Pay-for-Performance - An Opportunity to Improve

Dr. Les Vertesi is the Executive Director of the British Columbia Health Services Purchasing Organization.

For many people, ‘Pay for Performance’ (P4P) implies commission-like payments such as those used in sales, but in Canadian health care it means nothing like that.  BC’s version of ED P4P paid money to hospitals, never to individuals.  Since hospitals were expected to invest all of the money earned and possibly some of their own as well, the money never really acted as a reward but as a way of monitoring success, and supporting the cost of the innovations created by their staff.   In other words, it was a way of acknowledging that change costs money but also that spending would be done more carefully if hospitals and front-line staff were invested in the choices and shared in the risk of success or failure.

For government, the assurance that they would not have to pay for measures that were not successful was a major motivating factor.   For front-line staff, it was their ability to be involved in the improvement process and in helping ensure its success.   The real reward, in other words, was never the money (since it was all reinvested) but the opportunity to improve the satisfaction of front-line ED staff by giving them the ability to control their environment and provide better patient access.   In order to maintain this motivation, all the money had to remain under the control of the hospital and its staff rather than the Health Authority.  Experience showed that those hospitals that were able to maintain this principle over time showed the best success.

* Watch the video on Pay-for-Performance, part of the Health Council of Canada's Wait Times series.

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Waiting for care: Bad for the economy

Dr. Anna Reid,
President, Canadian Medical Association

In its most recent report, the Wait Time Alliance has said many Canadians are still waiting too long to access a wide range of necessary medical care (See  http://www.waittimealliance.ca/2013/2013-WTA-Report-Card_en.pdf). Moreover, Canadians experience longer waits to access care than citizens of most other industrialized countries. These lengthy waits not only apply to specialty care but also to access primary care and to be seen in the emergency department.
 
Wait times within provinces and among populations can vary significantly. For example, low-income patients experience more problems accessing primary care and some types of specialty care than those with high incomes. Your wait depends on where you live, your income, and your gender.

Lengthy waits can have serious health consequences. We know that for some conditions, such as cancer, heart disease and mental health, the longer the wait for treatment, the worse the health outcome. There is also the mental anguish and uncertainty associated with waiting for necessary care.

The impact goes beyond the patient’s health. For individuals and their families, a lengthy wait can mean a substantial loss of income, particularly if they do not have insurance to cover this period of economic inactivity. A longer wait can also mean greater deterioration and a longer recovery time for the patient, leading to a further loss of income.

The substantive financial costs of lengthy waits for both patients and Canada’s economy have been previously documented. A study prepared by The Centre for Spatial Economics for the CMA and the British Columbia Medical Association calculated the economic impact of excess wait times for five procedures (hip and knee replacement surgery, MRIs, coronary artery bypass graft surgery and cataract surgery) in all 10 provinces. It found that, in addition to the obvious emotional, physical and financial toll endured by patients and their families, lengthy waits for these medical treatments cost Canada’s economy an estimated $14.8 billion overall in 2007 in reduced economic activity. This took a $4.4 billion chunk out of federal and provincial government revenues. Keep in mind that this study only examined a limited number of procedures and therefore underestimates the full cost of waiting that Canadians experience for a wider range of services.

Lengthy wait times don’t need to be a given. A recent report by the Organisation for Economic Co-operation and Development (OECD) identifies a number of strategies other countries have found successful in reducing medical wait times (http://www.oecd.org/health/waitingtimepolicies.htm). These include changing how we fund hospitals, offering wait-time guarantees with teeth, and making use of information technologies to better track and manage patient wait times. As Dr. Chris Simpson, Chair of the Wait Time Alliance recently stated, additional funding is not the sole solution to achieving shorter wait times. Structural change is necessary alongside the funding if we are to reduce wait times across the full continuum of care on a sustained basis. 

* Watch the Health Council of Canada's video series on Wait Times.

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The Impact of Emergency Department Pay-for-Performance on Patient Flow and Access

Michelle de Moor is Operations Director Critical Care, Emergency, Burns Plastics and Trauma, and Patient Flow and Access at Vancouver General Hospital, Vancouver Coastal Health

When Emergency Department Pay-for-Performance (EDP4P) funding was introduced in British Columbia it represented a new model of financing for the health sector that was poorly understood. The intent was to provide financial incentives for good performance as it related to creating access for patients who arrive to the emergency department. The advantage, for organizations that were able to quickly adapt to this new funding model, is the ability to invest in resources, initiatives and systems to achieve improved patient flow.

At Vancouver General Hospital, within Vancouver Coastal Health, the senior leadership team has fully embraced the opportunities within the EDP4P funding model. Enhancing patient flow and access is a strategic priority and is considered to be inextricably linked to quality outcomes for patients. I believe VGH has been so successful with this work as a result of the willingness of the senior leadership team to take risks with the investments related to EDP4P revenues, and the organization-wide commitment to achieving improved outcomes.

In order to be successful, the investments have been diverse, from opening beds in acute care and community, to creating key frontline leadership positions that focus on patient flow and transitions, and putting in place critical infrastructure support in the form of electronic tools. Having said that, the most fundamental and powerful change has been the leadership accountability framework that has accompanied the organization’s commitment.

Through daily leadership rounding, daily reviews of outcomes, and establishing clear expectations for all programs, the organization has achieved a fundamental shift in the culture of flow.

There are still a lot of challenges with respect to ever-increasing demand, and we continue to look for the next opportunity to create access and capacity. However, we are absolutely committed to this work as a united leadership team and will continue to take risks with our resources in order to achieve better outcomes for our patients.

*Watch the video on how Pay-for-Performance has impacted wait times in the Vancouver area.

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