



2. ADMINISTRATION:

Our single payer system is simpler, allowing us to run the administration of our offices and hospitals with much fewer staff – about 4%.

We don’t have to deal with multiple payers, or chase bad debts.

We don’t have to charge higher fees to compensate for unpaid for procedures

Public Contractors Model: not a publically delivered model. Doctors and nurses are not civil servants.



3. PHARMACEUTICAL PRICE CONTROLS:

Although drug costs are rising in Canada as in the US, we’re able to exercise more control over the cost of drugs as a result of our Patented Medicine Prices Review Board.



4. MALPRACTICE INSURANCE:

The not-for-profit Canadian Medical Protective Association covers medical malpractice for all Canadian physicians with comparatively low premiums.

Doctors’ remuneration does not have to reflect those extra costs and our justice system has successfully kept the awards in a reasonable range.



5. EVIDENCE-BASED CARE:

From vaginal births after C-sections to, lumpectomy, to x-rays for sprained ankles, applying evidence to determine the appropriateness of tests and procedures translates into fewer unnecessary tests and procedures and less defensive medicine.

We are committed to moving from the error of pure cost-containment approach of the early 90s into true evidence-based cost effective care.



6. PREVENTION:

Diseases are cheaper to treat if they’re caught early, and since all Canadians are insured, they’re more likely to have pap smears, mammograms and other early detection visits and tests, than US patients who are not covered.



7. FAMILY MEDICINE:

A long-standing speciality in Canada, family doctors are trained to help patients navigate their care;

We interpret the difference between what patients think they `want`, and what they actually `need` .

A point of first contact, a trusted coach to explain the evidence and the choices.


The Goal: Preventing the Preventable


Most appropriate care

In the most appropriate place

By the most appropriate person (paid and unpaid)



“We are not tinkers, who patch and mend what is broken. We

must be watchmen, guardians of the life and health of our generation, so that stronger and more able generations may come after.”

Dr. Elizabeth Blackwell(First woman physician North America)



For a copy of these slides and additional resources and links, please visit: http://carolynbennett.liberal.ca/blog/presentation-role-federal-government-health-healthcare/

http://carolynbennett.liberal.ca/blog/presentation-role-federal-government-health-healthcare/




The Role of the Federal Government in Health and Healthcare American Society of Neurosurgeons Hon....

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