Health Systems in Transition: Toward Integration

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1 Leading knowledge exchange on home and community care Health Systems in Transition: Toward Integration A. Paul Williams, PhD. Full Professor & CRNCC Co-Director, University of Toronto El Instituto Nacional de Salud Pública (INSP) Ciudad de México, México Febrero, 2009 The CRNCC is funded by the SSHRC and Ryerson University

2 Leading knowledge exchange on home and community care Canadian Medicare The CRNCC is funded by the SSHRC and Ryerson University

3 Canadian Medicare: A Sacred Trust Medicare defining characteristic of Canadian identity Top policy issue All political parties & health professions support Medicare on ethical and economic grounds Tommy Douglas, father of Medicare, voted greatest Canadian in 2005

4 Canadian Medicare: Health Insurance Public Financing/Private Delivery 10 separate provincial health care insurance programs cost-shared with federal government under minimal conditions (Medicare principles) Public payment for services provided by private fee-for-service physicians and not-for-profit hospitals

5 National Health Care Systems in Comparison Public Delivery Private Delivery Public Financing National Health Service (e.g., UK) Public Insurance (e.g., Canada) Private Financing --- Private Insurance (e.g., US)

6 Medicare Principles Universality: The plan must entitle 100% of the insured population (i.e. eligible residents) to insured health services on uniform terms and conditions Comprehensiveness: The plan must insure all medically necessary services provided by hospitals and physicians

7 Medicare Principles Accessibility: The plan must provide, on uniform terms and conditions, reasonable access to insured hospital and physician services without barriers Portability: Residents are entitled to coverage when they move to another province within Canada or when they travel within Canada or abroad

8 Medicare Principles Public administration: The health insurance plan of a province must be administered and operated on a non-profit basis by a public authority accountable to the provincial government

9 The Triumph of Canadian Medicare Compared to U.S. free market All Canadians covered Total costs lower Total admin costs lower Monopsony purchasing power Greater ability to plan Competitive advantage for Canadian employers

10 Infant Mortality, Deaths per 1000 Live Births ( ) Death per 1000 Live Births United States United Kingdom Canada Mexico OECD Health Data 2008

11 Life Expectancy of Males at Birth ( ) Age United States Canada United Kingdom Mexico Years Source: OECD Health Data 2008

12 Percentage of Total Expenditure on Administration ( ) Percentage of Expenditure (%) Canada United States Source: OECD Health Data 2006

13 The Limits of Medicare Medicare does require coverage for Medically necessary hospital and doctor services Medicare does not require coverage for Services provided outside of hospitals or by other providers (e.g., home and community care, pharmaceuticals)

14 Leading knowledge exchange on home and community care International Comparisons The CRNCC is funded by the SSHRC and Ryerson University

15 International Health Care Trends (OECD, 2008) Spending on health care in 30 OECD countries rising steadily , cost containment, little change , annual increases above inflation raised average %GDP from 7.8 to 8.9% U.S. health spending grew fastest

16 International Health Care Trends (OECD, 2008) Key cost drivers: New and more expensive medical technologies and treatments Aging populations Increasing public expectations

17 Total Expenditure on Health (% GDP) % GDP 10 8 Canada United Kingdom United States Mexico Year Source: OECD Health Data 2008

18 Public Expenditure on Health as % Total Expenditure on Health ( ) % Total Expenditure Canada United Kingdom United States Mexico Year Source: OECD Data 2008

19 Canadian Health Spending Categories (2007)

20 Spending Patterns Have Changed Hospitals still account for largest, but declining, share of health dollars In 2005 record $42.4 billion However, hospital % declined from 44.7% (1975) to 29.9% (2007) Key factors: More out-patient and community care More rapid rises in other sectors (e.g. pharmaceuticals)

21 Hospital Spending in Canada (CIHI, 2005)

22 Hospital Spending As Percentage of Total Health Care Spending (CIHI, 2005)

23 Acute Care Beds, Per 1000 Population ( ) Beds Per 1000 Pop UK US Canada Mexico Year Source: OECD Health Data 2008

24 Average Length of Stay in Acute Care, Days ( ) Avg. Days in Acute Care US UK Canada Mexico Year Source: OECD Health Data 2008

25 Total Expenditure on Prevention and Public Health ( ) 7 6 Percentage of Total Expenditure Canada United States Mexico Year Source: OECD Health Data 2008

26 Leading knowledge exchange on home and community care Improving System Performance: Key Indicators The CRNCC is funded by the SSHRC and Ryerson University

27 Key System Performance Indicators Hospital Admissions Hospital Emergency Departments (EDs) Ambulatory Care Sensitive Conditions (ACSCs) Hospital Discharges Alternative Level of Care (ALC) beds Residential Long Term Care Admissions Wait times for LTC (e.g., nursing homes)

28 Emergency Department (ED) Wait Times

29 Who Uses Hospital EDs? ED patients are grouped using the Canadian Triage and Acuity Scale (CTAS) CTAS I: severely ill, requires resuscitation CTAS II: requires emergent care and rapid medical intervention CTAS III: requires urgent care CTAS IV: requires less-urgent care CTAS V: requires non-urgent care Source: CIHI, Understanding Emergency Department Wait Times (2005)

30 Severity Of ED Patients, 2003/04 (CIHI, 2005) In 2003/04, less than 10% of patients in Canadian hospital EDs required emergency care (CTAS I & II)

31 Alternative Level of Care (ALC) Beds Acute care hospital beds occupied by patients who do not require acute care ALC patients cannot be discharged because more appropriate care is not available In Ontario, 2009, up to 20% of all hospital beds are ALC

32 Where ALC Patients Go Died 9% Transferred to Inpatient Rehabilitation Facility 10% Home 32% Transferred to Continuing Care Facility 40% Other Inpatient Facility 9%

33 Ambulatory Care Sensitive Conditions (ACSCs) Clinical conditions for which hospitalizations may be avoidable through appropriate ambulatory care Asthma, Angina, Congestive Heart Failure, Hypertension, Epilepsy, Diabetes, Chronic Obstructive Pulmonary Disease

34 Wait Times for Long Term Care (LTC) Once individuals can no longer live safely at home, how long does it take to admit to LTC? Is there sufficient LTC bed capacity? Are there community alternatives to LTC?

35 Leading knowledge exchange on home and community care Toward Integration The CRNCC is funded by the SSHRC and Ryerson University

36 Toward a Systems Perspective The OHA recommends that the ALC issue be addressed from a health system perspective, and involve additional investments in the acute care, long-term care, home care, complex continuing care and rehabilitation sectors and in supporting housing beyond what is currently planned.. Concerted action is needed to ensure that patients, particularly elderly patients, receive the care that they need, where and when they need it Hillary Short, President and CEO, Ontario Hospital Association, March 22,

37 Local Health Integration Networks (LHINs) LHINS aim to transform a collection of fragmented services into a personcentred, balanced, managed continuum

38 Integrating Care Across Silos Reduce inappropriate hospital ED use Ambulance crews now trained to assess whether a hospital admission is needed Geriatric Emergency Management (GEM) nurses in hospitals redirect non-medical admissions to community care Reduce hospital ALC bed rates Link to LTC and home and community care to facilitate timely discharge

39 Integrating Care Across Silos Reduce hospital use for Ambulatory Sensitive Conditions Manage with community-based primary care Shorten LTC wait lists Provide integrated home and community care

40 Medicare s Second Stage First stage of Medicare Funding universal access to hospital and doctor care without regard to economic means Second stage of Medicare Provide an integrated continuum of health and social services so that people get the care they need, when they need it, in a cost-effective way which contributes to system sustainability

41 Leading knowledge exchange on home and community care Help us make the case -- membership is free The CRNCC is funded by the SSHRC and Ryerson University

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