Program in Policy Decision-Making
McMaster University
28 June 2005
Health Policy Update from Canada:
Primary Care Reform and
Timely Access to High-Quality Care
AcademyHealth Annual Research Meeting
Boston, MA, USA
John N. Lavis, MD, PhD
Associate Professor and
Canada Research Chair in Knowledge Transfer and Uptake
McMaster University
Overview
Policy context and climate
Two current policy issues
• Primary care reform
• Timely access to high-quality care (or waiting lists)
Conclusions
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Policy Context and Climate
British North America Act
• Health care is a provincial responsibility
• Canada has 14 different healthcare systems
- 10 provincial healthcare systems
- 3 territorial healthcare systems
- 1 “federal” healthcare system for First Nations and
soldiers
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Policy Context and Climate (2)
Canada Health Act (and preceding legislation)
• Federal government has a role to play in healthcare
as an overseer and partial source of finance
• Politics of blame avoidance, which makes for a lot of
finger-pointing and noise
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Policy Context and Climate (3)
Canada Health Act (and preceding legislation)
• Private delivery / public payment bargain (the “core
bargain”)
• Private practice physicians deliver care with firstdollar, one-tier public (fee-for-service) payment
• Private not-for-profit hospitals deliver care with
first-dollar, one-tier public payment
• Same debates play out over and over
- Change the way primary health care is delivered?
- Continue to provide one-tier public payment?
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Primary Care Reform
Changes in the framing of the policy issue
• Until about five years ago, the issue was cast as a
search for big-bang primary care reform, and this
proved challenging given
- Delivery is in the private domain and fee-forservice payment is entrenched
- Medical associations often sit at the policy table
- Research does not support a single model
• Since then, the issue has been re-cast as a search
for incremental reforms with a plurality of approaches
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Primary Care Reform (2)
Problems in the organization & delivery of primary care
• Lack of continuity of care for patients
• Lack of involvement of other healthcare providers
• Focus on acute or episodic care, not chronic diseases
such as diabetes, heart disease or hypertension
And from the perspective of physicians
• Many family physicians are reducing (or considering
reducing) their workload
• Less than 30% of medical students are choosing
family medicine as a career
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Primary Care Reform (3)
Priorities for action (with examples of strategies used)
• Improved continuity and coordination of care (24/7
access and multidisciplinary teams)
• Early detection and action (disease prevention,
chronic disease management)
• Better information (electronic health records,
telehealth technologies)
• Incentives to change practice (innovative funding
models, involvement of non-medical staff)
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Primary Care Reform (4)
Strategies being used
• Mixed remuneration methods
• Incentives or requirements for
- Rostering patients
- Providing certain types of services (e.g.,
immunizations)
- Hiring or working with other types of providers
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Primary Care Reform (5)
Strategies being used (2)
• Incentives or requirements for
- Making organizational changes (e.g., working in
groups/networks, providing 24/7 coverage,
adopting an electronic health record)
- Engaging in continuing medical education
• Additional support provided centrally (e.g., telephone
health advisory service)
• Limits placed on patient choice (e.g., notify MD if
seeking care elsewhere unless it’s an emergency)
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Primary Care Reform (6)
Provincial efforts to move forward on primary care
reform have been supported by some degree of
national consensus about action
• General commitment to one primary care goal in the
First Ministers’ Accord in 2003
- By 2011, 50% of Canadians will have 24/7 access
to an appropriate healthcare provider
- Some initiatives involve shifting the point of
first contact to nurses or nurse practitioners
- Most initiatives involve supporting physicians
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Primary Care Reform (7)
Where to from here?
• Options for bringing about change
- Offer alternatives to all new physicians (and
experienced physicians who are ready for a
change)
- Entice a broad range of physicians into generous
contracts and then use the contracts as a tool to
bring about other changes and/or to bring some
uniformity to the models being used
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Timely Access to High-Quality Care
Changes in the framing of the policy issue
• Until very recently, the issue was cast as a delivery
issue (i.e., long waiting lists) that needed to be
addressed, and this proved challenging given
delivery is primarily in the private domain
• Supreme Court recently re-cast the issue as a
financing issue (i.e., ban on two-tier public payment)
that needed to be addressed, at least in Quebec, and
this is proving challenging given financing is primarily
in the public domain and governed by a highly visible
core bargain
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Timely Access to High-Quality Care (2)
Problems with long waiting times
• Waiting can cause harm
• Waiting can be unfair (e.g., remote and rural regions,
populations with special needs, and areas where
providers and services are in short supply)
• Waiting can undermine confidence in the system
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Timely Access to High-Quality Care (3)
Potential causes of long waiting times
• Lack of coordination
• Lack of accountability
• Clinical judgements vary
• New technology has increased demand and lowered
threshold for treatment
• Emergency cases bump non-emergency cases
• Lack of capacity
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Timely Access to High-Quality Care (4)
Actions being taken to address long waiting times
• Enhance capacity
• Study waiting times (e.g., standardize measures,
evaluate outcomes)
• Post waiting times (e.g., BC, ON, QC)
• Set benchmarks regarding waiting times
• Manage waiting lists (e.g., Cardiac Care Network)
- Define need for care with precision and fairness
- Manage flow of patients
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Timely Access to High-Quality Care (5)
Provincial efforts to address long waiting times have
been galvanized by a national consensus about action
• General commitment to timely access in the First
Ministers’ Accord in 2003
• Specific commitments in the Ten Year Action Plan
released in September 2004
- Meaningful reductions in waiting times for
diagnostic imaging, cancer care, cardiac care,
cataract procedures, and joint replacements
- Comparable indicators, benchmarks, and multiyear targets, all of which will be reported publicly
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Timely Access to High-Quality Care (6)
And then, on 9 June 2005, Canada’s Supreme Court recast the issue as a financing issue (i.e., ban on two-tier
public payment) that needed to be addressed, at least
in Quebec
• 4 to 3 decision struck down Quebec’s ban on private
health insurance, saying the public system failed to
deliver timely care, which imperils patients’ Charter
right to “security of the person”
• 3 to 3 vote about the decision’s applicability to other
provinces, so the citizens of other provinces would
need to pursue a similar court challenge (if their
government did not proactively end the ban)
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Timely Access to High-Quality Care (7)
Where to from here?
• Quebec has asked the Supreme Court for a stay of
between six months and two years to consider the
implications
• Options
- (Re) Introduce a two-tier system of “medically
necessary” hospital and physician care, as
Canada has in all other parts of its healthcare
system
- Move rapidly to set benchmarks and achieve them
- Both, with likely result that the private tier is small
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Conclusions
Changes to the core bargain have been difficult
• Private practice physicians deliver care with firstdollar, one-tier public (fee-for-service) payment
• Private not-for-profit hospitals deliver care with firstdollar, one-tier public payment
Primary care reform continues to bang up against it
Timely access to high-quality care may have needed a
Supreme Court decision to trigger meaningful action
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References
Primary care reform
• Hutchison BG, Abelson J, Lavis JN. Primary care
reform in Canada: So much innovation, so little
change. Health Affairs May/June 2001;20(3):116131.
Both policy issues
• Health Council of Canada (2005). Report to
Canadians. Ottawa: Health Council of Canada.
- http://hcc-ccs.com/index.aspx
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Contact Information
John N. Lavis
• lavisj@mcmaster.ca
Program in Policy Decision-Making, McMaster
University
• www.researchtopolicy.ca
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