Transcript Stitches in Time - Michael Rachlis

Innovative Solutions for
Optimum Health Care Delivery
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Michael M Rachlis MD MSc FRCPC LLD
Ontario Economic Summit Toronto November 22, 2011
www.michaelrachlis.ca
Current received wisdom
• Health Care costs are wildly out of control
• My fellow baby boomers and I will really
deep six Medicare as we get older
• The only alternatives are to either hack
services, go private, or better yet do both
• We need an “adult conversation” about
whom gets tossed out of the life raft
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What’s my story?
• The diagnosis
– Most of health care’s problems are due to antiquated,
provider-focused processes of care
– Health Care costs are not “out of control”
– The aging population won’t break the bank
• The solutions
– We need to complete Tommy Douglas's vision for the
Second Stage of Medicare -- a patient-friendly
delivery system focussed on keeping people healthy.
• The real issue should be how we spread these
proven innovations
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After-Hours Care and Emergency Room Use
Difficulty getting after-hours care
Used emergency room in past two
without going to the emergency room
years
Percent
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
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Waited Less Than a Month to See Specialist
Percent
Base: Saw or needed to see a specialist in the past two years.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
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Spine surgeons in Ontario: A
wasted precious resource
• Only 10% of patients referred to a spine
surgeon actually need surgery
• $24 million in unnecessary MRI scans
(http://www.theglobeandmail.com/news/opinions/editorials/spine-surgery-can-become-much-more-efficient/article2023173)
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Traditional Joint Replacement
Referral Process
Spaghetti junction!
There are affordable solutions to all of
Medicare’s apparently intractable problems.
With current resources Canadians could have:
• Have elective surgery within two months
• Have elective specialty input within one week
• Have same day access to our regular family
doctor or someone on the doctor’s team
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Toronto Arthroplasty Model
Referring
Physician
Central
Intake
Assessment
Advanced
Practice
Physio
Surgeon
Consult
Surgery
Holland Centre
Holland
Centre
Holland
Centre
and
Toronto
Western
Mt. Sinai
St. Michael’s
St. Joseph’s
Toronto East General
Toronto Western
Post-Op
Discharge
Follow-Up
Good news in West Toronto! There is
already heavy use of non-profit “assembly-line
surgery” in Canada
• The Queensway Surgicentre – part of the
Trillium Health Centre – is the largest freestanding ambulatory surgery facility in North
America!
• I have tried (unsuccessfully) to convince a
dozen journalists to write about Queensway
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Good News in Hamilton! We could have
elective specialty consultations within 7 days
– The Hamilton Family Medicine Mental
Health Program increased access for
mental health patients by 1100% AND
decreased psychiatry outpatients’ clinic
referrals by 70%.
– The program staff includes 22
psychiatrists, 129 family physicians, 114
Nurses and Nurse Practitioners, 20
Registered Dietitians, 77 Mental Health
Counsellors, 7 pharmacists and
provides care to 250,000 patients
Good News in Cambridge! We could
access primary health care within 24 hrs
In Cambridge, Dr. Janet
Samolczyk aims to see her
patients WHEN they want
to be seen including
within 24 hours
There is substantial evidence
that for profit patient care tends
to cost more and is of poorer
quality -- but the most salient
argument is Tony Soprano’s:
“Fuhgetaboutit!”
We don’t need it.
Provincial Government HC Exp as share
of program spending
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Ontario
Canada
1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010
f/p
Data from: https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC1671
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Provincial Government HC exp as % of GDP
9%
8%
7%
6%
5%
4%
3%
2%
1%
0%
Ontario
Canada
Data from: https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC1671
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Percent of GDP devoted to Health Care
Average
Austria
Belgium
Canada
Denmark
Finland
France
Germany
Iceland
Ireland
Italy
Luxem
Nether
NZ
Norway
Spain
Sweden
Switz
UK
US
20
18
16
14
12
% of 10
GDP
8
6
4
2
0
All data from 2009. Source: OECDE Health Data 2011.
http://www.oecd.org/document/16/0,3746,en_2649_37407_2085200_1_1_1_37407,00.html
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Annual impact of Aging on health costs 2010-2036
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
From Mackenzie and Rachlis 2010
“There is a remarkable consistency and repetition in
the findings and recommendations for improvements
in all the information we reviewed. Current
submissions and earlier reports highlight the need to
place greater emphasis on primary care, to integrate
and coordinate services, to achieve a community focus
for health and to increase the emphasis on health
promotion and disease prevention. The panel notes
with concern that well-founded recommendations
made by credible groups over a period of fifteen years
have rarely been translated into action.”
Ontario Health Review panel 1987
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We need to change the way we deliver
services
“Removing the financial barriers between
the provider of health care and the
recipient is a minor matter, a matter of
law, a matter of taxation. The real
problem is how do we reorganize the
health delivery system. We have a health
delivery system that is lamentably out of
date.”
Tommy Douglas 1982
The Second Stage of
Medicare is delivering
health services differently
to keep people well
Why are we still waiting for the
Second Stage of Medicare
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Ontario decision-making frustrates change
• Policy on delivery models is largely set at
the negotiations table with the OMA and
the Ministry of Health and Long-Term Care
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High performing health organizations
and physician engagement: There are
only two models.
1.
A disciplined medical group that comanages with the board
E.g. The Kaiser Permanente system in the US,
the Sault Ste. Marie Group Health Centre
2.
Doctors as salaried employees
E.g. The Mayo clinic, the Cleveland Clinic, and
the Saskatoon Community Clinic
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Summary:
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•
•
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Health Care costs are not out of control
The aging population won’t break the bank
Medicare was and is good public policy
We have problems because we failed to implement
Tommy Douglas’s Second Stage of Medicare
• There are affordable solutions to all of our apparently
intractable problems
• We have to chart new ways to make policy that
integrate key evidence and spread best practices
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