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Innovative Solutions for Optimum Health Care Delivery + 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
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
After-Hours Care and Emergency Room Use Difficulty getting after-hours care without going to the emergency room Used emergency room in past two years Percent Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
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.
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)
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
Toronto Arthroplasty Model Referring Physician Central Intake Assessment Advanced Practice Physio Surgeon Consult Post-Op Discharge Follow-Up Surgery Holland Centre Mt. Sinai St. Michael’s St. Joseph’s Toronto East General Toronto Western Holland Centre and Toronto Western Holland Centre
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 free-standing ambulatory surgery facility in North America! • I have tried (unsuccessfully) to convince a dozen journalists to write about Queensway
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.
Annual impact of Aging on health costs 2010-2036 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
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
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
High performing health organizations and physician engagement: There are only two models. 1. A disciplined medical group that co-manages 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
Summary: • 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