We must change the way we pay for our health care
Health care costs the public sector about $160 billion a year in Canada, a higher per capita cost than most industrialized nations. Yet Canadians are not markedly healthier, nor do we receive better care. The Commonwealth Fund has ranked Canada 10th out of 11 developed nations for the efficiency of our health care system (only the United States was worse). We came at or close to the bottom in access to care, timeliness of care and overall quality of care, and didn’t rank in the top three in any of the metrics reviewed.
Maybe our health care system isn’t as great as we like to think it is. How can Canadian health care move to the front of the pack?
Part of what holds us back is how public health care spending is allocated. For example, the way we spend health care dollars is often process- rather than outcomes-oriented. Most provincial governments pay health care providers, at least in part, according to the tasks they’ve performed rather than the outcomes they’ve achieved.
Doctors, too, are often paid, at least in part, by the number of patients they see or activities they perform with little consideration given to the quality or appropriateness of care delivered.
A system that encourages improved quality and access to care, providing the best possible value for public spending, and rewards innovation may be what’s needed.
The outcomes that matter to many patients — a good care experience, the highest quality of life for the longest time possible — could be how success is judged.
Financial incentives that reward care providers for helping to keep their patients healthy would encourage innovation in valuable areas of health that historically have been difficult to build a business case around, such as health promotion and disease management and prevention. How do we get there? Governments can’t mandate innovation, but they do have levers they can use to encourage those who want to experiment and innovate.
Setting a forward-looking national vision for change would provide a powerful signal that the status quo is not in the best interests of Canadians.
Some interesting funding experimentation is already taking place.
In Mississauga, Trillium Health Partners and Saint Elizabeth home care have agreed to be paid jointly by the province based on how well cardiac patients do after leaving hospital.
After a year, the results are promising. Patients are being discharged sooner and post-op readmissions to hospital and emergency department visits are down.
New Brunswick is implementing new ways to deliver better health care in the community. Medavie Health Services, a private provider of emergency medical and community care services, will soon enter into a performance-based contract with the province. Its reimbursement will be linked to metrics related to increased system capacity, improved patient experience and improved population health outcomes.
And the federal government recently unveiled Canada’s first social impact bond in health to pay for a blood pressure control program run by the Heart and Stroke Foundation with support from MaRS Discovery District and its Centre for Impact Investing. The payments Heart and Stroke will receive will vary according to how well it can control par- ticipants’ blood pressure.
These experiments are vital first steps, but the scale of ambition needs to be much greater for meaningful transformation.
Canada needs a national outcomes measurement and health funding strategy, in partnership with the provinces and territories, with a substantial commitment to test new approaches and adopt those that work. A federal support and evidence collection unit could provide expertise in funding innovation for provinces and health care providers seeking to test new payment approaches and allow others to learn from those who have already done so within Canada and internationally.
We need to shift our focus to understand how to drive the best health outcomes and get better value from limited health dollars. Governments and care providers must strategically experiment with ways to pay for care that align health stakeholders to seek better quality and value. This is the future of health care.