Back to Basics, 2010 POPULATION HEALTH (3A): Health Care Organization and Vital Stats

1. Back to Basics, 2010POPULATION HEALTH (3A):Health Care Organization and Vital Stats N Birkett, MD Epidemiology & Community Medicine Based on slides prepared by Dr. R. Spasoff

2. THE PLAN(2) • First class • mainly lectures • Other classes • About 2 hours of lectures • Review MCQs for 60 minutes • A 10 minute break about half-way through • You can interrupt for questions, etc. if things aren’t clear.

3. THE PLAN (5) • Session 3 (April 1) • Organization of Health Care Delivery in Canada • Elements of Health Economics • Vital Statistics • Overview of Communicable Disease control, epidemics, etc.

4. COMMUNICATIONS!!! C2LEO

5. Organization of Health Care (0) • Provincial governments are responsible for Health Care. • 1962: First universal medical care insurance • 1965: Hall commission recommended federal leadership on medical insurance • 1966: Medical Care Act (federal) established medical insurance with 50% funding from federal government • 1977: EPFA reducing federal role; led to extra billing debate • 1984: Canada Health Act • 2001: Kirby & Romanow commissions • 2005: Chaoulli decision (Quebec) • Controversial interpretation of the CHA in regards to banning of private clinics.

6. Organization of Health Care (0A) • Canada Health Act established five principles • Public administration • Comprehensiveness • Universality • Portability • Accessibility • Bans ‘extra-billing’

7. Organization of Health Care (0B) • 2003: total health care expenditures were $3,839/person or about $135billion, 10% of GDP • 73% from public sector (45% in the USA) • 32% spent on hospitals, 16% on drugs,14% on MD’s and 12% on other HCP’s • Research shows that private-for-profit care is more expensive and less effective

8. Methods of paying doctors (I&PH link) • 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. • Salary: unit is time. Productivity depends on professionalism and institutional controls • Practice plans • Combinations of above, e.g., "blended funding“ • Family networks (Ontario) (I&PH link)

9. Methods for 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: OHTAC reviews requests. If approved, government pays. If declined, hospitals can pay for it from core budget.

10. How good is the Canadian health care system? • The World Health Report 2000 (from WHO) placed Canada 30th to 35th in the world, slightly above US but well below most of western Europe • Implies that we should be healthier, given our high levels of income and education • Methods used by the Report have been highly criticized

11. Organization of Health Care (1)Student & Resident Issues • “The role of student and resident associations in promoting protecting their members’ interests.” • Student organizations will be familiar to you • PAIRO (Professional Assoc of Interns and Residents of Ontario) has been extremely effective in negotiating salaries, working conditions, educational programs

12. Organization of Health Care (2)CMPA • “The role of the CMPA as a medical defence association representing the interests of individual physicians.” • Canadian Medical Protective Association is a co-operative, replacing commercial malpractice insurance. It advises physicians on threatened litigation (talk to them early), and pays legal fees and court settlements. Fees vary by region and specialty ($500-$75,000/year).

13. Organization of Health Care (3) Interprovincial Issues • “The portability of the medical degree.” • Degrees are portable across North America • “The transferability of provincial medical licences.” • Traditionally, provincial Colleges of Physicians and Surgeons set own requirements (with input from provincial governments) • As part of attempts to improve intra-provincial trade, recent legal changes have established a common lisencing standard • Pass LMCC • Family med or Royal College fellowship

14. Organization of Health Care (3b) • Certification vs. licensing • Medical College of Canada • Certifies MD’s (LMCC) • Royal College of Physicians and Surgeons of Canada • Certifies specialists • College of Family Physicians of Canada • Certifies family physicians • College of Physicians and Surgeons of Ontario • Issues a licence to practice to MD’s.

15. Organization of Health Care (4a)Physician Organizations • Medical Council of Canada • Maintains the Canadian Medical Registry • Does not grant licence to practice medicine • 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.

16. Organization of Health Care (4b)Physician Organizations • Royal College of Physicians and Surgeons of Canada. • Maintains standards for post-graduate training through-out Canada. • Sets exams and issues fellowships for specialty training • Ontario Medical Association • Professional association; lobbies on behalf of physicians re: fees, working conditions, etc. • College of Family Physicians of Canada • Organization certifying/promoting family practice

17. Organization of Health Care (5)Medical Officer of Health • Reports to municipal government. • Responsible for: • Food/lodging sanitation • Infectious disease control and immunization • Health promotion, etc. • Family health programmes • E.g. family planning, pre-natal and pre-school care, Tobacco prevention, nutrition • Occupational and environmental health surveillance.

18. Organization of Health Care (6)Medical Officer of Health • Powers include ordering people, due to a public health hazard, to take any of these actions: • Vacate home or close business; • Regulate or prohibit sale, manufacture, etc. of any item • Isolate people with communicable disease • Require people to be treated by MD • Require people to give blood samples

19. The Coroner • Notify coroner of deaths in the following cases: • Due to violence, negligence, misconduct, etc. • During work at a construction or mining site. • During pregnancy • Sudden/unexpected • 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.

20. 78.1: MEDICAL ECONOMICS (1) • Define the socio-economic rationales, implications and consequences of medical care • Medical care costs society financial and other resources. • This objective aims to raise awareness of these types of issues.

21. MEDICAL ECONOMICS (2) • Is there a net financial benefit from medical care? • 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).

22. Principles of cost-containment • Eliminate ineffective care • Reduce costs of effective care • Substitute cheaper but equally effective care, • day surgery for hospital admission, • nurse practitioners for some primary care, • generic drugs • Reduce unit costs • reduce salaries (risk of reduced effectiveness) or fees (but quantity provided may increase)

23. Types of economic analysis [Costs always expressed in dollars] • Cost-minimization: assume equal outcomes • Cost-benefit: outcomes in dollars • *Cost-effectiveness: outcomes in natural units (deaths, days of care or disability, etc.) • *Cost-utility: outcomes in QALYs (quality-adjusted life years)

24. 78.1: VITAL STATISTICS INFORMATION • What are the key causes of illness or death in Canada? Common things are common – using epidemiology can help you run a better clinical practice • How have disease incidence and mortality change in Canada in the past 20 years? • Little good information on disease incidence except for cancer (cancer registries)

25. # deaths in Canada from 1979-2004; men and women. 13/7/2008 25

26. Mortality RATES in Canada from 1979-2004; men and women. 13/7/2008 26

27. VITAL STATISTICS (2) • Leading causes of death • ‘Cardiovascular disease’: 37% • Heart disease: 20% • ‘Other circulatory disease’: 10% • ‘Stroke’ 7% • ‘Cancer’: 28% • Lung cancer: 9% (M); 6% (W) • Breast cancer: 4% (W) • Prostate cancer: 4% (M) • Respiratory Disease: 10% • Injuries: 6% • Diabetes: 3% • Alzheimer’s: 1%

28. CANCER: 30.3% Circ Disease: 27.6% †† † † Pneumonia & influenza grouped with respiratory disease. Would increase infectious % to about 3.4%.

29. CANCER: 29.8% Circ Disease: 29.0% † † † Pneumonia & influenza grouped with respiratory disease. Would increase infectious % to about 3.5%.

30. CANCER: 31.6% Circ Disease: 27.3% † † † Pneumonia & influenza grouped with respiratory disease. Would increase infectious % to about 3.3%.

31. Sex ratio (M/F) in Canada from 1979-2004.

33. 33

39. Vital Stats (3) • In the USA, it is estimated that 86,000 people are sent to ER every year after a fall caused by a cat or dog! • Mainly minor injuries but 10% are fractures, internal bleeding, etc. • Cats mainly trip people by walking under your feet. • Dogs (the main source of injuries!) causes trips, push people over or pull them over on walks. • Watch out!!

41. Overall trends in mortality from Cancer 1976-2005: rates and numbers

42. Overall trends in mortality 1976-2005: rates and numbers

43. Cancer and AgeAge-Specific Incidence Rates for All Cancers by Sex, Canada, 2003 Surveillance Division, CCDPC, Public Health Agency of Canada

44. Cancer and AgeAge-Specific Mortality Rates for All Cancers by Sex, Canada, 2003 Surveillance Division, CCDPC, Public Health Agency of Canada

45. Time trends in incidence - Males Estimated Age-Standardized Incidence Rates (ASIR) for Selected Cancer Sites, Males, Canada, 1978-2007 Surveillance and Risk Assessment Division, CCDPC, Public Health Agency of Canada

46. Time trends in mortality - Males Estimated Age-Standardized Incidence Rates (ASIR) for Selected Cancer Sites, Males, Canada, 1978-2007 Surveillance and Risk Assessment Division, CCDPC, Public Health Agency of Canada

47. Time trends in incidence - Females Estimated Age-Standardized Incidence Rates (ASIR) for Selected Cancer Sites, Females, Canada, 1978-2007 Surveillance and Risk Assessment Division, CCDPC, Public Health Agency of Canada

48. Time trends in mortality - Females Estimated Age-Standardized Incidence Rates (ASIR) for Selected Cancer Sites, females, Canada, 1978-2007 Surveillance and Risk Assessment Division, CCDPC, Public Health Agency of Canada

49. Population Pyramids • Canada, 1901-2001 • Newfoundland 1951-2001 • Ontario 1951-2001 • Nunavut, 1991-2001