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Raisa Deberasdasdasdasdasd Lecasdasdasdture 4
Raisa Deberasdasdasdasdasd Lecasdasdasdture 4
Raisa B. Deber, PhD Department of Health Policy, Management and Evaluation University of Toronto
Topics to be covered
Dimensions of health systems Paying for insured services Historical development of Canadian Medicare Organization of health services Public health system Professionals and Professionalism Trends Economic Evaluation
In Market Models
Money follows patients Advantage: Client responsiveness
Services (Delivery)
Service Recipients
Service Providers
Payment (Financing)
Service Recipients
Paym (Fina ent ncing )
Service Providers
t n e m Pay nt) e m e rs u b m ei
(R
Service Recipients
Payment (Financing)
Service Providers
Payment (Reimbursement)
Provider Organizations
time (salary, sessional) task (fee-for-service) case/client (capitation, DRG) In Canada: most hospitals paid by global budgets Most doctors paid by fee-for-service
If supply fixed and demand high: Price should ??? If price free:
Demand should ???
These are merit goods. Supply and demand does not seem to apply.
Historical development
contrast with U.S. balance of powers) don't lobby MP, as much as lobby Cabinet and bureaucrats and health is provincial
Federal
Difficult to block a determined government from acting Provincial government is both main financer and main regulator
Trusting of authority Carry through program (vs. checks and balances) (Used to be) pro government intervention
means less opposition to socialized medicine, more support for 'public goods'
Distributed powers between federal and provincial government Section 91 - federal powers Section 92 - exclusive powers of provincial legislatures, includes
The establishment, maintenance and management of hospitals, asylums, charities, and eleemosynary institutions in and for the province, other than marine hospitals.
Whose jurisdiction?
Health interpreted to be under provincial jurisdiction Canadians think that service levels should be roughly equal, regardless of geography Provinces vary in their ability to pay Solution:
2.
Passed 1957 Introduced gradually over next few years (as provinces set up complying programs) Introduced cost sharing for "all necessary inpatient services and facilities at standard ward level, excluding payment of private physician", if terms and conditions were met.
HIDS
Covered the most expensive part of the system (acute care) Allowed adding outpatient and emergency services (by separate agreement) Omitted mental, tuberculosis, or custodial care hospitals (which were seen as being covered in other ways)
1964 - Hall I report (recommends introducing universal insurance for medical care)
Passed 1966 Cost sharing for all medically necessary physician services. At provincial discretion, could include other services (e.g., optometry, podiatry), but these not cost shared. Came into effect July 1, 1968 (2 provinces participating).
1966 - Canada Assistance Plan (cost shared plan for social services; eligibility based on means testing) 1971 - All provinces have participating health insurance and hospital plans considered date when Medicare in place across Canada
Public administration Comprehensiveness - insures all medically required services Universality Portability - insured persons are covered anywhere in Canada Accessibility - reasonable access to insured services on uniform terms and conditions which do not impede access, either directly or indirectly
Replaced HIDS and Medical Care Act Keeps same terms and conditions (more or less) fiscal penalty for direct charges to insured persons for insured services (extra billing, user fees)
Added requirements
Provision of information Visibility of federal contributions Allows designation of non-physicians as health care practitioners under the act Note: accessibility also requires reasonable compensation to providers for insured services
Hospital Services
Means any of the following services provided to in-patients or out-patients at a hospital, if the services are medically necessary for the purpose of maintaining health, preventing disease or diagnosing or treating an injury, illness or disability, namely:
(Continued)
B) C)
It can move outside terms of Canada Health Act Particular issues: (in Romanow, Kirby)
Home care Pharmaceutical coverage Public health, mental health, rehabilitation, But it doesnt have to
Also:
System is popular
Changes:
Encouraged high cost medicine Costs were unpredictable Federal government incurred costs, without receiving credit. Provincial government had priorities steered by federal programs Paid bills, but did not encourage reorganization of system. Irritant to provinces (who didnt want federal control in areas of provincial jurisdiction)
1977 Federal-Provincial Fiscal Arrangements and Established Programs Financing Act (EPF)
Change in financing of Medicare (although NOT in terms and conditions). Replaced cost sharing for medical insurance, hospital insurance, and post-secondary education with a combination of tax room and per capita cash grants, partially indexed to GNP, plus some complicated elements (equalization, stabilization, revenue guarantee) to appease poorer provinces.
Transfers under EPF went into general provincial revenues (I.e., no longer cost shared programs) Provinces have leeway on how to use these funds, as long as national conditions for hospital and medical insurance are complied with (no such requirements for postsecondary education)
Federal-Provincial Battles
What to include? What strings to attach? One time vs. ongoing funds?
To combat deficit, federal government unilaterally reduced indexation (to less than growth in GDP)
1986 Bill C-96 (grew at GDP 2%) 1991 Bill C-69, Government Expenditures Restraint Act (frozen; no growth with changes in GDP) 1991 Bill C-20 (extended the freeze to 1995)
Since cash portion was residual, it actually diminished (since yield from tax points did increase with inflation)
And with it the federal ability to enforce national terms and conditions
replaced EPF and Canada Assistance Plan cut total amount put in cash floor (which couldnt bind subsequent governments) removed most CAP requirements Canada Health Act basically unchanged
Increase to cash floor (e.g., set at 12.5 billion in 1996; increased to 15.5 billion, and then in 2000 federal budget to 21 billion over the next 5 years) Increase to CHST entitlements (growth rate usually set below inflation, but subject to change) One-time funding, purportedly for extra programs (e.g., $2.3 billion more, said to be for medical equipment, information technology, and primary care, in 2000 budget; funds for home care, pharmacare, primary care reform in 2003, etc.)
The shares debate whereby the federal and provincial governments argue about whose fault it is that healthcare is under pressure
There is one taxpayer Health care is under provincial jurisdiction One could argue that there have been no federal transfers earmarked for health care since 1977 If so, the only relevant issue is whether those responsible for funding services (provincial governments) have the resources they need
Numerator: provinces include only cash but not tax points Denominator: provinces include all health spending, not only physicians and hospitals (which is all that were cost-shared) Shares: ignore that transfers are also for post-secondary education and welfare, which have been cut in many provinces
Data sources:
International data: OECD Health Data 2001 Canadian data: Canadian Institute for Health Information (CIHI) Note: they are not responsible for the interpretations made of their data
Looking at 22 OECD developed countries: Canadas share started below the 22 country average, ranking 14th in 1975, 18th in 1993, and 19th in 1997. At this stage, rather than being among the most publicly funded, Canada ranks above only Australia, Portugal, and the United States.
Following chart gives 22 OECD countries, listed in order of spending as % of GDP As measured in the proportion of Gross Domestic Product (GDP) devoted to health care spending, Canada was the fourth highest spender in 1998 (down from 3rd in 1994)
Were #4
10
12
14
Following chart gives the same 22 OECD countries, listed in the same order (spending as % of GDP) But shows data in health expenditures per capita in US dollars Canada ranked in 14th place
Were #14
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Ratios have numerators and denominators Dont just look at health spending Look at what the economy can sustain
Again, contrary to current rhetoric, Canadian health spending was not out of control, at least until 1997 After that, some catch up Basically, returning us to where spending would have been without cuts (and not making up the lost spending)
Spending in million $
Other public
Spending in million $
Other public
Crisis? Or Catch-Up?
Method: Take CIHI data, expenditures per capita, in 1997 $ Compute trend-line, using actual data for 1975 to 1992 Extrapolate what would have been, had spending continued to grow at that rate Graph, and compare
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81
78
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91
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87
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88
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f/
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Source: CIHI
fiscal role steering, leadership, coordination role (e.g., health promotion) special issues (e.g., quarantine, food and drug safety, medical devices, research) special groups (e.g., First Nations, military) For further information, see: www.hcsc.gc.ca
education regulating professionals financing hospitals, physicians, etc. public health managing the system
Only services delegated to them by provinces In every province but Ontario, regional authorities manage an array of services In earlier years, some local governments were involved with building/running civic hospitals In some provinces (including Ontario), a major role in managing and delivering public health
Regional authorities
Geographically based, with responsibility for a defined population Replace individual local boards for individual sectors (e.g., hospitals, home care) and place these under a common management structure with a common budget Considerable inter-provincial variation in which services are under the jurisdiction of these boards, how the boards are set up (elected, appointed, mixture), and what powers the boards are given
Independent not-for-profit organizations, usually with their own boards of directors Play a major role in:
health care delivery (e.g., hospitals, meals on wheels, etc.) Fund-raising, research, advocacy (e.g., disease agencies) Social action, community support (e.g., self-help groups) System management (e.g., professional regulatory bodies)
Public Health
Many homes
Not all public health activities conducted by public health departments. Other departments of government (including schools), private health providers, etc. do considerable public health activities
Characteristics of Professions
Expertise based on body of theoretical knowledge Application of this knowledge in form of specialized skills and competencies Commitment to professional code of ethics Strategic and operational autonomy (what you do, and how you do it)
Specialized knowledge Self-regulation Established training programs Certification procedures Risk to public from unqualified practitioners Agency relationship with clients Provision of services
Existence of a college to deal with registration, standards of practice, maintenance of competence, complaints, protection of public Legislative authority for delegating these responsibilities (e.g., Regulated Health Professionals Act)
Deals with controlled acts Defines which professions are allowed to perform which of these acts I.e., particular professions may no longer have monopoly over particular services
E.g., College of Physicians and Surgeons of Ontario responsibility for professional self-regulation Ontario Medical Association responsible for representing interests of the profession
Disputes about rents - how much to pay providers, skill mix, distribution, etc. Disputes about public-private mix - who should pay for what re-balancing - shifting the emphasis from hospitals/doctors to the community (but also de-insuring) re-organizing - especially regionalization
Critical point: We are always comparing at least two alternative courses of action (call them A and B)
Define the alternatives being compared (option A vs. Option B) Compute the costs of A and B Compute the consequences of A and B Do the math Select the best option
Measuring Costs
Relatively straight-forward (which is not to say that it is easy) Issues include: Discount rate Whose costs should be included? Which costs should be included?
Measuring Consequences
Many types of consequences could be examined. But most usually focus primarily on clinical impact - safety, effectiveness Difference between examining consequences for individual and for population. Statistically, need to know how great, and how likely, benefits are.
Cost Minimization
Therefore, take the option with the lowest cost Simplest: dont even have to measure the consequences
Cost Benefit
Assumes that consequences of A and B can both be measured in the same monetary unit as the costs.
Therefore, take the option with the best pay back (return on investment) In health, can result in some odd computations
Cost Effectiveness
Assumes that consequences of A and B can both be measured in the same (non-monetary) unit
Therefore, take the option with the best bang for the buck
Cost Utility
Assumes that consequences of A and B can both be measured in the same (non-monetary) unit, adjusting for the quality of life
Therefore, take the option with the best bang for the buck
Consequences: Mortality
Did the patient live or die? Can measure mortality rates fairly easily. Issues: over what time period? (30 days?) What, if any controls? (Reason for mortality? Age? Severity of illness?)
Consequences: Hospitalization
Did the patient require readmission? Can measure re-admission rates to your own institution fairly easily. Issues: over what time period? (30 days?) What, if any controls? (Reason for admission? Age? Severity of illness?)
Did the patient get bed sores? Did wounds heal? Not routinely collected. No agreement on appropriate measures (but progress is being made)
What was the quality of life? Much harder to measure - enormous controversy about appropriate measurements. Data not routinely collected Ethical issues - what is the value of a life spent with a disability?
How satisfied was the patient? Even harder to measure Data not routinely collected Relates to intangibles and process variables - continuity of care, provision of information, etc. - which usually has little direct relationships to outcomes
How were the caregivers affected? Even harder to measure - enormous controversy about appropriate measurements. Data not routinely collected Ethical issues - what responsibility do family members have for one another?
How were the providers affected? Impact on institution, professions, individual providers Even harder to measure Short term or long term? Ethical issues - how important is to to ensure well paid, skilled jobs?
Are there broader societal, ethical, etc. Implications? Even harder to measure Usually ignored, except in obvious areas (e.g., Reproductive technology)
Beware the tendency to ignore soft or difficult to measure outcomes Beware the technocratic fallacy - that is, the tendency to disguise value choices behind seemingly technical decisions
One example: Discount rate: Should it be 5%? 3%? 0% Looks technical, but...
What is the payback for a prevention program whose effects will be seen in 30 years?
1 year 30 years 0% 1000 1000 1% 990.09 741.92 3% 970.87 411.98 5% 952.38 231.37
Mass = small benefit to large population High tech = large benefit to small population
100 90 80 70 60 50 40 30 20 10 0
lo w
hi g
No
Another example: Who decides? Whose costs and consequences matter? Are there procedural justice issues?
At one level: Part of quest for evidence-based practice May be critical for providers to help justify the value of what they are doing, and to stop doing what cannot be justified
At a deeper level: Those who help set the agenda and write up the minutes can control the results of a meeting Those who determine which costs and consequences will be considered, and how they will be measured, can control the results of an evaluation
Help define assessments Keep an eye on process issues Ensure seemingly technical issues dont camouflage ideological/ethical assumptions Ensure that the issues addressed are those relevant to patient care
http://www.cihi.ca/eindex.htm
http://www.hc-sc.gc.ca/english/index.htm