April 11, 2011 1

Back to Basics, 2011POPULATION HEALTH : Health Care Organization

Presented by Doug Coyle

Epidemiology & Community Medicine

Based on slides prepared by Dr. R. Spasoff

April 11, 2011 2

MCC Objectives: Population health 78-4 Administration of effective

health programs at the population levelRationale: • Knowing the organization of the health care and public health systems in Canada as well as how to determine the most cost-effective interventions are

becoming key elements of clinical practice. Physicians also must work well in multidisciplinary teams within the current system in order to achieve the maximum health benefit for all patients and residents.

Terminal objectives: • Know and understand the pertinent history, structure and operations of the Canadian health care system. • Be familiar with economic evaluations such as cost-benefit / cost effectiveness analyses as well as issues involved with resource allocation.• Describe the approaches to assessing quality of care and methods of quality improvement. Enabling objectives:• Describe at a basic level:

– methods of regulation of the health professions and health care institutions;– supply, distribution and projections of health human resources; – health resource allocation; – organization of the Public Health system; and – the role of complementary delivery systems such as voluntary organizations and community health centres.

• Describe the role of regulated and non-regulated health care providers and demonstrate how to work effectively with them. • Outline the principles of and approaches to cost containment and economic evaluation.• Describe the main functions of public health related to population health assessment, health surveillance, disease and injury prevention, health

promotion and health protection.• Demonstrate an understanding of ethical issues involved in resource allocation. • Define the concepts of efficacy, effectiveness, efficiency, coverage and compliance and discuss their relationship to the overall effectiveness of a

population health program.• Be able to recognize the need to adjust programs in order to meet the needs of special populations such as new immigrants or persons at increased risk. • Participate effectively in and with health organizations, ranging from individual clinical practices to provincial organizations, exerting a positive

influence on clinical practice and policy-making.• Define quality improvement and related terms: quality assurance, quality control, continuous quality improvement, quality management, total quality

management; audit. • Describe and understand the multiple dimensions of quality in health care, i.e. what can and should be improved.

April 11, 2011 3

What Will We Cover?

• Organization of Health Care Delivery in Canada

• Elements of Health Economics

April 11, 2011 4

COMMUNICATIONS!!!

C2LEO

1867 British North America Act Provincial gov. given regulatory power over hospitals, asylums etc.

1914-1917 Saskatchewan Moves towards paying retainers for physicians and the right to collect taxes to finance health care

1920 Creation of Federal Department of Health • Response to Spanish flu epidemic • Focus on public health, child health food and drug standards

1935 Provinces stop Federal gov. plan to provide social and health benefits

1947 Saskatchewan Introduces public insurance for hospital services

1957 Federal Hospital Insurance and Diagnostic Services Act (HIDS)

Provinces given 50% of funding from Federal gov to provide a service which is:

Publicly administered, comprehensive, universal, portable and accessible.

1961 All provinces participate in HIDS

1966 Medical Care Act Universal coverage for physician services

1977 Federal-Provincial Fiscal Arrangements and Established Programs Financing Act (EPFA)

Reduced requirements of federal government to match funding

1984 Canada Health Act

April 11, 2011 5

Historical Progression in the Organization of Health Care (0)

April 11, 2011 6

Events Post 1984 (0)

• 2001: Kirby & Romanow commissions– Attempts to reform the health care system– Focus on long term sustainability

• 2005: Chaoulli decision (Quebec)– Controversial interpretation of the CHA in regards to banning of

private clinics.

April 11, 2011 7

Organization of Health Care (0A)

• Canada Health Act established five principles that provinces must adhere to obtain federal funding for health care– Public administration– Comprehensiveness– Universality– Portability– Accessibility

April 11, 2011 8

Organization of Health Care (0A)

• Problems with the Canada Health Act– Only partial coverage

• Physician services in and out of hospital only• What is “medically necessary”• Only those “provided by hospitals”• Not all hospitals must provide all services

– Does not legislate which services must be provided• Only that federal government will not provide funding if

conditions not met

– Impact of other legislation• Canadian Charter of Rights and Freedoms

April 11, 2011 9

Organization of Health Care (0B)

• 2008: total health care expenditures were $5,170/person or about $172billion, 10.1% of GDP (SIM web link)

• 70% from public sector (45% in the USA)• 28% spent on hospitals, 17% on drugs, 13%

on MDs and 11% on other HCPs• Research shows that private-for-profit care

is more expensive and less effective

April 11, 2011 10

Methods of paying doctors (SIM web link)

• Fee-for-service: unit is services. Incentive to provide many services, especially procedures.

• Capitation: unit is patient. Fixed payment per patient. Incentive to keep people healthy, but not to make yourself accessible.

• Salary: unit is time. Productivity depends on professionalism and institutional controls– Practice plans

• Combinations of above, e.g., "blended funding“– Family health networks (Ontario)

April 11, 2011 11

Methods for paying hospitals

• Line-by-line: separate payments for staff, supplies, etc. Cumbersome, rigid.

• Global budget: fixed payment to be used as hospital sees fit. Fails to recognize differences in case mix.

• Case-Mix weighted: payment for total cost of episode, greater for more complicated cases. Now used in Canada.

• New technology: OHTAC reviews requests. If approved, government pays. If declined, hospitals can pay for it from core budget.

April 11, 2011 12

How good is the Canadian health care system?

• The World Health Report 2000 (from WHO) placed Canada 30th in the world, (US was 37th)– Below most of western Europe– Methods of report have been highly criticized

• Belief that we should be healthier, given our high levels of income, education and health expenditure.

April 11, 2011 13

Organization of Health Care (1)Student & Resident Issues

• “The role of student and resident associations in promoting protecting their members’ interests.”

• Student organizations will be familiar to you

• PAIRO (Professional Assoc of Interns and Residents of Ontario) has been extremely effective in negotiating salaries, working conditions, educational programs

April 11, 2011 14

Organization of Health Care (2)CMPA

• “The role of the CMPA as a medical defence association representing the interests of individual physicians.”

• Canadian Medical Protective Association is a co-operative, replacing commercial malpractice insurance. It advises physicians on threatened litigation (talk to them early), and pays legal fees and court settlements. Fees vary by region and specialty ($792-$39,828/year).

April 11, 2011 15

Organization of Health Care (3) Interprovincial Issues

• “The portability of the medical degree.”– Degrees are portable across North America

• “The transferability of provincial medical licences.”– Traditionally, provincial Colleges of Physicians and

Surgeons set own requirements (with input from provincial governments)

• As part of attempts to improve intra-provincial trade, recent legal changes have established a common licensing standard

April 11, 2011 16

Organization of Health Care (3b)

• Certification vs. licensing– Medical College of Canada

• Certifies MDs (LMCC)

– Royal College of Physicians and Surgeons of Canada

• Certifies specialists

– College of Family Physicians of Canada• Certifies family physicians

– College of Physicians and Surgeons of Ontario• Issues a licence to practice to MDs.

April 11, 2011 17

Organization of Health Care (4a)Physician Organizations

• Medical Council of Canada– Maintains the Canadian Medical Registry

– Does not grant licence to practice medicine

• College of Physicians and Surgeons of Ontario– Responsible for issuing license to practice medicine

– Handles public complaints, professional discipline, etc.

– Does not engage in lobbying on matters such as salaries, working conditions.

April 11, 2011 18

Organization of Health Care (4b)Physician Organizations

• Royal College of Physicians and Surgeons of Canada.– Maintains standards for post-graduate training through-

out Canada.

– Sets exams and issues fellowships for specialty training

• Ontario Medical Association– Professional association; lobbies on behalf of

physicians re: fees, working conditions, etc.

• College of Family Physicians of Canada– Organization certifying/promoting family practice

April 11, 2011 19

Organization of Health Care (5)Medical Officer of Health

• Reports to municipal government.• Responsible for:

– Food/lodging sanitation

– Infectious disease control and immunization

– Health promotion, etc.

– Family health programmes• E.g. family planning, pre-natal and pre-school care, tobacco

prevention, nutrition

– Occupational and environmental health surveillance.

April 11, 2011 20

Organization of Health Care (6)Medical Officer of Health

• Powers include ordering people, due to a public health hazard, to take any of these actions:– Vacate home or close business– Regulate or prohibit sale, manufacture, etc. of

any item– Isolate people with communicable disease– Require people to be treated by MD– Require people to give blood samples

April 11, 2011 21

The Coroner

• Notify coroner of deaths in the following cases:– Due to violence, negligence, misconduct, etc.

– During work at a construction or mining site.

– During pregnancy

– Sudden/unexpected

– Due to disease not treated by qualified MD

– Any cause other than disease

– Under suspicious circumstance or by ‘unfair means’

– Deaths in jails, foster homes, nursing homes, etc.

April 11, 2011 22

78.1: MEDICAL ECONOMICS (1)

• Define the socio-economic rationales, implications and consequences of medical care– Medical care has impact on costs to society;

both financial and other (non monetary) resources.

– This objective aims to raise awareness of these types of issues.

April 11, 2011 23

MEDICAL ECONOMICS (2)

• Does effective medical care reduce health care spending?

• How do we value non-fiscal benefits such as quality of life, ‘health’, not being dead?

• Should resources be spent on health or other societal objectives?

• How do we value non-traditional expenditures, etc which impact on health (Healthy Public Policy).

April 11, 2011 24

Year

April 11, 2011 25Source: CIHI, National Health Expenditure Trends, 1975 to 2009

April 11, 2011 26

% o

f tot

al fi

nanc

e

% o

f tot

al s

pend

ing

YearYear

* Provincial government includes transfer payments.

* Hospitals include non-physician professionals in hospital practice

Trends in health care: sources and allocation of finance. Canada, 1975 to 2009

April 11, 2011 27

Principles of cost-containment

• Three approaches to improve cost effectiveness of health care delivery– Eliminate ineffective care– Reduce costs of effective care

• Substitute cheaper but equally effective care,– day surgery for hospital admission, – nurse practitioners for some primary care, – generic drugs

• Reduce unit costs– reduce salaries (risk of reduced effectiveness) or fees (but quantity

provided may increase)

– Adopt only new interventions that are cost effective

Assessing Cost Effectiveness

April 11, 2011 28

April 11, 2011 29

Types of economic analysis (SIM web link)

Form of Analysis Measurement of Costs

Measurement of Benefit

Synthesis of Costs and Benefits

Cost Minimization Analysis

Dollars None Incremental cost

Cost Effectiveness Analysis

Dollars Single dimension of effectiveness (e.g. life years gained)

Incremental cost effectiveness : incremental cost per unit gained

Cost Utility Analysis

Dollars Utility gained (e.g. QALYs - quality adjusted life years)

Incremental cost-effectiveness: incremental cost per QALY gained

Cost Benefit Analysis

Dollars Monetary value of benefits gained

Net benefit gained

April 11, 2011 30

Health System

Multiple Choice Questions

For discussion

April 11, 2011 31

In 2006, which country spent the least on health care as a percentage of GDP (gross domestic product):a) Canada

b) France

c) Sweden

d) UK

e) USA

April 11, 2011 32

The component of Canada's health care system that receives the highest percentage of the health care budget is:a) hospitals

b) physician fees

c) drug benefit plans

d) laboratory services

e) administration

April 11, 2011 33

Regarding health expenditure and health outcomes:a) the U.S. has the greatest health expenditure and

the lowest infant mortality rates

b) there is a positive association between national expenditure on health and GDP

c) increased national health expenditure always increases health status of a country

d) all of the above

e) none of the above

April 11, 2011 34

Regarding the regulation of health professionals, provincial colleges of physicians and surgeons:a) have the advancement of the public interest as

their primary goal

b) protect the public from incompetent or unfit MDs

c) act as licensing bodies for MDs

d) do not advance the professional and political interests of MDs

e) all of the above

April 11, 2011 35

All of the following statements are true EXCEPT:a) the data collected on a death certificate is uniform and

in conformity with WHO guidelines

b) Section 7 of the Coroner’s Act states that the coroner’s office must be notified if a patient dies after some mishap such as leaving an instrument in the body at surgery

c) diseases which must be reported to the local medical officer of health include AIDS, food poisoning, influenza and gonorrhea

d) a tuberculin reaction greater than 5 mm is considered positive in all individuals

e) all of the above

April 11, 2011 36

All of the following are responsibilities of local public health units in Canada EXCEPT:a) communicable disease control

b) health education

c) investigation of sudden death

d) immunization

e) health promotion

April 11, 2011 37

Who is ultimately responsible for the quality of care in a hospital?a) chief executive officer

b) board of trustees

c) medical director of the division

d) chief of staff

e) attending physicians

April 11, 2011 38

Which of the following is not one of the five Terms and Conditions of Medicare?a) portability

b) flexibility

c) universality

d) comprehensive coverage

e) accessibility

April 11, 2011 39

More MCQs

• Here are some more questions that students can use to test their own knowledge:

http://www.medicine.uottawa.ca/sim/data/Self-test_Qs_HC_System_e.htm

• (The questions contain comments on the answers, to illustrate why a given response is not correct)