Does the “Rise” of the Private Sector Lead to the “Demise” of Academic Medicine in Canada?

1. Does the “Rise” of the Private Sector Lead to the “Demise” of Academic Medicine in Canada? Presentation to ACAHO Fall Invitational Conference Ottawa, November 3, 2006 Dr. Hugh Scully Professor of Surgery and Health Policy University of Toronto, and University Health Network, Toronto General Hospital

2. Shared Statement on Ethical Principles for Everyone in Health Care • Health care is a human right. • The care of the individual is at the centre of health care but the whole system needs to work to improve the health of the population. • The health care system must treat illness alleviate suffering and disability and promote health after illness and disability.

3. Shared Statement on Ethical Principles for Everyone in Health Care • Cooperation with each other, those served and those in other sectors is essential for all who work in health care. • All who provide health care must work to improve it. • Do not harm.

4. Pressures Aging population New technologies An expanding continuum of care Unsustainable funding Workforce shortages Increasing demand Impact Decreased access to care Increased waiting times & waiting lists Increased workloads Demoralized workforce Loss of confidence in the health care system Environmental Scan

5. Environmental ScanChanging Attitudes 1.Decline in public trust • not given …. must be earned 2. Rise of the “knowledge” consumer •  education •  access to the Internet • opinionated / demanding • want accountability 3. Search for certainty • want quality of life standard of living • want detailed assuranceIpsos/Reid2003

6. Environmental ScanFive Public Opinion Principles • Certainty - essentials > frills - public funding • Social Cohesion • Quality → Choice • Availability • Public Accountability e.g.: National Health Council Ipsos/Reid 2003

7. Environmental ScanPrinciples & Values of a Health Care System Cornerstones of a Health Care System • Patient Focused • Quality • Accessible • Research

8. Sustainability “the ability to maintain something at a proper level or standard” Sustainability is not about maintaining the status quo.

9. What Does Sustainability Mean in Health Care? • The balance of the amount of resources going to health versus other areas of expenditure. - eg. Education, social services • The relative allocation of resources to different program areas within health. - eg. Acute, chronic, community, hospital • The balance of the amount of public versus private funds as a proportion of total health expenditures.

10. What Does Sustainability Mean in Health Care The future ability of health care systems to: -provide a range of services that cover the full continuum of care (comprehensiveness); -provide health care services to the entire population (universality); World Health Organization’s New Universalism “universal coverage means coverage for all, not coverage of everything”

11. What Does Sustainability Mean in Health Care? • The future ability of health care systems to: - Adjust to specific pressures (economic, social, demographic, etc.) without threatening access to services, quality or health outcomes (flexibility) - To keep pace with technological progress (innovation);

12. What Does Sustainability Mean in Health Care? • The future ability of health care systems to: - care for the increased proportion of the elderly population (accessibility); - renew the health workforce.

13. Environmental ScanChallenge to Sustainability • In a world of shifting costs, there cannot be sustainability – the framework isn’t there for transparency or predictability. • Where there is an environment of shifting blame, there cannot be responsible accountability.

14. Environmental ScanThe Organizational Triad Administrator A Physician Nurse B C Canadian Nurses Association 2001

15. Leadership in Health Care Improving Service • Safe - avoid injuries • Effective - evidence-based • Patient centered • Timely • Efficient • Equitable

16. The Need for MD LeadershipRegaining Public Confidence • No institution or organization can function without “public consent” • To gain and preserve that consent and trust, we must act - and be seen to act - in the public interest, as the public interpretsit. • The basis of the public’s acceptance is the institution’s performance and integrity. Golden, 1961

17. Building Your Tool KitGood to Great, J. Collins 2005 The Hedgehog Concept in the Social Sectors:

18. What Does the Future Hold? • Increasingly health care professionals are seen to be integral to creating innovative solutions not labeled or ‘targeted’ as ‘the problem’.

20. Physicians per 1000 population (incl. residents) Source: 2005 OECD Health Data

21. First Year Enrolment in Medical Schools(including 40-50 Visa students) CMF report 10% cut Source: Medical Education Statistics, ACMC Note: Figure for 2005-07 are estimated based govt announcements

22. Postgraduate Practice Entry Cohort (excludes visa trainees) Source: CAPER

23. IMGs in Ministry Funded Positions(excludes Visa trainees) Source: Canadian Post-MD Education Registry Note: Excludes Visa trainees

24. Opportunities for Medical Students Country Enrolment Population Ratio UK* 7,932 61 million 1 : 7,690 Australia* 19.3 million 1,460 1 : 13,200 293 million USA*** 17,978 1 : 16,297 Canada** 2,193 32 million 1 : 14,591 Sources: * International Medical Workforce Conference, 2002 & 2005 ** AFMC Canadian Medical Education Statistics, 2005 *** Association of American Medical Colleges, 2005

25. A Physician Human Resource Strategy for Canada: FINAL REPORT Final Report of Task Force Two proposes the following strategic directions: • Preparing for the Future – Education and Training • Making Teamwork Work – Interprofessional Practice and Education • Attracting Physicians and Keeping Them Here – Recruitment and Retention • Clearing the Legal Hurdles – Improving Licensure, Regulatory Issues and Liability • Making the Most of the Physicians We Have – Infrastructure and Technology

26. Preparing for the Future:Education and Training Core Strategies Cont’d • Plan for adequate number of ministry funded positions to accommodate all graduates of Canadian medical schools, Canadian re-entry applicants and qualified IMGs • Create a physician workforce that reflects the population’s diversity and needs

27. Attracting Physicians and Keeping Them Here:Recruitment and Retention Core Strategies Cont’d • Focus on professional, personal and intangible variables, in addition to financial factors that impact on practice choices and practice locations • Support models of service delivery that recognize the full range of professional activities and that serve to attract and retain providers

28. Making the Most of the Physicians We Have:Infrastructure and Technology Strategic Direction Ensure that critical components that support effective and efficient system delivery and interoperability are expanded to assist physicians and other providers to deliver quality health care at all practice sites and points of care in a timely manner.

29. Making the Most of the Physicians We Have:Infrastructure and Technology Core Strategies • Develop a “wired medical world” encompassing a wide range of communication and information technologies • Create and maintain an up-to-date inventory of the current stock of medical equipment, technology and physical infrastructure • Continue to invest appropriate funds to achieve the required medical technologies

30. Effective Framework and Toolto Analyze Models of Care Dimensions within the framework: • Access to care • Coordination of care • Continuity of care • Efficiency / Productivity • Comprehensiveness

31. Health Care Financing: Canada vs OECD Countries Total as % of GDP - 9.9% (9th) Public - 6.9 (9th) Private - 3.0 (7th) Total per capita - 2998 (9th) in US dollars US - 5711 (1st)

32. Health Care Financing:Canada vs OECD Countries Public Expenditures - 2103 (10th) in US dollars Public as a % of total - 70.1 (21st) health expenditures Private as a % of total - 29.9 (10th) health expenditures

33. Realities of the Public-Private Mix in Canada Key Findings

34. Just the Facts - Canada • Different approaches by provinces to regulate privately funded & delivered medical care • Ontario only province to prohibit opting out • Private funding for physician services is very limited: • 2% of physician expenditures • <1% of physicians opted-out • 65% of population purchases supplemental PHI to cover services partially or not at all covered under Medicare • Significant portion of health care privately delivered

35. Number of Opted-out/Non-participating physicians in Canada (2005)

36. Contribution to growth of private health care spending (1975-2005)

37. Breakdown of Private Health Care Spending in Canada 1988 vs. 2003

38. The Public-Private Mix in Other Industrialized Countries Key Findings

39. Just the Facts - International • Compared to OECD average, Canada characterized by: • higher public funding of physician services • lower public funding of drugs & dental services • Canada’s share of private health insurance expenditures almost double OECD average • Canada not alone in providing first dollar coverage for medical & hospital care • however most other OECD countries do allow user charges

40. Just the Facts– International(cont’d) • 12 of 30 countries allow private health insurance for medical & hospital care • However most countries have higher supply of physicians and beds • Advantages and disadvantages of private health insurance: • Improves choice and access for some populations • No significant impact on reducing overall system costs & improving quality

41. AAMC Reporter: May, 2006 The AAMC is concerned that specialty (private) hospitals treat disproportionately low shares of very sick (complex) patients, create conflicts of interest and negatively impact the revenue of teaching hospitals. Richard Knapp Exec. V.P. AAMC

42. Independent SectorTreatment CentresU.K. 2005-2006 Objectives: • ↑ elective capacity available to the NHS to ↓ waiting times no major direct contributions • ↓ spot purchase price in the private sector some, but compromising viability of community hospitals • ↑ patient choice / access yes, but selective and variable

43. Independent SectorTreatment CentresU.K. 2005-2006 Objectives • Encourage best practice and innovations ISTC’s not necessarily more efficient, and knowledge not being adopted in NHS facilities • Stimulating reform within the NHS through competition ISTC’s poorly integrated into the NHS and not training doctors. Note: considerable skepticism about whether the ISTC program represented value for money (£3.75 B)

44. 10 First Order Policy Principles • Timely Access to medically necessary care; individual recourse should wait times be unreasonably long. • Equity: Access to medically necessary care must be based on need and not on ability to pay. • Choice: Canadians should have choice of physician; and physicians should have choice of practice environment.

45. Policy Principles (cont’d) • Comprehensiveness: Canadians should have access to a full spectrum of medically necessary care. • Clinical autonomy:Care models respect autonomous decision-making within the patient-physician relationship. Payers and/or other 3rd parties not interpose themselves between patients and their physicians. Physicians be free to advocate on behalf of their patients.

46. Policy Principles (cont’d) • Quality: Public and private health care sectors be held to same high quality standards and be independently monitored. Facilities providing medical services be subject to medical supervision. • Professional Responsibility: Medical profession promote strongest possible health care system that best meets patients’ needs. Both public and private sectors be responsible for training next generation of health professionals and advance knowledge through teaching/research.

47. Policy Principles(cont’d) • Transparency: Decisions affecting public-private funding and delivery be made through open and transparent process. Providers faced with potential conflicts of interest have duty to recognize and disclose them and resolve them in best interest of patients. • Accountability: Public and private health sectors be held to same high accountability standards including clinical outcomes, full cost accounting and value-for-money for use of public funds.

48. Policy Principles(cont’d) • Efficiency: Public and private sectors should be structured to optimize the use of human and all other resources.

49. Concluding Observations • Don’t lose sight of our collective goal: Ensuring Canadians have timely access to quality care • Public-private mix is only one factor affecting access to timely care. Others include HHR, illness prevention, etc. • Public-private mix is subject to change as needs and models of care evolve • Tradeoffs exist will all funding and delivery models: Must find acceptable range of policies and tradeoffs

50. Conclusion Excellence • The result of caring more than others think is wise. • Risking more than others dare. • Dreaming more than others think is practical. • Expecting more than others think is possible.