Why the NDP leader forced the election, how she deals with those nasty party veterans, her new look — and personal tragedy,
Leaders seem to want to talk about anything but. So we got a dozen experts to weigh in on what’s wrong with the system
Too many Ontarians cannot get appointments with their family doctors on short notice. Too many go to ERs even though they don’t need emergency treatment. And too many fall through the cracks when multiple health-care providers are involved in their care.
It’s widely accepted that Ontario tax- payers should be getting much more value for all the money they spend on health care, an amount that last year totalled $51 billion or 42 per cent of the entire provincial budget.
The three major political parties each claim to have the answers. Progressive Conservatives are proposing the most drastic solution, with major structural reorganization. The Liberals have put a strong focus on improving access. And the New Democrats’ platform emphasizes reducing wait times.
But substantive debate on their plans has been scant during the election campaign, not really unusual even though health is always at the top of the list of voter concerns.
The health system is convoluted and full of acronyms that are meaningless to most. It’s difficult for politicians to engage voters on important nuances. And some ideas on how to fix the system are so explosive, politicians are wary of discussing them, especially during an election.
So the Star has turned to a dozen highlevel players, leaders and advocates in the system to get their takes on what’s behind the problems and what it will take to fix them.
Many agreed to speak only on background.
Some ideas about how to fix the system are too explosive for politicians to even talk about
Among the biggest stumbling blocks, they agree, are a struggling primary care system, lack of accountability and systemic fragmentation.
The number of visits to Ontario hospital emergency departments has jumped by 14 per cent over eight years, according to an internal study by the Institute for Clinical Evaluative Sciences (ICES), the results of which have never before been made public.
Accounting for population growth, the rise in ER volumes is 5.5 per cent.
There were 391.5 visits per 1,000 residents in 2011-12 compared to 371 in 2004-05, with the biggest increase seen over the last three years of the study. (The H1N1 outbreak is likely related to the jump in 2009/10.)
The overall increase has left policymakers scratching their heads given that so many reforms have been aimed at taking pressure off hospitals.
A prevailing theory is that it is a reflection of the difficulty patients have in accessing primary care. When patients have easy access to family doctors and other primary care providers like nurse practitioners, they are less likely to visit ERs.
“There are still questions about access to alternatives” to ERs, says the institute’s president, Dr. Michael Schull. “There is still a disconnect between primary care and some parts of the health system. But at this stage we are not sure what is driving the increases.”
A report released earlier this year by the now-defunct Health Council of Canada shows only 42 per cent of Ontarians can get a same-day or next-day appointment with a family doctor.
Ontario’s health system ranked last compared with 11 developed countries in providing quick primary care appointments, according to the Health Council report and the Common- wealth Fund Health Policy Survey.
The studies reveal 58 per cent of Ontarians have difficulty getting care on weekends and evenings without having to go to an ER.
Roger Martin, former dean of the University of Toronto’s Rotman School of Management, says Ontario’s primary care system also lags behind that of international peers on wait times, delivery of chronic care, use of IT and provision of team-based care.
To be fair, the Liberal government has made some headway in improving primary care. More than two million more Ontarians have a family doctor today compared with a decade ago.
The government has made a big push to change the way Ontario’s 9,500 family doctors are paid. Traditionally, they were paid a fee for each service they provided, billing OHIP for every patient visit. That model gives doctors incentive to see lots of patients and not spend much time with them.
Today, 40 per cent of family physicians receive much of their income through a capitation model of payment, providing a lump sum for each patient enrolled in their practices.
Many of these doctors work in teams with other family physicians and health professionals.
But critics say too many doctors are still paid fee-for-service. And too many continue to work in solo practices.
Primary care reform needs to accelerate and more family physicians need to move into multidisciplinary teams to treat an aging population, Martin says. The health system needs to change its focus from acute care — serious illness that lands people in hospital — to chronic care, for conditions like diabetes, heart disease and dementia, he says.
Reforms so far have been costly. In 2010, family doctors received $3.7 billion, 32 per cent more than four years earlier. But despite hopes that changed practices would go along with the money, the payouts had less effect than desired, such as a reduction in ER usage. A 2012 ICES study shows patients in the new primary care team models still visit ERs too much.
“Emergency volumes are going up because the primary care system is still not well enough organized and primary care providers are not accountable for having extended hours to keep people from wanting to go to the emergency department,” charges Tom Closson, former president of the Ontario Hospital Association.
If doctors were financially penalized when their patients unnecessarily use ERs, they would have incentive to improve access, he says.
Making primary care doctors more accountable means attaching more strings to payments.
Terrence Sullivan, a professor in the Dalla Lana School of Public Health at Uof T and former president of Cancer Care Ontario, is calling for wholesale change in the way doctors are paid.
It’s a bold statement you are not likely to hear on the campaign trail from politicians loath to take on doctors.
Sullivan says the province should change the way it bargains with doctors and move further away from feefor-service. Payments should be tied to quality objectives whether doctors work in primary care, hospitals or long-term care, he says.
“If physicians order procedures that are not wise . . . rarely does anyone come back to them and say, ‘Why are we doing this? There is no evidence that supports this.’ In some cases, they just do procedures to make money.”
Ontario’s health system is notoriously fragmented with silos that include hospitals, home and community care, long-term care, primary care, special-
ist care and public health.
When patients move from one sector to another, the handover can be sloppy.
The PCs’ solution is to gut Ontario’s local health integration networks, which they criticize for failing in their mandate to plan and integrate services within the boundaries of 14 regions. The Tories also want to scrap the province’s 14 community care access centres, tasked with co-ordinating home and community care and authorizing admission to long-term-care homes.
LHINs and CCACs are bloated bureaucracies, the party charges. It wants to replace them with 30 to 40 “health hubs,” which would be linked to regional hospitals and co-ordinate and deliver all aspects of patient care.
There is much agreement in the upper echelons of the system that fundamental restructuring is necessary to reduce fragmentation.
“What we need to do now is structurally redesign our health-care system,” says one high-ranking health official.
He says LHINs should be scrapped or given more teeth to properly do their job. They were created in 2005 to organize care regionally, an impossible task given that they only have jurisdiction over parts of it, he says.
LHINs have authority over CCACs, hospitals, long-term care, community services, mental health agencies and some parts of primary care — but not over most doctors and public health.
On paper, hospitals are under the purview of LHINs, but in reality hospitals often big-foot the networks. That’s because they have bigger budgets, larger workforces, powerful CEOs and more clout on boards of directors.
The job of LHINs is made even more difficult because there are, in fact, more than 2,000 boards of directors for organizations that deliver health care in the province, making lines of accountability fuzzy and intensifying competition for resources.
“This makes the system extremely complicated for patients to understand and the resulting fragmentation negatively impacts the care that patients receive,” says Closson, who be- lieves there should be more consolidation and fewer boards.
But communities’ allegiance tends to be to local institutions and boards, particularly hospital boards, says health policy consultant Steven Lewis. “The LHINs are always playing bad cop and every time they try to do something that makes good sense like rationalizing the system or consolidating services, all hell breaks loose,” he says, citing a 2008-09 uproar in the Niagara area, when the LHIN decided to overhaul hospital services and close two ERs.
But it’s precisely for this reason that advocates like the Ontario Health Coalition are wary of regionalization. It argues that regional bodies like LHINs allow politicians to distance themselves from controversial decisions. And fewer boards would mean fewer avenues for community input.
The coalition is upset over the PCs’ plans to regionalize the health system through the creation of health hubs, arguing it would lead to the amalgamation of 146 hospitals into 30 or 40.
If the Conservatives get elected, get ready for “merger mania,” says the coalition, warning of years of upheaval.
The Tories would privatize hospital surgeries, diagnostic tests and other health-care services, the coalition contends, based on its reading of promises to increase competition and expand the role of specialty clinics.
Meanwhile, some senior officials think LHINs should be replaced with a regional system of seven or eight geographically located “accountable care organizations,” like the much heralded Kaiser Permanente model in the U.S.
Such organizations are structured to cut through silos by taking full responsibility for patients, from primary to acute care. They place an emphasis on disease prevention. “You look after the entire span of the care continuum and if you think the money is better spent on obesity management rather than building a new wing, you can make that decision,” explains one official.
CCACs have come under fire for add- ing another layer of bureaucracy between the patient and front-line health-care provider. To explain the problem, health policy analyst Dr. Michael Rachlis describes what it takes for a frail senior to get home-care support from a personal support worker:
“Before somebody can get a bath, the money has to go from the Ministry of Health to the LHIN, then it has to go from the LHIN to the CCAC.”
The CCAC then spends a big chunk of its budget getting home and community-care companies to bid on contracts to provide front-line services, Rachlis continues. Those companies, in turn, hire employees like personal support workers on contract.
“There are four levels of contracts before a patient gets a bath,” Rachlis exclaims. “That’s a problem.”
Some insiders, including government policy people, concede Rachlis may have a point. Still, they say instead of nixing CCACs, the organizations should be allowed to hire employees like (personal support workers) rather than contract out work.
To what extent the health system can be restructured after the election will depend on whether there is a minority or majority government.
“If you do change the status quo, you are going to have to gore some oxen,” says Lewis, explaining that he doubts a minority government will want to create a big wedge issue in health care and precipitate another election.
Whatever the outcome on June 12, the system needs to be organized more around patients than providers, says Closson.
The first order of business for the next health minister should be primary care reform, Lewis says.
“If we get that right, if we have really good primary care that really focuses on chronic disease management and aging and frailty, you are going to get dividends down the road in terms of reduced demand on more expensive services, even if the rest of the system still looks a bit chaotic.
“If we get that right, I am not sure the rest matters so much.”