Service Integration The Canadian Way
Presentation to the King’s Fund Study Tour
September 17th, 2007
Cathy Fooks
President and CEO
The Change Foundation
Presentation Overview
• Structure of Canadian health system
• Regionalization in Canada
• Ontario version of integration
• Implications for patient outcomes
• Predictions for the future
Structure of Canadian Health System
• Health care delivered by provinces and territories with some
federal funding
• Amount of federal funding negotiated and subject of much
argument
• The Canada Health Act gives funding authority and covers
physician care and services delivered in hospital. Different
ways that private care is dealt with across jurisdictions.
• Everything else is up to p/ts thus significant variation across the
country
Structure of Canadian Health Care System
• Physicians are largely in private practice, on a fee for service
basis – gradually changing to more group practice based on
capitation and program funding
• Drugs are privately covered, often through employment benefits
with some public funding for elderly or low income individuals
• Very little quality oversight, public reporting of outcomes
• Very little experience with purchasing service, contracting or
commissioning
Expenditure per capita by source of funding, 2004
Japan
1832
389 28
2176
UK
1940
Australia
370
582 354
public
out of pocket
private
Germany
2350
313 342
2210
Canada
472 483
2727
US
0
1000
803
2000
3000
2572
4000
5000
6000
7000
System Design
“Canada has a series of disconnected parts, a hodge-podge
patchwork, health care industry comprised of hospitals, doctors
offices, group practices, community agencies, private sector
organizations, public health departments and so on.”
Toward a Model of Integrated Care, 2000
Leatt et al.
Reform Reviews in All Provinces
• Common themes – need for:
–
–
–
–
–
Primary care reform
Regionalization
Reigning in of drug expenditures
Increased spending in home care/community
A focus on non medical determinants of health
Move to Regionalize – mid 1990s
• Everywhere but Ontario
• Ontario had at the time District Health Councils – Ministerially
appointed local individuals to provide advice to the Minister
• Health Services Restructuring Commission – legal authority to
mandate merger/closure of hospitals – saw some amalgamation
at governance level but most physical plants were kept and/or
redeveloped
Timing
• Initial efforts at reform coincided with multi year reductions in the
federal transfers (which have subsequently been increased up
to previous levels)
• Choices for provinces to cut, cover the federal portion or
reorganize
• Ontario chose to cover, the rest of the country reorganized
Lessons from the Initial Regionalization Experience
1a) Had to fiddle with the numbers –
• BC went from 9 to 5
• Alberta went from 17 to 9
• Saskatchewan went from 32 to 12
• Nova Scotia went from four regional boards to 9 district
authorities
1b) still need provincial authority to tertiary care (eg, cancer,
transplants)
Current Numbers Against Population
Jurisdiction
BC
Alberta
Saskatchewan
Manitoba
Ontario
Quebec
Nova Scotia
New Brunswick
PEI
N&L
NWT
Nunavut
The Yukon
# of Regions
5 regions and
1 provincial authority
9 regions and
provincial cancer board
12 regions and
provincial cancer
agency
11 regions and
provincial cancer
agency
14 LHINs and
provincial cancer
agency and provincial
cardiac care network
18 regions and 95 local
service networks
9 districts
7 regions
No regions, 5
community hospital
boards
6 regions with 15
health boards
8 health and social
service regions
No regions
No regions
Population, April 2007
4,352,800
3,455060
990,210
1,182,920
12,753,700
7,687,060
932,970
748,880
138,800
506,550
41,795
31,220
30,880
Lessons from the Initial Experience
2) Experimented with Public Participation – quick decision to dump
it
• Saskatchewan elected 2/3rds of its Boards but moved to wholly
appointed Boards
• Quebec had elected Boards by representative assemblies but
moved to wholly appointed Boards
• Alberta had directly elected Boards but moved to wholly
appointed
• Some form of advisory council or committee created in some
jurisdictions
Lessons from the Initial Experience
3) Lack of clarity around roles and responsibilities
• Survey done by the Centre for the Analysis of Regionalization
and Health (2003) found that:
– Majority of respondents found that division of responsibility
was unclear
– CEOs felt that residents had a tendency to bypass the
Boards and present issues to the province
– Boards felt they had less authority than they should
– Ministry felt the RHAs were not restricted in their authority
and that special interests had too much influence in
decisions
Made in Ontario
• Ministry of Health and Long Term Care is steward
• LHINS- regional planning and eventual resource allocation
(although Ministry has already set three year budgets)
• CCACs – purchase for home care and LTC
• Providers – maintaining separate governance for now
• Physicians outside any accountability system other than
professional self regulation and some performance targets with
financial incentives for family health teams
LHINS and Regions: Key Differences
(S. Lewis, 2007)
Feature
LHINS RHAs
Hold budget for community care,
hospitals, LTC
Boards appointed by MOH
√
√
√
√
Boards/CEO have clear authority over
services in their area
Mandate to manage programs and
services directly
Responsible for MDs and drugs
?
√
X
√
X
X
X
√
Fewer local boards with reduced
power
Critical Differences
LHINS
Purchasers, funders within Ministry
allocation
Employ only their own central staff
Exercise authority through
accountability and service
agreements
Agreements with independent
providers boards
RHAs
Purchasers, funders and managers
of services within negotiated budget
Major regional employer
Direct authority as employer and
service agreements with affiliates
Very few independent provider
boards
Physician Report Use of Multi Disciplinary Teams and NonPhysician Clinicians, 2006
51
New Zealand
30
70
UK
81
38
Australia
32
56
Germany
49
22
Canada
32
39
US
29
0
10
20
30
40
% use multidisciplinary teams
50
60
% use non-MD clinicians
70
80
90
Primary Care MDs Use of Information Technology, 2006
80
NZ
92
92
UK
89
68
Australia
79
81
Germany
42
26
Canada
23
37
US
28
0
10
20
30
% MDs using electronic record
40
50
60
70
80
% of primary care practices generating list of pts by diagnosis
90
100
Quality Measures, 2006
49
NZ
41
65
UK
70
39
Australia
26
22
Germany
70
46
Canada
27
37
US
50
0
10
20
30
% MDs set formal targets for clincial performance
40
50
60
70
% MDs reporting problems due to poorly coordinated care
80