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Main Themes. The Canadian health care landscape, 2010Community care and the evolution of MedicarePenny wise, pound foolish: how we got here and what it tells us about ourselvesComprehensiveness: the principle that isn'tWhat's a core service? Ask the client!Mobilizing support
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1. The Time is Now:Putting Community Care at theHeart of MedicareOCSA Annual General MeetingRichmond Hill, ONOctober 20, 2009 1
2. Main Themes The Canadian health care landscape, 2010
Community care and the evolution of Medicare
Penny wise, pound foolish: how we got here and what it tells us about ourselves
Comprehensiveness: the principle that isn’t
What’s a core service? Ask the client!
Mobilizing support – some strategies to think about
3. When Medicare Was Young (and So Were We) Medicare was a child of post-war recovery, optimism, and the science of the times
Canada was a young country with few elderly
Health meant doctors and hospitals and antibiotics
In the 1960s there were no
Statins and NSAIDS
Hip and knee replacements
Day surgeries
So we defined “medically necessary” to mean (mostly) doctors and hospitals
4. How Canadians Think AboutHealth and Health Care Health is the goal, but health care insurance is the publicly financed vehicle
If it’s medical, it’s fundable - generously
Community care is not fundamentally a societal responsibility (well, maybe home care nursing)
Medicare defines much of our solidarity with each other
The rest is dependent on the politics of the day and the jurisdiction
5. Public and Private Health Spending, Canada, 2007, Selected Categories
7. The Current Climate Greater accountability for performance
Increased capacity to measure and evaluate
Balanced budgets have given way to big deficits
Sustainability argument takes two forms:
Health care can’t continue to gobble up bigger and bigger share of provincial government budgets; OR
The overall price tag is affordable but we’re not getting good value for money
If either (or both) are true, changes are on the horizon
9. What Do We Want to Achieve? Better quality
Faster, more equitable access to needed care
Better value-for-money (VFM)
Reduce disparities between population groups
Prevent more, intervene less
More seamless care (continuity, transitions)
Less waste, redundancy, muda (useless work)
More self-reliant, health-oriented public
10. Changing Public Expectations Higher quality and more independent housing for LTC residential clients
Bring care to the condo rather than moving clients to care
LTC public facility viewed as last resort for:
The very old
Very frail
Significantly demented
Without a lot of money
With smaller nuclear families and high geographic mobility, intergenerational family caregivers are disappearing
12. Issue #1: TheCommunity Care:Residential Care Ratio Rhetoric supports transformation of system to community from facilities
Canadian experience has been bed-oriented
Home care budgets often among first to be scaled back in times of fiscal restraint
In some LHINs as much as 40% of complex continuing care beds occupied by people with lesser care needs – at a cost of $150,000+ annually
Question: Will provinces invest enough in community care to dramatically reduce dependency on beds?
13. Issue #2: Standards, Turf, and the Division of Labour Continuing Care—a medical service with social care components, or a social service with a medical component?
Major arguments over scope of practice
Nature and cost of care affected greatly by who does it
A medical orientation increases costs and often neglects the social issues that affect client well-being
Question: Can we develop an evidence-based model that optimizes efficiency, safety, acceptability, and job satisfaction?
14. Issue #3: Who Controls the Resources? Some move in Canada towards voucher systems and greater client/family choice of care pattern
Some countries, e.g., Germany, devolve much more control to recipients and families
Need to understand extent to which political and social culture affects feasibility of policies
Question: Should more control lie with clients/families, and if so, how do we guarantee safety and quality?
15. Issue #4: Risk and Risk Management Canadian health care system generally risk averse
In continuing care, often a trade-off among freedom and choice, cost-effectiveness, and safety
Care recipients and families typically value quality of life over risk minimization
Question: Who decides on and manages risk levels? What price are we willing to pay for reduced risk? What demarcates reasonable from unacceptable risk levels?
16. Issue #5: Dealing with Caregiver Burden Family caregivers play a prominent role in looking after clients living in the community
It is prudent to encourage this role and many adopt it happily
However, there is well-documented evidence of the extent of caregiver burden
Different caregivers have different capacity and inclination to provide care
Question: How do we calibrate the right amount of care to maintain the caregiver role without exploiting the caregiver?
17. Issue #6: Anticipating Innovation and Avoiding Irreversible Mistakes Three main technologies have huge potential to preserve independence and enhance quality of life:
Communications devices, e.g., call systems, automated monitoring and surveillance
Medical interventions to manage chronic diseases (drugs, surgery, testing)
Scientific breakthroughs, e.g., brain plaque removal, genetic engineering
These will change how people stay independent and affect the need for facilities
Question: How do we model innovation and maintain flexibility to adapt programs to changing profiles of need?
18. Issue #7: Primary Health Care – the Fulcrum for System Transformation Growing evidence that “middle of the curve” primary care is problematic, especially for chronic disease management (Marshall et al, UK; McGlynn et al, US; Katz et al, Manitoba)
Good and comprehensive primary health care is essential to maintaining capacities and avoiding some acute episodes
Interest in expansive model of PHC and geriatrics waning in Canada
Question: what model of PHC will prevail and what incentives can reinvigorate PHC and encourage improved care for the at-risk elderly?
19. Issue #8: Enriching the Housing, Sharing the Responsibility Generally sound policy to separate housing needs from care needs
People who secure care-compatible housing will need care at some point and want to age in place
Need public policy that maximizes the impact of public spending in partnership with private spending
Question: What should govt. do to encourage self-management without discriminating against those who make these choices?
20. So Why Does Community Care Go to theBack of the Line? Not as glamorous as medicine and technology
Does not map onto a disease-specific model of health and illness
Does not figure prominently in doctors’ thinking
Canadians’ solidarity is highly concentrated on medical care
Perception that families are responsible for their own
Ageism
21. The Economics of Policy Remember this equation: expenditures = income
Health care spending puts money in people’s pockets
Many benefit enormously from the status quo
Incomes are higher in institutions and specialized services
Communities value visible and costly taxpayer-funded institutions
People steeply discount future health benefits
They also discount health benefits that do not originate in medical interventions
22. Overtrained or Underused? “The varying objectives and levels of specificity found in different professions’ scopes of practice are more than frustrating; they have encouraged a system that treats practice acts as rewards for the professions rather than as rational mechanisms for cost-effective, high quality and accessible service delivery by competent practitioners. …Scope of practice battles have come to resemble contests for more patients, more status and power, more independence, and more money.”--Finocchio et al. 1995
23. Framing the Debate Comprehensiveness is the great shrinking principle of the Canada Health Act
A comprehensive system is also a more cost-effective system:
Removes incentive to use more costly, covered care
Greater likelihood of preventing or deferring needs
Encourages partnerships and self-reliance
Independence is easy to market
24. Making the Economic Case Highlight the findings of the cost-effectiveness literature
Create real-case scenarios of differences in costs of meeting people’s needs in different settings
Quantify how many people can be looked after in the community for the cost of one CCC or LTC bed
Promote research that compares total health system costs of people receiving community care vs. no care
Costs over time
Incidence of falls, medication errors
Use of doctors, hospitals, residential care, drugs
25. Toward A New Medicare Accord What most people need, most of the time, is what Medicare overlooks
“Medically necessary” services address only a small portion of the needs of millions of people
“Functionally necessary” defines what people need to:
Remain independent
Avoid excessive dependence on medicine
Retain capacities
Comprehensiveness is a false promise precisely because Medicare remains rooted in its hospital-doctor history
26. Mobilizing Support Survey community care clients and their families about their values, needs, and preferences
Brand community services as the client-friendly option
Do the accounting on community vs. institutional care
Advocate for global budgets that span community through institutional services
Endorse primary health care funding models that create incentives to seek the lowest cost and most effective care
27. The Politics of Health and Health Care Who gets to define what’s important gets first claim on resources
Governments and LHINs need a political warrant to put community care at the centre of the system
The public is easily persuaded that its interests are best served by more of the same
Making different choices possible depends on doing the fundamental work of political mobilization
28. The Bottom Lines Integrating primary health care (in its robust definition), community-based services, and residential care will be key to the future
Assessing, quantifying, and legitimizing the need for community-based care is critical to building and sustaining support for resource reallocation
Financing methods and co-payments should be consistent across the system and encourage appropriate use of cost-effective services
“Silent suffering” is a barrier to public awareness and sound decision-making
Therefore, make the case loudly, and often
29. Contact Information Steven LewisAccess Consulting Ltd.211 – 4th Ave. S.Saskatoon SK S7K 1N1
Tel: (306) 343-1007E-mail: Steven.Lewis@shaw.ca