Back to Basics, 2015
POPULATION HEALTH :
Health Care Organization
Prepared by
Trevor Arnason
PGY4 – Public Health and Preventive
Medicine, University of Ottawa
Acknowledgement: This presentation was
originally created by Doug Coyle
MCC Objectives: Population health 78-4 Administration
of effective
health programs at the population level
Rationale:
• 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.
MCC Objectives: Population health 78-4 Administration
of effective
health programs at the population level
Key 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.
MCC Objectives: Population health 78-4 Administration
of effective health programs at the population level
Enabling objectives (1)
• 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.
MCC Objectives: Population health 78-4 Administration
of effective health programs at the population level
Enabling objectives (2)
• 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.
MCC Objectives: Population health 78-4 Administration
of effective
health programs at the population level
Enabling objectives (3)
• 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.
78.1: Medical Economics
• 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.
What Will We Cover?
• Organization and history of health care in
Canada
• Medical economics (brief overview)
• Physician organization and regulated health
professions Public health in Canada
• Key definitions and frameworks for exam
Historical Progression in the
Organization of Health Care
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 with
stipulations.
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
Specifies the conditions and criteria with which the provincial and
territorial health insurance programs must conform in order to receive
federal transfer payments. Prohibited user fees and extra billing.
Canada Health Act Principles
Public administration
Administered for non profit and
accountable to a provincial
government
Comprehensive
All medically necessary services
provided by hospitals, medical
practitioners
Universal
All insured persons have equal
coverage
Accessible
Reasonable access without
financial and other barriers
Portable
Coverage between provinces
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 Freedom
Events Post 1984
• 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.
• 2012 Drummond report (Ontario)
– Emphasis on home care
Role of Federal Government
• Directly responsible for compliance with international
health regulations, First Nations/Inuit health, Canadian
Forces/RCMP and those in federal penitentiaries and
refugee claimants
• Funding to Provinces - has the greatest taxing power
• Its provision of funding allows it to enforce the Canada
Health Act.
• Reductions in federal contributions have reduced its
influence
Role of Provincial Governments
• Responsibility for healthcare services (and most other
social services)
• Provinces now provide most of the funding for health
services
• Therefore, they are the main decision-makers
– Block budgets to regional authorities (eg: LHINs)
– Physician fees (eg: negotiations with OMA)
– Other services covered (eg: physiotherapy, home-care
through CCAC)
– Special payments for technologies
– Which drugs funded through Provincial programs (eg:
Ontario Drug Benefit Program)
What is a LHIN?
• A regional health authority – only created in 2007!!!
• 14 in number – basically subsidiaries of MOHLTC
• Plan, coordinate, integrate and partially manage care at
the local level
• Not aligned with Public Health Units (PHUs)
• Hospitals, community health centres (CHCs), long-term
care homes, the Champlain Community Care Access
Centre and more than 100 Community Support
Services including mental health and addictions
agencies
Methods of 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: by request.
– If approved, government pays.
– If declined, hospitals can pay for it from core budget.
Methods of paying doctors
• 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.
– Incentive to recruit young, healthy people, not the ‘sick’
• Salary: unit is time.
– Productivity depends on professionalism and institutional
controls
– Practice plans
• Combinations of above, e.g., "blended funding“
– Family health networks (Ontario)
Ways of organizing a health care system
• Publicly funded and delivered
– Most developed after WWII (eg: UK National Health Service)
– NOT THE CANADIAN SYSTEM
• Purely private
– Mainly developing countries (eg: Canada in 1867)
• Mixed public and private funding and mostly private
delivery
– US (prior to Obamacare)
• Mostly public funding (single-public payer insurance
system) and mixed private/public delivery
– Canada
A brief foray into Medical Economics
• 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
What does the slide NOT tell you???
Types of economic analysis
Form of Analysis
Measurement of
Costs
Measurement of
benefits
Synthesis of
Benefits and Costs
Cost minimization
Dollars
None
Incremental cost
Cost Effectiveness
Dollars
Single Dimension
of Effectiveness
(e.g. life years
gained)
Incremental cost
effectiveness:
- incremental cost
per unit gained
Cost Utility*
Dollars
Utility gained (e.g.
QALYs)
Incremental cost
effectiveness:
- incremental cost
per QALY gained
Cost Benefit
Dollars
Monetary values
of benefits gained
Net benefit gained
* Often referred to as sub-category of cost-effectiveness
Medical Economics Definitions
Effectiveness: the impact of a treatment under realistic conditions in which
the patient’s compliance may not be optimal.
Efficacy: the impact of a treatment when administered under ideal conditions
(the patient takes the correct dose at the correct intervals).
Efficiency: the extent to which time, effort, or cost is well-used for the
intended function.
Quality-Adjusted Life Years (QALYs): the average number of additional years of
life gained from an intervention, multiplied by a judgment of the quality of life
in each of those years.
Incremental Cost-Effectiveness Ratio (ICER): the ratio of costs to incremental
benefits of a therapeutic intervention or treatment
ICER = Costs #1 – Costs #2 / Effect #1 – Effect #2
Physician Organization
• 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.
• Licentiate of the Medical Council of Canada
– Maintains the Canadian Medical Registry
– Does not grant licence to practice medicine
– Administers country-wide examinations of competency
• serving as the base for provincial registration
Physician Organization
Ontario license requirements:
– Graduate of an accredited medical school
• or ‘acceptable unaccredited’ school
– Meets standards of moral behaviour
•
•
•
•
mentally competent
integrity, honesty and decency as applied to practice
sufficient skill, knowledge and judgement
communicates effectively and professionally
– Successful completion of MCCQE part 1 & 2
– Certification by either:
• the Royal College of Physicians & surgeons of Canada
• College of Family Physicians of Canada
– One year post grad training or clinical clerkship in Canada
– Canadian citizen or landed immigrant
Physician Organizations
• Royal College of Physicians and Surgeons of
Canada.
– Maintains standards for post-graduate training
throughout Canada.
– Sets exams and issues fellowships for specialty training
• College of Family Physicians of Canada
– Organization for certifying/promoting family practice
Physician Organizations
• Ontario Medical Association
– Professional association; lobbies on behalf of physicians re: fees,
working conditions, etc.
• Canadian Medical Association
– National, voluntary association of physicians that advocates on behalf
of its members and the public for access to high-quality health care.
• Canadian Medical Protective Association
– Advises physicians on threatened litigation and pays legal fees and
court settlements.
– A co-operative that has largely replaced commercial malpractice
insurance.
Regulated Health Professions
The practice of a regulated professional is:
1) Covered by provincial or federal legislation and
2) Governed by a professional corporation or
regulatory authority, for instance a College of
Physicians or an Order of Nurses.
Regulated Health Professions
Audiologists and speech-language pathologists -Hearing and understanding, speech, language, and swallowing disorders
Chiropractors - Diagnosis, treatment, and prevention of mechanical disorders of the musculoskeletal system
Dieticians - Evaluation of the nutritional state of people in order to choose and implement a nutrition strategy that takes account of their
need to improve or re-establish health.
Midwives -Assessment and monitoring of women during pregnancy, labour, and the post-partum period, as well as of their newborn babies;
the provision of care during normal pregnancy, labour and post-partum period, and the conducting of spontaneous normal vaginal
deliveries
Nurses - Care of individuals of all ages, families, groups, and communities, sick or well, and in all settings
Occupational therapists- Helping people to learn or re-learn to manage the everyday activities that are important to them, including caring
for themselves or others, caring for their home, and participating in paid and unpaid work and leisure activities
Optometrists - Assess the eye and visual system, sensory and ocular motor disorders and dysfunctions of the eye and the visual system, and
diagnose refractive disorders
Pharmacists- Evaluate and dispense prescription medications; advise on their correct use and mode of action
Physiotherapists - Through understanding of how the body moves and what prevents it from moving, manage and prevent many physical
problems caused by illness, disease, sport- and work-related injury, aging, and long periods of inactivity
Psychologists - Assessment, treatment, and prevention of behavioural and mental conditions
Respiratory therapists - Monitor, evaluate, and treat individuals with respiratory and cardio-respiratory disorders
Social workers - Help individuals, families, groups, and communities to enhance their individual and collective well-being; help people
develop their skills and their ability to use their own resources and those of the community to resolve problems. Social work is
concerned with individual and personal problems, as well as with broader social issues such as poverty, unemployment, and domestic
violence.
Quality in healthcare
• Many professional colleges and regulatory bodies have
incorporated quality improvement practices into their mandate and
operational approaches.
• Most have quality assurance committees and routinely conduct
audits of professional practices.
• In the past many of these bodies merely responded to complaints,
they are now studying and implementing ways of improving quality.
• The relationship with clinicians is shifting from a focus on discipline
to one of continuing professional education and training.
•31
Public Health in Canada
• Public health is defined as the organized efforts of
society to keep people healthy and prevent injury,
illness, and premature death. It is a combination
of programs, services, and policies that protect
and promote the health of all Canadians.
• Population health is “the health of the
population”
Core Functions of Public Health
• Public Health is the branch of the health
system concerned with:
– health protection
– health surveillance
– disease and injury prevention
– population health assessment
– health promotion
– emergency preparedness and response
Public Health Units in Ontario
• 36 PHUs – each appoints a physician to be a Medical Officer of
Health (MOH) and sometimes one or more Associate MOHs
• Program standards outlined in the Ontario Public Health
Standards
• Responsible for:
– Food/lodging sanitation (eg: restaurant inspections)
– Infectious disease control and immunization (eg: providing schoolbased immunization programs)
– Health promotion/Disease prevention (eg: Healthy Eating and Active
Living strategy)
– Family health programmes (eg: breastfeeding support)
– Environmental health surveillance.
– Emergency preparedness and response
Public Health Units in Ontario
- Medical Officer of Health
• Report to a local Board of Health and the Ministry of Health and Long-Term
Care in Ontario
• Medical Officer of Health is afforded certain powers (related to a public
health hazard) including orders to:
• Vacate a home or close a business
• Regulate or prohibit sale, manufacture of any item
• Isolate people with communicable diseases
• Require people to be treated by MD
• Require people to give blood samples
• No licensing or regulatory powers over physicians/health practitioners
except in the case where a “public health hazard” exists
• Public Health Unit should not be confused with the Local Health Integration
Network
Federal Role in Public Health
• Public Health Agency of Canada (created post-SARS and
Health Canada)
• Health Canada - regulation of food, water, medicines,
medical devices.
• Coordination
– Between Provinces
– With other countries and international bodies (eg: World Health
Organization)
• Public health services for all the individuals that are not
covered under Provincial health plans: (eg: military, First
Nations/Inuit on reserves, federal penitentiaries, etc.)
What is a coroner?
• Coroners are medical doctors with specialized death investigation
training, who have been appointed to investigate sudden death –
organization of system depends on the province
• Role in improving public safety, through coroner inquests
• Notify coroner of deaths in the following cases:
–
–
–
–
–
–
–
–
Sudden/unexpected
Due to violence, negligence, misconduct, etc.
During work at a construction or mining site.
During pregnancy
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.
Multiple Choice Questions
The federal government is responsible for
healthcare delivery to which of the following
groups?
a) Inmates of federal penitentiaries
b) Inuit living on reserves
c) Active Canadian military personnel living in
Canada
d) Refugee claimants awaiting a hearing
e) All of the above
Which of the following is not one of the five
Principles of the Canada Health Act?
a) Portability
b) Flexibility
c) Universality
d) Comprehensive coverage
e) Accessibility
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) Pharmaceuticals
d) Laboratory services
e) Administration
What regulatory body is responsible for licensing
physicians to practice in Ontario?
a) Royal College of Physicians and Surgeons of
Canada
b) College of Physicians and Surgeons of Ontario
c) Licentiate of the Medical Council of Canada
d) Medical Officer of Health for the Local Health
Integration Network
e) Health Canada
Which of the following is NOT considered a core
function of public health in Canada?
a) Health Promotion
b) Health Protection
c) Population health surveillance
d) Emergency Preparedness and Response
e) Health Equity
More MCQs and a Great Resource
• More MCQs:
http://www.medicine.uottawa.ca/sim/data/Selftest_Qs_HC_System_e.htm
• AFMC Primer on Population Health:
http://phprimer.afmc.ca/