Inching Toward Reform: Health Care Transformation Flashcards
Inching Towards Reform
“over the past several decades in Canada, academics, health professionals, and provincial and national commissions have indicated that reform of primary care is key to sustaining a high-performing health care system. Yet despite considerable investment, primary care reform has proven difficult to achieve. WHat are the implications of different ways of organizing and financing primary care, and why has reform proved to be so difficult?
Policy Issues Addressed
- primary care delivery models
- implications of different modes of reimbursement
- factors involved in achieving reform, with particular emphasis on the role of institutions and interest groups
Where are reforms implemented? Care settings and Continuum
Primary
- provided in the home, clinic or health centre
- basic medical attention from a provider (varies depending on where you live) and can offer medication-prescribing services, immunizations, screening, counselling, pharmacy, dental and ophthalmic care
Secondary
- often thought of that offered in hospitals - admitted for treatment - route is often through primary provider esp. in Canada and the UK
- diagnosis, treatment, surgery - more concerned with CURE vs. prevention
Tertiary
- Patients requiring further specialist care in specialized facilities
- e.g. radiation, chemotherapy, trauma
Two others?
- Public Health Health Promotion and Health Protection
- alternative and complementary care (used to complement traditional western medicine
Framing (Problem Identification)
- access
- better quality/integrated/patient-centred care
- the type of care model desired - e.g. chronic disease prevention, a wide range of services, E.D. diversion
- Spending control
- wait times?
- access to services at all levels (primary/secondary/tertiary)
Policy Legacies
the net result of Historical Institutionalism, path dependency and critical junctures
- HI: the importance of institutions in influencing outcomes
- PD: prior policy constraints
- CJ: key decisions that help set future policies (Tommy Douglas, Canada Health Act)
Historical Institutionalism and Path Dependency
- governments’ policy choices/priorities often shaped/constrained by past policy decisions
- the federal government has few policy levers apart from transfer
- constitution act
- public insurance programs incrementally, initially covering hospital care, followed by physician services (moral hazard - insulating people from risk may make them less concerned with potential negative consequences)
- Canada Health Act - comprehensiveness in terms of medically necessary services, but only if delivered in hospitals or by physicians
- Historically, FFS basis with the fee schedules negotiated between the provincial/territorial ministry of health, and the association representing the province’s physicians
Primary Care vs. Primary Health Care
- PC - first point of contact with the system; services are provided comprehensively, continually and not affected by social, physical, or cultural characteristics
- PHC - is a WHO term; first level of contact with the national health system, close as possible to where people live and work
- PHC tends to focus on the population as well as individuals (community); health teams
- PC focuses on the provider
- reform is trying to shift away from PC to PHC; should be at the centre of any high performing system
PC to PHC
- who is cared for and where? (individual patients vs. individuals and community)
- what services are available and when
- who is providing the care (provider vs. community)
- how is it paid for
- how does it interface with other aspects of the system
(variability between patients, shifting costs, cream skimming - only taking the “best” patients) - how is care delivered (physicians vs. health care teams)
Corollary: you have to have a system in the first place
Trends in Data
LOOK AT SLIDES FOR GRAPHS
- how much are we usually spending and why does it change (how much you put in vs. what you take out)
- how much do we spend vs. economic output
- why does healthcare spending change? (inflation, aging population)
- where are we spending money (hospitals, drugs, physicians)
- who are we spending it on? (a lot of babies and old people)
- who is providing care?
- are there enough providers? How many do we need? (patient:provider ratio)
- who are the providers? men vs. women
- different types of medical services (does all care cost the same?)
- what does our healthcare budget look like?
- what are our ideologies on spending? (politics)
Primary Care Reform in Ontario
- started in 2005
- many different primary care models and compensation approaches have been developed and implemented
- the resulting “alphabet soup” includes Family Health Organizations (FHO), Family Health Networks (FHN), Family Health Groups (FHG), Family Health Teams (FHT), Nurse Practitioner-Led Clinics, community health centres (CHC), and other specialized models
- variations in funding model used, rostering of patients, roles and composition of care teams, governance, comprehensiveness, the focus of care (e.g. chronic disease management)
Status of Reform
By November 2011: 2/3 of family physicians in Ontario were in one of these reformed models (only started around 2005);
- of those, over 50% were in blended capitation models
- 41% in enhanced FFS models
- 5.1% in other patient enrolment models
- Traditional PHC models have not disappeared, but are less common
- 10 million of Ontario’s 13 million population were rostered to a family physician
LOOK AT TABLE FOR DIFFERENT TYPES
Payment Mechanisms
- FFS (fee for service) ($/service provided)
- enhanced FFS (comprehensive care model) (FFS + $/enrolled patient - small basket, therefore mostly FFS)
- blended capitation (age and sex-adjusted $/enrolled patient + FFS)
- blended salary ($/time (rostered) + premiums and incentives)
- salary ($/time only)
- blended complement ($/# of physicians in organization + premiums and incentives)
LOOK AT TABLES
PROMs
Patient-Reported Outcome Measures
- measurement tools that patients use to provide information on aspects of their health status that are relevant to their quality of life, including symptoms, functionality, and physical, mental and social health
- many PROMs tools are available. They are categorized as:
- generic (applied across different populations)
- condition-specific (used to assess outcomes that are
specific or unique to particular diseases or sectors
of care)
PREMs
Patient-reported Experience Measures
- help to understand a patient’s experience when they received health care - this helps to improve patient-centred care (i.e. personalism)
- capturing/reporting this information is an important part of our overall efforts to measure health system performance
Examples of PROMs and PREMs
PROM short term: feedback on immediate individual care
PROM Long-term: Feedback on longer-term clinical outcomes
PREM short term: feedback on the current integration of care
PREM long term: feedback on the system of integrated care)
