Brian Day Past President Canadian Medical Association

1. Kananaskis February 16th 2009 Coping with Change in Canada: Best and Emerging Practice Brian Day Past President Canadian Medical Association

2. Global Budget or Block Funding Less Care Less Facilities Procedures Innovation Nurses Physicians Patients

3. Patient Focused Funding • PFF • PbR • P4P • ABF • SBF • EBP • Empowering the Patient

4. Orthopaedic Residents in Canada Approximately 50% leave for US “No jobs”

5. Fig. 1 The quality-improvement cycle. P4P must not become “Pay for Paperwork”

6. A Patient Focused System

7. Worst: sick patients waiting 6 days plus to see doctor Canada Worst ranking: 4 hours plus in E.R. 65% Children wait a medically unacceptable period Last in use of information technology Last in use of interventional radiology

8. Health Care and the Economy

9. The Cost of Waiting

10. Paying for the Privilege of Waiting Four Targeted Areas $15 Billion January 2008 Wait Lists: an Unfunded Liability

11. “In total the economic burden was $51 billion…”

12. MEDIX GP Survey on Wait Lists Pre-PbR • 66% - had patients admitted as emergencies • 90% - consultations from delays • 70% - significant problems from delayed treatment • 1.5 million extra consultations

13. England: the New NHS Carole Heatly Market conditions and competition Patient choice - quality and service Local control Bottom up instead of top down Wait lists gone, productivity up

14. Patient Power and the New NHSDamien Fletcher , The Mirror, 31st March 2008 The greatest change since 1948 Patients choose from 350 hospitals, including private Bunions to heart surgery Flexibility and convenience for patients Stimulates failing hospitals to improve Patients avoid MRSA hotspots or wait lists

15. Public Private Non Debate

16. Worksafe BC No Waits for Injured Workers Health Care Costs 1999 $204 million 2002 $187 million Health costs constant at $200 million per year for the past 10 years

17. “A System Focus”

19. and Performance Data: Costing CMG HRG DRG

20. FOI Document Billings versus Costs

21. Total Indirect Costs (per sample $1000 direct surgical cost) BC Hospital A: Add $1220 BC Hospital B: Add $850

22. Measurement and Accuracy(Garbage in = Garbage Out) BC Medicare 15-16%1 U.S. Medicare and Medicaid 7-8%2 1Turchen, 2008 2 Matthews,2006 Independent audit Federal FOI to include CIHI Outcomes clearly defined Turchen 2008

23. Costing and Accountability Calgary Health Region (CHR) “CHR administration argues that accurate cost accounting would require a diversion of effort better expended elsewhere”

24. US Medicare:10 procedures, 4 Settings 2008

25. 2008 NHS Tariff Examples

26. Economic Impact of Early Treatment • Patients’ income • Medical expense • State revenue or payments • Medical tourism income

27. Medical Tourism $20 Billion 2006 $40 Billion 2007 $80 Billion 2008 U.S. Medical Tourists ¾ million 2008 6 million 2010 12 million 2012

28. Service - Based FundingThe Health of Canadians – The Federal RoleFinal Report Volume Six Senator Michael Kirby • Encourage efficiencies • Keep or reinvest savings • Create competition • Specialized teams • Centres of excellence • Improve quality with increased volume • Improve patient service • Reduce inefficiencies “Kirby Report”

29. OECD: Competition in the Provision of Hospital Services October 27 2006

30. Competition in the Provision of Hospital Services (OECD) • Market mechanisms reduce government hospitals costs • Close hospitals or change management for poor results • Choice of provider • Capacity is needed • Rural hospitals benefit from benchmark competition • With long waits, funds following patients increases output • Centres of excellence may need entry constraints

31. ONTARIO HOSPITAL ASSOCIATION January 2007

32. Patient Focused and Centred