Values and Ideas: Regulation, Competition or Integration?

1. Values and Ideas: Regulation, Competition or Integration? The Impact of Managed Competition on Health Care January 24, 2001 Susan D. VanderBent, MSW., MHSc, CHE Executive Director Ontario Home Health Care Providers’ Association

2. Overview of Presentation • Drivers of Change • Facts about the Ontario Home Care System • Facts about the Private Sector • Public Delivery and Private Delivery • The Role of Government and Competition • Impacts and Outcomes

3. Drivers of Change in Long Term and Community Care • A decade of consumer criticism about the organization of the long term and community care system • need for integration-greater efficiency and effectiveness and accountability • changing demographics • response to acute care restructuring (24/7) and overall health care reform

4. Ontario Home Care System • Delivered by the private sector (Proprietary and NFP) • Not-for-profit and Proprietary sectors worked in partnership for the past 30 years in the publicly-funded and privately-delivered system • Proprietary sector used as ‘secondary workforce’ • System becoming inherently unstable due to lack of level playing field and increasing demands caused by health care reform

5. Ontario Home Care System • The most generous in Canada in terms of spending per capita, but wages lower • One of the few home care systems which: • Is delivered by the private sector (Not-for-profit and Proprietary) • Does not impose user fees • Uses a contracting system to choose providers (Hollander)

6. Scope of the OHHCPA • 30 year history • Currently employs 28,000 Ontarians • 6,500 RN’s and RPN’s • Therapy companies, Pharmacies • By 1995, estimates were that proprietary sector delivered 30% of nursing care and 50% of homemaking care in Ontario

7. Values and Ideas • In every conceivable social policy, a choice must be made, even if the choice is to do nothing. Every choice raises the question of what ought to be done. Choice means putting our personal or corporate values into action. Those individual choices embodying our values come together in the structures, processes and services through which we work (Wistow, 1995).

8. Values and Ideas • Ideas are the natural ‘outputs’ of our value system • Our values determine which of the ‘drivers’ for change take precedence in terms of changing structures and processes for health service delivery • Twin concerns of efficiency and effectiveness predominate • Health care reform (in acute, long-term and community care), similar to Ontario’s, is taking place across Canada and the world

9. Public Delivery vs Private Delivery(NFP and Proprietary Sector) • Is the state actively encouraging an increase in the role of the private sector (NFP and P) in welfare state programs (health/education)? • What happens when NFP and P compete? • Due to the process of ‘isomorphism’, is the corporate status of provider relevant? • Are there consequences of private sector (NFP and P) provision for equity and justice in health care? • What about public sector accountability for the needy?

10. Competition or Regulation Steering or Rowing? • Welfare state development throughout the world has proceeded on the assumption that only the state can assure adequate, universal health care and the state’s role is legitimate • In the 1980’s, all governments attempted to control health care expenditures by the introduction of of market mechanisms (competition) to regulate supply and demand (C. Ham, 1996)

11. The Role of Government • There are continuing debates about the appropriateness of market forces shaping health care provision Britain, Canada and the US. • Clearly, government is a fundamental actor in the field of health care and always will be, however its focus will change

12. Public Sector Delivery Issues • Public sector rollbacks justified for the following reasons: • failures in government provision, (ie. lack of effectiveness, efficiency and accountability) • economic uncertainties • private sector (NFP and P) seen to be more ‘vibrant’ in modes of organizing health care • private sector (NFP and P) relieving the state of burdens it can no longer adequately shoulder

13. Restructuring Impacts and Outcomes • Social Impacts • Political Impacts • Financial Impacts • Professional Impacts • Governance Impacts

14. Impacts and Outcomes • The welfare state and the long term care sector is not being dismantled through the introduction of competition, although the role of the state and actors are changing • “Current changes in the role of the state represents potential enhancement of the states’ capacity from provision of service to greater authoritative control and regulatory role” (“steering, not rowing”, Osbourne and Gaebler, 1996)

15. Regulation, Competition and Integration • New roles and relations between the private sector and the government are not well captured by the terms of current terms: • New roles and relations between the public and private sector are best understood as the beginning of an integrative policy regime, in terms of intermingling of roles and the social construction of new relations between the two spheres.

16. Competition in Health Care Delivery • “Conceptual dichotomies between public and private, state and market, regulation and competition are inadequate to understand fully current developments in health care provision. It suggests that contemporary relations between any set of conceptually dichotomous spheres are best understood as ‘interfused’ “(Ruggie:1996).

17. Competition in Health Care Delivery • In an ‘interfused’ relationship, is the market shaping the state’s provision of health care or is the state shaping the market?

18. Impacts and Outcomes • Competition allows increased potential and opportunity for the private sector (NFP and P) to provide health care within terms mutually agreed-upon with state actors. • Greater accountability through a process of choosing providers • Higher transaction costs in terms of choosing providers – cost of choice

19. Impacts and Outcomes • Evolution of home care system • Discussion of home care’s place in the broader health care system (priority-setting) • Greater need to form alliances to advocate for shared outcomes • Impacts on professional caregivers - not dissimilar to other major shifts due to health care reform efforts in other sectors

20. Impacts and Outcomes • Individual providers have learned to: • develop initiatives to reduce overhead costs • improve use of technology • create more efficient organizations (Hamilton Spectator, Jan 17, 2001, VON Canada) • There has been some consolidation, losses and growth among all providers

21. Impacts and Outcomes • Lack of standardization of implementation process has led to frustration • There is a need for a stronger regulatory role on the part of the state • The system must be managed by outcome, not by process – the industry needs to define ‘outcomes’ in home care

22. The Role of Government • While increasing constraints have accompanied economic recession, the state has not pulled back from an authoritative role in guiding a broader social base of health care provision (Ham, 1996). • Given this analysis, access to the private sector has given the state a broader span of services over which it can exercise legitimate control

23. Final Analysis • Managed competition is the development of new relationship which will result in the state being more able to guide the private sector (NFP and P) toward collective purposes • “We are witnessing the emergence of an integrative policy regime which will tie the public and private sectors together in an overall system of health care with the government as the chief overseer of a broader base of social provision” (Ruggie, 1996).

24. Definition of Terms • Isomorphism- different kinds of organizations begin to work in similar ways due to the fact that they operate in similar environments • Typology of Health Policy Regimes: • Segmented Policy Regime-Roles and relations between government and private organizations and professional groups are based on a traditional division of authority. • Interventionist Policy Regime- Roles and relations between government and private organizations and professional groups can be changed as governments engage in greater involvement in order to correct perceived problems. • Integrated Policy Regime - The government assumes a leadership role in which the state guides private organizations and professional groups in order to influence and negotiate change based on ‘shared values’. There is a construction of forums to air alternative views and mediating among them.

25. OHHCPA Web Site A copy of today’s presentation is available on the OHHCPA web site at: http://www.ohhcpa.on.ca/publications.htm and click on “Presentations”

26. Ontario Home Health Care Providers’ Association The Ontario Home Health Care Providers' Association (OHHCPA), founded in 1986, currently has 42 members providing services throughout rural and urban Ontario. It represents private organizations that employ front-line service providers of health care services (acute, chronic, rehabilitation). Members of OHHCPA are contracted by all three levels of government, Community Care Access Centres, insurance companies, corporations, and private individuals. Association members provide employment for approximately 28,000 Ontarians and are key providers in the delivery of community health care to an estimated 100,000 clients annually. The mission of the OHHCPA is to promote the provision of quality care to consumers of health and support services in the home, through the development of, and adherence to, standards of professionalism and integrity. OHHCPA is a member of the Ontario Health Providers Alliance, an alliance of 18 members including: The Victorian Order of Nurses-Ontario, the Canadian Red Cross Society - Ontario Zone, Saint Elizabeth Health System, Ontario Community Support Association, the Ontario Medical Association, the Ontario Hospital Association, the Ontario Nursing Home Association, Ontario Pharmacists Association, the Ontario Association of Non-Profit Homes and Services for Seniors, Association of Ontario Health Centres, Canadian Mental Health Association - Ontario Division, Cancer Care Ontario, Ontario Association of Children's Rehabilitation Services, Ontario Association of Medical Laboratories, Ontario Federation of Community Mental Health and Addiction Programs, Ontario Home Respiratory Services Association, Association of Local Public Health Agencies. The OHHCPA supports, and participates actively, in the advancement of research in the home health care field through its involvement with the Ontario Community Services Research Evaluation Network and the Institute for Clinical Evaluative Sciences (ICES). OHHCPA is a leader in promoting provision of adequate financial and other resources for home health care in Ontario. OHHCPA participates regularly, both federally and provincially, in task forces, consultations and committees in order to develop consistent approaches to policy and funding issues affecting home health care provision.  For more information, please contact:  Susan D. VanderBent, MSW., MHSc, CHE, Executive Director Ontario Home Health Care Providers’ Association 19 Melrose Avenue South, Hamilton, Ontario L8M 2Y4 Phone: (905) 543-9474 Fax: (905) 545-1568 Email: suevan@ohhcpa.on.ca Web Site:http://www.ohhcpa.on.ca