Back to Basics, 2015POPULATION HEALTH :

Health Care Organization

Prepared by Trevor Arnason

PGY4 – Public Health and Preventive Medicine, University of Ottawa

Acknowledgement: This presentation was originally created by Doug Coyle

MCC Objectives: Population health 78-4 Administration of effective health programs at the population level

Rationale: • Knowing the organization of the health care and

public health systems in Canada as well as how to determine the most cost-effective interventions are becoming key elements of clinical practice.

• Physicians also must work well in multidisciplinary teams within the current system in order to achieve the maximum health benefit for all patients and residents.

MCC Objectives: Population health 78-4 Administration of effective health programs at the population level

Key objectives: • Know and understand the pertinent history,

structure and operations of the Canadian health care system.

• Be familiar with economic evaluations such as cost-benefit / cost effectiveness analyses as well as issues involved with resource allocation.

• Describe the approaches to assessing quality of care and methods of quality improvement.

MCC Objectives: Population health 78-4 Administration of effective health programs at the population level

Enabling objectives (1)• Describe at a basic level:

– methods of regulation of the health professions and health care institutions;

– supply, distribution and projections of health human resources; – health resource allocation; – organization of the Public Health system; and – the role of complementary delivery systems such as voluntary

organizations and community health centres.

• Describe the role of regulated and non-regulated health care providers and demonstrate how to work effectively with them.

MCC Objectives: Population health 78-4 Administration of effective health programs at the population level

Enabling objectives (2)

• Outline the principles of and approaches to cost containment and economic evaluation.

• Describe the main functions of public health related to population health assessment, health surveillance, disease and injury prevention, health promotion and health protection.

• Demonstrate an understanding of ethical issues involved in resource allocation.

• Define the concepts of efficacy, effectiveness, efficiency, coverage and compliance and discuss their relationship to the overall effectiveness of a population health program.

MCC Objectives: Population health 78-4 Administration of effective health programs at the population level

Enabling objectives (3)• Be able to recognize the need to adjust programs in order to meet

the needs of special populations such as new immigrants or persons at increased risk.

• Participate effectively in and with health organizations, ranging from individual clinical practices to provincial organizations, exerting a positive influence on clinical practice and policy-making.

• Define quality improvement and related terms: quality assurance, quality control, continuous quality improvement, quality management, total quality management; audit.

• Describe and understand the multiple dimensions of quality in health care, i.e. what can and should be improved.

78.1: Medical Economics

• Define the socio-economic rationales, implications and consequences of medical care– Medical care has impact on costs to society; both

financial and other (non monetary) resources.– This objective aims to raise awareness of these

types of issues.

What Will We Cover?

• Organization and history of health care in Canada

• Medical economics (brief overview)• Physician organization and regulated health

professions Public health in Canada• Key definitions and frameworks for exam

1867 British North America Act Provincial gov. given regulatory power over hospitals, asylums etc.

1914-1917 Saskatchewan Moves towards paying retainers for physicians and the right to collect taxes to finance health care

1920 Creation of Federal Department of Health • Response to Spanish flu epidemic • Focus on public health, child health food and drug standards

1935 Provinces stop Federal gov. plan to provide social and health benefits

1947 Saskatchewan Introduces public insurance for hospital services

1957 Federal Hospital Insurance and Diagnostic Services Act (HIDS)

Provinces given 50% of funding from Federal gov to provide a service with stipulations.

1961 All provinces participate in HIDS

1966 Medical Care Act Universal coverage for physician services

1977 Federal-Provincial Fiscal Arrangements and Established Programs Financing Act (EPFA)

Reduced requirements of federal government to match funding

1984 Canada Health Act Specifies the conditions and criteria with which the provincial and territorial health insurance programs must conform in order to receive federal transfer payments. Prohibited user fees and extra billing.

Historical Progression in the Organization of Health Care

Canada Health Act PrinciplesPublic administration Administered for non profit and

accountable to a provincial government

Comprehensive All medically necessary services provided by hospitals, medical practitioners

Universal All insured persons have equal coverage

Accessible Reasonable access without financial and other barriers

Portable Coverage between provinces

Problems with the Canada Health Act

• Only partial coverage– Physician services in and out of hospital only– What is “medically necessary”?– Only those “provided by hospitals”– Not all hospitals must provide all services

• Does not legislate which services must be provided– Only that federal government will not provide funding

if conditions not met

• Impact of other legislation– Canadian Charter of Rights and Freedom

Events Post 1984

• 2001: Kirby & Romanow commissions– Attempts to reform the health care system– Focus on long term sustainability

• 2005: Chaoulli decision (Quebec)– Controversial interpretation of the CHA in regards to banning of

private clinics.

• 2012 Drummond report (Ontario)– Emphasis on home care

Role of Federal Government

• Directly responsible for compliance with international health regulations, First Nations/Inuit health, Canadian Forces/RCMP and those in federal penitentiaries and refugee claimants

• Funding to Provinces - has the greatest taxing power

• Its provision of funding allows it to enforce the Canada Health Act.

• Reductions in federal contributions have reduced its influence

Role of Provincial Governments• Responsibility for healthcare services (and most other

social services) • Provinces now provide most of the funding for health

services• Therefore, they are the main decision-makers

– Block budgets to regional authorities (eg: LHINs)– Physician fees (eg: negotiations with OMA)– Other services covered (eg: physiotherapy, home-care through

CCAC)– Special payments for technologies– Which drugs funded through Provincial programs (eg: Ontario

Drug Benefit Program)

What is a LHIN?

• A regional health authority – only created in 2007!!!• 14 in number – basically subsidiaries of MOHLTC• Plan, coordinate, integrate and partially manage care at

the local level• Not aligned with Public Health Units (PHUs)• Hospitals, community health centres (CHCs), long-term

care homes, the Champlain Community Care Access Centre and more than 100 Community Support Services including mental health and addictions agencies

Methods of paying hospitals• Line-by-line:

– separate payments for staff, supplies, etc. – Cumbersome, rigid.

• Global budget:– fixed payment to be used as hospital sees fit. – Fails to recognize differences in case mix.

• Case-Mix weighted: – payment for total cost of episode, greater for more

complicated cases. – Now used in Canada.

• New technology: by request. – If approved, government pays. – If declined, hospitals can pay for it from core budget.

Methods of paying doctors• Fee-for-service: unit is services.

– Incentive to provide many services, especially procedures.

• Capitation: unit is patient. Fixed payment per patient.– Incentive to keep people healthy, but not to make yourself

accessible.– Incentive to recruit young, healthy people, not the ‘sick’

• Salary: unit is time. – Productivity depends on professionalism and institutional

controls– Practice plans

• Combinations of above, e.g., "blended funding“– Family health networks (Ontario)

Ways of organizing a health care system

• Publicly funded and delivered– Most developed after WWII (eg: UK National Health Service)– NOT THE CANADIAN SYSTEM

• Purely private– Mainly developing countries (eg: Canada in 1867)

• Mixed public and private funding and mostly private delivery– US (prior to Obamacare)

• Mostly public funding (single-public payer insurance system) and mixed private/public delivery– Canada

A brief foray into Medical Economics

• Does effective medical care reduce health care spending?

• How do we value non-fiscal benefits such as quality of life, ‘health’, not being dead?

• Should resources be spent on health or other societal objectives?

• How do we value non-traditional expenditures, etc. which impact on health– Healthy Public Policy

What does the slide NOT tell you???

Types of economic analysisForm of Analysis Measurement of

CostsMeasurement of benefits

Synthesis of Benefits and Costs

Cost minimization Dollars None Incremental cost

Cost Effectiveness Dollars Single Dimension of Effectiveness (e.g. life years gained)

Incremental cost effectiveness:- incremental cost per unit gained

Cost Utility* Dollars Utility gained (e.g. QALYs)

Incremental cost effectiveness:- incremental cost per QALY gained

Cost Benefit Dollars Monetary values of benefits gained

Net benefit gained

* Often referred to as sub-category of cost-effectiveness

Medical Economics DefinitionsEffectiveness: the impact of a treatment under realistic conditions in which the patient’s compliance may not be optimal.

Efficacy: the impact of a treatment when administered under ideal conditions (the patient takes the correct dose at the correct intervals).

Efficiency: the extent to which time, effort, or cost is well-used for the intended function.

Quality-Adjusted Life Years (QALYs): the average number of additional years of life gained from an intervention, multiplied by a judgment of the quality of life in each of those years.

Incremental Cost-Effectiveness Ratio (ICER): the ratio of costs to incremental benefits of a therapeutic intervention or treatmentICER = Costs #1 – Costs #2 / Effect #1 – Effect #2

Physician Organization

• College of Physicians and Surgeons of Ontario– Responsible for issuing license to practice medicine– Handles public complaints, professional discipline, etc.– Does not engage in lobbying on matters such as

salaries, working conditions.

• Licentiate of the Medical Council of Canada– Maintains the Canadian Medical Registry– Does not grant licence to practice medicine– Administers country-wide examinations of competency

• serving as the base for provincial registration

Physician Organization

Ontario license requirements:– Graduate of an accredited medical school

• or ‘acceptable unaccredited’ school

– Meets standards of moral behaviour• mentally competent

• integrity, honesty and decency as applied to practice

• sufficient skill, knowledge and judgement

• communicates effectively and professionally

– Successful completion of MCCQE part 1 & 2

– Certification by either:• the Royal College of Physicians & surgeons of Canada

• College of Family Physicians of Canada

– One year post grad training or clinical clerkship in Canada

– Canadian citizen or landed immigrant

Physician Organizations• Royal College of Physicians and Surgeons of

Canada.– Maintains standards for post-graduate training

throughout Canada.– Sets exams and issues fellowships for specialty training

• College of Family Physicians of Canada– Organization for certifying/promoting family practice

Physician Organizations

• Ontario Medical Association– Professional association; lobbies on behalf of physicians re: fees,

working conditions, etc.

• Canadian Medical Association– National, voluntary association of physicians that advocates on behalf of

its members and the public for access to high-quality health care.

• Canadian Medical Protective Association– Advises physicians on threatened litigation and pays legal fees and court

settlements. – A co-operative that has largely replaced commercial malpractice

insurance.

Regulated Health Professions

The practice of a regulated professional is:

1) Covered by provincial or federal legislation and

2) Governed by a professional corporation or regulatory authority, for instance a College of Physicians or an Order of Nurses.

Audiologists and speech-language pathologists -Hearing and understanding, speech, language, and swallowing disorders

Chiropractors - Diagnosis, treatment, and prevention of mechanical disorders of the musculoskeletal system

Dieticians - Evaluation of the nutritional state of people in order to choose and implement a nutrition strategy that takes account of their need to improve or re-establish health.

Midwives -Assessment and monitoring of women during pregnancy, labour, and the post-partum period, as well as of their newborn babies; the provision of care during normal pregnancy, labour and post-partum period, and the conducting of spontaneous normal vaginal deliveries

Nurses - Care of individuals of all ages, families, groups, and communities, sick or well, and in all settings

Occupational therapists- Helping people to learn or re-learn to manage the everyday activities that are important to them, including caring for themselves or others, caring for their home, and participating in paid and unpaid work and leisure activities

Optometrists - Assess the eye and visual system, sensory and ocular motor disorders and dysfunctions of the eye and the visual system, and diagnose refractive disorders

Pharmacists- Evaluate and dispense prescription medications; advise on their correct use and mode of action

Physiotherapists - Through understanding of how the body moves and what prevents it from moving, manage and prevent many physical problems caused by illness, disease, sport- and work-related injury, aging, and long periods of inactivity

Psychologists - Assessment, treatment, and prevention of behavioural and mental conditions

Respiratory therapists - Monitor, evaluate, and treat individuals with respiratory and cardio-respiratory disorders

Social workers - Help individuals, families, groups, and communities to enhance their individual and collective well-being; help people develop their skills and their ability to use their own resources and those of the community to resolve problems. Social work is concerned with individual and personal problems, as well as with broader social issues such as poverty, unemployment, and domestic violence.

Regulated Health Professions

Quality in healthcare

• Many professional colleges and regulatory bodies have incorporated quality improvement practices into their mandate and operational approaches.

• Most have quality assurance committees and routinely conduct audits of professional practices.

• In the past many of these bodies merely responded to complaints,

they are now studying and implementing ways of improving quality. • The relationship with clinicians is shifting from a focus on discipline

to one of continuing professional education and training.

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Public Health in Canada

• Public health is defined as the organized efforts of society to keep people healthy and prevent injury, illness, and premature death. It is a combination of programs, services, and policies that protect and promote the health of all Canadians.

• Population health is “the health of the population”

Core Functions of Public Health

• Public Health is the branch of the health system concerned with: – health protection– health surveillance– disease and injury prevention– population health assessment– health promotion – emergency preparedness and response

Public Health Units in Ontario

• 36 PHUs – each appoints a physician to be a Medical Officer of Health (MOH) and sometimes one or more Associate MOHs

• Program standards outlined in the Ontario Public Health Standards

• Responsible for:– Food/lodging sanitation (eg: restaurant inspections)– Infectious disease control and immunization (eg: providing school-

based immunization programs)– Health promotion/Disease prevention (eg: Healthy Eating and Active

Living strategy)– Family health programmes (eg: breastfeeding support)

– Environmental health surveillance.– Emergency preparedness and response

Public Health Units in Ontario- Medical Officer of Health

• Report to a local Board of Health and the Ministry of Health and Long-Term Care in Ontario

• Medical Officer of Health is afforded certain powers (related to a public health hazard) including orders to:

• Vacate a home or close a business• Regulate or prohibit sale, manufacture of any item• Isolate people with communicable diseases• Require people to be treated by MD• Require people to give blood samples

• No licensing or regulatory powers over physicians/health practitioners except in the case where a “public health hazard” exists

• Public Health Unit should not be confused with the Local Health Integration Network

Federal Role in Public Health

• Public Health Agency of Canada (created post-SARS and Health Canada)

• Health Canada - regulation of food, water, medicines, medical devices.

• Coordination– Between Provinces– With other countries and international bodies (eg: World Health

Organization)

• Public health services for all the individuals that are not covered under Provincial health plans: (eg: military, First Nations/Inuit on reserves, federal penitentiaries, etc.)

What is a coroner?• Coroners are medical doctors with specialized death investigation training,

who have been appointed to investigate sudden death – organization of system depends on the province

• Role in improving public safety, through coroner inquests

• Notify coroner of deaths in the following cases:– Sudden/unexpected– Due to violence, negligence, misconduct, etc.– During work at a construction or mining site.– During pregnancy– Due to disease not treated by qualified MD– Any cause other than disease– Under suspicious circumstance or by ‘unfair means’– Deaths in jails, foster homes, nursing homes, etc.

Multiple Choice Questions

The federal government is responsible for healthcare delivery to which of the following groups?

a) Inmates of federal penitentiariesb) Inuit living on reservesc) Active Canadian military personnel living in Canada d) Refugee claimants awaiting a hearinge) All of the above

Which of the following is not one of the five Principles of the Canada Health Act?

a) Portabilityb) Flexibilityc) Universalityd) Comprehensive coveragee) Accessibility

The component of Canada's health care system that receives the highest percentage of the health care budget is:

a) Hospitalsb) Physician feesc) Pharmaceuticalsd) Laboratory servicese) Administration

What regulatory body is responsible for licensing physicians to practice in Ontario?

a) Royal College of Physicians and Surgeons of Canada

b) College of Physicians and Surgeons of Ontarioc) Licentiate of the Medical Council of Canadad) Medical Officer of Health for the Local Health

Integration Networke) Health Canada

Which of the following is NOT considered a core function of public health in Canada?

a) Health Promotionb) Health Protectionc) Population health surveillanced) Emergency Preparedness and Responsee) Health Equity

More MCQs and a Great Resource

• More MCQs:http://www.medicine.uottawa.ca/sim/data/Self-test_Qs_HC_System_e.htm

• AFMC Primer on Population Health:http://phprimer.afmc.ca/