1. Dollars and Sense: Medicare is Sustainable
if we do our work differently
Michael M Rachlis MD MSc FRCPC LLD
Quebec Medical Association April 20, 2012
www.michaelrachlis.ca

2. Current received wisdom
• Health Care costs are wildly out of control
• My fellow baby boomers and I will really
deep six Medicare as we get older
• The only alternatives are to either hack
services, go private, or better yet do both
• We need an “adult conversation” about
whom gets tossed out of the life raft
2

3. 3

4. What’s my story?
• What’s the diagnosis
– Health Care costs are not “out of control”
– The aging population won’t break the bank
– Most of health care’s problems are due to antiquated,
processes of care
• What are the solutions
– We need to complete Tommy Douglas's vision for the
Second Stage of Medicare -- a patient-friendly
delivery system focussed on keeping people healthy
• How do we get there?
– What are the roles for health care providers
– What is the role of the medical profession
4

5. Total health care expenditures as % of GDP
14
12
QC CAN
10
8
6
4
2
0
1981 1986 1991 1996 2001 2006 2011 f / p
5
Data from: http://secure.cihi.ca/cihiweb/products/NHEX_Trends_Report_2010_final_ENG_web.pdf

6. Total health care expenditures as % of GDP
16
QC ON
14
MB AB
12
CAN
10
8
6
4
2
0
1981 1986 1991 1996 2001 2006 2011 f / p
6
Data from: http://secure.cihi.ca/cihiweb/products/NHEX_Trends_Report_2010_final_ENG_web.pdf

7. Canadian Provincial Govt health care
Expenditures as share of Provincial GDP
9%
8%
7%
% 6%
GDP 5%
4%
3%
2%
1%
0%
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
2011 f
7
Data from: http://secure.cihi.ca/cihiweb/products/NHEX_Trends_Report_2010_final_ENG_web.pdf

8. Provincial Govt health care expenditures
as % of Provincial GDP
10%
9%
8%
7%
6%
5%
4%
ON MB AB
3%
QC CAN
2%
1%
0%
1981 1986 1991 1996 2001 2006 2011 f
Data from: http://secure.cihi.ca/cihiweb/products/NHEX_Trends_Report_2010_final_ENG_web.pdf 8

9. The sustainability of Medicare in Canada
• Health slowly increased its share of Canadian GDP from 2000
to 2008
• Health’s share of GDP rose dramatically in 2009 because the
economy collapsed.
• In 2010 and 2011, governments controlled costs, the
economy grew again, and health decreased its share of GDP
• This downward trend of health costs as a share of GDP will
likely continue for the next 3-5 years
• Public health care spending in 2011 was 0.6% higher than its
previous peak in 1992 (8% in relative terms) vs. private sector
cost rise of 0.9% (35% in relative terms)
9

10. Canadian Provincial Government HC Exp
as share of program spending
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010
f/p
https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC1671 10

11. Provincial Govt health care expenditures
as share of program spending
50%
45%
40%
35%
30%
25%
ON MB AB
20%
QC CAN
15%
10%
5%
0%
1975 1980 1985 1990 1995 2000 2005 2010
f/p
11
Data from: http://secure.cihi.ca/cihiweb/products/NHEX_Trends_Report_2010_final_ENG_web.pdf

12. Canadian Provincial Government
program spending as share of GDP
25%
20%
15%
10%
5%
0%
2001
2007
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2003
2005
2009
12
Data from: https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC1671

13. Provincial Government program
spending as share of GDP
30%
25%
% 20%
GDP
15%
10%
Canada Quebec Ontario
5% Alberta Man.
0%
2001
2007
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2003
2005
2009
13
Data from: https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC1671

14. Life Exectancy (both sexes)
90
80
70
60
CAN QC
50
ON
40
30
20
10
0
1927 1937 1947 1957 1967 1977 1987 1997 2007
14

15. Provincial Govt health care expenditures and
Canadian Gov’t outlays as share of GDP
60%
50%
40%
30%
Canada Prov Govt Health Exp
20%
Canadian Government outlays
10%
0%
1985
1989
1981
1983
1987
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
15
Data from: https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC1671

16. Canadian and US Govt Outlays as % of GDP
60
50
40
%
GDP 30
20
10
0
1991 1993 1995 1997 1999 2001 2003 2005 2007 2009
16
Data from: : https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC1671 and http://www.fin.gc.ca/frt-trf/2011/frt-trf-11-eng.asp

17. The shrinking Canadian public sector
• Overall Canadian government revenues have
fallen by 5.8% of GDP from 2000 to 2010, the
equivalent of $94 Billion in lost revenue
– Just half of this, 47 Billion, could eliminate all 2012
Canadian government deficits OR fund first dollar
universal pharmacare, long term care and home care
AND regulated child care for all parents who want it
AND free university tuition AND build 15,000 units of
affordable housing units AND the new fighter jets
17

18. Percent of GDP devoted to Health Care
20
18
16
Average
14
12
% of 10
GDP
8
6
4
2
0
Belgium
France
Luxem
Sweden
Italy
Iceland
NZ
Denmark
Germany
Nether
Austria
Canada
UK
Spain
US
Finland
Norway
Switz
Ireland
All data from 2009. Source: OECDE Health Data 2011. 18
http://www.oecd.org/document/16/0,3746,en_2649_37407_2085200_1_1_1_37407,00.html

19. The aging population won’t kill Medicare
• Canada is aging and health costs increase with age
• But Aging of the population per se has had and
will have only a moderate impact on health
expenditures
• Aging is like a glacier not a tsunami. We have lots
of time to prepare and adapt our health system
before we get swamped!
– The elderly are healthier than ever
– High performing health systems can hold costs while
enhancing quality of care for the frail elderly
19

20. Annual impact of Aging on health costs 2001-2010
1,6%
1,4%
1,2%
1,0%
0,8%
0,6%
0,4%
0,2%
0,0%
From Mackenzie and Rachlis 2010

21. Annual impact of Aging on health costs 2010-2036
2,5%
2,0%
1,5%
1,0%
0,5%
0,0%
From Mackenzie and Rachlis 2010
21

22. The Compression of Morbidity
JF Fries. Millbank Memorial Fund Quarterly. 1983.

23. American prevalence of disabled elderly 1984 - 2004
Year 1984 1989 1994 1999 2004
Disability
No 73.8% 75.2% 76.8% 78.8% 81.0%
Disability
Light or 15.9% 14.8% 13.9% 13.3% 11.8%
Moderate
Severe 10.0% 9.2% 7.9%
10.3% 7.2%
Requiring > 2.5 hrs
personal care daily
Manton et al. PNAS. 2006:103(48):18734-9

24. “Our results, supporting the
hypothesis of morbidity
compression, indicate that younger
cohorts of elderly persons are living
longer in better health.”
K Manton et al. Journal of Gerontology: SOCIAL SCIENCES
2008, Vol. 63B, No. 5, S269–S281

25. Dependency of the elderly in wealthy countries
2005-2010 2025-2030 2045-2050
Old Age Dependency 0.28 0.41
Ratios 0.53
(OADRs)
Prospective Old Age 0.19 0.23
Dependency Ratios 0.27
(POADRs)
Adult Disability
Dependency Ratios 0.11 0.12 0.12
(ADDRs)
W Sanderson. Science. 2010;329:1287-8. Canada was not included

26. “It is not the aging of our population
that threatens to precipitate a financial
crisis in health care, but a failure to
examine and make appropriate changes
to our health care system, especially
patterns of utilization.”
Dr. William Dalziel. CMAJ. 1996;115:1584-6

27. Most of health care’s problems are
due to antiquated, processes of care
27

28. After-Hours Care and Emergency Room Use
Difficulty getting after-hours care Used emergency room in past two
without going to the emergency room years
Percent
28
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

29. Waited Less Than a Month to See Specialist
Percent
Base: Saw or needed to see a specialist in the past two years. 29
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

30. Spine surgeons in Ontario: A
wasted precious resource
• Only 10% of patients referred to a spine
surgeon actually need surgery
• $24 million in unnecessary MRI scans
(http://www.theglobeandmail.com/news/opinions/editorials/spine-surgery-can-become-much-more-efficient/article2023173)
30

31. Traditional Joint Replacement
Referral Process
Spaghetti junction!

32. There are affordable solutions to
all of Medicare’s apparently
intractable problems: The Second
Stage of Medicare
32

33. We need to change the way we deliver
services
“Removing the financial barriers between
the provider of health care and the
recipient is a minor matter, a matter of
law, a matter of taxation. The real
problem is how do we reorganize the
health delivery system. We have a health
delivery system that is lamentably out of
date.”
Tommy Douglas 1982

34. Catching Medicare’s second stage
“I am concerned about Medicare – not its
fundamental principles -- but with the problems we
knew would arise. Those of us who talked about
Medicare back in the 1940’s, the 1950’s and the
1960’s kept reminding the public there were two
phases to Medicare. The first was to remove the
financial barrier between those who provide health
care services and those who need them. We
pointed out repeatedly that this phase was the
easiest of the problems we would confront.”
Tommy Douglas 1979

35. “The phase number two would be the much
more difficult one and that was to alter our
delivery system to reduce costs and put and
emphasis on preventative medicine….
Canadians can be proud of Medicare, but
what we have to apply ourselves to now is
that we have not yet grappled seriously with
the second phase.”
Tommy Douglas 1979

36. The Second Stage of
Medicare is delivering
health services differently
to keep people well

37. Health Promotion intervention for BC frail elders
Outcome Living in the Resident of a LTC
at 3 yrs community facility or dead
Group
Health 75.3% 24.7%
Promotion (61) (20)
Group (N=81)
Control 58.7% 42.3%
Group (98) (69)
(N=167)
(P = 0.04) N Hall et al. Canadian Journal on Aging. 1992;11(1):72-91

38. Step right up!
Get your ELIXIR of
Health Promotion!
Reduce your risk of dying
or ending up in a nursing
home by over
40%!
Increase your chances of
staying in your own
home by nearly
30%!

39. Per Person Average overall costs of health care for
continuing care patients in areas with/without cuts
to social and preventive home care (Hollander 2001)
Year Prior First Year Second Third Year
to Cuts After Cuts Year After Cuts
After Cuts
Areas with $5,052 $6,683 $9,654 $11,903
cuts
Areas $4,535 $5,963 $6,771 $7,808
without
cuts
http://www.hollanderanalytical.com/Hollander/Reports_files/preventivehomecarereport.pdf

40. With current resources Canadians could:
• Have elective surgery within two months
• Have elective specialty input within one week
• Have same day access to our regular family
doctor or someone on the doctor’s team
40

41. Toronto Arthroplasty Model
Referring Central Assessment Surgeon Surgery Post-Op
Physician Intake Advanced Consult Discharge
Practice Follow-Up
Physio
Holland Centre
Holland Mt. Sinai
Holland Centre
Centre and St. Michael’s
Toronto St. Joseph’s
Western
Toronto East General
Toronto Western

42. Good News in Hamilton and Winnipeg!
We could have elective specialty consultations
within 7 days
– The Hamilton Family Medicine Mental
Health Program increased access for
mental health patients by 1100% AND
decreased psychiatry outpatients’ clinic
referrals by 70%.
– The program staff includes 22
psychiatrists, 129 family physicians, 114
Nurses and Nurse Practitioners, 20
Registered Dietitians, 77 Mental Health
Counsellors, 7 pharmacists and
provides care to 250,000 patients

43. Good News in Cambridge, Cape Breton,
Penticton, etc! We could access primary health
care within 24 hrs
In Cambridge, Dr. Janet
Samolczyk aims to see her
patients WHEN they want
to be seen including
within 24 hours

44. There is substantial evidence
that for profit patient care tends
to cost more and is of poorer
quality -- but the most salient
argument is Tony Soprano’s:
“Fuhgetaboutit!”
We don’t need it.

45. How do we get to the Second
Stage of Medicare?
45

46. How do we get to the Second
Stage of Medicare?
• Get your values right
• Focus on the health of the population
• Follow the 10 commandments for quality
• Create quality workplaces for providers
• New roles for health care providers
• A new role for doctors and the medical
profession

47. Attributes of High Performing Health
Systems Ontario Health Quality Council.
April 2006. (www.ohqc.ca)
1. Safe
2. Effective
3. Patient-Centred
4. Accessible
5. Efficient
6. Equitable
7. Integrated
8. Appropriately resourced
9. Focused on Population Health

48. Population Health and the IHI
Triple Aim
“The health system should work to prevent
sickness and improve the health of the people
of Ontario.”
Health Quality Ontario

49. The Institute for Health
Improvement’s Triple Aim
1. Enhance the Care
experience for
patients
2. Improve the health
of the population
3. Control overall
health care costs
http://www.ihi.org/IHI/Programs/StrategicInitiatives/TripleAim.htm

50. Canadian disparities in
health between different
groups are responsible for
20% of health care costs
Health Disparities Task Group of the Federal Provincial
Territorial Advisory Committee on Population Health and
Health Security. Health Disparities: Roles of the Health Sector.
2004. http://www.phac-aspc.gc.ca/ph-
sp/disparities/pdf06/disparities_discussion_paper_e.pdf

51. Toronto Diabetes Prevalence Rates by Neighbourhood 2001
From: R Glazier. Neighbourhood environments and resources for healthy living http://www.ices.on.ca/file/TDA_Chp2.pdf
Age and sex adjusted
Diabetes prevalence rates
2.8 – 4.0
4.1 – 5.0
5.1 – 6.0
6.1 – 6.5
6.5 – 7.6

52. Crossing the Quality Chasm: Ten Rules to
Heal the Health Care System (www.iom.edu)
1. Care should be based upon continuous healing relationships
instead of mainly in-person visits.
2. Care should be customized for individual patients’ needs and
values instead of being dictated by professionals.
3. Care should be under the control of patients not
professionals.
4. Knowledge about care should be shared freely between
patients and providers and between different providers. This
transfer should take maximal advantage of leading-edge
information technology. Patients should have unrestricted
access to their records.
5. Clinicians should make decisions on the basis of the best
scientific evidence. Care should not vary illogically from clinician
to clinician or from place to place.

53. Crossing the Quality Chasm:
Ten Rules to Heal the Health Care System
6. Safety is the responsibility of the whole system not individual
providers.
7. The content of care is made transparent instead of being held in
secret. The health system should give as much information as is
required to patients and families to enable them to fully
participate in clinical decisions, including where to seek care.
8. Patients’ needs should be, as much as possible, anticipated and
not treated in a reactive fashion.
9. The health care system should continually decrease waste
(goods, services, and time) instead of focusing on cost reduction.
10. Providers should cooperate and work in high-functioning teams
instead of attempting to work in isolation. Concern for patients
should drive cooperation among providers and drive out
competition based upon professional and organizational rivalries.

54. Quality workplaces for
providers
• Happier staff = healthier patients
• Happier staff = lower turnover
• Healthier patients = lower costs
• Lower turnover = lower costs

55. New roles for health care providers
• Patient and family centred care means big
changes in roles for providers and patients,
especially for chronic disease
• Providers now need to be more like
supportive coaches than deliverers of the
revealed truth
55

56. Ontario’s Chronic Disease Prevention & Management Framework
INDIVIDUALS
Healthy
AND FAMILIES
Personal
Public Policy
Skills & Self- HEALTH CARE
Supportive Management ORGANIZATIONS
Support
Environments Information
Delivery Systems
Community Provider
System Design
Action Decision Support
Productive interactions and relationships
Informed,
Activated communities & activated
prepared, proactive Prepared, proactive
individuals Practice teams
Community partners & families
Improved clinical, functional and population health outcomes
: http://www.health.gov.on.ca/english/providers/program/cdpm/pdf/framework_full.pdf

57. New roles for health care providers
• Transfer of Accountability at the bedside
– Nothing with me without me!
• The Eden Alternative in Long Term care
– Human relationships are the key to quality of life
57

58. New roles for physicians
• Follow the CANMEDS roles
– Medical Expert
– Communicator
– Collaborator
– Manager
– Health Advocate
– Scholar
– Professional
58

59. New roles for physicians
• Embrace patient/family centred care
• Our identity as doctors must flow from our
service to patients instead of vice versa
• Follow the patient!
– Winnipeg HIV/AIDS care
– Hamilton shared care psychiatry
59

60. “Deputy ministers last 18 months,
Ministers last 2-3 years, CEOs rarely last 4
years. I’ve been here for 15 years and I will
be here forever. I can’t make change but I
can block it!”
Dr. Richard Steyn, Thoracic surgeon
Birmingham UK
60

61. High performing health organizations
and physician engagement: There are
only two models.
1. A disciplined medical group that co-
manages with the board
E.g. The Kaiser Permanente system in the US,
the Sault Ste. Marie Group Health Centre
2. Doctors as salaried employees
E.g. The Mayo clinic, the Cleveland Clinic, and
the Saskatoon Community Clinic
61

62. Summary:
• Health Care costs are not out of control
• The aging population won’t break the bank
• Medicare was and is good public policy
• Our health system’s problems reflect our failure to
implement Tommy Douglas’s Second Stage of
Medicare
• There are affordable solutions to all of our apparently
intractable problems
• Health care providers, especially doctors, need to do
their work differently to ensure Medicare’s
sustainability
62