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Dean On Campus Blog

DeanOnCampus Responds to Drummond Report

This past week, Don Drummond, a Queen’s scholar in our School of Policy Studies, delivered his much-awaited report.1 The report entitled “Public Services For Ontarians: A Path to Sustainability and Excellence” makes sweeping recommendations for the entire public sector. These recommendations are based on the assumption that we are in for extreme economic hardship, and if we have any chance of addressing our deficit, it can’t be business as usual.

The controversial report focuses much of its attention on health. Indeed, there are 105 recommendations (and many sub-recommendations) for the health care sector. I have gone through the report and have briefly responded to all of them, http://www.fin.gov.on.ca/en/reformcommission/.

To truly appreciate Drummond’s points, one really has to read the report in full; however, for the purposes of this blog, I abstracted the first line of the 105 recommendations and many of the sub-recommendations on health, and have given my personal opinion on all of them. Long blog, but the report is an important piece of work and critical to all Ontarians.

Drummond: Develop and publish a comprehensive plan to address health care challenges over the next 20 years. The plan should set objectives and drive solutions that are built around the following principles.

Dean On Campus Responds: Hard to argue with planning, but assumptions that drive a model may change drastically over a 20 year horizon.

Drummond: The system should be centred on the patient, not on the institutions and practitioners in the health care system.

Dean On Campus Responds: Does not adequately acknowledge the tonne of work we have all been doing to focus on patient-centred care, both within institutions and in the community.

Drummond: The plan should focus on the co-ordination of services for patients in a fully integrated, system-wide approach.

Dean On Campus Responds: I agree that our efforts to date, to focus on a health care system, as opposed to an amalgam of individual institutions, have been inadequate. One of many reasons that’s so has been the lack of financial empowerment that promotes and enables integration.

Drummond: Reforms should recognize changes and challenges in both demographics and lifestyles by putting more emphasis on chronic than acute care.

Dean On Campus Responds: The fact that we need to focus more on chronic care should not mean that we systematically decimate the great hospital-based care that we have worked so hard on for so many years. To be sure we need to do both, but that should not mean diverting money away from hospitals.

Drummond: At the provincial level, the system must be able to carry out health care capacity planning; it must look at the health needs of the population and project future needs for facilities, services, funding and human resources;

Dean On Campus Responds: Agree we need to carry on with this agenda, not that we have not been trying, but intensifying these efforts warranted.

Drummond: Policies should be based on evidence that provides guidance on what services, procedures, devices and drugs are effective, efficient and eligible for public funding;

Dean On Campus Responds: I would argue we have been trying to promote evidence-based decision making for several decades. We do, however, fail in quickly translating evidence into action.

Drummond: There should be a heightened focus on preventing health problems, including the role of public health in meeting this goal.

Dean On Campus Responds: I couldn’t agree more; wellness promotion and illness prevention need to be an augmented focus of medical schools, physicians, institutions, industry and government.

Drummond: It should ensure that health data are collected efficiently and shared.

Dean On Campus Responds: Our investments in IT have been both sub-optimal and those that have been made are not actualized.

Drummond: Funding to providers should be based primarily on meeting the needs of patients as they move through the health care continuum.

Dean On Campus Responds: Linking payment to the patient has been a theme under consideration for quite some time. It will require a total blow-up and revamping of physician compensation.

Drummond: The quality of care can and should be enhanced despite the need to restrain increased spending; the objectives of quality care and cost restraint must go hand in hand;

Dean On Campus Responds: Drummond is arguing for better, faster and cheaper. He is counting on us not having to “pick two”.

Drummond: Evaluate all proposals for change that include efficiencies and cost savings within the vision and plan developed above.

Dean On Campus Responds: Hard to argue.

Drummond: Divert all patients not requiring acute care from hospitals and into a more appropriate form of care that will be less expensive, improve the patient experience and reduce the patient’s exposure to new health risks.

Dean On Campus Responds: Much along the lines of the Walker report (http://www.health.gov.on.ca/en/public/publications/ministry_reports/walker_2011/walker_2011.aspx), we have to a better job of having the right patient in the right place at the right time.

Drummond: Increase the use of home-based care where appropriate to reduce costs without compromising excellent care. For example, home-based care should be used more extensively for recovery from procedures such as hip and knee surgery.

Dean On Campus Responds: Agree, but we have been pushing at this for years. For example, our center is doing ultra-short stay major orthopaedic surgery with excellent results.

Drummond: To improve the co-ordination of patient care, all health services in a region must be integrated.

Dean On Campus Responds: Agree, we need more effective regionalization. Drummond suggests strengthening the LHINs. This may well be the most appropriate approach, but to date we have not really empowered the LHINs to function appropriately.

Drummond: Cap the government’s health budget at 2.5 per cent or less annual growth through 2017–18.

Dean On Campus Responds: That will be tough! This centers around assumptions made by Drummond that our economic outlook is abysmal and that we will not raise taxes. Hard to argue with a world-class economist, but this simple-minded surgeon would suggest that these assumptions are just that, assumptions.

Drummond: Support a gradual shift to mechanisms that ensure a continuum of care and care that is community-based.

Dean On Campus Responds: This implies we will be successful in a re-education of the public regarding their current expectations of the acute care sector.

Drummond: Achieve spending restraint by moving the health care system towards a more efficient overall design and finding efficiency gains within its constituent parts.

Dean On Campus Responds: The Holy Grail!

Drummond: Do not apply the same degree of fiscal restraint to all parts of health care. Some areas — including community care and mental health — will need to grow more rapidly than the average.

Dean On Campus Responds: A big worry for our hospitals. With a fixed envelope, Drummond is ostensibly suggesting a major hit to our hospitals.

Drummond: Set the overall principles for province-wide health care, but continue to organize the delivery of health care on a regional basis.

Dean On Campus Responds: As Drummond suggests, this will require dramatically intensifying the effectiveness of the LHINs.

Drummond: A regional health authority should be clearly identified as the key point for integrating services and institutions across the full continuum of care for a geographic area.

Dean On Campus Responds: We all thought the LHINs would either disappear or be radically restructured. So much for amateur pundits.

Drummond: Reduce the number of organizations with which the Local Heath Integration Networks must deal on a day-to-day basis.

Dean On Campus Responds: Ostensibly he is calling for mass mergers. Let’s all remember the enormous “cultural costs” of merging institutions. Also, looking to Alberta, as a way to reduce the number of authorities, has its own issues.

Drummond: Consolidation of health service agencies and/or their boards should occur where appropriate, while establishing any new consolidated agencies as separate legal entities to limit major labour harmonization and adjustment costs.

Dean On Campus Responds: Will have to deal with some pretty tough issues, like should Ontario have faith-based institutions?

Drummond: Establish an advisory panel in each Local Health Integration Network with appropriate representation of the regional health care stakeholders, including community hospitals, physicians, community care and long-term care homes.

Dean On Campus Responds: Our Southeast LHIN ostensibly has this type of panel already.

Drummond: The Local Health Integration Networks must integrate care across the system by sharing information on patients among health care providers, coordinating decisions and allocating funds to best reflect regional needs.

Dean On Campus Responds: In an era of massive constraint, where is the money coming from for what will be a massive investment in IT?

Drummond: Use data and information sharing to better understand and address the fiscal impacts of chronic and complex conditions and at-risk patients with mental health and addiction issues.

Dean On Campus Responds: Important point and an urgent issue.

Drummond: Use information from funding models such as the Health-Based Allocation Model to examine where services may not be provided equally across health regions and conduct ongoing evaluations of each Local Health Integration Network’s progress in managing high-use populations.

Dean On Campus Responds: There are enormous regional disparities that are multi-factorial and will require a series of initiatives to address.

Drummond: Where feasible, services should be shifted to lower-cost caregivers. Across the spectrum of caregivers, full scope of practice needs to be exercised.

Dean On Campus Responds: Drummond is suggesting there are many things physicians do that other health care providers, with appropriate training, can do at a lesser cost. I agree with that opinion.

Drummond: A broader perspective should be applied to decisions that are made on the scope of practice of health professionals. Government should play a more active role in working with the professional colleges to apply a system-wide approach rather than dealing with individual professions in isolation.

Dean On Campus Responds: Very tough issue that unlikely can be dealt with on a provincial basis. If we radically alter scope of practice in Ontario, without a national consensus, we will have mass migration of healthcare providers.

Drummond: Maximize opportunities to use nurse practitioners with the aim of efficiency, while maintaining excellent care.

Dean On Campus Responds: Agreed; we have just augmented our NP training program by 20%, and could do more.

Drummond: Recognize the increased demand for nurses in the capacity of nursing programs at colleges and universities and their ability to train more nurses.

Dean On Campus Responds: Agree, we need to train more nurses, and as Drummond suggests work on the retention factor.

Drummond: Increase the use of personal support workers and integrate them into teams with nurse practitioners, registered nurses and other staff members where appropriate to optimize patient care.

Dean On Campus Responds: No doubt, but on what budget?

Drummond: Local Health Integration Networks need to use funding as a lever to encourage hospitals and other health care providers to use the full scope of practice of their staff.

Dean On Campus Responds: I really don’t know what he is referring to by “sub-optimal” use of practitioners.

Drummond: Make changes to the Pharmacy Act to enable an expanded scope of pharmacy practice. This would involve developing supporting regulations to permit pharmacists to administer routine injections and inhalations, including immunization.

Dean On Campus Responds: Good idea!

Drummond: Hospital capital plans that extend out-of-hospital services such as those for outpatients should not be entertained by Local Health Integration Networks. Hospitals should conduct affairs largely within hospitals, and others, such as Community Care Access Centres (CCACs) and private health care operators, should be responsible for providing out-of-hospital services.

Dean On Campus Responds: Drummond appears to be promoting an “anti-hospital sentiment with which I disagree. Some of our best, most creative, and fiscally responsible institutions are our acute care hospitals.

Drummond: Resist the natural temptation to build many more long-term care facilities for an aging population until the government can assess what can be done by emphasizing, to a greater extent, the use of home-based care that is supported by community services. Home-based care is less expensive and should generate greater population satisfaction.

Dean On Campus Responds: Would certainly agree with a “care at home first” as an important principle.

Drummond: Grant Local Health Integration Networks the authority, accountabilities and resources necessary to oversee health within the region, including allocating budgets, holding stakeholders accountable and setting incentive systems.

Dean On Campus Responds: Drummond is calling for reducing health care expenditure increases to 2.5%. Where is the money coming from?

Drummond: Tie compensation for CEOs and senior executives in all parts of the health care system to strategically targeted health outcomes, not the number of interventions performed, through a performance pay framework.

Dean On Campus Responds: We need to resist focusing on CEO compensation. This is either not a problem at all, or at most, a miniscule part of the issue. Having been part an of a hospital executive team for much of the last twenty years, I continue to be amazed that some truly believe our hospital CEO’s are not working flat out to bring efficiencies to our system.

Drummond: Support transparency in senior executive and CEO salaries throughout the health care system by publicly posting comprehensive compensation information in a timely fashion.

Dean On Campus Responds: How about measuring our CEO’s compensation with respect to the hours they put in?

Drummond: Allocate funding based on meeting the needs of patient as they move through the continuum of care.

Dean On Campus Responds: Agree.

Drummond: Some regions have developed roles for “clerical system navigators” that co-ordinate appointments and assist patients with required forms and paperwork. Local Health Integration Networks should ensure that a sufficient number of people in this role are put in place across the entire health care system.

Dean On Campus Responds: Agree.

Drummond: Empower primary caregivers and physicians in the Family Health Teams (FHTs) or specialized clinics to play the role of “quarterback,” tracking patients as they move through the integrated health system.

Dean On Campus Responds: Will require a massive investment in IT.

Drummond: Tightly integrate Community Care Access Centres (CCACs) with Local Health Integration Networks (LHINs) to improve patient case management.

Dean On Campus Responds: Hard to know how long it will take to have the LHINs, as currently constituted, to tae on so much more responsibility.

Drummond: Require hospitals to make discharge summaries available electronically to other care providers (e.g., general practitioners, home care) immediately.

Dean On Campus Responds: Again, this requires massive IT investment. Hospitals will do this gladly if funding is floated.

Drummond: Switch to electronic delivery of laboratory test results to improve timeliness and efficiency, as well as support patient privacy.

Dean On Campus Responds: Again, needs IT investment.

Drummond: Reduce absenteeism for Ontarians and office visits, while improving patient satisfaction, through secure messaging between patients and providers, online appointment scheduling, access to test results for patients, and online requests for prescription refills and renewal.

Dean On Campus Responds: Again, needs IT investment.

Drummond: Complex care patients should be managed through interprofessional, team-based approaches to maximize co-ordination with Family Health Teams and other community care providers.

Dean On Campus Responds: No argument.

Drummond: Chronic issues should be handled by community and home-based care to the fullest extent possible.

Dean On Campus Responds: No argument.

Drummond: Reach out to patients who need preventive care, particularly chronic disease and medication management, rather than waiting for them to come to get services.

Dean On Campus Responds: I do believe most primary health care providers are striving for this, albeit, improvements can be achieved.

Drummond: Reduce mortality, hospitalizations and costs while improving patient satisfaction by connecting Ontarians who have serious chronic health problems (e.g., congestive heart failure) with ongoing monitoring and support through expanded use of telehomecare.
Dean On Campus Responds: Many efforts are ongoing to achieve this goal. Certainly, they can be intensified.

Drummond: Centralize leadership of chronic disease management by developing coordinating bodies for chronic conditions including mental health, heart and stroke and renal disease, based on the Cancer Care Ontario model.

Dean On Campus Responds: I am not sure a “central control model”, like CCO, will be effective for conditions such as mental health disorders.

Drummond: Resource the Local Health Integration Networks adequately to perform their expanded functions.

Dean On Campus Responds: To a certain extent, this is just “shuffling the deck”, and I am uncertain as to what this will accomplish.

Drummond: Put in place clear structures to clarify the lines of accountability up to the Local Health Integration Networks (LHINs) and the accountability of LHINs to the Ministry of Health and Long-Term Care.

Dean On Campus Responds: I agree.

Drummond: Move critical health policy decisions out of the context of negotiations with the Ontario Medical Association and into a forum that includes broad stakeholder consultation.

Dean On Campus Responds: This is really a knock against physicians and the OMA, which I am not certain it is warranted.

Drummond: The Institute for Clinical Evaluative Sciences and Health Quality Ontario must work in tandem, integrating their respective expertise into practical recommendations for health care providers.

Dean On Campus Responds: I don’t really believe we have a problem with the generation of evidence. We have a problem with comprehensively translating evidence into practice.

Drummond: As a body of practice is established, expand the mandate of Health Quality Ontario to become a regulatory body to enforce evidence-based directives to guide treatment decisions and OHIP coverage.

Dean On Campus Responds: Hard to do, but don’t disagree.

Drummond: Make all Health Quality Ontario work public. Use the evidence found to inform directives on practices and what will be covered by OHIP.

Dean On Campus Responds: Why not?

Drummond: More work must be done on the efficiency front for the Institute for Clinical Evaluative Sciences.

Dean On Campus Responds: I agree.

Drummond: Explore the potential for a national Organization for Economic Co-operation and Development-type entity that collates and enhances evidence-based policy directions and provides enhanced collaboration on issues across jurisdictions.

Dean On Campus Responds: Agree with this, but it is very hard to make the operational components of health care a provincial responsibility, and then drive them by national directives.

Drummond: Use data from the Health-Based Allocation Model (HBAM) system to set appropriate compensation for procedures and cease the use of average costs to set hospital payments.

Dean On Campus Responds: I agree we can drive costs lower by aggressive target setting. However, the desire to transition from a small percentage of HBAM based funding to a very high one, will challenge many of our hospitals.

Drummond: Create a blend of activity-based funding (i.e., funding related to interventions or outcomes) and base funding managed through accountability agreements.

Dean On Campus Responds: As per above, this is what the government is now pushing, and our hospitals will struggle to manage this aggressive change.

Drummond: Create policies to move people away from inpatient acute care settings by shifting access to the health care system away from emergency rooms and towards community care (i.e., walk-in clinics and Family Health Teams), home care and, in some cases, long-term care.

Dean On Campus Responds: Certainly as it stands, the acute care sector would welcome this, and indeed is trying to promote it. It’s not as if our hospitals are advertising their emergency rooms as a destination of choice.

Drummond: Encourage hospitals to specialize so all are not trying to provide all services regardless of their comparative advantages.

Dean On Campus Responds: I would endorse this. It is certainly easier to accomplish this in a large urban environment, and becomes much more difficult the farther you are away from a big city.

Drummond: Given the burden of alternate level of care (ALC) patients on hospital capacity, hospitals must become more effective in optimizing this capacity while applying best practices in planning patient discharges. Further, small hospitals with large ALC populations must be assessed with a goal of redefining their role in care for the elderly. Again, funding should be aligned appropriately.

Dean On Campus Responds: ALC is a big problem. As Walker suggests, we need a change in mindset, culture and funding allocation.

Drummond: Use hospitalist physicians to co-ordinate inpatient care from admission to discharge.

Dean On Campus Responds: I am not so sure that “hospitalists” are the answer. The comprehensive use of hospitalists would greatly drive up the cost of care. Are we suggesting that hospitalists, manage all surgical, psychiatric and obstetrical patients…I don’t think so.

Drummond: Make primary care a focal point in a new, integrated health model.

Dean On Campus Responds: This is a very complex issue, and I am not quite certain what Drummond means by this one line statement.

Drummond: Regional health authorities must integrate physicians into a rostered health system and adopt the appropriate measures to address compensation issues across disciplines; that is, the proper blend of salary/capitation and fee-for-service.

Dean On Campus Responds: Of course, this would only be germane for primary care docs. This sector has already undergone a major transformation in the last decade.

Drummond: Reduce the sole proprietorship nature of the offices of many primary care physicians and encourage more interdisciplinary integration through performance incentives and accountability.

Dean On Campus Responds: Already underway.

Drummond: Compensate physicians using a blended model of salary/capitation and fee-for-service; the right balance is probably in the area of 70 per cent salary/capitation and 30 per cent fee-for-service.

Dean On Campus Responds: Once again, this most easily applies to the primary care sector, and translation to specialty medicine is very difficult.

Drummond: Aggressively negotiate with the Ontario Medical Association for the next agreement.

Dean On Campus Responds: It is going to be an aggressive negotiation, to be sure!

Drummond: Adjust fee schedules in a timely manner to reflect technological improvements, with the savings going to the bottom line of less expenditure on health care.

Dean On Campus Responds: This is a huge issue! The “relativity problem” has not been adequately addressed in previous OMA-MoHLTC negotiations. Why a nephrologist should make three times as much a geriatrician is a major issue.

Drummond: Make Family Health Teams (FHTs) the norm for primary care and design the incentive structure of physicians’ compensation to encourage this development.

Dean On Campus Responds: It would appear to me we are quickly heading in this direction.

Drummond: Require Family Health Teams (FHTs) to accept patients who choose them, and the FHTs should work with each patient to connect them with the most appropriate constellation of care providers.

Dean On Campus Responds: Agree.

Drummond: The regional health authority should establish incentives to discourage Family Health Teams from referring patients to acute care.

Dean On Campus Responds: Agree.

Drummond: Regional authorities should also be responsible for assigning heavy users of the health care system to the appropriate Family Health Team (FHT). If, for example, there were 300 heavy users within a region and three FHTs, the regional health authority would try to steer 100 to each, so that no FHT is overburdened.

Dean On Campus Responds: Sound reasonable.

Drummond: Because Family Health Teams (FHTs) will be responsible for patient tracking; they will need to build a critical mass of an administrative arm to carry out this task. This administrative arm should be shared among a number of FHTs.

Dean On Campus Responds: Sound reasonable.

Drummond: Better after-hours care must be offered and telephone/Internet services should direct patients to the most appropriate and convenient care provider.

Dean On Campus Responds: Sound reasonable, but need to factor in the cost of this arrangement.

Drummond: All Family Health Teams must be encouraged to add more specialists to their teams, which will reduce referrals and ease some of the complexities of patient tracking.

Dean On Campus Responds: There is an assumption that specialists will willingly join FHT’s. Not all specialists buy in to the fact hat they will have to become generalists.

Drummond: The Ministry of Health and Long-Term Care should allow the flexibility necessary for Family Health Teams to share specialists by permitting part-time contracts.

Dean On Campus Responds: Flexibility in health care operational issues has not been strength of government.

Drummond: All Family Health Team physicians must begin engaging in discussions with their middle-aged patients about end-of-life health care.

Dean On Campus Responds: I couldn’t agree more. We have shied away from this critical issue, and as a result, we have seen countless dollars spent on aggressive end of life care that has often been futile. We can also do a better job of teaching our medical students to be proactive with their patients in regards to end of life discussions. It’s an enormous issue and wonderful to see in this report.

Drummond: Improve access to care (e.g., in remote communities) and productivity for specialists by triaging appropriate patients for telemedicine services (e.g., teledermatology, teleophthalmology).

Dean On Campus Responds: Drummond is right. We are not doing a good job in addressing the regional disparities of health care provision.

Drummond: Remove perverse incentives that undermine the quality and efficiency of care.

Dean On Campus Responds: The fee for service model does create a set of potentially inappropriate incentives. I am not sure I would refer to them as “perverse” which would seem to imply we have a bunch of ill-willed physicians out there taking advantage of the system.

Drummond: The model described in the above recommendations must be supported by a robust data collection and sharing system that allows the creation of the necessary records.

Dean On Campus Responds: This again will require a major investment in IT.

Drummond: Increase the focus on home care, supported by required resources, particularly at the community level.

Dean On Campus Responds: We all agree.

Drummond: Match seniors to the services that they need from the earliest available care provider, reduce alternate level of care days, and improve co-ordination of care through the use of referral management tools for long-term care, home care and community services.

Dean On Campus Responds: We all agree.

Drummond: Implement the recommendations contained in “Caring for Our Aging Population and Addressing Alternate Level of Care,” a report prepared by Dr. David Walker and released in August 2011.66

Dean On Campus Responds: Queen’s is proud to have David Walker as the ALC lead for the province, and we support his report whole-heartedly.

Drummond: In addition to recommendations contained in “Caring for Our Aging Population and Addressing Alternate Level of Care,” a report prepared by Dr. David Walker and released in August 2011,67 there is a need for more and varied palliative care; at home and in residential hospices.

Dean On Campus Responds: I agree we need a major investment in palliative care.

Drummond: Integrate the public health system into the other parts of the health system (i.e., Local Health Integration Networks).

Dean On Campus Responds: I believe Drummond is correct by suggesting better alignment of Public Health and the LHINs would be beneficial.

Drummond: Review the current funding model that requires a 25 per cent match from municipalities for public health spending.

Dean On Campus Responds: Agree.

Drummond: Consider fully uploading public health to the provincial level to ensure better integration with the health care system and avoid existing funding pressures.

Dean On Campus Responds: Agree.

Drummond: Improve co-ordination across the public health system, not only among public health units, but also among hospitals, community care providers and primary care physicians.

Dean On Campus Responds: Agree.

Drummond: Replicate British Columbia’s Act Now initiative, which has been identified by the World Health Organization (WHO) as a best practice for health promotion and chronic disease prevention, in Ontario.

Dean On Campus Responds: We likely need solid additional evidence to triple the spending on Public Health before we do so.

Drummond: Have doctors address diet and exercise issues before reaching for the prescription pad when dealing with health issues such as cardiovascular disease and late-onset Type 2 diabetes.

Dean On Campus Responds: I believe this is unfair. I don’t know a single family doctor who trivializes the importance of a good diet for his/her patients.

Drummond: Do more to promote population health and healthy lifestyles and to reverse the trend of childhood obesity, especially through schools.

Dean On Campus Responds: I agree that this is very important. It will require a massive shift in policy within our primary schools and municipalities.

Drummond: Work with the federal government on nutrition information and, where appropriate, regulation.

Dean On Campus Responds: Hard to argue.

Drummond: Medical schools should educate students on “system issues,” so they better understand how physicians fit into the health care system; for example, how to deal with patient needs efficiently and effectively, but using fewer resources by connecting different parts of the health care system.

Dean On Campus Responds: We already have extensive coursework on systems issues; and indeed two major competencies of our CanMEDS framework, (manager and advocate) are, in large part, dedicated to this issue.

Drummond: Do a better job of flagging health professions and locations that are currently in short supply or where shortages can be expected in the future.

Dean On Campus Responds: We have been struggling with HHR issues for decades. We have had innumerable reports followed by innumerable policies. We have oscillated between undersupply and oversupply. We have never, in a material way, addressed the issue of mal-distribution.

Drummond: Link the Ontario Drug Benefit program more directly to income.

Dean On Campus Responds: I agree that high-income seniors can afford to pay for their prescriptions, as long as we have a “catastrophic illness” clause.

Drummond: Help reduce medication errors through the use of electronic supports to cross-reference multiple prescriptions.

Dean On Campus Responds: Agree, but will require major IT investment.

Drummond: Reduce fraudulent prescription medication use through the use of drug information systems.

Dean On Campus Responds: Agree, but will require major IT investment.

Drummond: Pursue — with other provinces — the possibility of establishing a national entity that would set a common price for pharmaceuticals for the entire country (or at least jurisdictions opting in).

Dean On Campus Responds: Great idea, if doable.

Drummond: Conduct drug-to-drug comparisons to determine which drug is the most efficient at addressing a given ailment.

Dean On Campus Responds: This recommendation somewhat trivializes the expense, sophistication and capacity needed to do large-scale trials for complex issues in health. It also presupposes that the global medical community is not attempting to do this already.

Drummond: Work with the federal government to ensure that Ontario’s interests in expanding use of generic drugs are not undermined by a Canada-European Union Free Trade Agreement.

Dean On Campus Responds: Agree.

Drummond: Use pharmacists to their full scope of practice.

Dean On Campus Responds: I agree. My Dad was a pharmacist and was forever bemoaning the fact that what came to define a successful versus an unsuccessful pharmacist was the ability to make a profit from selling perfume and toilet paper.

Drummond: Centralize all back-office functions such as information technology, human resources, finance and procurement across the health system.

Dean On Campus Responds: I am not sure that the LHIN, as currently constituted, could even start the process of centrally controlling procurement for a region. We have to remember that hospitals have been at this game for decades, and have indeed made great strides.

Drummond: Establish a central mechanism to oversee the creation of a “spot market” for goods and discretionary services, such as diagnostics, infusions and specialist consultation services.

Dean On Campus Responds: I agree this would be a laudable goal. One wonders how achievable this is in a public sector environment.

Drummond: Put a wider array of specialist services to tender based on price and quality, while remaining under the single-payer model.

Dean On Campus Responds: I believe the report is a bit confusing on the issue of “private versus public” issue. Drummond argues for maintaining the principles of a single payer system, but argues for introducing an expansion of private – for profit – delivery. This is a very slippery slope, and I have grave concern, that encouraging this model will ultimately result in an American style system and erode one of Canada’s most cherished processions.

Drummond: Put to tender more service delivery, but with the criteria for selection based on quality-adjusted metrics rather than just price.

Dean On Campus Responds: This is very difficult to do, especially if delivery is done by private -for profit – entities.

Drummond: Accelerate the adoption of electronic records, working in a bottom-up fashion.

Dean On Campus Responds: Agree, but again, incentives to transform medical records will cost money. Drummond is recommending we hold expenses to 2.5% growth, down form its current 6% level. That’s a massive effective reduction of dollars into the system, and I am unclear as to where the savings are coming from.

Drummond: Adopt the Nova Scotia model in which emergency medical technicians provide home care when not on emergency calls; this requires integrating municipal and provincial funding structures.

Dean On Campus Responds: Sounds like a good idea.

Drummond: Provide better information to individuals and families to facilitate self-care, for people with conditions such as diabetes.

Dean On Campus Responds: Also sounds like a good idea.

Drummond: Begin a dialogue with Ontarians on the issue of expanding the coverage of the health system to include, for example, pharmaceuticals, long-term care and aspects of mental health care.

Dean On Campus Responds: I don’t quite get this one. How can we begin a dialogue to spend a lot more money when the overall intent is to deal with a 17 billion dollar deficit by decreasing public spending?

Drummond: Involve all stakeholders in a mature conversation on the future of health care and the 20-year plan.

Dean On Campus Responds: I have heard this before… that we need to have an adult conversation. The implication is that health care professionals and administrators have been somehow child-like in their approach.

Recommendation 5-104: Establish a Commission to guide the health reforms.
The scale of reform we propose is vast, dealing with organizational, clinical and business issues. There is a precedent for this approach; the Health Services Restructuring Commission was given power from 1996 to 2000 to expedite hospital restructuring in the province and to advise the Minister of Health on revamping other aspects of Ontario’s health system.

Dean On Campus Responds: I would not disagree that we need to translate many of Drummond’s great ideas into action. This will require a non-governmental or quasi-governmental body to effect change. As Drummond implies, we have to somehow divorce this from the political realities of the day…not an easy task.

Drummond: Do not let concerns about successor rights stop amalgamations that make sense and are critical to successful reform.

Dean On Campus Responds: Perhaps we at Queen’s should be encouraging Don to run for office. Not outside the realm of possibility?

I’ve learned a lot by studying the report. Hope my reflections add at least one other perspective on some issues. If you have thoughts about this report from the Commission on the Reform of Ontario’s Public Services, please respond to this blog, or better yet… please drop by the Macklem House, my door is always open.

Richard

1. http://www.fin.gov.on.ca/en/reformcommission/

14 Responses to DeanOnCampus Responds to Drummond Report

  1. Ryan K says:

    A very enlightening read. I agree completely with your assertion that relativity is something that has failed to be adequately addressed thus far. It seems to be a sore point for many hard-working practitioners who feel that their services and skills are de-valued by the current fee structure relative to their colleagues.

    As a thought experiment, I sometimes think what the system would look like if all physicians made the same incomes, and personal interest/enjoyment was the sole reason that person chose his or her specialty over the other ones.

    • reznickr says:

      Thanks Ryan,

      I believe there are some countries where this is the case for public service in medicine. That being said most jurisdictions (other than Canada) have some element of private medicine which creates a heterogeneity of income.

      Richard

    • Medical student says:

      This issue was broached at the OMA President’s tour in Kingston in the fall. Was very disappointed to hear Dr. Kennedy’s long explanation as to why physicians are not all paid the same amount, all other things equal, essentially boil down to “historical precedence”.

      • reznickr says:

        Dear Medical Student,

        I do believe you are correct that the attempts so far to address historical inequities in the fee schedule have been modest at best.

        Richard

  2. Paul Rosenbaum says:

    Thanks for the summary Richard. I would like to comment on two points: a 2.5% cap on public expenditure and the recommendation that we introduce competition based on price.

    I think it very unlikely that cost increases in care (price plus ddemand due to demographic change) will fall below 2.5%. To achieve what Drummond recommends would require shifting cost from the state to the individual. There are two fundamental problems with this. First, it sees a weakening of the OHIP system, growth in personal insurance for those able to afford it and concomitant loss of interest among the insured in maintaining OHIP. Secondly, what matters to society is total burden of care and not the distribution between individual burden and government burden. For example, fifteen percent of GDP on health care is still 15% regardless of what share is carried by individuals. That money is then not available for other purposes.

    My second concern is the introduction of price competition. Lots of evidence suggests the first to go will be health provider education and research. For example, ophthalmologists can work faster without residents and clerks and would, therefor, compete better without them. Pathologists not conducting research can reduce numbers and price service lower. We have seen this in other jurisdictions and even in Ontario (more difficulty placing Rehab students when hospitals shed the service and it moved to private providers).

    • reznickr says:

      Paul,

      Thanks for your thoughtful and analytical comments. For readers who do not know Paul, these words of wisdom are coming form someone who has invested more than 20 years understanding and working in the economics of health care. I certainly share your concern Paul, for the slippery slope of chasing after the price of a procedure or service.

      Richard

    • Rick Janson says:

      There is also an inherent contradiction between the idea of planning health care and locating it with providers that can achieve a certain price point. Where does the question of access come into the picture when decisions are made on price? This is a particularly relevant question when addressing northern and rural health services.

      And how often do you conduct such competitions? Does this not, of itself, lead to questions of instability when health care providers don’t know from year to year whether they will be continuing on?

      In home care it has already created high levels of turnover of professionals within the agencies, and a bust and boom cycle in terms of available care. At this time of year the agencies and the CCAC have already spent most of their money, so accessing home care is difficult for anyone but the most acute patients. Given it is also the time of year when hospitals are at peak demand, it makes it more difficult to discharge patients.

  3. Michael Jewett says:

    Richard, as an alumnus and practicing academic urological surgeon in Ontario, I am constantly amazed that the reviewers of our provincial systems don’t raise the question of why we don’t work towards a national system of health care. There has been some movement in drug approval but cancer care is a good example of very little cross talk. BC has a great cancer drug approval process for example. All provinces have tumour registries with various reporting timelines so we really don’t have good national stats. Wait times for cancer surgery are being approached in 10 ways rather than doing an randomized trial of methodologies. We carry huge administrative costs for duplication of “back office” functions in each province. Physicians are accused of being parochial but I would argue that the provincial politicians are in another league.

    • reznickr says:

      Dear Michael, so nice to hear your views, and for those who don’t know you, these views are coming from one of Canada’s most respected academic surgeons.

      The federal-provincial divide is quite striking, especially in health. One could argue that the chasm has been deepened by the recent move by Flaherty “pre-empting” the 2014 accord. I couldn’t agree more that we need to address our issues together. There may be some movement on this as Premiers Ghiz and Wall have just been appointed to lead a trans-provincial initiative on addressing some common issues. The three highlights will be HHR planning, scope of practice and evidence-based care. But even this initiative is “in the void” of federal governmental input.

      Agree with the theme of your comment.

      Richard

  4. Will Falk says:

    Richard,

    I applaudyou for your diligence and intelligence in working through each of the Recs. I learned something reading your comments. What donyounthink ofnthenreport inToto?

    Will
    @willfalk on twitter

    • reznickr says:

      Dear Will,

      In response to my view on the total report, I would start by saying its difficult to formulate an opinion because the report is so broad and covers so much territory. I do applaud Don for being very courageous in tackling the issues in such a comprehensive way. Therein lies its value, but also its limitations.
      I would characterize the recommendations into three categories. There are many which challenge us to do better and attempt to effect transformative change, much in the way we did in the early 90′s in response to a financial crisis. There is a second group that I would characterize as unduly harsh and unfair towards doctors, hospitals and other elements of acute care. And I third I would suggest are areas in which we have been working for a very long time, have made great progress, but of course could do more.

      All my best, and I know the readership would enjoy your recent excellent work, Shifting Gears at http://www.mowatcentre.ca/general/SGHealthSept23_final.pdf

      Richard

  5. Paul Rosenbaum says:

    Further to the recommendation that Ontario introduce price competition, this article in JAMA seems to demonstrate that Ontario hospital expenditure is related positively to outcome. “No free lunch”m Mr. Drummond.

    http://jama.ama-assn.org/content/307/10/1037.full.pdf#page=1&view=FitH

    • reznickr says:

      Paul,

      Thank you for this contribution to the discussion. The article is very interesting and certainly presents evidence to suggest Drummond’s assumptions need to be challenged. thanks for bringing this perspective to our readers attention.

      Richard

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