Rethinking visiting hours

We can see that parking policy should be developed in partnership with patients. Hospital visiting hours are a similar issue. We can trace some of the changes in patient-oriented policy as hospitals become more patient-friendly by looking at policies about visiting hours.

In the early days of the modern hospital, visiting was discouraged. In the comprehensive manual from 1913, The Modern Hospital, the authors are very clear:

We may begin with the flat argument that it would be best for all sick people if all visiting could be prohibited and it is a recognizable situation in nearly every hospital that has visiting days that the temperatures are higher at night on the visiting days than at other times, all else being equal, and this is due to the excitement caused by visitors, not alone one’s own visitors but those who come to see other people…

In considering the visiting question, therefore, we have two or three fundamental ideas in the foreground; one of them is that we ought to restrict visiting as much as possible and we ought in any event to limit visits to the one patient whom visitors come to see. And visits should be as short as possible and whenever it can be done each patient should be restricted to one or two or at least a minimum number of visitors. (Hornsby, Schmidt 490)

In the old days, visiting hours varied by class of patient. Charity (free) patients had severely restricted visiting hours, often limited to a few hours every week. For example, visiting hours for the Children’s Department are listed:

Large (free) wards, 2 to 4 pm Wednesday and Sunday

Small (private ) wards: 1 to 8 pm daily

Private rooms: without other limitations than the order of attending physicians. (Hornsby, Schmidt 340)

Times have changed. Today there is a recognition that patients can benefit from visits, and typically visiting hours have been much extended. Nonetheless there are usually restrictions imposed that vary widely from unit to unit. Restrictions can make things difficult especially if one is trying to stay to support an elderly relative or stay close to a very sick friend.

A recent article in the New York Times describes the view of the Institute for Patient and Family Centred Care (IFPCC) which is to lift all restrictions on visiting hours. They point out that, increasingly, families and those close to patients can play a crucial role in their care. Beverley Johnson, the President of the IFPCC says, “People should go to a hospital with a family member or trusted friend to be an advocate, to ensure continuity, to answer questions and prevent errors.” The article in the New York Times goes on to explain that,

Because she was with her centenarian mother in a Florida hospital, for example, she could explain to a doctor who had never met either of them that that no, her mother did not have a pacemaker, and perhaps he had confused her with a different patient. (Span para 8)

The IFPCC argues that if hospitals do want to partner with patients and their families, it will be important to begin to lift restrictions on visiting hours as a matter of policy. As Johnson says, “You can’t partner with families if you’re locking them out of the hospital, especially when patients are most vulnerable” (Span para 4). We agree that policies about visiting hours should be reviewed with this in mind.

Hornsby J, Schmidt R. The Modern Hospital. Philadelphia, Pennsylvania: W. B. Saunders Company; 1913.

Span, Paula. “A Move to Extend Visiting Hours at Hospitals.” The New York Times. Web. 11 July 2014.

Parking policy from the patient and family perspective

Last week we started to identify some policies that are meant to improve patient experience in health care. Parking costs are a good example of a policy area that is of concern to patients, but one that they are usually excluded from. It’s also a policy area that rarely enters the minds of providers as a factor in patient-centred care.

Parking policy is not central to the range of hospital concerns, but in my experience, discussions about parking take up quite a lot of administrative time – both in terms of privilege (who gets to park where) and cost (how much do we charge employees, patients, doctors, etc.) This is so even though hospital parking does not provide much more than 0.25% of hospital income. As patients begin to participate in health care, this is a pretty straightforward area to redesign with patient input.

We are not alone in this. An editorial from the Canadian Medical Association Journal in January 2012 brought the perspective of some doctors to the issue:

A patient who seeks care in a Canadian hospital has to pay for parking. Parking fees amount to a user fee in disguise and flout the health policy objective of the Canada Health Act… Parking fees are a barrier to health care and add avoidable stress to patients who have enough to deal with. They can and sometimes do interfere with a clinical consultation, reducing the quality of the interaction and therefore of care. Almost every hospital doctor in Canada would be able to narrate anecdotes of patients being preoccupied with parking fees. Such distraction interferes with the clinical consultation. For example, some patients (who have often waited several weeks to see a doctor) try to end a consultation abruptly when they realize that they will have to pay for an additional hour for parking. This is parking-centred health care, which is not compatible with patient-centred health care (Kale).

The editorial goes on to expand the argument about the impact of high parking costs on the doctor-patient interaction. It argues against the resistance of hospital administrators:

Hospital administrators and politicians will argue that they will lose a valuable source of essential revenue if parking fees are abolished and will look to ministers to make good such losses. Though hospitals rake in several million dollars from parking fees, the net revenue from parking is likely to be around 1% of the total revenue. For example, for The Ottawa Hospital, for the fiscal year 2011/12, the net parking revenue is projected at $10.8 million while the total revenue is about $1.16 billion, excluding revenue from parking. That is a small sum to pay to get rid of parking-centred health care (Kale).

A comprehensive study at by the Centre for Health Economics at York University in England concludes:

Donabedian (1973) defined accessibility to health care as “those characteristics of the resource that facilitate or obstruct use by potential clients.” Travel, parking and time costs, both monetary and non-monetary, are one such characteristic. Microeconomic theory predicts that the price of access will affect the level of demand (utilisation by patients or visits from friends or relatives) if access is price-elastic (or cost-elastic). The empirical studies reviewed here provide some support for view that access levels by visitors are sensitive to cost, but the review found no evidence on the relationship between monetary access costs and uptake of hospital services by patients…

The majority of patients attending for outpatient appointments use cars to access the hospital. In England, parking charges vary geographically and the parking experience can sometimes be an additional source of financial pressure, worry and stress (Mason 11).

The report recommends that hospitals be encouraged “to do all they can to make the parking experience a good one” (Mason 11). At Patients Canada, we agree and suggest that a critical component of this effort is to partner with patients to co-design improved parking policies from the patient and family perspective. Patients and families have had both good and bad experiences with parking that can help inform parking policy. Some clear examples concern costs: the cost of frequent use by family members of long stay patients, the high cost of lengthy emergency room visits, costs that deter visits by friends to inpatients, and so on. Another concern is way-finding: the difficulty of getting from the visitors’ parking lot to the part of the hospital to be visited and at times, the great distances involved. Yet others are about the lack of easily accessed information about hospital parking policy: patients and families are often unaware of existing policies that might make the experience of parking easier and less costly.

On Saturday, the New York Times reported that hospitals are extending visiting hours and in some cases, removing restrictions on visiting altogether (Span). This is a significant change that is being advocated by the Institute for Patient and Family Centred Care. It will allow friends and family members more access to patients who can benefit from their company. The impact of this change in visiting policy on parking will make it even more critical to review parking policy. The experience of patients and those close to them can make important contributions to the development of patient-centred policies throughout health care. We will continue our discussion in upcoming blog entries.

Kale, Rajendra. “Parking-centred health care.” Canadian Medical Association Journal 184. 1 (2012): 11.

Mason, Anne. “Hospital Car Parking: The Impact of Access Costs.” Centre for Health Economics, York University CHE Research Paper 59 (2010).

Span, Paula. “A Move to Extend Visiting Hours at Hospitals.” The New York Times. Web. 11 July 2014.

Patient developed health care system

Several weeks ago I wrote that according to the World Health Organization’s definition, we do not have universal healthcare coverage in Canada. I also said that as far as I could tell, we are the only country in the industrialized world that does not have universal coverage. The example that I used was that we do not have coverage for prescription drugs administered outside the hospital. But there is lots more that we don’t have and also some things that we do have that show how limited our system really is.

The reason for this limitation is largely historical. The Canadian publicly-funded health care system began with hospital insurance in Saskatchewan in 1947. We can be proud of that first step – we had hospital coverage a year before the NHS was created in England. However we were left behind once the far more comprehensive NHS was established in 1948. It covered hospitals, drugs, primary care, eye care (with the now famous NHS spectacles), dentistry, and a lot of diverse health care in the community. We never caught up.

Our limited system developed from hospital coverage in Saskatchewan and then for all of Canada in 1961. It was only in 1972 that all provinces provided coverage for doctors. That is where we seem to have stopped – we still do not have national coverage for all those other things covered by the NHS.

A little over ten years ago, I was asked by the researchers for the Romanow Commission to write a description of what a well-functioning health care system in Canada would look like. Brenda Zimmermann and I toiled for months on our paper which was well-received and is still widely referred to. It has since occurred to me that it would be a good idea to develop the specifics of what a well-functioning Canadian health care system would look like from the patient’s point of view. What would the policies of our system look like if patients were to lead us toward a system with universal coverage?

In our paper, Brenda and I used the now widely quoted basic requirement for a well-functioning health care system that: “It should be there for you when you need it.” What we meant was that healthcare should be a support for us in our anxiety and pain when we, or those close to us, are not feeling well. Its policies should encourage caring and generous support for us. We have a way to go to provide such a system at the moment, although lots of things can easily make it better. An excellent example of this, although seemingly innocuous, is parking.

PARKING

At an Open Meeting held by Patients Canada, we tried a new way of gathering peoples’ thoughts about health care services. We collected short phrases about three emergency rooms (ERs): the current state of the ER, the ideal ER and the ER from Hell. We also asked what might characterize each of them. The discussion was lively and everyone had brilliant ideas about what might constitute the emergency room in heaven and not surprisingly, some said that the current emergency room is the ER from hell.

Most everyone enjoyed the exercise and found it gave them a chance to work with others and provided lots to think about. Waiting times were not the only issue. Some more lateral-thinking participants pointed out that in heaven there would be no emergency room at all. If you needed hospitalization, you would go straight in. If you did not, you would be cared for by a community agency. Parking costs loomed high in many of the discussions. In fact, when we created the word clouds from the patients’ lists, the word “Parking” was among the most prominent. For patients, parking costs at emergency departments are an indication of the lack of generosity and compassion displayed by many hospitals. What patients need is reassurance that the institutions who offer care do so with a generosity of spirit that is evident in all their policies.

Below are some of the parking costs at major hospitals in Toronto, as well as the price for on-street metered parking near Toronto General Hospital for 30 minutes and one hour slots. There is no all-day street parking nearby. If you want to visit someone at the Hospital for Sick Children or one of the downtown hospitals and park in their facility, a one hour visit can cost $12.00 and if you go a few minutes over an hour, it will be $18.00.

ParkingWe repeated the exercise with providers at the Central West LHIN with a similarly enthusiastic response. This time there were about 100 participants. We collected their ideas and had volunteers help us to input the material to create another word cloud. Here, “parking” did not appear at all. The most prominent word was “doctor.” The skill and dedication of ER doctors and nurses is certainly critical to the quality of emergency medicine. Providers need the money offered by parking and do not recognize the impact it has on patients and their families.

Parking seems like an odd thing to begin with, but it is useful to show that patients bring a different perspective to policies than providers. It seems that in Canada everyone might want to think about what comprehensive coverage means. In England, there is now a fierce debate as to whether hospitals have the right to charge patients for parking. Comprehensive health care coverage should, according to many advocates, include the cost of parking. Charging for parking, they say, institutes a user fee for health care services.

In Canada, there are other problems with parking. When your relative is in an acute hospital, rehabilitation facility or a long-term care institution for any period of time, the costs of parking add up. What is on offer by many such institutions is a recognition of the extreme costs of daily parking by offering reductions to long-term users. Given the amount of care provided by such family caregivers, the institutions might reduce costs to the level of staff or even give a free pass (like they do to some volunteers), if relatives could guarantee that they are there providing free care and support every day.

The argument made for charging for parking is that it is a significant source of income for the hospitals. However the money might not be worth the impression it makes on us: it demonstrates a lack of generosity and compassion. From the patient point of view these are critical components of care.

A Canada day celebration of Canadian health policy

For the last few weeks I have been writing about health policy in Canada from the patient’s perspective and Paradigm Freeze, a new and interesting book that has a narrow view of the Canadian health care system and hence a somewhat limited view of what constitutes health policy. The selection of policy topics it studies leaves out the most significant policy document in the history of Canada, and one which has had a continuing impact on how Canadians perceive health and healthcare. It is, of course, the Lalonde Report.

The week of Canada Day seems to be a good time to speak about the Lalonde report, A New Perspective on the Health of Canadians. That we no longer think of health as a product of medical science, but rather as a consequence of a complex array of determinants, is in no small measure due to the Lalonde report. Its publication marked a rather rapid paradigm shift around the world concerning the nature of health and health policy. Soon after the report was issued an international movement began to think about health policy in terms of health promotion and overall health status. This resulted in international declarations like the Ottawa Charter for Health Promotion in 1986.

The Lalonde report is named for the then Minister of Health and Welfare, Marc Lalonde, but it was actually written under the leadership of Hubert (Bert) Laframboise, an Assistant Deputy Minister in the Federal Department of Health and Welfare, where he created a “free-wheeling think tank” with which to inform government policy discussions.

The ideas of Thomas McKeown about health and health policy formed the core of this new approach. In the UK the National Health Service (NHS) had been created with the belief that a universally funded health care system would improve the health of the population and eventually reduce the demand for health care. This hope was never realized, and perhaps it never could have met that goal. In this context McKeown’s central idea was that one had to go beyond standard medical services to improve the health of the population. Indeed McKeown’s arguments were a polemic against the view that medical care was a major contributor to improving the health of a population. He argued that the medicine of the day had mistakenly reduced the concept of health to a mechanistic explanation of the state of the human organism.

The approach to biology and medicine established during the seventeenth century was an engineering one based on a physical model.  Nature was conceived in mechanistic terms, which led in biology to the idea that a living organism could be regarded as a machine which might be taken apart and reassembled if its structure and function were fully understood. In medicine the same concept led further to the belief that an understanding of disease processes and of the body’s response to them would make it possible to intervene therapeutically, mainly by physical (surgical), chemical, or electrical methods.

For McKeown,  “the major contributions to improvement in health in England and Wales were from limitations of family size (a behavioural change), increase in food supplies and a healthier physical environment (environmental influences), and specific preventive and therapeutic measures.”

The Lalonde report identifies four major influences on health and speaks of them as constituting the “health field”. The table below describes the four quadrants of the health field.Lalonde report table

Here are some examples of policies that have increased Canadians participation in their own health

There is no question that the Lalonde report marked a paradigm shift in Canadians’ sense of responsibility for their health, however I am offering only a few examples of major change and looking at only one of the quadrants. (For a more complete account please look at Towards A New Perspective on Health Policy)

Exercise

At the time of the Lalonde report moderate exercise meant going to the gym three times a month. After its publication and the introduction of policies and programs that encouraged fitness training, like ParticipACTION, moderate exercise means going to the gym at least three times a week.

Nutrition

In 1974, Canadians ate red meat and few green vegetables. The Canada Food Guide had been dormant since 1961. A new Food Guide emerged in 1977 soon after the Lalonde report. It recommended less red meat and more fruits and green vegetables. Since then Canadians have significantly changed their eating habits for the better.

The Canadian Organic Growers organization was founded in 1975 immediately after the Lalonde report was published. At the time organic foods were sold in the back part of a very few health food stores, but now regulated organic food is now sold in every major supermarket in Canada.

Smoking

At the time of the Lalonde report 46.7% of adults in Canada smoked cigarettes. That number in 2013 was 19.3% proving that policies to reduce smoking have had a strong impact on smoking reduction. According to The Emperor of All Maladies: A Biography of Cancer, smoking reduction campaigns have had a far greater impact on cancer reduction than all the billions of dollars spent on cancer research.

These three sets of policies have had a major contribution to the changing mortality and morbidity rates in Canada. We no longer die in our 60s of heart attacks, of lung cancer and strokes. We live longer and are prone to longer chronic conditions. This is largely due to the paradigm shift that happened after the publication of the Lalonde report, something that I think is worth celebrating on Canada Day.

 

Health policy from the patient perspective: does Canada have universal health care coverage?

The last topic covered in Paradigm Freeze is prescription drug plans. The multiplicity of provincial plans in Canada ranges from complete to very little coverage to serve as a safety net. Here it isn’t necessary to follow the book to make a point from the patient perspective.

In recent years, the World Health Organization (WHO) has made a strong effort to encourage developing countries to provide universal health care coverage to their populations.

Universal coverage (UC), or universal health coverage (UHC), is defined as ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.

This definition of UC embodies three related objectives:

  • equity in access to health services – those who need the services should get them, not only those who can pay for them;
  • that the quality of health services is good enough to improve the health of those receiving services; and
  • financial-risk protection – ensuring that the cost of using care does not put people at risk of financial hardship.

Universal coverage brings the hope of better health and protection from poverty for hundreds of millions of people – especially those in the most vulnerable situations (WHO).

It is clear from the definition and supporting documents that universal coverage includes not only hospitals and doctors, but also a wide range of health-related services that add to the cost of healthcare: prevention, therapeutic services, costs of access and so on. Prescription drugs are clearly a significant part of universal health coverage.

The Canada Health Act does not provide for universal coverage – out of pocket expenditures on health care has been increasing over the years. One of the consequences of this is that the cost to Canadians has grown significantly over the last few decades. The figure below shows that the burden of this falls mainly on the poorest part of the population who spend close to 6% of their after-tax income on healthcare (Government of Canada). This is largely on prescription drugs.

Figure 1In an investigation by CTV, it was found that the cost of drugs for cancer care is being passed on to patients when they can take these very expensive drugs at home (CTV). Having to provide for these expenses can impoverish patients and their families. This defies one of the main principles of the WHO’s definition of universal coverage. The story of one of our members is not atypical: the surprise at the pharmacy counter that comes when discovering the cost of cancer drugs outside the hospital; the slow realization that those costs will eat up the family’s life savings; the desperate search for other sources of funding; the disappointment with drug coverage by private insurance plans; and the threat of impoverishment because of the lack of proper drug coverage under medicare.

Which other major developed countries do not include prescription drug coverage in their publicly funded health plans? None. Now that the United States has the Affordable Care Act, Canada is alone among major developed countries in not having universal health care coverage.

WHO: What Is Universal Coverage?” WHO. Accessed June 12, 2014. http://www.who.int/health_financing/universal_coverage_definition/en/

Government of Canada, Statistics Canada. “Trends in out-of-Pocket Health Care Expenditures in Canada, by Household Income, 1997 to 2009,” April 2, 2014. http://www.statcan.gc.ca/pub/82-003-x/2014004/article/11924-eng.htm.

“CTV Investigates: The Cost of Cancer Care.” Kitchener. Accessed June 12, 2014. http://kitchener.ctvnews.ca/ctv-investigates-the-cost-of-cancer-care-1.1862427

Policy for patients – waiting list management

Waiting lists are the fifth research topic in Paradigm Freeze. The chapter on Alberta presents the problem by saying that “expenditure reductions undermined capacity of the system to meet increasing demands for services” (Lazar, Lavis and Forest 47). As a result, waiting lists were given special attention at the Federal Provincial Accord on Healthcare in 2003. Increased dollars were lavished on resources and researchers. And ten years of effort should have resolved the problem, or at least brought us into line with other countries. We had no such success. The Alberta report explains:

The initial political response in 1996 was to devote additional public money to alleviate immediate demands for cardiac and joint replacement surgeries. As the decade progressed and long wait times persisted despite the infusion of additional resources politicians and bureaucrats grew to better understand the complex relationship among surgeons, facilities and other health providers such as acute care surgical nurses. By the late 19990s resources were directed to all three of these areas as opposed to the earlier approach of targeting money to pay for operating room time only (Lazar, Lavis and Forest 48).

The infusion of money was accompanied by the research community’s relatively unsuccessful efforts to gain access to full waiting list numbers. This is described with perhaps the most mouth-twisting coded language in all of the policy literature:

To address the specific issue of wait times, Alberta introduced a voluntary, publicly accessible Internet-based wait list registry in 2003. The choice of a voluntary registry reflected the interplay of three factors: preference for personal responsibility and choice; and recognition of the original bargain with organized medicine with its primary focus on professional autonomy (Lazar, Lavis and Forest 48).

In short, the doctors would not give up their closely held waiting lists and it was up to the general public to take responsibility for the choices they made without adequate information because the internet did not and could not provide accurate waiting times.

Kenneth Arrow who was the father of health economics said that unlike the usual law of supply and demand, in healthcare supply drives demand: the more health care that is supplied, the greater the demand for it. Here is an excellent example of the application of what we might call Arrow’s Law: the more resources that were thrown at the problem of long waiting lists for elective surgery, the more people were on the lists.

Perhaps the most important thing to know about waiting lists is that we, as patients, do not simply get into line like we do at movie theatres. We are put on those lists based on several factors: firstly, the surgeon judges that we would benefit from the surgery and secondly the surgeon will make the list long enough so that in case of a cancellation, there will always be someone waiting to receive the procedure. From personal information given to me by a friendly surgeon, a three month waiting list is perfectly adequate for this purpose.

What have we learned? Patients do not have the right to put themselves on waiting lists for elective surgery, doctors do. And secondly, the more doctors we have, the more people will be on waiting lists. This is so even if each one has only a three-month waiting list. If you think this is a vicious cycle, you are right – more resources means more people waiting, and more people waiting means more resources are needed, et cetera. Go figure.

Next week we will discuss prescription drugs, the last topic of Paradigm Freeze.

Lazar, Harvey, John Lavis and Pierre-Gerlier Forest. Paradigm Freeze: Why is it so hard to Reform Health-care Policy in Canada. McGill-Queen’s University Press, 2013.

Policy from the patient’s perspective: alternative payment plans

The third policy change discussed in Paradigm Freeze is about alternative payment plans. This is a particularly critical area from the patients’ point of view. The longstanding method of payment for doctors in Canada has been what is called “fee for service.” According to this method of payment doctors are considered to be independent agents who do not work for the government. Every time a patient sees a doctor, the doctor bills the government for that visit. There is a schedule of fees that is established, usually in negotiation with the medical association in each province. For a long time the vast majority of doctors were paid in this way.

This method of payment carried with it the financial incentive of seeing as many patients as possible, for the shortest time possible. There is some reason to believe that this payment method resulted in the erosion of home visits because doctors were not adequately paid for the time required for such visits. It also restricted visits to predetermined periods of time, usually ten or fifteen minutes. This would let doctors’ offices schedule and bill in a cost efficient way. There were no higher fees if visits took more time. Further, at times it encouraged such patient unfriendly policies as “one issue per visit.” Patients were told that in order for them to deal with more than one health issue they would have to make separate appointments because the doctor was only paid a small amount of money for each visit. To be fair, this policy was adopted by a minority of doctors and for a fairly short period of time. It was too patient unfriendly and only the most tough-minded doctors continued to follow this policy for any length of time.

Although most doctors enter medicine somewhat altruistically and not merely to maximize their income, there is a widespread policy view that economic incentives are the most effective way to change medical practice. And so alternative payment plans have been introduced to offer such incentives. The most common ones are annual salaries, to assure income and change accountability and capitation – where doctors are paid by the number of patients who are tied to their roster. The book describes how such plans are applied in the five provinces studied. Some of the alternative payment plans also encourage doctors to practice in groups rather than in stand-alone practices by paying additional sums.

From the patient perspective, the most promising organization of primary care doctors is one in which the doctors work for the community they serve. In Ontario, this has taken the form of Community Family Health teams. Here is a description of them taken from the Association of Ontario Health Centres’ web site.

Community Family Health Teams (CFHTs) are non-profit primary health care agencies that provide patient-centred care delivered by inter-professional teams. Their services are varied and include clinical care along with health promotion and illness prevention. Health teams can include physicians, nurse practitioners, physician assistants, physiotherapists, chiropractors, dietitians, social workers, nurses, health promoters, respiratory educators, and administrative support.  Many teams are also complemented by other health care professionals through partnership agreements.  Fifteen CFHTs are members of AOHC.

CFHTs differ from the provinces’ more numerous physician-led Family Health Teams in that they are governed by community members who direct the policies and priorities for services offered. This means CFHTs are well equipped to orient their services to the needs of the communities they serve and, increasingly, CFHTs are deciding to focus their resources on the needs of community members who face barriers accessing care or whose living circumstances leave them vulnerable to poor health.

Another important difference between CFHTs and FHTs is that in CFHTs physicians are employed on a primarily salary basis; in FHTs physicians are a member of a physician group that is associated with the FHT and compensated using a capitation model.

Interestingly there is almost no mention of this type of Family Health Team in Paradigm Freeze. There is also no discussion of the advantages to patients and other community members of increasing their capacity to plan and develop the range of services available in primary care in their community. Such organizations are structured to respond to the expressed needs of patients and their families. Their introduction in Ontario, like the introduction of CLSCs in Quebec, is certainly noteworthy from the patients’ point of view.

“What is a Community Family Health Team?” Association of Ontario Health Centres. N.P., n.d. Web. 09 June 2014.

Policy from the patients’ perspective: needs-based funding

So far in this series on Paradigm Freeze, I’ve presented the various areas that the writers of selected for study. I’ve also focused on regionalization, as it became clear that the processes and consequences considered in the book were restricted to the boundaries of the current healthcare system and were especially focused primarily on acute care. The book appears to argue that it is hard to reform that system, but does not consider expanding or even significantly changing what the system contains.

The same appears to be true in their discussion of needs-based funding. For a long time, the funding for health care was historical: every year the budget for each health care organization was revised based on the previous year’s funding. The problem was that this funding model provided no basis for change or development, nor was it related to the changing needs of the population. The model of needs-based funding presented in Paradigm Freeze derives from an article called “The Financial Management of Acute Care in Canada” by McKillop, I., Pink, G.H., and Johnson, L.M. This article is concerned only with how hospitals are funded. Here is the main table that sets out the various types of “needs-based funding.” Note: Global funding is what we usually mean by historical funding.

Method  //  Description

1. Population-based:    Uses demographic or other characteristics of the population (such as age, gender, socio-economic status, etc.) to determine the relative propensity of different population groups to seek health services.

2. Facility-based:    Uses characteristics of the organization providing care (such as size of the organization, type of the organization, geographic isolation, occupancy rate) to estimate the cost to sustain a specified profile of cases and/or service volumes in the future.

3. Case Mix-based:    Uses a profile of cases and/or service volumes previously provided (such as a number of knee replacements, number of dialysis procedures) to estimate the cost to sustain a specified profile of cases and/or service volumes in the future.

4. Global:    Applies a factor to a previous spending figure (or to a forecasted cost) to derive a predicted spending level for an upcoming period.

5. Line-by-line:   Applies factors on an individual basis to previous cost experiences (or to forecasted costs) to derive a proposed funding level for each line item (such as housekeeping, inpatient nursing, etc.) for an upcoming period.

6. Policy-based:    Directs spending to address specific policy initiatives of the Department or Ministry of Health. These policy initiatives affect the operation of multiple organizations within the jurisdiction.

7. Project-based:    Flows funds to a single health service organization in response to evaluating a proposal from that organization for one-time funding, often for a major expenditure.

8. Minister discretion:    The Minister of Health decides on the specific dollar amounts to flow to health service organizations.

This is pretty comprehensive if we are looking only at what hospitals need. But it is not so good if you consider the health care system on a larger scale and the needs of people with non-acute long term conditions. It is especially not effective if we want to consider what such people need to stay out of hospital. During the study period of this book, we already knew that we had an aging population that could benefit from many health-related interventions apart from acute care and that it was generally a good idea to keep people out of the hospital. Therefore it seems really odd that Paradigm Freeze considers the health care system to be made up of hospitals and doctors and little else.

The result of this rather myopic view is that the study considers only provincial policies. It does not discuss the policy struggle between the health promotion community and population health researchers at the federal level. There is little doubt that this battle has important consequences for needs-based funding for health care in the broader healthcare system.

Health promoters were the offspring of the Lalonde Report, perhaps the most widely known policy document to emerge from Canada. In the 1970s and 1980s, they were a dominant force in Health Canada that instituted programs like ParticipACTION to encourage personal fitness, pressed successfully for anti-smoking campaigns, lobbied for and instituted seat belt legislation, reinstituted the Canada Food Guide which had been dormant since 1961, and initiated community development programs. Their loss of influence and funding meant that these and similar efforts slowed down and often stopped completely. ParticipACTION, for example, was disbanded in 2001 and only re-emerged in 2007 in response to the growing concern about inactivity and obesity.

Population health researchers derived their view from inequalities in health research in the UK. They argued that health promotion was an ineffective way of improving the health of the population – that it was important to consider the underlying causes of “why some people were healthy and others not” – that is to say, the underlying social and economic forces. The efforts of health promotion were considered to be ineffective in dealing with such disparities and some even argued that because they were largely focused on a middle class population, they actually increased inequalities in health. The population health group made up of health economists, demographers and health services researchers gained ascendency. Their mantra of reducing inequalities in health kept the focus on determinants of health over which individuals and communities had little or no control. Over the next decade it emerged that their control over the research agenda had very little influence on reducing inequalities in health through policy development. In fact, during their period of influence, inequalities have actually increased. Little wonder that current policy thinkers who emerged from that period should think that health policy has little impact on the system.

McKillop, Ian, Lina M. Johnson, and George H. Pink. The Financial Management of Acute Care in Canada: A Review of Funding, Performance Monitoring and Reporting Practices. Ottawa, Ont: Canadian Institute for Health Information, 2001. Print.

A primer on policy from the patient perspective

Reading some more of Paradigm Freeze, it became clear that its authors consider that the Canadian health care system primarily includes hospitals, doctors and the services they provide, and that policy changes are meant to reform that landscape. In the book, they are worried about how slowly this system changes. Let’s take a look at how the system came to be in the first place – here are some significant events in Canadian health system development:

• 1947 Saskatchewan Hospital Insurance Program
• 1949 British Columbia Hospital Insurance Service
• 1962 Saskatchewan Hospital & Doctor care
• 1957 A National Hospital Insurance Program across Canada
• 1966 Medicare Hospital & Doctor care across Canada
• 1984 Canada Health Act:
- Covered hospital care and Doctors’ fees for medically necessary services
- Did not cover drugs outside hospitals
- Did not cover much non-medical treatment outside hospitals and doctor’s  offices

The “centre local de services communautaires,” or CLSCs as they are known, are an example of a service that is hardly considered in the book. These local community services organizations came into existence in Quebec as a result of major reforms and since then have virtually disappeared in the process of regionalization.

CLSCs were put in place in the 1970s during the quiet revolution in Quebec. These organizations, along with others like the CEGEPs (Collège d’enseignement général et professionnel or in English, General and Vocational College), were part of a larger vision to create a comprehensive social umbrella that would be responsible for the overall wellbeing of its citizens. At the time, participative democracy determined the expressed values of the CLSCs. They were governed by citizens of the local area and staff members who together set the policies, planned the services and managed them.

The CLSCs became significant members of the health and social services system. Doctors, nurses and social workers were their major employees, and the hope and expectation was that these local organizations would develop and thrive while providing a broad range of locally needed services – everything from preventive services to primary care, to financial and marital advice. Overall the CLSCs would increase the capacity of the population to live well through education and service.

Because they were indeed local, there was a wide variety of CLSCs that provided different services in their different locations. There was also quite a variation in their uptake and effectiveness. In some better off communities, the vast majority of people had family doctors and little need for social services; in others, the CLSC was a vital part of the community with ever evolving services and support. The result was that there was little standardization of their services, which had been the original idea. By the time of regionalization, some CLSCs, such as CLSC Notre Dame de Grace in a working class neighbourhood of Montreal, were very effective in their localities – providing a wide range of services including education and prevention programs, social and other supports for people at risk living in the community. Others were very small and provided a minimal range of services, mostly community nursing and home support.

Regionalization resulted in disbanding the large, more effective CLSCs like the one in Notre Dame de Grace. The smaller ones lost their local governance and were merged into home care agencies, and continued to exist in that form. Regionalization in Quebec quickly and effectively ended the CLSC experiment at exactly the time when it would have been a good idea to see how to expand services in the community even more. Interestingly, only a small mention is made of this rather devastating change in Paradigm Freeze. That is, I think, largely because the loss of these services is not seen as having a connection to the health care system as they understand it. It’s important that we expand the notion of health care to include precisely the range of services that are largely ignored in the book – positive change comes even more slowly when impactful community-based solutions are overlooked.

Policy 101: A patient’s introduction to the policy world

Paradigm Freeze: Why it is so hard to reform health-care policy in Canada, edited by Harvey Lazar, John Lavis, Pierre Gerlier Forest and John Church, is a very detailed attempt to explain the problem described in its title. The authors examine six policy issues that played a role in health care reform from 1990 to 2003. The issues were specifically chosen to provide a range that covered governance, financing, delivery arrangements and program content.

The authors assess how these reform ideas fared in five provinces. The scope of the study is worth exploring. The policy areas they cover are:

  • Regionalization (governance)
  • Needs-based funding (finance)
  • Alternative payment plans for physicians (finance)
  • For-profit delivery (delivery arrangements)
  • Waiting lists (delivery arrangements)
  • Prescription drug insurance coverage (program content)

The five provinces studied in detail were Alberta, Saskatchewan, Ontario, Quebec and Newfoundland, and there was no uniformity in the provincial responses. The pace of decision making varied from province to province, as did the considerations employed in making the decisions. As a result, they came up with a wide array of different policies about each of the six areas considered.

Throughout the next several weeks I will explore these and other policy issues in an attempt to bring a patient perspective to some of the material in this book. Because patients are beginning to play a role in policy development, I think it is worthwhile to present these and other policy issues from the patient perspective. I encourage you to tell me if I have succeeded and if these blog entries are of any interest to you, as I anticipate a learning curve for both of us. This week I will write about regionalization.

The idea of regionalization was taken from the structure of the National Health Service (NHS) in the UK. It was closely tied to two ideas: centralization of control and the introduction of general management into health care to make it more efficient through better management. The idea was to separate responsibility for health care from the bureaucratic Ministry of Health and put it into the hands of managers who would be responsible for managing the health of the population in their geographical areas.

The NHS had a traditional hierarchical structure with geographical regions that were each divided into a number of districts with their respective senior manager. The head of the NHS was the most senior figure and he or she reported to the Ministry. There were fourteen regions and almost 100 districts. Employees of the NHS were fond of bragging that it was the largest single organization in Europe apart from the Red Army. Now it is undoubtedly larger than the Red Army. The average population in a region was almost 4 million and each district had roughly half a million inhabitants.

In 1994, Alberta, with a population of a little over 2.5 million, created 17 regions – each with populations of less than 200,000. The transformation meant that the heads of hospitals and other health organizations would no longer report to their own boards; they now were managed by a regional general manager who in turn was responsible to a regional board. This meant that hospitals were no longer locally owned and governed not-for-profit organizations: they were now provincially owned and regionally governed.

Similar changes in governance occurred in other provinces that adopted regionalization. The effect was to centralize governance from the local level to the regional level, a major change in the structure of the healthcare systems. As you can imagine, this had a great impact on the social role of hospitals as well as their role in the healthcare system. It effectively changed the people who controlled healthcare by switching the focus from local to regional. One of the policy questions that should be explored is what are the benefits and disadvantages of taking health care organizations from the not-for-profit sector of governance and turning them into governmental organizations?

Next week we’ll look at need-based funding: what does this mean and how can changes in policy affect your health care.

Lazar, Harvey, Pierre-Gerlier Forest, John N. Lavis, and John Church. Paradigm freeze: why it is so hard to reform health-care policy in Canada. Kingston: McGill-Queen’s University Press, 2013. Print.