What follows are my Big 5 ideas.
1. WAIT TIMES GUARANTEE
A patient that fails to receive a procedure within the established medically appropriate time frame shall have the right to a voucher covering the service at an accredited community-based, not-for-profit facility.
We need to establish, collect, and report ALL surgical wait times using the existing platform. This is a long overdue step toward transparency and accountability. Even if some of the data are troubling, we all need and deserve to know.
We need to create a regulatory framework to enable the formation of not-for-profit clinics offering services to non-OHIP-insured individuals (non-resident expats, professional athletes, and medical tourism patients), taking all steps to protect against threat of two-tiers (real or perceived).
We have to broaden the health care connect role, empowering real live health care professionals to connect individual patients, who are sometimes stragglers, to timely care. The voucher should be co-funded by the health ministry and the non-performing LHIN or hospital, thereby ensuring accountability and an incentive for performance improvement at the health system level.
While the primary thrust here is to address the chronic quality question facing too many Canadians as they wait for care, the approach differs from prior wait times strategies, where almost all the action was dependent on new spending. In my proposal, new funding would be allocated based on real patient experience. This would shift the power. In particular, poor-performing LHINs or hospitals or surgical teams would feel the pain and gain a greater motivation to care for their captive patients proactively rather than suffer high rates of voucher cases in their captive territory.
There are also two tremendously important benefits that would go along with the emerging not-for-profit facility capacity envisioned here: 1) leveraging our substantial public health care knowledge for more jobs and for the generation of foreign revenues through the promotion of medical tourism; and 2) enhancing our critical event or epidemic surge capacity, as not-for-profit clinics would be legislatively obligated to shift their resources for public health emergencies when prescribed circumstances warrant (such as SARS).
2. CHOICE IN PRIMARY CARE
Create competition in primary care by allowing alternative providers and teams of providers to roster patients and provide care.
We should modernize primary care by providing real choice for patients to designate and roster with a provider or team of providers of their choice rather than just doctors, as is now the case. That would immediately improve access to timely care for people in under-serviced areas.
Why not compensate alternative primary care providers or teams of providers when they can fulfill a similar scope of practice as family physicians? This would provide the benefit of timely care to patients while accentuating team models of care.
A rostering model prevents a patient from having a whole fleet of different providers, ensuring cost effectiveness. Case in point: My local pharmacy helps to advertise a physician home-call service. I needed a timely response to my daughter’s need for a medicated cream for eczema. Simple enough. The health care system was willing to pay a doctor to come to my home for this ailment. Meanwhile we were at the pharmacy, and it was very obvious that this ailment could have been diagnosed and treatment initiated immediately at huge savings while greatly enhancing the patient experience.
The premise of our current primary care model is that OHIP would pay for a physician for anyone that wants one. Since we have established how much we are willing to pay (physician compensation) and what we can get for that money (scope of practice), this pool of funding should be open to a broader array of providers. We should start first by getting care to patients living in rural and remote areas who have been teased for too long with the promise of every sort of program and incentive possible to address their physician shortages. Meanwhile, models of teams meeting service need already abound, including the stand-alone nurse-practitioner model I initiated in Sudbury. But rostering patients and the compensation for doing that is not currently allowed.
Downstream we could see a model where regulated practitioners of traditional Chinese medicine work alongside practitioners of Western medical philosophy to meet the patient’s needs holistically. Or pharmacists and nurse practitioners could consult with a physician as needed to allow their team to meet patient needs.
Extended hours of operation that push health care delivery into real-life hours and beyond nine-to-five would be a condition for participating in the Primary Care Choice Program.
3. RIGHTS, OBLIGATIONS, AND REWARDS
Look at the words behind the OHIP acronym: Ontario Health Insurance Plan. Why don’t those people ever talk to me as a plan member and engage me in the way I use the health care system? Some critics have proposed patients get an invoice showing the cost of the services they have used. I bemoan the lack of any sophisticated system user guide that outlines rights, expectations, and services for the insurance program’s members, the residents of Ontario. If we ever want to engage as a society in the goal of trying to make our health care system more sustainable (think quality, not just money), then the power is in our own hands. That’s because so many of the highest costs the system is asked to deal with are influenced by the personal choices we all make. Not just lifestyle choices, which are important, but choices like when is the right time to go to the ER?
With timely access as the cornerstone, I think we need to reimagine the patient’s experience and develop a Patients’ Bill of Rights that balances expectations of timeliness with the fulfillment of obligations. For instance, I would have preferred to introduce “presumed consent” for organ and tissue donations, but the panel I appointed to advise me on increased organ and tissue donation didn’t recommend it. That would have meant anyone could “opt out,” but no “opt in” would be required, as consent to offer valuable organs and tissues would be presumed.
More importantly, I believe it should be the mandatory obligation of plan members to have executed a binding power of attorney or care direction by the time they reach age fifty-five. Such an obligation would reduce our costly reliance on usually pointless and always expensive end-of-life heroics, thereby saving both anguish and hundreds of millions of dollars annually. At the same time, it would ensure that your end-of-life wishes are not trumped by family members who can’t stand to lose you.
Furthermore, it is time to encourage and reward our plan members for doing their best to help achieve good outcomes in the same way that an insurance company rewards good drivers. Now don’t allow yourself to get worked up in a lather pretending that I just endorsed fat-shaming, or a ban on horseback riding for OHIP members because of the inherent risks. Rather, I am saying that in this day and age, personalized health care is becoming the new normal; yet our health care system refuses to recognize the power shift.
I think we should develop a reward system, funded by health premiums, that provides a refund to Ontarians who actively help to achieve the best measurable outcomes particular to their status, be that healthy or with underlying challenges. It makes a material difference, for instance, if a person with type 2 diabetes, no matter how obtained, takes a very active interest in his or her blood sugar levels. Compliance is sometimes hard, but we human beings are known to respond well to incentives. So why not reward people for their efforts at best possible outcomes even if their baseline isn’t and will never be perfect or even great? Compliance rewards for the person with schizophrenia who stays on his or her drug regime could prevent untold trauma. Payback for that approach would be nearly immediate, and in the secure app world we can achieve that faster than ever while encouraging innovation. A well-developed model would equitably reward Ontarians for doing their upmost to protect and improve their health regardless of their starting point. Such incentives would of course restore rewards to people of all ages for enrolment in sports, exercise, or gym activities.
4. INDIGENOUS HEALTH LHIN
Eyes
glaze over when one brings constitutional issues into the discussion of health care — or most public policies, for that matter. But when it comes to Ontario’s Indigenous population, I would say it’s high time we ditched the paternalism and hand over autonomy for the provision of health care to Indigenous Peoples themselves for the entirety of their traditional lands in the province.
The shocking irony is that we see medicare as a core national value while the federal government has always had primary responsibility for Indigenous health care, and Indigenous Peoples suffer from the worst (by far) health outcomes. Count me as cautiously optimistic as I recognize that some big steps are being made by the national and provincial governments (here in Ontario for instance) in recognizing that autonomy on the part of Indigenous people in organizing and running their health care is essential in achieving first-world health outcomes.
However, there are attendant risks if funding and program delivery are allowed to narrowly revolve around reserves or individual nations. I believe that a province-wide Indigenous LHIN would be an effective model. As in the case of Regent Park, where the concept of community succession (local people getting the good jobs) drove expectations of better educational performance and attainment, so, too, can the promise of economic opportunity in health care delivery and administration be a motivation to enhance the socio-economic situation for Indigenous people in Ontario. Let’s face it. There are big dollars to be made in health care and pensions to be earned. We need to turn these into opportunities for today’s Indigenous youth and put the pressure on us all to produce better educational attainment.
5. HOSPITAL-TO-HOME BUDGET SHIFT
If health care really is the big deal that Canadians seem to think it is, then maybe it is time for a little straight talk about how we need to adjust our expectations and use of the system. We have a very serious maldistribution of resources, much of it due to our aging population. This problem is only going to get worse, and we are no doubt headed toward a permanent state of crisis in the system where the needs of seniors run the risk of diminishing the chance for a quality outcome for them and for everyone else, too.
Everyone wants improvements in health care, and most people asking for them are largely hoping more money will be invested in the system. The truth is we are pretty much spending as much as we can. So what’s going to give? There are two related areas that I believe need to be treated with urgency: one would put the onus for change on the patient; the other would put the onus on the system. In both cases, we need to enhance health care literacy to better arm our society to survive aging with as much grace and dignity as possible. Why live longer if you can’t also live better?
There isn’t much in the way of low-hanging fruit in health care that can be achieved by pursuing more “efficiencies.” But there is unnecessary care being provided, and there is a lot of care being provided in settings that are far too costly. Reprofiling these several billions of dollars of current hospital operations is the most promising area for reform to create more care in the right place. I said in Big 5 idea number three that I believe that, as a condition of good citizenship, every Ontarian reaching age fifty-five should have designated a power of attorney and given direction about their care expectations. These steps should be mandatory before someone gains access to the Ontario Drug Benefit program at age sixty-five. This task can be completed thoughtfully and with assistance from community support agencies and entities like legal aid clinics. These are things that the patient can do.
The second matter is that 20 percent of Ontario’s hospital beds are housing “alternate level of care” patients, sometimes called “bed blockers.” Rather than add beds, as Ontario is mostly doing, I believe we need to cash out all those high-priced hospital beds and the costly ambulance rides that deliver patients there. Instead, we should buy more beds in the community, including the novel idea (for us) that an admitted patient of a hospital can remain in his or her own home.
The hospital waits all night long for the $700 ambulance ride to offload the needy cargo. It’s high time that we set a goal of sharply reducing the number of ambulance deliveries and transition ourselves from the reactive to the proactive. In my model, the long-term care home would reverse its role. Rather than sending patients to the hospital, the long-term institution would deliver greater care and serve as an added resource for others, keeping aged loved ones in their own home.
Arguing that insecurity and social isolation are sometimes the source of 9-1-1 calls, I would deploy a small army of trained social assistance beneficiaries (the disabled and those on welfare) in a friendly home-calling program that would consistently check in on the isolated and would send any concerns about their situation up the food chain. The incremental wages for these home callers would provide a secondary benefit by reducing their underlying poverty and health status. A third benefit would be the ability to develop a vulnerable-persons database as a resource for emergency planning and civil defence, which is sorely lacking in Canada.
Recently many physicians have expressed frustration with the practice of hallway medicine, whereby a hospital patient is stationed in a hallway, not a room. In trying to fashion a response, I was reminded of an opportunity I was given to rethink capacity and save lives. A lot of adverse patient outcomes can occur in hospitals when an admitted patient’s deteriorating health runs up against the sheer limits of critical-care or intensive-care capacity in a hospital. Dr. Tom Stewart led the development of a critical-care plan, where we created mobile capacity within the hospital that assembles en route to the patient, rather than the old model where we tried to move the patient to the often non-existent capacity.
I believe it’s time to rethink the ER and its magnetic appeal. Rather than sit there and wait for the inevitable return of frail Mrs. Jones, we would check in on her proactively and organize our resources to suit her, including delivering more care right in her hallway at home.
CHAPTER SEVEN
Energy
After the 2007 election, I wasn’t moved out of the health portfolio, at least not immediately. I was grateful for that because I had some unfinished business to deal with, including sex reassignment surgery, which the Harris government had delisted from OHIP funding. Earlier in 2007, I had met with the premier and won his commitment to move forward on the issue AFTER the election. (He didn’t want the hassle of dealing with a social conservative backlash during the campaign.) McGuinty kept his word. He actually called me and told me to set the wheels in motion to restore funding for the surgery.
In support of my position, I noted that even Ralph Klein’s Alberta was funding it. “If they are doing it, how can we not?” I asked. It wasn’t a cost issue: fewer than two dozen sex reassignment surgeries had been performed annually in the early 1990s, when the Rae government had funded the procedure. In announcing the decision to restore funding in early 2008, I estimated the cost to taxpayers at just $200,000 (out of an overall health budget of $40 billion) and added: “It’s a very serious medical condition that affects a very small number of people.”
Of course, soon after that Alberta delisted sex reassignment surgery. And the number of people seeking the operation has climbed significantly as “trans” identification has emerged to an extent no one could have foreseen back then. Caitlyn (formerly Bruce) Jenner has something to do with that. But maybe she found the courage to come out because the world view of transgendered people changed. It is a chicken and egg question. Personally, I have great admiration for the trans community, which has been marginalized and abused for so long. Now they have a chance to match their body parts with their brains. I am proud of the role I played in making that happen and recall signing name change forms for constituents transitioning as one of the most emotional experiences ever.
* * *
My days were numbered in the health portfolio, however. One can never grow bored there, but there are declining rewards for initiative as one bears more of the institutional history. As time marches on, the incumbent minist
er becomes a symbol of inertia rather than a force for change, even though you are still trying to bring about change. I began to realize this in dealing with the issue of the perceived quality of care in our long-term care homes. Early on in my days at Health, I was exposed to images on the front page of the Toronto Star of a patient named Natalie Babineau. They are not images I will soon forget. She had gangrenous bed sores on her back as big as an adult hand. Wiping away tears at a press conference, I promised a “revolution” in long-term care. “We will fix this,” I said. “We will.” To address understaffing in nursing homes, I managed to secure more than $1 billion in additional funding that provided for nearly three thousand new employees. But because I had promised a revolution, nobody was inclined to offer up much credit for that improvement.
Looking back, I think long-term care was one of the files I handled most poorly, in terms of giving people confidence about performance. I rate myself poorly most especially because I set expectations so high. Pointedly, though, I came to realize as well that because the clientele is so vulnerable, they can appear neglected even if perfectly well supported.
After the 2007 election, long-term care remained an issue for me. The question then was whether to implement a new type of adult diaper that was more absorbent and, accordingly, would require fewer changes. In a scrum with reporters, I let down my guard. Despite ample warning from my staff, I candidly said I was seriously considering putting myself in the place of nursing home residents by wearing an adult diaper for a time. This exposed me to ridicule, from both the media and the opposition. Despite my having approached the issue with the seriousness it warranted, others couldn’t help playing political games with it. (NDP critic Peter Tabuns called me “a damned embarrassment,” and Conservative Leader John Tory said I was “a disgrace.”)
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