Wednesday, April 30, 2008

Canada's Health System and the Determinants of Health

As I mentioned in previous blog posts, we are halfway through a Futures Task Force II (FTF II) planning process. As you will recall, Futures Task Force I was implemented in 2000, and using scenario planning, was completed in 2001.

Based on this experience, we identified that the two major drivers of significant change for all of health care, including CHRISTUS Health, would be declining reimbursement and the rapid introduction of new and predominately non-invasive technology.

Based on these findings, which continue to be true to this day, 19 recommendations were articulated and have been incorporated in our three-year rolling process on an annual basis. Because most of these recommendations have been fully implemented, we began FTF II six months ago utilizing scenario planning and learning journeys with the goal of having fully gained and reviewed the applicable knowledge by December of 2008 with a set of new recommendations coming forward at our Governance Conference in February of 2009, our 10th anniversary.

One such learning journey that I have previously discussed was our 3-day trip to Canada where we focused on three major areas:
1. The Canadian health care system, its successes and challenges as well as reviewing unique care models which they have developed;
2. Understanding the learnings from the SARS epidemic that could be applied to a pandemic in the U.S. or even worldwide and
3. Visiting and learning from the staff of an innovation institute which is associated with an outstanding university and has been in place for nine years.

Let me begin by summarizing the learnings we gained from the Canadian health care system overall.

For years, Canada has had a truly socialized health care system, which means that they provide health insurance to cover basic health care for all registered Canadians. This includes the large immigrant population, which was discussed in the prior blog, because Canada encourages immigration from multiple countries to supplement the population which is needed to fill their many job opportunities.

This program provides hospital care and primary outpatient care. The program recognizes that there are seven determinants of health care, of which hospitals are only one. Therefore, they believe that building more hospitals and buying more technology will not and has not improved the status of health care in Canada. They recognize that the other six determinants must therefore have intense focus and must also be supported by governmental grants and subsides. These include:
1. Primary outpatient locations
2. Schools
3. After school programs for working parents
4. Appropriate housing
5. Appropriate nutrition
6. Appropriate psychological and psychiatric services

In order to address these issues with a multi-disciplinary team, each community—with community volunteers—are encouraged to develop a business plan for a community clinic and center where all of these activities can be addressed. If they meet certain levels of quality and service in each of these areas, the community center is usually approved and then funded.

By placing a great deal of emphasis on these six other determinants of health care, they have proven that they can keep a large portion of the population in relatively good health and also manage a greater array of chronic illnesses on an outpatient basis.

Their emphasis on the importance of wellness and prevention as well as the need to provide a medical home for each and every patient appear to be hallmarks of their greatest successes. However, this system has many of the same negatives that many other countries must deal with, namely the rising costs of health care and therefore the need for the government to identify other means of securing additional funds. Of course this generally leads to raising taxes, which is never well-received.

Therefore, priorities for funding must be identified. Those things that are not rapidly funded include elective surgical procedures such as hip and knee replacements as well as cosmetic surgery and surgeries which tend to be somewhat controversial (like bariatric surgery to control type II diabetes). Therefore, there is a waiting list for these procedures which numerous people find unacceptable. Therefore, they are seeking other ways to obtain this care, which include both medical travel and the acquisition of private insurance.

Overall, however, based on conversations with administrators of hospitals, physicians and nurses as well as a small array of patients, I found that all believe that for the most part, the values provided by the Canadian health care system outweigh the negatives that were just discussed.

What, then, can health care providers in the U.S. as well as CHRISTUS Health learn from this experience?

First, we learn that all the determinants of health care must be considered in developing a redesigned health care system. Second, a great deal of money and attention must be given to providing primary care medical homes and developing sound preventive and wellness programs. Third, clear criteria must be developed for elective procedures based on evidence-based medicine so that when these criteria are met, the patient somehow is given the ability to have this care. Fourth, perhaps a mixture of governmentally-supported health care for primary and non-elective hospital procedures is workable and in fact should be supplemented by private insurance for those who can afford it to cover the non-elective procedures, particularly if they are desired before the medically indicated criteria are met.

In summary, as I have said before, we all know that the U.S. health care system must eventually be redesigned, either in an evolutionary or revolutionary manner. It would appear that the learning journey processes that we are using in FTF II are an outstanding tool to be utilized to gather the knowledge and learnings that we should be brining to the table when this redesign process is initiated.

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