Future of Healthcare with Arshdeep Flashcards
What is optical coherence tomography (OCT)? How can AI be used?
Imaging technique used in ophtalmology
There is a limited supply of ophthalmologists to interpret the images
Researchers used AI to interpret OCT images and compared their accuracy vs specialists. After training on 15, 000 scans they performed at least as well or better as several specialists
How can AI be used in dermatology? Accuracy? Why?
Using the camera on the phone to diagnose skin conditions. Accuracy is equivalent to trained dermatologist.
Wait to see a dermatologist in some provinces is over a year
How can AI be used in ophthalmology
Interpret OCT images to recognize AMD
When can telehealth be useful? What is the state of telehealth in Canada?
Contacting patients in remote communities or who are socially isolated
Canada used telehealth in 1970 but then lost its leadership in this area, now we’re playing catch-up
Why is Canada falling so far behind in telehealth?
There is a very large disparity in patients who would like to use telehealth vs MDs who offer the service
There is a large demand however very few MDs offer the service
How could telehealth be improved?
Reducing provincial barriers so providers across the country could provide care
Australia has adopted a model like this.
Example of Telehealth
DermaGO (Quebec)
Patients send pictures of skin to dermatologists and pay to receive the diagnosis within a certain amount of time
Telehealth barriers? Barriers identified by CMA?
Advances in Telehealth are privately funded.
This means a major barrier to TeleHealth is funding, specifically public funding.
System by which providers are reimbursed, billing is usually based face to face encounters
CMA:
Portability: Traditionally, Medicare only allowed for a patient to receive services from an out-of-province provider temporarily
Mainly emergencies
How can analytics be used to create efficiencies? How can smart devices be used? Inhalers?
“big data”
Data is used to answer questions about health
Data can be collected using advanced methods such as smartphones, wearable devices, smart devices, and implantable devices.
Implant microchips in smart devices such as glucometers. Readings can be tracked and uploaded.
Smart inhalers: Sensor attached to an inhaler which senses the environment and correlates it with inhaler use, sending reports to the patient’s phone
What is big data? What is machine learning?
creates efficiency in analytics
Data is collected from a patient and that data is used to improve the care for all patients
Combining data on everything and use AI to use the data and improve care.
Machine learning:
The goal is to input large amounts of data and have the computer make predictions
How was big data used in COVID
China used thermal scanners at train stations to track people with elevated temps, they were then tested and everyone who came into contact were alerted automatically.
Downside of big data
Privacy concerns limit the potential of using big data
Pharmanet
Analytic efficiencies
All pharmacy record in BC are connected
What was the concern that stalled the used of pharmanet?
Privacy concerns delyaed the implementations
Despite the fact that the risk of privacy breaches is low and potential benefit is clear
How can creating efficiencies and devices apply to health care
Hospitals are necessary institutes for short term stays, but often hospitals serve a more chronic role in care.
This could provide hospital care to chronic care to not take up space in hospitals
How can the hospital be brought to the patient? Concern?
Wearable tech that can measure a variety of vital signs
Point of care devices to measure other signs
test kits for screening
gene testing for susceptibilities
Portable ultrasound machines (images sent to MD)
Concern: temptation for patients to act as their own doctor
It is important that any home test be _______
Approved
Who is in charge of evaluating medical devices such as home tests
health Canada
How can a relative shortage of workers be solved
robots
How can robots be used in health care? Advantages?
Sort medication pharmacy much faster with greater accuracy
Surgery: remote surgery, assist in delicate surgeries
Companions for the elderly/ isolate adults: perform tasks and reminders
Assistants:Perform mundane tasks in hospitals or transport between hospitals, now being used for more complex tasks like drawing blood
What is nanotech
Very small robotics that may be used in targeting drugs, fixing ulcers, retrieve swallowed objects, drug delivery
CPSS and CMA
College of Physicians and Surgeons of Saskatchewan
Canadian Medical Association
Describe the first microbots to be successfully deployed in vivo
Were made from a polymer coated with Zinc
Were about the thickness of a human hair
Were administered orally
Were propelled by a reaction between the zinc coating and the acid in the stomach
And using this technology they successfully delivered drug into the lining of the stomach…
Is the federal or provincial government responsible for health?
provincial
How does federal government affect health? How is this a source of controversy
federal government transfers money to the provinces to fund health and education
Provinces believe they should control how to spend the money however the federal government believes they should have some control over the expenditure of the money
Critical underlying principle of the Canadian government
All citizens should enjoy the same minimum standards regardless of where they live.
SK had a history of _____ governments and policies.
socialist
Until the 1960s, government medical coverage was limited to _____
hospitals
T/F SK became the first place in north America to have a health plan of this type
true
________, in particular, were not happy about the advent of _______
Physicians
Medicare
Describe the fight for medicare in the 1960s
The 1960s were a time of social revolution
And particularly socialist revolution
Therefore, in Canada at least the idea of universal health coverage was popular with the public
However, there were groups that opposed the idea
Who opposed the universal health care and why
Conservatives made the following arguments:
Governments controlling health care would mean that patients would lose control
And would no longer be able to choose their own physician
Would no longer have any choice in their own care
These are the same arguments we see being made today…
T/F CMA was unofficially opposed to medicare
false officially
Compared it to the USSR
What did doctors refer to medicare as? What did they think to would lead to
Compulsory state medicine
Lead to poorer quality of care
What was the government’s position on Medicare?
Believed it to be another advance toward a more just and humane society
Prior to medicare what was there
The CPSS had their own insurance system which patients paid premiums into
The CPSS and CMA were okay with a government sponsored system
But only for patients who could not afford to pay premiums
Describe the physician’s strike of 1962. SK
CCF won 1960 election with the promise of medicare
Physicians refused to accept it, vowing not to see patients
Strike lasted 23 days
There were ‘Keep Our Doctors (KOD)’ groups that supported the physicians
Strike gained international attention
SK brought in a mediator from the UK and a deal was struck
What was the agreement that was struck
Medicare would continue
Private plans through the CPSS could also continue
However, most citizens would be expected to use the public plan
Physicians could opt out of the public plan
Describe how Medicare went national
As the SK Medicare model was finalized, a national model was taking shape
Prime Minister John Diefenbaker struck a Royal Commission on Health Services
He appointed Emmitt Hall to lead the commission
When the hall commission gathered data, what did they find about coverage
The Commission consulted countless stakeholders across the country
Not all were in favour, including some provincial governments (Alberta, Quebec)
Found that half of the Canadian population had no coverage
Many stories of Canadians without coverage who went broke from serious illness
5
What were the Hall Commission’s specific recommendations in 1964?
Individuals need to be responsible for maintaining their own health and using health services prudently
Individuals need to contribute to the costs of Medicare (taxation or premiums)
Health facilities should be expanded
Funding should be allocated for health research
Also mentioned are health promotion/preventive measures, including smoking cessation and social determinants
What were the conclusions of the hall commission in 1964?
Large gap between our knowledge/skills and organization/ arrangements to apply them
Recommended that the gap be closed
make all the fruits of health sciences available to all residents
What were the Hall Commission’s specific recommendations in 1964?
Individuals need to be responsible for maintaining their own health and using health services prudently
Individuals need to contribute to the costs of Medicare (taxation or premiums)
Health facilities should be expanded
Funding should be allocated for health research
Also mentioned are health promotion/preventive measures, including smoking cessation and social determinants
As the fight to pass national Medicare legislation continued for a few years, what were the barriers?
Physicians continued to advocate for a mixed private/public model
Insurance companies were also in favour of this model
Various provinces insisted they could not afford a publicly funded system or just didn’t agree with the model
How did Canadians voters vote on July 1, 1968
Voted to implement the new legislation
What ensured that provinces would all fall into line
Implementation was tied to federal funding
When did all provinces fall into line?
By 1972
What was the next step after passing Medicare
Determining how to pay for it
It was quickly realized that HC costs were rising and that some form of cost control would be necessary
This is where the government turned to ________ to find evidence of how to contain costs
Academia
What was the greatest consistent threat to medicare
Financing
What was the major threat in 1975
Deficits forced the liberals to threaten to abandon Medicare (negotiating tactic)
Much of the debate over Medicare was really about _______ _______
Federal-provincial relations
in 1984, the government produced what document that clearly laid out ________-_______ _____________
Federal-provincial responsibilities
Five principles of medicare
Public administration
Accessibility
Comprehensiveness
Universality
Portability
The issue of _____ ______ hung over the principles of medicare? What is it
extra billing
Extra billing, as it suggests, occurs when physicians/public insurers charge patients for services they deem ‘extra’. Physicians were adamant that it was their right to charge these fees
Such practices run contrary to the principles of medicare
So why not just pour more money into the HC system to cover these extra costs? How did they solve this impasse
The federal government had no more money to transfer to provinces
Ottawa accused the provinces of diverting $$ that was supposed to go to health and education
The provinces accused the federal government of underfunding health care
Another Royal Commission
Conclusions of the 2nd Hall report
They said, through these two Acts, that we, as a society, are aware that the pain of illness, the trauma of surgery, the slow decline to death, are burdens enough for the human being to bear without the added burden of medical or hospital bills penalizing the patient at the moment of vulnerability
They were a fundamental need, like education, which Canadians could meet collectively and pay for through taxes.
Public support for Medicare was _____ ______
Very strong (70% to 80%)
How did Ottawa combat extra billing
By withholding transfer $$ from the provinces equal to the amount of extra billing that was occurring
After moving away from the concept of privately funded health care, the pendulum shifted again
Why?
Cuts to public plans began to erode public confidence in the quality of care
Including long wait times for certain procedures
A major challenge to Medicare beginning in the 1980s
Two-tiered system
What is a ‘Two-tiered’ system
This is a model that goes back to the origins of Medicare, where both public and private insurers are payers
Patients are much more like consumers, and are allowed to choose to use the private system when needed
What is public administration
The provinces are responsible for administering programs that fall under Medicare and
Must spend the public funds in a responsible manner
Any insurance programs must be non-profit and can be administered by the government or arms-length
Where was HC money spent? (top three)
Hospitals (26.6%)
Drugs (15.3%)
Physicians (15.1%)
How has healthcare spending changed over time
Spending on hospitals decreased
Spending on physicians decreased and then increased
Spending on drugs has increased
Why has spending on hospitals decreased?
Patients spend less time in hospitals than they used to, technology helped facilitate this
Recognition that patients recover better at home
Why has spending on physicians increased (after decreasing)?
We are training more physicians
the growth in the number of physicians
There are still regions where physician shortages occur
Where does the money for health care spending come from?
mainly taxes
70% of HC funding comes from public funds
30% from the private sector: private insurers, out-of-pocket
What is accessibility
Canadians must have reasonable access to health services, without being charged or paying a user fee
How are physicians paid
In Canada, most physicians practice under a fee-for-service (FFS) model.
There are other models as well:
Capitation
Alternative payment plan (APP)
Salary
What is fee for service? Who decides the fee
Almost all physicians use FFS for at least part of their salary
FFS means that physicians receive a fixed fee for a specific service
MDs submit invoices to the government with codes that indicate the service for which they are billing
These fees are negotiated between the Saskatchewan Medical Association (SMA) and the government each year
What is capitation
A variation on FFS, physicians are paid based on the number of patients they have
Not as popular, encourages under-provision of services
What is alternative payment plan? Examples?
In this model, physicians may be at least partially paid by a more traditional salary model
Based on agreements made between physicians/practices and the government
Examples that fall under this model include:
Payment by hour (or day or week)
Fees for clinical services
Rewards for participation in specific clinical initiatives
Bonuses for achieving specific targets
Guaranteed minimums
Describe salaried physicians
Salaried physicians
This is the least common model
Physicians paid via a regular salary
Most commonly seen in academic centres
This century there has been more emphasis on ______-centred models
patient
New models for physicians payment
Physicians would be rewarded for keeping their patients out of hospitals
The number of visits required to do so would be up to the physician (and patient)
Public health plans are required to cover what?
Hospital services
Medically required physician services
What is comprehensiveness
All medical services must be included under provincial insurance programs
These services are defined as those that have a purpose in ‘maintaining health, preventing disease, or diagnosing or treating an injury, illness, or disability’
What are some additional services that are optional to be covered
Prescription drugs
Optometry
Dental care
Ambulance services
Chiropractor services
Often coverage is targeted to specific groups, such as seniors, children, low income
And these additional services are not typically portable when travelling
What are physiotherapists? Are they covered by Medicare?
Represented by the Canadian Physiotherapy Association (CPA)
Also often referred to a Rehabilitation Science
Specialize in rehab from injury, illness
Coverage typically only through 3rd party payers
What are nurses? Which nurse has the most responsibility?
There are many different types of nurses, separated by professional designation
Responsibilities of nurses vary widely, depending on their level of training
NPs are the most advanced in their training, requiring an advanced degree
In many jurisdictions, NPs are allowed to act much like a family physician
What are dentists? Who are they assisted by? Coverage? How can those needing dental service but who cannot afford it receive it?
Dentists specialize in maintaining oral health
Represented by the Canadian Dental Association (CDA) as well as provincial Colleges
Operate in private practice, coverage through third party, Exceptions include children of lower socioeconomic status and dental services deemed to be ‘required’
Dentists are also assisted by:
Dental Hygienists
Dental Assistants
Those needing dental services but who cannot afford them can receive discounted care at the College of Dentistry Clinic
Nutritionists? Coverage?
promote healthy eating practices, as well as provide specific guidance to patients tailored to their needs
Majority of nutrition services are paid for, as part of a hospital or through a referral from a physician
A minority of nutritionists work in private practice, and bill directly to patients
Physician assistants?
PAs are able to perform the tasks of a family physician
But must work under the supervision of an MD
Pharmacists? How has their role evolved?
Pharmacists primarily work in retail and in hospitals
In retail, can be small business owners or be employed (by a large company or single entity)
Traditionally, pharmacists’ main role was to:
Dispense medications prescribed by a MD/other
Provide advice/recommendations about non-Rx drugs
Educate patients about their medications
New roles for pharmacists
Medication management
Prescribing
Administering vaccines
Disease management (diabetes, asthma)
Diagnostic tests
Psychologists? Overlapping jobs? What services do they provide? Coverage?
Study how people think, feel and behave, from a scientific perspective
And apply this knowledge in order to help people understand, explain and change their behaviour
Therapists
Counsellors
Cognitive behavioural therapy
counselling services
Their services are typically only covered by 3rd Party Payers
Unless working out of a hospital
What is universality
Provinces must insure all of their citizens for all medically necessary hospital and physician care
Canadians are not required to pay insurance premiums in order to receive coverage
What is portability
Insurance coverage is portable, meaning that it is maintained when a patient is out of province
But only for temporary absences
Who pays the most for healthcare per capita:
US
Canada
UK
USA: 14k
Canada: 7k
UK: 5k
More recently, the USA began to take steps to move closer to the Canadian model with
More recently, the USA began to take steps to move closer to the Canadian model with Obamacare
Why do americans spend more on HC for little in return
They pay more! For everything!
Drugs prices are much higher
Salaries are higher
Administrative costs are higher
What approach do americans to to HC
Free market
Why are adminstrative costs higher in USA
Administrative costs are high because of a fragmented, complex system
Instead of there being one insurer (like Canada), there are multiple insurers
What is The Patient Protection and Affordable Care Act (aka ‘Obamacare’, or ‘ACA’)? What were insurance companies required to cover?
The idea was to ensure health care was available to all Americans
The ACA mandated that all Americans purchase health insurance
Insurance companies could not decline insurance to patients.
More subsidies for middle-income families
Expanded definition of poverty
Insurance companies are required to cover:
Outpatient care
ER services
Hospitalizations
Preventive care, wellness visits, chronic disease management
Maternity/newborn care
Mental health/behavioural treatment
Rx drugs
Services/devices for persons with disabilities
Lab tests
Pediatric care
What are insurance exchanges
The ACA also provides information to patients to facilitate shopping for the best insurance plans
And prices
These are called Insurance Exchanges
Online shopping sites where the public can ‘shop’ for the best insurance deals
what are the different models of health care provision around the world?
Beveridge Model
Bismarck Model
National Health Insurance Model
Out of Pocket Model
Beveridge Model? Advantages and disadvantages?
UK system
In this model, the government is the sole payer and insurer
Funded by tax revenue
Some physicians are essentially government employees
While others submit invoices to the government as payment for services
This fee for service resembles the Canadian system
Advantages:
A single-payer/insurer facilitates keeping prices low
All citizens receive equal access to care
Disadvantages:
Longer waiting lists
Bismarck Model? Disadvantage?
EU members + Japan
A decentralized system where employers and employees contribute premiums
Providers/hospitals are typically private institutions
There can be a single insurer or multiple insurers that compete with each other
But the government controls pricing
Must be employed to benefit from this plan
National Health Insurance Model? Disadvantages
Closest to Canadian Medicare
Taiwan
A mix of the Beveridge and Bismarck models
Providers are private firms
However…
Insurance is provided by the government
All citizens pay into the plan
Disadvantage:
Long waiting list
Out of Pocket Model? disadvantage?
Developing countries
Patients must pay for services, there is no national insurance plan
Tends to be seen in developing countries, due to lack of resources
Disadvantages:
Access to health care is based on ability to pay
4
WHO key determinants of a well-functioning HCS
Reliably funded
Properly trained workforce (with adequate pay)
Well-maintained facilities
Access to reliable information
5
Metrics that can be used to assess the quality of a HCS
Access
Administrative efficiency
Equity
Health outcomes
Adequate care provesses
Using those metrics, the Commonwealth Fund ranked 11 HCS (including Canada)
Where do you think Canada ranked?
Where did USA rank?
Who came out on top?
Top ranked:
Australia
Lowest ranked:
USA
Canada ranked:
9th
What are these countries doing better than us?
Most things
We fared poorest in Access and Equity
Access would be due to long waiting lists
Equity:
Canada does not have a national Rx drug plan
Also, many other services not covered, like dental
Australia HC? Key difference between australia and canada
Universal HCS
Coverage provided by government
private system plays a larger role in Australia
Nearly half of the hospitals are privately run
Public is encouraged to purchase private health insurance
The key difference seems to be the role the private ‘stream’ plays in Australia
Perhaps increased competition results in reduced wait times, Private hospitals tend to focus on elective procedures
The argument against increasing access to private services
They increase costs
Private firms are for-profit entities
They increase inequality
Wealthier citizens have better access to care
HC in Cuba
Cuba has gained a reputation for its emphasis on preventive care. Physicians pay surprise visits to families in their homes once/year.
To assess their living conditions
3
Issues facing health care
Rising prices
Particularly Rx drug prices
Inequality
Social determinants of health
Aging demographic!
By far, the biggest issue
The baby boomer generation is the largest in human history
Rising prices are a function of ________ __ ________
improvements in technology
Are we getting better results for prices?
Not always but in some cases we get great results in a subpopulation
Why are drug prices increasing
Improvements in therapeutics
we are acquiring treatments for diseases we previously could not treat
Or diseases where treatment options were very limited
What is Belimumab? What does it treat and how
First drug ever approved to spcifically treat lupus
Belimumab binds to BLys and this promotes B cell destruction
Destruction of autoreactive B cells improves Lupus in some
Several hundred $/month
What is lupus
Lupus is an auto-immune disorder
Impacts multiple systems (pretty much every one)
Significant impact on quality of life due to pain, arthritis, fatigue, etc
Chronic disorder, no cure, and often strikes early in life
What is regenerative medicine? Is it a problem or solution?
Sets an ambitious goal of ‘regenerating’ or replenishing tissue/organs using stem cells
The ‘disease’ we are now treating is often the aging process itself
Note that at this point we cannot say whether this is a problem or a solution
We may be able to thwart the effects of a number of diseases simply by replacing tissues
T/F an important consideration for the future of health care will be to determine how to best allocate funds
True
How do indigenous population experience inequality
limited access to housing
Poor living conditions are a major contributor to disease.
less likely to have access to:
Clean drinking water
Fresh, healthy food
Health services
Employment opportunities
Indigenous people are more likely to have experienced:
Childhood trauma
Racism
Can racism kill you
Yes
How can racism affect healthcare
An all-too common example is when someone who is a visible minority is not taken seriously when presenting with symptoms
And a serious illness is missed
What was the case of JR? what did it show
male of african descent who received a spinal tap and started experiencing symptoms relate to CSF leaking. He presented to five hospitals in the toronoto area and on each occasion was refused care because they believed he was seeking drugs
After suffering for months he got help
Showed the effects of racism
How did the pandemic highlight ageism
As COVID raged through nursing homes, it became apparent that there were problems
The military was called in to help and they were appalled at what they saw
Describe the demographic shift
The Baby Boomer generation is the largest in human history…
And they are now reaching old age
In 2015, for the first time, the number of seniors in Canada exceeded the number of children
Is the term senior homogeneous or heterogeneous
Heterogeneous
Why is the population aging
Life expectancy is rising over time, and this means a significant increase in the ‘very elderly’ (>85 years old)
Describe the propotion of seniors in Canada compared to other OECD countries
Canada is still relatively young compared to other OECD countries
However…
The proportion of seniors in Canada is expected to rise faster than other countries
We had a more significant ‘baby boom’
And a more significant fall in births post-baby boom
Why is an aging population an issue
seniors make much greater use of HC resources
stay in hospital longer
use more resources in hospital
Will have a lower proportion of working adults to seniors
Seniors also use other HC resources to a greater extent than adults: (what are they)
Home care
family physicians
Rx drugs
What are the issues associated with the transition of seniors from their home to a facility
reluctant to leave their homes, but moves to a facility are necessitated by limitations in their functional abilities
Spread of disease
