Healthcare’s Governance: What’s the Goal?

 

Common and central to the mission statements of Canada’s provincial/territorial Ministries of Health, so far as they are clearly articulated[1], is the overarching goal of protecting and enhancing the health of the population. Most then go on to focus on discharge of the Ministry’s responsibility for the development and leadership, i.e. the governance, of a system of healthcare services as the principal means of achieving that goal. These statements beg some questions:

  • Is population health really top-of-mind among Canada’s governments and the agencies they have established to govern healthcare?
  • If so, what elements need to be incorporated into the governed system to achieve that goal?
  • If we had one, to what extent would a smoothly functioning, integrated healthcare system protect and enhance the population’s health?

Fully 75% of people’s health is attributable to its social determinants – Continue Reading »

The Healthcare “System” Needs Governance

 

Healthcare is top-of-mind for the great majority of Canadians. They worry about its sustainability and long wait times to access many services. Too many with lower incomes worry about paying for its uninsured prescription drugs, rehabilitation, home care, dentistry, etc. Together with social services, healthcare employed over 2.3 million people in 2016; it consumed some $228 billions of taxpayers’ (70%) and consumers’ (30%) money, some 11% of the Gross Domestic Product. By any measure, Canadian healthcare is a big and important business. Surprisingly, it lacks a governance. It has no single body to lead what we call the “system”, a governance that can be held accountable for how well or poorly healthcare is meeting people’s needs. It is inconceivable that other big businesses in Canada, the banks for example, would carry on without governing Boards.

Why doesn’t the healthcare “system” have a governance?

In the first place, Continue Reading »

Physicians pay and their taxes

 

Finance Minister Morneau’s recent proposal for tax reform has revealed both bad tax policy and irrational reimbursement mechanisms. Furthermore, the debate has become engulfed in clouds of indignant rhetoric.

First things first: Let’s be honest. While some incorporated physicians do indeed operate small businesses with significant overhead, many, if not most, run more modest operations and many more, especially hospital based physicians, have their work-places and interdisciplinary colleagues provided at no personal cost. So, when Dr. Jones, a hospital- based physician generating the “average” annual billing revenue of $385,000 in her corporation, provides an annual dividend of $35,000 to each of her children who are away at university (and who will pay little or no tax), a reasonable non-incorporated Canadian might consider that legal arrangement unfair.

We also must acknowledge some other truths. Physicians were offered the opportunity to incorporate, reduce their taxes, Continue Reading »

Closing Indigenous Socio-Economic Gaps Key to Raising Canada’s Economic Growth

 

The Government of Canada is in discussion with First Nations people on a new Government-to-Government relationship, a new fiscal relationship and on closing socio-economic gaps between Indigenous and non-Indigenous Canadians; all of this in recognition of the need to improve the lives of all of Canada’s Indigenous people. There appears to be less recognition, however, of how much is at stake for Canadians generally and, specifically, for the entire Canadian economy. Indigenous people will form a rapidly-growing portion of Canada’s labour force. How the large Indigenous youth population in particular fares economically will determine to a very important extent how the Canadian economy fares. Addressing Indigenous issues is a win-win for all Canadians.

In 2011, the Indigenous population accounted for 3.5 per cent of the total Canadian working age population. A superficial reading of this statistic might suggest that Indigenous people will be at the periphery of Canadian economic growth prospects. Continue Reading »

The “Big Squeeze” on hospital budgets in Ontario: Get ready for the backlash

 

Since shortly after the 2008-2009 downturn, Ontario’s relatively modest economic growth has meant for public services a prolonged period of austerity. For the healthcare sector, where annual growth had previously been in the 6.5% range, the change from the base of 2010-11 to 2.6% per annum, representing a slight decline in real per capita terms, has been painful. This reduction in spending growth has been largely borne by the hospital sector, where after contracted salary increases, inflation, etc., are factored in, there has been essentially zero growth for nearly a decade. Continued restraint in health spending, which now exceeds 40% of the total, anchors the government’s 2017/18 balanced budget projection.

At the same time, the much discussed demographic shift has started. The Baby Boomers are starting to retire: the number of Canadians over the age of 65 will double in 20 years and those over 85 will quadruple. Continue Reading »

Do-Able Actions to Improve Co-ordination of Healthcare

 

That fundamental reform of healthcare throughout Canada is required has been increasingly obvious for at least two decades, long enough for five full-term governments and a whole generation of health professionals to do something about it. There have been some changes. Healthcare’s governance has been partially devolved to some provincial regions and elsewhere de- and re-centralized without conclusions drawn about the most effective model to achieve change. Teamwork in primary care has been fostered through a wide variety of programs but no evidence has appeared as yet strong enough to trigger policy decisions to drive widespread adoption of multi-professional teams as the best way to provide Canadians with 24/7 primary, home, and community care. Mental health and addiction have finally appeared on the radar but remain far from optimally linked into what is glibly referred to as “the system”. The latter continues to lack coordination, collaboration, or even effective communication among its elements; Continue Reading »

Are the Health Professions Self-Regulators Doing Their Jobs?

 

Professional self-regulation is anchored on the principle that professionals can be depended upon to protect the public by putting ahead of their own the well-being of those they serve. It is extended to the health and other professions to avoid governments having to retain the substantial knowledge and expertise necessary to regulate directly those conducting sophisticated professional activities. Self-regulation is a privilege delegated to the health professions by governments respectfully confident that it will be discharged faithfully in the public interest.

That confidence, at least in the medical profession, has been shaken recently by the increasing incidence of addiction and deaths attributable to opioid over-prescribing and of charging patients willing to pay for preferential access to some diagnostic and other procedures, a direct contravention of the Canada Health Act. Yet, strangely, the general tenor of discussion tends to look to Canada’s provincial and federal governments to do something to rectify these clearly medical/surgical issues rather than to the Colleges of Physicians and Surgeons that hold the power of self-regulation in each province. Continue Reading »

Governing the Primary Healthcare Home

 

If healthcare is to be “people-centered”, as it must be, every Canadian will have to have a primary healthcare home, a place where s/he is known and can confidently seek help with problems large and small that bear on his or her health, broadly defined. It doesn’t take much imagination to generate an image of such a home. Take the old-fashioned family physician’s office, add a number of others so its services cover a broader spectrum and are available 24/7 – more physicians, some nurse practitioners, nurses, home care providers, a pharmacist, physio- and occupational therapist or two, a dietitian, psychologist, social worker, and some office staff – and you have it. The family health teams that have been developing both spontaneously and with government support since the dawn of the 21st century form a pretty good nucleus. Community Health Centres (CHCs) have been in place longer and are all but there, Continue Reading »

Aligning Primary Care Compensation to Health Outcomes

 

For primary healthcare homes to meet the expectations of patients, their families, and communities, incentives linked to the health outcomes they need to achieve are essential. Those expectations include the ‘triple aim’:

  • Improved indices of health status within the served population and measures of individual outcomes of care
  • Patient, care-giver, and community satisfaction
  • Demonstrable efficiency and effectiveness

Financial incentives are obvious. Prominent among the others are the team’s status and standing in its community and freedom for the primary care team to innovate – to make its own decisions on how to operate within the policy guidelines established by the responsible regional authority and/or government.

Today’s ‘triple aim’ expectations of primary care teams require much more than visits to the doctor’s office. They require the provision of a wide range of health services, many bordering on social services, Continue Reading »

Better Access for Patients to Their Health/Medical Record

 

Ask anybody, “what’s in your medical record?” Chances are nobody has ever seen theirs; they don’t even have a clue where it is. Most people’s records are scattered here and there among the offices of their family physician, dentist, optometrist, physiotherapist, some specialist physicians and surgeons, one or more hospitals, a home care provider, etc., many of them in different cities, provinces, and sometimes countries. Chances are also that few people know that the records are their personal property – they own them. They have been led to believe over the years that those files behind the desk or on the shelves behind the doctor’s receptionist or increasingly on that computer in the examining room belong to the providers who provide them with safekeeping; they believe also, correctly, that healthcare’s providers control access to them. That patients themselves do not have free access to their own health/medical records and that they don’t control whom else should have that privilege is bizarre. Continue Reading »