The Future of Healthcare in North America: Is U.S.-Canada convergence in the cards?

BREAKFAST WITH THE CHIEFS
Friday, October 18, 2013 
Introductions and welcome by Moderator Anton Hart, Chair, the HealthcareBoard and Publisher, Longwoods Publishing. Mr. Hart thanked the event’s sponsors, the Health Council of Canada and Accenture, then introduced today’s chiefs: 
Trudy Lieberman is a past president of the Association of Health Care Journalists in the U.S. and currently covers health for the Columbia Journalism Review. Lieberman is visiting four cities across Canada as a Fulbright Scholar and guest of the Evidence Network of Canadian Health Policy, commonly known as EvidenceNetwork.ca. 
André Picard is a health reporter and columnist at The Globe and Mail, with a new book launching through The Conference Board of Canada on October 30.

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TRUDY LIEBERMAN began by indicating what she believed to be the main question people have, which is “what is Obamacare?” She then provided a brief overview while mentioning that André Picard would discuss the areas of convergence between the two country’s health care systems.

What is the “Affordable Care Act”? First off, says Lieberman, it does not provide health insurance to all Americans. It affects the individual market, where people go for healthcare when they do not have coverage.  Even so, pre-existing conditions, such as asthma are often not covered by insurance companies in this market. Obamacare makes it easier for people to shop in that market.

Lieberman has been writing about U.S. health care for more than twenty years and knows that people in the U.S. have trouble navigating that system.

Approximately 25 million people in the U.S. shop in the individual market, and that’s who Obamacare is aimed at helping. Some may have had healthcare coverage, while others are new to buying coverage. In order to coax people to buy in to the system, the government is offering subsidies . However, 40% of the individual market will not qualify for subsidies and yet, there are penalties for not purchasing insurance, even when a good policy could cost upwards of $16,000.

People are worried and do not know if the subsidies will be sufficient enough to buy an adequate healthcare policy, or if the subsidies will last over time. Those in the middle class are especially concerned.

The reform law called for an expansion of Medicaid, the federal-state program for the poor. But 27 states chose not to expand, leaving those with incomes below the poverty line with no options. They are barred from shopping in the exchanges and are too poor to buy coverage ion their own.

In her opinion, the Achilles heel of Obamacare is the lack of expansion of Medicaid.

The confusion about Obamacare also lies in the fact that the press and media not always explained it properly to the American public.

OTHER MAIN POINTS:

Obamacare does not build in equity.  There will be four types of plans sold in the exchanges. Most will/are expected to opt for the bronze plan which covers 60% of costs. Then there’s silver at 70%, gold at 80%  and platinum at 90%. However, many states won’t be able to offer a platinum plan because it will be too expensive for most shoppers.

Out of pocket spending is high. Deductables will be around $4,000 or $6,000 for a family policy but might be as high as $10,000 or $20,000. Co-insurance consists of the percentage of insurance a patient has to pay for, such as diagnostic imaging, which is not covered by plans.

There have been multiple cost-cutting moves, including moving services from the hospital to outpatient settings.  Insurance companies are asking people to pay for high cost sharing for he most commonly-used services. This is something that has not yet sunk in with the American public.

Obamacare also does not include a cost containment clause

Lieberman does not know if Obamacare will work and expects it will take at least two or three insurance cycles to see what companies are doing with the premiums and whether people actually buy and have insurance.

While the goal is affordable health care, she predicts Americans may not get it.

The administration and the media could have done a better job in promoting the new law, says Lieberman. As a result there’s been somewhat of a backlash against Obamacare. But there hasn’t been a sustained discussion as to what it can and will do. The individual mandate was never made clear; which was probably a deliberate act by the administration to prevent backlash. The irony is, this type of plan was first introduced by the Republicans in the nineties to counter the Clinton Administration’s plan.

Lieberman finds the press could have tied the threads together better for the public to make things more clear because most Americans are quite confused.

ANDRÉ PICARD thanked Trudy and indicated her talk better informs him every time.

His discussion centred around the common challenges existing between Canada and the U.S.

He stated that in many ways, we do many of the same things in Canada as in the U.S. but without the debate, so we should guard against self-righteousness. There is no “Affordable Care Act” in Canada. There are a lot of disparities between the provinces, Picard found, but we just don’t talk about them.

We also have many of the same financial challenges that exist in the U.S. but again, there’s no discussion. Health care in Canada covers only 70 per cent of the costs. Canadians pay about 30% of the medical costs because more things like drugs may not be covered.

COMMON CHALLENGES:

      1. MOVING CARE TO THE COMMUNITY: Hospital-based models need to be turned into community-based models. There isn’t a plan or the organization to meet the demands and needs for homecare and nursing homecare.
2. PRIMARY CARE: Better primary care services are needed. A central coordinating point for healthcare is needed – one that provides support throughout the patient journey. We know all the bad things happen in transition through a lack of coordination, says Picard. So who is going to coordinate care and guide us through the complexity of care, he asks?
3. Need to move to a CHRONIC CARE MODEL from an ACUTE CARE MODEL.
4. DRUGS: Costs are high and this is a big void in the Canadian system. Only 45% of drugs are covered by public plans. Private plans are also tightening their strings. As a result, almost 600,000 Canadians do not have catastrophic drug coverage, which is a gaping hole in Medicare.
5. SOCIAL DETERMINANTS: Inequality is having a major impact on people’s welfare.
6. QUALITY: This is paramount. Medical errors or adverse events due to a lack of quality are some of the leading causes of avoidable death. People want affordable healthcare, but not at the sacrifice of quality.
7. RATIONING: The U.S. rations care economically. If you can’t afford it, you don’t get it.  In Canada, services bottleneck, create wait lists and people have to wait for certain kinds of care. Rationing is a reality, but the trick is to find the best way to do it. 
8. PATIENTS WHO USE TOO MUCH HEALTHCARE: In Canada, 1% of the patients use 25% of care, while another 5% consume 50%. Costs can be controlled by better management of difficult patients. We need to be more innovative and smarter, says Picard. For instance, there was a man who had all sorts of health issues and visited Emergency 238 times a year, costing the system an estimated $1.5 million per year. So it was decided to assign him a full-time nurse at a cost of $60,000 per year.  This nurse even found the man an apartment. She was a guiding light of sorts. The following year the man reduced his ER visits to 60. This was a pragmatic solution that saved the system close to one million dollars.
9. PUBLIC VS. PRIVATE: Canada has both, whether we know it or not. The U.S. has both. We need to discuss the right mix of public and private healthcare. Currently it’s about 70-30.

Both countries need to have real conversations about healthcare. But what is the proper forum for such a debate. There is too much extremism. So how are we to have this much-needed discussion?, asks Picard.

TRUDY LIEBERMAN: Long term care is a real issue in the U.S.. It’s interesting to see what has been done in the U.S. The Affordable Care Act included a Class Act that was championed by the late Senator Ted Kennedy.  Originally it wasn’t very popular. The idea behind this was to pay a bit into the federal system then tap into that when older. But the provision was repealed because it wasn’t going to work. As a voluntary program, people weren’t going to pay into it.

Since the Class Act was repealed, there’s been virtually no discussion of homecare in the U.S.

But we do have something that has worked somewhat called the “Older Americans Act” which dates back to the Johnson administration. This provides services to keep elders at home. Unfortunately, it hasn’t received adequate funding for the last few decades. Now there’s a long wait list for homecare services in almost every jurisdiction. Some people wait months just to get a hot meal from “Meals on Wheels.” PEOPLE DO THE BEST THEY CAN, BUT THE BEST ON MANY DAYS ISN’T ENOUGH, one man said.

 

QUESTIONS/COMMENTS from the audience:

1. DR. CHARLES WRIGHT, Council Member, Health Council of Canada: That was enlightening for me. You used the word “rationing” which is a highly allergenic word. If we could only capture a portion of unnecessary care, some sort of rationing might be needed but at least the system would be more sustainable.

ANDRE PICARD: 25-30 % of healthcare is overdone. We need to ration care on what works and what is effective. Evidence-based rationed care.

      TRUDY LIEBERMAN: We’ve been talking about this for many years but nothing is being done about it. There are powerful interests who like doing extra tests, and it’s hard to deal with those forces.

      2. SHOLOM GLOUBERMAN, President, Patients Canada: We don’t have healthcare services in the community. We don’t partner with patients on chronic care. Bloated hospital care, very few community services -- we spend here in Canada a fraction of what is spent on community services in Britain. Insurance doesn’t cover it but covers hospital stays for example. We have an aging population, and chronic diseases become a part of life. We don’t deal or care for it properly. Patients aren’t partners in their care. What we need is to start to build up community services because they’re not covered by insurance.

ANDRÉ PICARD: There are definitely administration issues. Medicare was created in the fifties for a population demographic for that era. Now demographics have changed -- needs have changed. But the system has not been adjusted to account for the change in demographics.

3. QUESTION: Who gets to define when care is necessary or futile? What will happen based on the upcoming Supreme Court of Canada decision?

ANDRÉ PICARD: It’s unfortunate this has to be settled by the courts, and there isn’t the political courage in this country to deal with it. The larger question in my opinion is “what is in Medicare, and what is not?” It’s a tough issue. How should public services be rationed? In Canada, we do this by sidestepping the discussion. We’re moving towards a populist system, like in the U.S.

4. JOHN G. ABBOTT, CEO, Health Council of Canada: How does Obamacare tie into the American deficit and any comparisons to Canada?

TRUDY LIEBERMAN: Obamacare won’t break the bank, per se. Ultimately, opponents of Obamacare want to deal with entitlement and the privatization of Medicare – like drug benefits. People are okay with richer citizens paying more for healthcare, but what is the definition of “rich”? That’s a concern for those who support Medicare and that’s a big issue. The other is entitlement and Social Security. Many want to privatize it. But the cost of living formula may be changed in order to reduce the amount that government needs to spend, which will hurt low-income households, especially women. Long-term subsidies under Obamacare will then come into play. They are financed for ten years, but we don’t know whether subsidies will be secure in the long-term. Ultimately they could meet the same fate as Medicare, whatever that will be.

5. COMMENT ABOUT HOSPITAL COSTS:

TRUDY LIEBERMAN: In the “Affordable Care Act,” there is nothing calling for negotiating prices or services.  Hospitals publish “retail” prices which are usually quite high. But they are wildly different from hospital to hospital even within the same community.  But these prices are essentially phony. [someone in audience: “They’re for the people who come from Canada for treatment.” – laughter]. In practice, the hospitals negotiate with insurance companies and bargain for much less than the published costs. Many hospital systems though are growing larger and are becoming conglomerates that compete against each other. They advertise who has the better equipment or the best cardiac care but not price. There’s a real fear that these conglomerates will have the power to set prices without much competition or push back from the government.

ANDRÉ PICARD: Canadians are ignorant about the real costs of healthcare. We overpay. We have a similar system to the U.S.

TRUDY LIEBERMAN: Steve Brill’s “Time Magazine” article about healthcare was really well done.

More transparency is needed.
Breakfast with the Chiefs concludes.

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The Future of American Health Care: What it Means for Canada

Janna Stam is a Toronto-based freelance writer and communications professional in Canada. She has written for diverse audiences, including healthcare IT users, non-profit organizations, and political campaigns. She holds a Master of Arts in English Literature from Queen's University. For more information, visit jstam.ca

Will Obamacare impact Canadian healthcare policy?

It’s among the many questions posed to Trudy Lieberman, past president of the Association of Health Care Journalists and press critic for the Columbia Journalism Review. Lieberman is visiting four cities across Canada as a Fulbright Scholar and guest of the Evidence Network of Canadian Health Policy, commonly known as EvidenceNetwork.ca.

Lieberman’s timely visit comes just two weeks after the official U.S. government implementation of the Patient Protection and Affordable Care Act (PPACA), also called the Affordable Care Act (ACA) or "Obamacare." Signed into law by President Barack Obama in 2010, PPACA legislation initially inspired some to hope for a more “Canadianized,” equitable version of American healthcare.

But closer analysis reveals this is far from the case. McGill University Associate Professor of Political Science Antonia Maioni aptly illustrates this in a recent Globe and Mail article informed by Lieberman’s observations, Obamacare vs. Canada: Five key differences.

Lieberman is quick to point out that Obamacare builds inequality into the system rather than legislating fundamental reform. Lieberman cites two major differences between attitudes toward health care in Canada and the United States:

1.     Equity. Canadian healthcare ideology dramatically differs from how Americans view healthcare. Lieberman admits that a market-driven economy and powerful politics from stakeholders, particularly health care providers and insurance companies, are major obstacles to changing cultural attitudes toward equitable health care coverage.  “If we (Americans) ever adopt a different system, the impetus would have to come from the business community. It won’t come from advocates or academics, or the media,” says Lieberman.  “We have a largely employee-based system with 160 million people covered by their employers. The spark for wholesale reform of the system will have to come from employers.

2.     Focus on Aboriginal health care. “I don’t recall ever writing about the Indian Health Service,” Lieberman muses. “In Canada, I’ve heard more discussion of aboriginal health than wait times.

Lieberman points out that the results of Obamacare legislation may take years to determine. In the meantime, there are ways our two systems have similarities.

1.      Health care costs increasingly shifted to individuals. “We can see a shift in both countries toward making the patient pay for more,” Lieberman notes. “Americans are paying more out of pocket for health care. In Canada, many services are not covered, and depending on the outcome of a court case in British Columbia, Canadians may pay more out of pocket, too.”

2.      Quality concerns. “Both countries have various problems with aspects of medical quality and both have to work on improving care, especially long-term care for the elderly,” Lieberman points out.

3.      Increasing Demand and Cost for Technology. “We still haven’t figured out a way to reign in the cost of technology. Patients want the latest and greatest but the U.S. doesn’t have anything like the United Kingdom’s NationalInstitute for Health and Care Excellence (NICE), which looks at the cost and efficacy of new treatments before recommending these to NHS doctors.”

What do you think: will Obamacare give Canadians a new perspective on health care policy? 

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A role for physicians in health reform

Sophia Harrison is in her first year of medical school at the University of Northern British Columbia. She was a winner in the Health Innovation Challenge, earning her a summer internship at the Health Council of Canada.

What role can physicians play in health care reform?  This question has been on my mind since completing a summer internship at the Health Council of Canada and starting my first year of medical school. 

On the job at the Health Council, I learned that the 2003 and 2004 health accords did not yield the transformative change promised by politicians. Rather, our health care system is lagging behind the needs of an aging and diversifying population and it consistently ranks in the middle of the pack compared to other high-income countries. After reviewing a decade of health care reform, the Health Council’s September 2013 report Better Health, Better Care, Better Value for all, calls for a unified approach to reform, with strong federal leadership and provincial collaboration. In addition to purposeful political leadership, I believe physicians have an important role to play in advocating on behalf of the general public for system improvements. 

General practitioners (GPs) are the front-line of the health care system and trained in a wide range of specialties. On any given day a GP may treat the whole gamut of illness from acute to complex chronic conditions, as well as providing preventative care and health education. The relationship that a family physician has with his or her patients is fundamental to their practice and essential for the provision of high-quality health care in the diagnosis and treatment of disease. A strong relationship is characterized by trust, mutual respect, and responsibility.

In large part due to the strength of the physician-patient relationship, the general public typically respects the judgment of physicians, even outside the realm of clinical medicine. Physicians who choose to treat patients both as people and as a population can leverage their standing to advocate for change at the policy level.  If a physician's mandate is to help the sick, it follows that physicians have a vested interest in advocating for enhanced collaboration and teamwork, for inspiring new ways of thinking and learning, and for becoming engaged in healthcare planning, priority setting, strategy development and patient-centred care delivery.

It is up to each physician to define a role for him or herself. As my colleagues and I embark on our careers, we are laying down the foundation for the practitioners we will become.  My experience at the Health Council has given me a sense of the importance of understanding policies that affect health care, and the efficacy, in terms of health outcomes, of change and innovation at the system level.  In this formative period, I am making a commitment to stay engaged and invest energy in improving the health care system we are all a part of.  I am confident I am not the only one.

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Time to unlock the potential from pockets of in innovation

Dr. Dennis Kendel serves on the Board of Directors of the Saskatchewan Health Quality Council and is a councillor with the Health Council of Canada. 

There is no shortage of upcoming conferences focused on healthcare quality improvement, innovation or transformation. So, what makes the Health Council of Canada’s (HCC) upcoming symposium in Toronto on October 29-30 unique and very interesting?

Over a decade has elapsed since Saskatchewan created the first Health Quality Council in Canada. Six other provinces have followed that lead to create agencies dedicated exclusively to monitoring and enhancement of safety and quality in healthcare.  To date no agency in Canada has brought all seven of these Quality Councils together in a single forum to compare their QI strategies,  candidly discuss both their achievements and disappointments, and consider future opportunities for more inter-jurisdictional collaboration.

In Toronto on Oct 29-30, we’ll have an opportunity to learn from all seven provincial Quality Councils and to explore with them future options for better integration of their work with the innovation agenda of the Council of the Federation and with many national agencies committed to healthcare QI.

We’ll also have an opportunity to learn from Australia’s National Health Performance Authority about what is working well in that agency’s efforts to transform healthcare quality, effectiveness and efficiency in a large nation of federated states.
We’ll have an opportunity to hear about CIHI’s future plans for more rigourous measurement of health system performance across Canada and more effective public communication about system performance.
And, we’ll have an opportunity to engage in conversation with Ross Baker about building system capacity for quality improvement.

Over the past decade I’ve had some marvellous opportunities to see first-hand some amazing evidence of small scale healthcare QI across this country. However, until recently, I’ve been disappointed in Canada’s record with respect to truly transformative change in any jurisdiction. As a Board member of the Health Quality Council in Saskatchewan, I believe we are now on the cusp of truly transformative change and I am delighted that Bonnie Brossart will be at the HCC symposium to share with the nation some key insights from our experience in Saskatchewan over the past three years.

As an HCC Councillor, I am also incredibly impressed with the pan-Canadian inventory of healthcare innovations now easily accessible to all Canadians through the HCC's Innovation Portal.
The challenge for all of us across Canada, as I see it, is to apply all that we’ve learned from “pockets” of innovation across the country to make future healthcare in Canada the best among all of the OCED countries.

The inspiration, energy and committed leadership that will be essential to our achievement of that goal may emerge from the crucial conversations that will occur at the HCC Symposium in Toronto on October 29-30. You will not want to miss an opportunity to be part of those crucial conversations!
Hope to see you in Toronto at the end of October.
denniskendel@gmail.com

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