The Role of the Federal Government in Health and Healthcare

1. The Role of the Federal Government in Health and Healthcare American Society of Neurosurgeons Hon. Carolyn Bennett, M.D., M.P. St. Andrews-by-the-Sea, New Brunswick June 9, 2014

2. The Role of the Federal Government in Health and Healthcare An Accidental Tourist in Politics Non Quo Sed Quo Modo Patient as Partner Doctor Multidisciplinary Hospital Community Social Determinants of Health Hon. Carolyn Bennett, M.D., M.P.

3. The Role of the Federal Government in Health and Healthcare Sir Michael Marmot “The worst thing for a physician is to help someone get well and then send them straight back into the situation that made them sick in the first place” - Sir Michael Marmot, Chair, WHO Commission on the Social Determinants of Health Hon. Carolyn Bennett, M.D., M.P.

4. The Role of the Federal Government in Health and Healthcare Canadian Institute of Advanced Research • 25% health attributable to health care system • 15% biology and genetics • 10% physical environment • 50% social and economic environments • HEALTH VS HEALTH CARE Hon. Carolyn Bennett, M.D., M.P.

5. The Role of the Federal Government in Health and Healthcare The Goal of Medicare • Sharing risk • getting people the health care they need when they need it • Solidarity Keeping people well not just patching them up once they get sick Hon. Carolyn Bennett, M.D., M.P.

6. The Role of the Federal Government in Health and Healthcare Health of Canadians Health Care delivery - Provincial • Except Federal Government is the 5th biggest provider • First peoples, military, veterans, RCMP, corrections Health of Canadians – shared • Health promotion, disease prevention • Social determinants of health • Regulator • Research Hon. Carolyn Bennett, M.D., M.P.

7. The Role of the Federal Government in Health and Healthcare The Tyranny of the Acute As long as citizens think of the sickness care system whenever they hear the word ‘health’ we are not going to be able to reorient health systems. Hon. Carolyn Bennett, M.D., M.P.

8. The Role of the Federal Government in Health and Healthcare Sustainability = Prevention + Quality • PREVENTION • Decrease the demand side • QUALITY • Increase the cost effectiveness on the supply side Hon. Carolyn Bennett, M.D., M.P.

9. The Role of the Federal Government in Health and Healthcare Health Goals for Canada • As a nation, we aspire to a Canada in which every person is as healthy as they can be: • physically • mentally • emotionally • spiritually Hon. Carolyn Bennett, M.D., M.P.

10. The Role of the Federal Government in Health and Healthcare Social Determinants of HealthvsChoose Health(modifiable risks) Hon. Carolyn Bennett, M.D., M.P.

11. The Role of the Federal Government in Health and Healthcare Citizens as Partners Hon. Carolyn Bennett, M.D., M.P.

12. The Role of the Federal Government in Health and Healthcare Canada Health Act 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 • 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 a certain level of coverage when they are in another province within Canada (or when they travel within Canada or abroad) • Subject to negotiation among provinces • 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 • This says nothing about delivery, which can be (and often is) private • Provinces are free to ignore these principles, but may have federal dollars withheld under the Canada Health Transfer Hon. Carolyn Bennett, M.D., M.P.

13. The Role of the Federal Government in Health and Healthcare Public Health 101 Hon. Carolyn Bennett, M.D., M.P.

14. The Role of the Federal Government in Health and Healthcare • Do you think we should have a: • A) strong fence at the top of the cliff • B) state of the art fleet of ambulances and paramedics waiting at the bottom • ??? Hon. Carolyn Bennett, M.D., M.P.

15. The Role of the Federal Government in Health and Healthcare • Would you prefer: • A) Clean air • B) Enough puffers and respirators • ??? Hon. Carolyn Bennett, M.D., M.P.

16. The Role of the Federal Government in Health and Healthcare • Would you prefer that that wait-times were reduced by: • A) A falls program to reduce preventable hip fractures • B) Private orthopedic hospitals and more surgeons • ??? Hon. Carolyn Bennett, M.D., M.P.

17. The Role of the Federal Government in Health and Healthcare • Governments should boast about: • A) How much they spent on the sickness care system • B) The health of their citizens, leaving no one behind • ??? Hon. Carolyn Bennett, M.D., M.P.

18. The Role of the Federal Government in Health and Healthcare Health vs. Healthcare My first rotation as a final year med student Night after night – subdural haematomas Has public policy changed the lives of neurosurgeons? Seatbelts, helmets, airbags? Hon. Carolyn Bennett, M.D., M.P.

19. The Role of the Federal Government in Health and Healthcare The Citizen and the Constitution Canada • The U.S.A. • Peace • Order • Good Government • Life • Liberty • The pursuit of Happiness Hon. Carolyn Bennett, M.D., M.P.

20. The Role of the Federal Government in Health and Healthcare U.S.A: Health care = a market commodity Medicare and Medicaid CANADA: • Health care = a universal common good for all citizens of all ages, all conditions • All universities are public and heavily subsidized by both levels of government Hon. Carolyn Bennett, M.D., M.P.

21. The Role of the Federal Government in Health and Healthcare OECD Data, Health Incomes, 2011 Hon. Carolyn Bennett, M.D., M.P.

22. The Role of the Federal Government in Health and Healthcare Infant Mortality Hon. Carolyn Bennett, M.D., M.P.

23. The Role of the Federal Government in Health and Healthcare Healthcare Costs as a Portion of GDP Hon. Carolyn Bennett, M.D., M.P.

24. The Role of the Federal Government in Health and Healthcare The Moral-Hazard Myth The bad idea behind our failed health-care system. Malcolm Gladwell, The New Yorker August, 29, 2005 Do you think that people whose genes predispose them to depression or cancer, or whose poverty complicates asthma or diabetes, or who get hit by a drunk driver, or who have to keep their mouths closed because their teeth are rotting ought to bear a greater share of the costs of their health care than those of us who are lucky enough to escape such misfortunes? The moral-hazard argument makes sense, however, only if we consume health care in the same way that we consume other consumer goods, and to economists like John Nyman this assumption is plainly absurd. We go to the doctor grudgingly, only because we’re sick “Moral hazard is overblown,” the Princeton economist Uwe Reinhardt says. “You always hear that the demand for health care is unlimited. This is just not true. People who are very well insured, who are very rich, do you see them check into the hospital because it’s free? Do people really like to go to the doctor? Do they check into the hospital instead of playing golf?” Hon. Carolyn Bennett, M.D., M.P.

25. The Role of the Federal Government in Health and Healthcare One implication: Canada does not have `Socialized Medicine` It has a system of public financing of certain categories of health services These services are delivered by private (albeit often not-for-profit) providers This system of publicly-financed hospital and medical insurance is referred to as “Medicare” Dr. RaisaDeber, PhD University of Toronto Hon. Carolyn Bennett, M.D., M.P.

26. The Role of the Federal Government in Health and Healthcare Who Pays for Health Care, 2011 Hon. Carolyn Bennett, M.D., M.P.

27. The Role of the Federal Government in Health and Healthcare Woolander and Himmelstein • NEJM: ‘for profit hospitals are 25% more expensive (admin costs) • JAMA 1999: ‘for profit’ HMO’s rated lower on all 14 quality indicators as measured by the National Committee for Quality Assurance • Johns Hopkins study dialysis patients • For-profit clinics 20% greater mortality • For-profit clinics 26% less referral for transplantation Hon. Carolyn Bennett, M.D., M.P.

28. The Role of the Federal Government in Health and Healthcare Profit… as a motivation PROFIT results in QUALITY OR COST Hon. Carolyn Bennett, M.D., M.P.

29. The Role of the Federal Government in Health and Healthcare Alberta Bone & Joint Health Institute (non-profit) • A time of urgent need • Model tested on hip and knee replacements • Putting patients at the centre • Delivering health care in a multi-disciplinary team environment • Encouraging patient choice with innovative compensation models • Aligning efforts across health regions • Diverting services to single-purpose focused facilities from overcrowded hospitals • Making all publicly funded health services evidence-based • Improving efficiency and asset utilization, and reducing demand on taxpayers • Ensuring the public health care system is sustainable • A satisfying journey through the health care system • Significant improvement in patient and health care provider satisfaction, driven by • A decline of approximately 80% in consultation waiting time • A decline of 90% in surgery waiting time • A decline of 30% in hospital stay • Faster recovery and enhanced patient engagement, accountability and education • More efficient utilization of scarce - and expensive - health care resources including major gains in the number of surgeries per day per operating room Hon. Carolyn Bennett, M.D., M.P.

30. The Role of the Federal Government in Health and Healthcare Achieving Health Reform’s Ultimate Goal How Successful Health Systems Keep Costs Low and Quality High U.S. Senate Committee on Aging Sept 30, 2009 INSURANCE COMPANIES 30% of US costs – almost a third – go to insurance companies. These insurers set premiums, design packages, assess risk, review claims and decide who to reimburse for how much. But they don’t deliver health care. Hon. Carolyn Bennett, M.D., M.P.

31. The Role of the Federal Government in Health and Healthcare 2. ADMINISTRATION:  Our single payer system is simpler, allowing us to run the administration of our offices and hospitals with much fewer staff – about 4%. We don’t have to deal with multiple payers, or chase bad debts. We don’t have to charge higher fees to compensate for unpaid for procedures Public Contractors Model: not a publically delivered model. Doctors and nurses are not civil servants. Hon. Carolyn Bennett, M.D., M.P.

32. The Role of the Federal Government in Health and Healthcare 3.  PHARMACEUTICAL PRICE CONTROLS: Although drug costs are rising in Canada as in the US, we’re able to exercise more control over the cost of drugs as a result of our Patented Medicine Prices Review Board. Hon. Carolyn Bennett, M.D., M.P.

33. The Role of the Federal Government in Health and Healthcare 4.  MALPRACTICE INSURANCE: The not-for-profit Canadian Medical Protective Association covers medical malpractice for all Canadian physicians with comparatively low premiums. Doctors’ remuneration does not have to reflect those extra costs and our justice system has successfully kept the awards in a reasonable range. Hon. Carolyn Bennett, M.D., M.P.

34. The Role of the Federal Government in Health and Healthcare 5.  EVIDENCE-BASED CARE: From vaginal births after C-sections to, lumpectomy, to x-rays for sprained ankles, applying evidence to determine the appropriateness of tests and procedures translates into fewer unnecessary tests and procedures and less defensive medicine. We are committed to moving from the error of pure cost-containment approach of the early 90s into true evidence-based cost effective care. Hon. Carolyn Bennett, M.D., M.P.

35. The Role of the Federal Government in Health and Healthcare 6.  PREVENTION: Diseases are cheaper to treat if they’re caught early, and since all Canadians are insured, they’re more likely to have pap smears, mammograms and other early detection visits and tests, than US patients who are not covered. Hon. Carolyn Bennett, M.D., M.P.

36. The Role of the Federal Government in Health and Healthcare 7.  FAMILY MEDICINE: A long-standing speciality in Canada, family doctors are trained to help patients navigate their care; We interpret the difference between what patients think they `want`, and what they actually `need` . A point of first contact, a trusted coach to explain the evidence and the choices. Hon. Carolyn Bennett, M.D., M.P.

37. The Role of the Federal Government in Health and Healthcare The Goal: Preventing the Preventable • Most appropriate care • In the most appropriate place • By the most appropriate person (paid and unpaid) Hon. Carolyn Bennett, M.D., M.P.

38. The Role of the Federal Government in Health and Healthcare • “We are not tinkers, who patch and mend what is broken. We must be watchmen, guardians of the life and health of our generation, so that stronger and more able generations may come after.” • Dr. Elizabeth Blackwell • (First woman physician North America) Hon. Carolyn Bennett, M.D., M.P.

39. The Role of the Federal Government in Health and Healthcare • For a copy of these slides and additional resources and links, please visit: http://carolynbennett.liberal.ca/blog/presentation-role-federal-government-health-healthcare/ Hon. Carolyn Bennett, M.D., M.P.