The Home First philsophy - creating safe transitions for patients from acute care to home

Caroline Brereton, RN, MBA is a registered nurse and holds an MBA from Queens University. She is a graduate of the Rotman School of Management Advanced Health Leadership Program.
A senior healthcare executive with 15 years of leadership experience, Caroline became Chief Executive Officer of the Mississauga Halton CCAC in May 2010. Caroline has a vision for a system that is fully aligned to support the needs of patients.

The growing population of seniors across the province will continue to increase pressure on the health sector to provide health care at home, including community services to help seniors move from  hospital to home following acute treatment and programs to help residents remain safely at home for longer. We feel it acutely in our Mississauga Halton communities of South Etobicoke, Mississauga, Oakville, Milton and Halton Hills.  We experienced one of Ontario’s highest growth rates in population, a 12 per cent increase in population from 2006 to 2011.  The Mississauga Halton region is the second fastest growing population of seniors in Canada (projected 32.3 per cent increase in 75 to 84 year-olds and 71.1 per cent increase in seniors 85 and older, by 2013).

 In 2009, anticipating population growth, the Mississauga Halton CCAC, was the first to launch the Home First Philosophy. In collaboration with our region’s hospitals, Trillium Health Partners and Halton Healthcare Services, funding was provided by the Mississauga Halton LHIN.

The philosophy embodied our objective: to slow the growth of alternate level of care (ALC) rates in hospital, while at the same time supporting the province’s goal to increase access aging at home. It was ambitious; the number of ALC days nearly doubled from 9.3 per cent in 2007 to 17.5 per cent in 2008.
The Home First Philosophy was the foundation for a new suite of Wait at Home services and that was our approach to tackling the growing ALC rate. It is a team-based philosophy that promotes safe and timely care, services and supports, which helps to meet the health care needs of patients and families in the most appropriate setting. The Home First philosophy recognizes that the home environment is the best place for recovery and supports people in returning to their homes from hospital wherever possible. It also provides the necessary services to help older adults maintain their continued independence in the community.

Challenges and Hurdles
This new philosophy necessitated changes in workflow, culture and communication. When we introduced it to our patients, staff and partners, it was a huge culture shift in health care thinking for families and physicians.  Traditionally, patients applied to long-term care homes from the hospital.

Physicians were concerned about safety and risk to patients leaving hospital and returning home. We helped physicians understand the quality of care provided in the community through the Mississauga Halton CCAC. We explained our approach and introduced new services that would ensure patients, even those with complex care needs, would be safe at home while they applied for long-term care or recovered and realized they could stay at home safely with services from our CCAC.

Better Outcomes
Together, with our partners, we drove better results and we continue to bring proactive change to the health care system. With innovative efforts and focused teamwork, the consistently low ALC rates in Mississauga Halton is evidence of system integration as a key mechanism for delivering the right care, in the right place, at the right time.  In fiscal 2012/13 our ALC rate was seven per cent and 6.3 per cent in the previous year. This means that 93 per cent of hospital beds in our region were available to patients needing hospital care.

Staying in hospital after surgery or treatment is not in a patient’s best interest. There is an increased risk of infection; and patients become less independent the longer they stay in hospital.The Home First philosophy is an enormous cost savings to our health system. Every ten per cent  shift of ALC patients from acute care to home care results in a $35-million saving.  And most importantly, it provides better outcomes for patients where they are happier and more comfortable in a familiar setting and they tend to recover more quickly.
Recently, a patient’s son, who is caring for his 83-year-old father at home, told us:  “The Mississauga Halton CCAC made it so simple and smooth. You take care of everything – personal support workers, nurses, occupational and physical therapists, medical equipment and supplies.  They brought the hospital to our home.  Now my father is safe and secure, and getting the quality of life he deserves.  My father belongs here.  Without you, we could not do it.  It would have been impossible. It is a blessing to have my dad here.”
However, if a patient and family decide that long-term care is the right place to be, we help them through the process from beginning to end. We start by directing them to our long-term care website – http://mhccac-ltc.com/ –which provides information about wait lists and costs, as well as a virtual tour of our region’s 27 long-term care homes.

At the Mississauga Halton CCAC, we look at health care differently. We recognize health care at home is not the future; it is the reality of health care today.

*Watch the video on the Home First program, part of the Health Council's Wait Times video series.

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Online education about elder care for community-based health care providers

Marney Vermette, Engagement Liaison, Saint Elizabeth First Nations, Inuit, and Métis Program

In my previous role as a nurse supervisor for a First Nations home and community care program, I saw that there were major challenges in finding affordable, accessible, and culturally appropriate health care provider training that meets the needs and realities of the First Nations people. Receiving an education within the community was not often an option for health care providers, and leaving the community for education and training had several negative impacts on the health care provider and the community—it affected the continuity of care for their clients, increased the burden on the family and community, and was a financial drain on already exhausted community budgets. These problems were especially common in remote communities.

It would take community home care staff several years to obtain their Personal Support Worker certificates. They would leave their families, communities, and positions for weeks at a time. If there were a crisis or a death in a community they would return home, losing out on training and delaying their education. In addition, many times nurses come to communities without a proper understanding of the importance of culture and protocol and of building relationships within the community.

Saint Elizabeth offers a First Nations Elder Care Course, one of several online professional development programs available at no cost to community-based health care providers across Canada. The course provides evidence-based, culturally sensitive education about First Nations history and culture, as well as clinical information on health topics related to elder care such as falls, medication, nutrition, depression, Alzheimer disease, elder abuse, and caring for yourself as a health care provider.

We were cautious not to develop a pan-Aboriginal approach. A key message spread throughout the course is the need to understand that every community is unique. Health care providers need to build relationships with the communities to learn more about community-specific cultural practices and protocols. They need to seek guidance from a community champion to learn about the culture, traditions, and practices within a community.

Our program uses a unique model involving First Nations health care providers, elders, and specialists in the development and review phases of our courses. Our goal was to ensure that we had comprehensive information to meet community needs and to develop relationships of mutual trust and respect.
The course was released in January 2013 and has received an enthusiastic response. Community representatives appreciate that the course provides their staff with understanding and knowledge to provide a safe environment along with respect and protocols in caring for the elders. The goal in many communities is to keep elders in their homes for as long as possible instead of moving them to long-term care facilities.

The online training means that health care providers don’t have to leave their communities to develop the knowledge and skills they need to care for elders. Health care providers are sometimes intimidated by online training, but most of them know how to use Facebook and once they realize it’s just as easy, they are very enthusiastic.

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Community health aides help with nursing shortages and cultural safety

Tina Buckle, Community Health Nursing Coordinator, Nunatsiavut Department of Health and Social Development

In Nunatsiavut, we use Community Health Aides to support nursing staff in remote communities. We have a challenge recruiting and retaining nurses, and the aide position has allowed us to manage with fewer nurses. It’s a model that borrows from Labrador in the past and from Alaska in the present, where community health aides, local people from the community, help to deliver health care in remote communities.  In Nunatsiavut, the community health aide has a role in both public health and home and community care.

In the Home and Community Care program, the community health aides function as the nurses’ “right hands.” They manage the home support workers, go with the nurse to client visits as needed, order equipment and supplies, schedule appointments, sterilize equipment, complete month-end reports, and anything else that doesn’t require a nurse to do. The nurse is then able to concentrate on direct client care. The aides also do independent home visiting to support the programs, both when a nurse is in town and when the position is vacant.

Just as important, the aides are the cultural advisors to new nurses. They are so trusted in the community that any new nurse is immediately accepted if accompanied by the aide. From a senior care perspective, the aides have the ability to spend more time with seniors than the nurses do; also, they have personal connections and speak the language. We have also given the community health aides tours of the regional health and long-term care centres in Happy Valley-Goose Bay so that they can describe them to seniors and their families and help them become comfortable with the transition.

It’s hard to quantify or even to put into words the value of community health aides —essentially, we would not be able to deliver care without them and clients would not be as willing to receive care. It’s hard to understand why this model hasn’t spread to other parts of the country, particularly since it’s also well known in Alaska. I think there’s almost a strange fear that by allowing this kind of practice we’re encouraging people to be community health aides instead of going into the health professions, but that’s not what it’s about at all. There is an incredibly valuable role for these people at the community level that no one else can fill like they do.

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One home care program for everyone: Bella Coola, British Columbia

Glenda Phillips, Manager, Home & Community Support, Bella Coola General Hospital

In my community, Bella Coola, we have a fully integrated home and community care program situated in a new health centre on-reserve that is used by everyone in the community, whether they are First Nations or not. But it wasn’t always that way.

Bella Coola is a geographically remote community with limited resources. I was the federal health nurse there for years, until I went back to university. When I returned, I was hired by the province to set up home care in the region. I saw that people on-reserve weren’t getting services. There was no structured home and community care program, and no integrated service delivery model between the services offered on-reserve and those offered by the province. We had five long-term care beds in a small community hospital, and no assisted living. Complicating the situation were factors such as budget constraints, nursing shortages, and a lack of clarity around staff roles and responsibilities.  

We wanted to give people equal access to care and the option to remain at home as long as possible—not just in their community but in their own homes. We needed an integrated care program to support this and we wanted to build capacity for culturally sensitive care.  We started the planning by going to the Chief and Council of Nuxalk Nation and saying, “Why don’t we work together and set up a program for everyone?” Then we went out on the road talking to the community, conducting a community needs assessment, and meeting with the many different organizations and government representatives who needed to be consulted.

In the end, we made just one home care program where there had been two (the province’s program and the federal FNIHCC program). There is no new money; we pooled our funding streams to work around budget constraints. And by coming together, we expanded our capacity and flexibility. For instance, there is a four-hour cap on the number of hours of home support we can provide to a client in a day. But if a couple of more hours a day means that the client can stay in the community and in their home, then we provide more hours. It’s good quality care, and it’s cost effective for the system.

Other communities have asked us how they can do similar types of integrated programs. We tell them the standards of care are going to be the same—how you do your assessments, how you clean your tools, how you chart—but how you deliver the care might be a little different because of the culture in your community. You have to know the community. 

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Supporting Métis seniors and families

Wenda Watteyne, Director of Healing and Wellness, and Dr. Storm J. Russell, Senior Policy and Research Analyst, Métis Nation of Ontario

Few Canadians realize that one third of all Aboriginal people in Canada are Métis, and that the Métis population is older compared to other Aboriginal groups. From our research, we know that many of our seniors are experiencing significantly higher rates of chronic disease and other complex conditions compared to non-Métis Ontarians. Métis people also fall under a different legislative and regulatory structure than do other Aboriginal groups, and do not have access to programming supports such as the Non-Insured Health Benefits program that is available to many Aboriginal peoples. Many also live in remote and rural areas, where access to services and supports can be limited. For Métis seniors living on limited incomes, things like transportation to see doctors and specialists, as well as having the means to fill expensive prescriptions, can also serve as barriers to care.  Finally, access to culturally safe care can be a challenge for older Métis citizens.

It is for all these reasons and more that the Métis Nation of Ontario (MNO) provides programs and services at the community level. Situated in 18 Métis communities distributed across the province, MNO community centres serve as important cultural and service hubs that link our Métis citizens to each other, as well as to health services and supports in their local areas. The MNO community centres are especially important in providing our Métis seniors with the kinds of culturally grounded services and supports they need, along with help in accessing medical services. Some of our MNO centres also offer specialist services such as foot care clinics for seniors and other Métis people suffering from diabetes. MNO community centre workers also much in the way of outreach to Métis seniors in need of assistance, visiting their homes to help with things like meal preparation, house maintenance, and other tasks of daily living, while at the same time providing that important cultural connection and support. Through the MNO Community Support Services program we are also able to provide transportation services to help Métis seniors travel to and from their medical appointments.

For the many Métis seniors and other community members who are suffering from significantly higher rates of chronic diseases and conditions, MNO community centres provide a place where they meet with other Métis community members and receive much-needed support and care, and get help in linking to essential services and programs in the broader community. The centres also provide a haven for culturally safe community care. 

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Minding the Gaps in Quality Improvement in Canada

John G. Abbott

John G. Abbott is the CEO of the Health Council of Canada

What can Canada gain by upping its investment to advance the health quality improvement agenda? And, in what areas should it invest?

A lot, in my opinion; and the focus needs to be on increasing the capability and capacity of our system and its leaders to deliver transformative change. 

This week, the Health Council of Canada held a national symposium on quality improvement under the theme: Towards a High-Performing Health Care System: The Role of Canada’s Quality Councils. 

Dr. Ross Baker

Over 200 senior leaders from across the country converged to talk about health system performance measurement and reporting, and building system capacity for quality improvement.  It was clear that there is no ‘one size fits all' when it comes to performance measurement or reporting and each jurisdiction with a quality and/or patient safety organization (there are seven in total) have adopted approaches that are working for them. So what are the gaps in Canada’s current quality improvement approach that need to be closed?

The first gap is the absence of a burning platform for transformative change so that quality improvement is embedded in everything we do in health care. Are health leaders and Canadians themselves convinced that we need to improve the quality of the care being delivered in each hospital, clinic and doctor’s office in this country? The evidence says we need to, but is that enough to make the case?

Panel on Building System Capacity for Quality Improvement

The second gap or challenge is treating QI as an add-on. Shouldn’t our health system encourage all its leaders to begin their day with the question: what have we got to do today to ensure all our activities deliver safe and appropriate care for our patients; and end their day by asking:  how do we know that we achieved this objective? If QI is its own silo, we are not going to achieve transformative change in any setting.

The third gap relates to resources. We need to increase the level of investment in resources to successfully design and manage a QI agenda. We need to train people at the front lines and in the back rooms to think as one, using a common language around performance improvement.  We need to continually support the work of quality councils in this country who in turn are aligning their activities in support of the health systems that they both monitor and engage on quality improvement initiatives.

A fourth gap is not appreciating the magnitude of managing complex system change.

A fifth gap lies in the area of technology and information sharing. We need to leverage the use of today’s technology to collect data and share information about system performance and patient outcomes in a consistent and timely way that can be used by all parts of the system to improve the quality of care.

No one organization or system has all the answers to addressing these gaps. All in all, we need to collaborate within and across organizations and jurisdictions to build capacity and capability in all these areas.  The Health Council’s report on the proceedings of its event will cover these points in greater detail and will be released on December 16, 2013 at www.healthcouncilcanada.ca.

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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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