Download Stitches in Time - Michael Rachlis

Medicare is as sustainable as we
want it to be
Michael M Rachlis MD MSc FRCPC LLD (Hon)
University of Toronto February 7, 2013
www.michaelrachlis.ca
Current received wisdom
• Health Care costs are wildly out of control
• My fellow baby boomers and I will really
deep six Medicare as we get older
• The only alternatives are to either cut real
services or use more private care and
finance.
• We need an “adult conversation” to
reduce our expectations and make us see
the need for private involvement
What’s my story?
•
•
•
•
•
Health Care costs are not “out of control”
The aging population won’t break the bank
Medicare was and is good public policy
Healthcare uses antiquated processes of delivery
The two key solutions are:
– Complete the First Stage of Medicare
– Implement the Second Stage of Medicare
Health Care costs are
not out of control
But Health care hasn’t
been starved either
Canadian Health Care Costs as % of GDP
14
12
10
%
8
GDP
6
4
2
0
Data from Canadian Institute for Health Information NHEX 2012
Public
Private
Total
Provincial Government HC Exp as % of GDP
9%
8%
7%
% 6%
GDP 5%
4%
3%
2%
1%
0%
Data from Canadian Institute for Health Information NHEX 2012
ON
CAN
Provincial Government HC Exp as % of GDP
12%
10%
% 8%
GDP
6%
4%
2%
0%
Data from Canadian Institute for Health Information NHEX 2012
NS
ON
AB
CAN
50%
45%
40%
% 35%
Prog 30%
Exp 25%
20%
15%
10%
5%
0%
Provincial Government HC Exp
as share of Program Spending
Data from Canadian Institute for Health Information NHEX 2012
ON
CAN
Provincial Government Program Exp as % of GDP
25%
20%
% 15%
GDP
10%
5%
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
2011 f/p
0%
Data from Canadian Institute for Health Information NHEX 2012
Canadian government Program Spending
45%
40%
35%
30%
%
GDP 25%
20%
15%
10%
5%
0%
Data from: http://www.fin.gc.ca/frt-trf/2012/frt-trf-12-eng.asp
Prov
Fed
Total
Prov Gov Program Exp as % of GDP
35%
30%
NS
ON
AB
CAN
25%
% 20%
GDP 15%
10%
5%
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
2011 f/p
0%
Data from Canadian Institute for Health Information NHEX 2012
Ontario and Canadian GDP
2,000
1,800
1,600
1,400
1,200
1,000
GDP 800
$Bil
600
400
200
-
Data from Canadian Institute for Health Information NHEX 2012
ON GDP
CAN GDP
Revenues as % of GDP
50
45
40
35
%
30
GDP 25
20
15
10
5
0
Data from: Data from: http://www.fin.gc.ca/frt-trf/2012/frt-trf-12-eng.asp
CAN
US
G7 Avg
Govt outlays as % GDP
60
50
% 40
GDP 30
20
10
0
Data from: http://www.fin.gc.ca/frt-trf/2012/frt-trf-12-eng.asp
?
Health Care as % of GDP (2010 Data)
Data from: http://www.oecd.org/els/healthpoliciesanddata/oecdhealthdata2012-frequentlyrequesteddata.htm
All OECD countries included with 2010 data and
GDP per capita > $30K US PPP (from http://en.wikipedia.org/wiki/List_of_OECD_countries_by_GDP_per_capita )
USA
UK
SWI
SWE
SPA
NOR
NZ
NET
KOR
ITA
IRE
ICE
GER
FRA
FIN
DEN
CAN
BEL
Average
AUT
20
18
16
14
12
% 10
GDP 8
6
4
2
0
The aging population won’t kill Medicare
• Canada is aging and health costs increase with age
• But aging of the population per se has had and will
have only a moderate impact on health
expenditures
• Aging is like a glacier not a tsunami. We have lots
of time to prepare and adapt our health system
before we get swamped!
– The elderly are healthier than ever
– High performing health systems can hold costs while
enhancing quality of care for the frail elderly
Health costs are related to
illness and Canadian seniors are
healthier than ever
19
American prevalence of disabled elderly 1984 - 2004
Year
1984
1989
1994
1999
2004
73.8%
75.2%
76.8%
78.8%
81.0%
Light or
Moderate
15.9%
14.8%
13.9%
13.3%
11.8%
Severe
10.3%
10.0%
9.2%
7.9%
7.2%
Disability
No
Disability
Requiring > 2.5 hrs
personal care daily
Manton et al. PNAS. 2006:103(48):18734-9
Dependency of the elderly in wealthy countries
2005-2010
2025-2030
2045-2050
Old Age Dependency
Ratios
(OADRs)
Prospective Old Age
Dependency Ratios
(POADRs)
0.28
0.41
0.53
0.19
0.23
0.27
Adult Disability
Dependency Ratios
(ADDRs)
0.11
0.12
0.12
W Sanderson. Science. 2010;329:1287-8. Canada was not included
Annual impact of Aging on health costs 2010-2036
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
From Mackenzie and Rachlis 2010
“It is not the aging of our population
that threatens to precipitate a financial
crisis in health care, but a failure to
examine and make appropriate changes
to our health care system, especially
patterns of utilization.”
Dr. William Dalziel. CMAJ. 1996;115:1584-6
Most of health care’s problems are
due to antiquated, processes of care
After-Hours Care and Emergency Room Use
Difficulty getting after-hours care
Used emergency room in past two
without going to the emergency room
years
Percent
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
Waited Less Than a Month to See Specialist
Percent
Base: Saw or needed to see a specialist in the past two years.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
Spine surgeons in Ontario: A
wasted precious resource
• Only 10% of patients referred to a spine
surgeon actually need surgery
• $24 million in unnecessary MRI scans
(http://www.theglobeandmail.com/news/opinions/editorials/spine-surgery-can-become-much-more-efficient/article2023173)
The three solutions are:
• Complete the First Stage of Medicare
• Implement the Second Stage of
Medicare
• Develop a healthier population
financed by fair taxation
Complete the First Stage of Medicare
• Medicare’s founders intended public
coverage for pharmaceuticals, long term
care, home care, and dental care
• Mainly private finance and for profit delivery
for these sectors means higher costs, poorer
quality, and needless suffering
• This would prevent cost shifting and
“passive privatization”
There are affordable solutions to
the delivery system’s apparently
intractable problems: The Second
Stage of Medicare
We need to change the way we deliver
services
“Removing the financial barriers between
the provider of health care and the
recipient is a minor matter, a matter of
law, a matter of taxation. The real
problem is how do we reorganize the
health delivery system. We have a health
delivery system that is lamentably out of
date.”
Tommy Douglas 1982
Catching Medicare’s second stage
“I am concerned about Medicare – not its
fundamental principles -- but with the problems we
knew would arise. Those of us who talked about
Medicare back in the 1940’s, the 1950’s and the
1960’s kept reminding the public there were two
phases to Medicare. The first was to remove the
financial barrier between those who provide health
care services and those who need them. We
pointed out repeatedly that this phase was the
easiest of the problems we would confront.”
Tommy Douglas 1979
“The phase number two would be the much
more difficult one and that was to alter our
delivery system to reduce costs and put the
emphasis on preventative medicine….
Canadians can be proud of Medicare, but
what we have to apply ourselves to now is
that we have not yet grappled seriously with
the second phase.”
Tommy Douglas 1979
The Second Stage of
Medicare is delivering
health services differently
to keep people well
With few if any new resources, Canada’s
health system could provide:
• Elective surgery within two months
• Elective specialized care within one week
• Same day access to one on our regular primary
health care providers – NOT a walk in clinic or ER!
• A healthier population!
These improvements should be
implemented in such a way that:
• Empowers patients and families in their own
healthcare, in program planning, and in policy
development and implementation
• Ensures that health care providers are available
where patients need care
• Enhances the quality of worklife of providers
• Strengthens communities
• And, Improves Canada’s overall health status
and quality of life
Toronto Arthroplasty Model
Referring
Physician
Central
Intake
Assessment
Advanced
Practice
Physio
Surgeon
Consult
Surgery
Holland Centre
Holland
Centre
Holland
Centre
and
Toronto
Western
Mt. Sinai
St. Michael’s
St. Joseph’s
Toronto East General
Toronto Western
Post-Op
Discharge
Follow-Up
Good News in Hamilton, Winnipeg, Nova
Scotia, etc! We could have elective specialty
input into patients’ care within 7 days
– The Hamilton Family Medicine Mental
Health Program increased access for
mental health patients by 1100% AND
decreased psychiatry outpatients’ clinic
referrals by 70%.
– The program staff includes 22
psychiatrists, 129 family physicians, 114
Nurses and Nurse Practitioners, 20
Registered Dietitians, 77 Mental Health
Counsellors, 7 pharmacists and
provides care to 250,000 patients
Good News in Cambridge, Cape Breton,
Penticton, etc! We could access primary health
care within 24 hrs
In Cambridge, Dr. Janet
Samolczyk aims to see her
patients WHEN they want
to be seen including
within 24 hours
New models of care for the elderly
and those with serious chronic
illness, show great potential for
improved quality
Step right up!
Get your ELIXIR of
Health Promotion!
Reduce your risk of dying
or ending up in a nursing
home by over
40%!
Increase your chances of
staying in your own
home by nearly
30%!
N Hall et al. Canadian Journal on Aging. 1992;11(1):72-91
Get your
community
services
corrective
right here!
They will reduce your
health costs by
50% in 3 years!
http://www.hollanderanalytical.com/Hollander/Reports_files/preventivehomecarereport.pdf
42
Going for gold: Re-engineering
services to immigrants in Toronto
• Access Alliance works with immigrant and
refugee communities to identify women who
are leaders and hires them as community
health workers (CHWs)
• They are given 3 months of paid training and
3 year contracts
• The CHWs run educational workshops and
facilitate well children and well women care
• CHWs have brought services to more than
12,000 women and their children
• 85% of CHWs get jobs in health or social
services after their contracts are over
43
Denmark: A country of best practices
• 1987 moratorium on building new nursing
home beds
– Accompanied by giving all benefits of long term
care to home care clients
– Scandinavian public responsibility for housing
– Increased construction of supportive housing
• 1998 country-wide policy of home
visits/assessments for people > 75
– Provide health promotion and system linkages
Denmark: A country of best practices
• Denmark has 17.1% population > 65 while
Canada has 15.9% > 65
• Total Health spending as share of GDP is
about the same in Denmark (11.1%) as in
Canada (11.4%) 2010 OECD data
• Public funding: Denmark 85% Canada 71%
– Denmark has better public coverage for home
care, drugs, and appliances and devices
There is substantial evidence
that for profit patient care tends
to cost more and is of poorer
quality -- but the most salient
argument is Tony Soprano’s:
“Fuhgetaboutit!”
We don’t need it.
Summary:
•
•
•
•
•
Health Care costs are not “out of control”
The aging population won’t break the bank
Medicare was and is good public policy
Healthcare uses antiquated processes of delivery
The two key solutions are:
– Complete the First Stage of Medicare
– Implement the Second Stage of Medicare
Courage my
Friends, it is
Not Too Late to
Make a Better
World!
Tommy Douglas
(paraphrasing
Tennyson)