The numbers are alarming. Canada’s 10 provinces and three territories currently combine to spend an average 36% (see table) of their budgets on health care. As that number continues to grow it crowds out their ability to fund other priorities. It’s up in Ontario to a whopping 41% or $48.8 billion annually. The bulk of that money is spent on a minority of patients. In Ontario, 1% of patients, 80% of whom are over age 65, account for 34% of total health care costs. The statistics in other provinces are comparable. For example, in B.C. those over 60 account for 20% of the population, but 47% of expenditures (2008). On the other side of the country in Nova Scotia, the 65+ cohort makes up 16% of the population and accounts for 51% of spending (2010, Canadian Institute for Health Information).
Toronto-area hospital Bridgepoint Active Healthcare is shopping an ambitious plan to shave $4 billion-$6 billion annually off Ontario’s bill by focusing on that minority. And it says its plan can serve as a model for the rest of Canada. All that has to happen is a complete overhaul of health-care service and delivery.
Does this idea have a hope in hell of working?
Colin Busby, a senior policy analyst at the C.D. Howe Institute, seems to bite his tongue, but he likes where Bridgepoint is going. “Overall, if this program is a success province wide, those figures are achievable, but they’re quite optimistic and it’s hard to say where those savings will go if they are met. Would it result in a reduction in the overall health budget of $4 billion to $6 billion? Probably not.”
Bridgepoint president and CEO Marian Walsh in June spoke before the Economic Club of Canada to outline her plan. In a subsequent interview she explained how the hospital’s “model for complexity management” works.
Take an elderly diabetes patient, for example. Walsh says there are times when such a patient needs immediate access to service, but under the current health care system doctors aren’t organized to deliver that care 24 hours a day. “So when somebody has an issue and it’s 7 o’clock at night they show up in an emergency department and they get some tests done, they get some drugs changed, they get sent back home. Then because that emergency department doesn’t know that person—they don’t have a health record on that patient—they end up with a drug interaction and that creates another complication and they go back again and the cycle kind of repeats itself.”
Bridgepoint proposes to create “complexity teams” for different profiles of patients who would be enrolled in a program. A patient might then see a family physician or cardiologist from a given hospital, via physical or virtual visit. Says Walsh, “When you’re in our complexity clinic, and you’re being seen by a complexity specialist, if we need to talk to the cardiologist we can dial them up and video them in. We can use technology in smarter, different ways to make sure the teams are aggregated. … And every team has someone who’s calling the play.”
Patients can be assessed remotely by these specialists—armed with a patient’s complete history—who can also make the decision to either send the patient along to hospital or stay at home.
“So we’re going to save visits to emergency departments and we’re going to keep people from having negative drug interactions or having tests they don’t need because we don’t know them. And we’re going to manage people more effectively at home. That’s the idea.”
Walsh says this team-based approach, combined with the use of integrated health records, increased out-patient support and direct admission to day hospital beds for those who don’t need an acute care facility, raises efficiency. And that saves money over the current system. “We’re … reducing the number of things that can and do go wrong by proactively managing you. We’re serving you outside of emergency departments and acute care, which is the most expensive part of our system, and we’re not duplicating everything and doing everything new every time you walk in the door.”
Doug Macnamara, head of the Canadian Diabetes Association, also spoke at the ECC event. He personalized the issue, noting his own long battle with diabetes and how dependent on the health care system are those afflicted with the disease. For diabetes alone, which is classified as a chronic illness, Canada is spending $2.5 billion/year (2010 figures) to treat patients and another $9.2 billion to treat complications arising from diabetes. By 2020 he said the total will reach $20 billion.
The cost to business is considerable. Also according to Macnamara, diabetes is responsible for 11%, or half a billion dollars annually, of the cost of business health care plans. Even worse is the productivity loss, which he pegs at $9.6 billion per year.
These figures are as large as they are partly because 60% of sufferers don’t comply with their medication or treatment regimen—for any number of reasons including cost, stress, work patterns or lack of education about how to self-manage the disease. Macnamara appeared with Bridgepoint’s Walsh because he believes the kind of program her hospital is proposing can change this, and as a result reduce costs and suffering. Failure to address the issue “will threaten the sustainability” of the health care system, he said.
Bridgepoint’s MCM is seemingly derivative of one plank in an existing plan from the Ontario government for health-care overhaul called the Action Plan for Health Care, which was introduced in 2012. Among various initiatives such as the key funding reform, the Action Plan deploys what’s called Health Links, which is essentially a model for connecting by geographic area doctors, community support organizations and hospitals both to each other and to patients. Bridgepoint’s MCM is similar but focuses exclusively on chronic care patients with complex conditions in addition to the above-mentioned services like increased out-patient support.
Busby says this idea of formal integration has been around for decades, but the considerable bureaucratic and planning inertia inherent in making such systemic change has until now put implementation on the back burner. “There’s always obstacles in getting different medical professionals to work together,” he says. “These aren’t easy things to do. The establishment of electronic health records has been very slow. Deciding how the primary care doctor is going to develop his relationship with other providers within this Links model, who’s going to be in charge, those questions are difficult ones to work through on a practical level.”
It’s amazing how looming fiscal crisis can focus the mind.
According to a 2009 survey (using 2005-06 data) by the Canadian Institute for Health Information, the estimated cost of an emergency room visit ranged between sub-$100 in the Maritimes to a high of $148 in Ontario. About 60% of patients enter a hospital through the emergency room. The Ontario Ministry of Health’s more recent figures, based on its own methodology for the fiscal year 2012-13, indicate an average cost per visit in the province of $246.93.
One and the same?
Despite some differences, Health Links and Bridgepoint’s MCM share enough similarities that observers may be inclined to wonder if there isn’t unnecessary duplication going on here. That Bridgepoint is requesting additional money—for a total of $3 million to $3-1/2 million per year—for its plan only heightens that inclination. The existing Health Links program, which now has 25 participants (including Bridgepoint), provides one-time funding of up to $1 million for each approved proposal.
Bob Gardner, director of policy at the Wellesley Institute, says duplication is always a danger and that “unfortunately, health reform has a long and not so glorious history of that.” And while he has other mild criticisms of Ontario’s reform efforts (most notably, he thinks the Action Plan should focus on people before they become part of that costly 1%—so they never get there in the first place), like others he too thinks the government and providers like Bridgepoint are on the right track. Investing money to test different approaches to health care delivery is a necessary part of the process, he says, adding that one of the roles of the Local Health integration Networks (LHINs) is to help prevent duplication. “And then when you identify what seems to be working well and why, you have to identify ways of spreading that around and basically [provide] incentives for other people to adopt those promising practices.” (Gardner served until 2013 on the board of the independent government agency Health Quality Ontario.)
Of course, Bridgepoint points in defence of its proposal to its more specific nature, its high-needs target demographic and the additional services it seeks to offer. But that also means its initiative remains under further study at the Ministry of Health. The Ministry has confirmed receipt of the proposal and says it remains under review.
Says Walsh, “We don’t have the cheque signed yet, but I’m very optimistic this is the year we’re going to be doing it.”
The program is to be a proof-of-concept project run in the eastern half of a central Toronto LHIN, an area that services about 2,000 people.
More broadly, the change in approach to health care delivery may already be paying dividends. In January Deb Matthews, head of the Ontario Ministry of Health, spoke before the Canadian Club of Toronto to provide an update on how the Action Plan had been performing. She said the goal was to slow the annual rate of increase in health care spending to 2% from 6%-7% and that “we’re on track to get there.”
At the time of this writing, the ministry says the 2% target has already been hit. Gardner says that while he can’t confirm those numbers, “the ministry is being much more disciplined at controlling the envelope of costs that’s going to [health-care] providers.”
If Bridgepoint’s MCM works as advertised those gains could in the future potentially be amplified.
Too good to be true
But delivering the kind of personalized care Bridgepoint—and to perhaps a lesser degree, the province’s Action Plan—calls for can actually be more expensive, at least up front, says Dr. Elaine Chin. The founder of the Executive Health Centre, she says she’s 100% in support of Bridgepoint and the province, but has a few words of caution: “Taking care of a patient in a multidisciplinary way takes time. You have to go from a doctor’s visit that’s basically 15 minutes to now a group and a team that needs to sit down, come up with a plan, write it out together, put it up in a place where people can share it. It’s the up-front cost of getting that organized and if there are house visits involved it’s difficult to be able to see, say, 10 people in a day.”
She says leveraging technology to help patients help themselves will be critical.
“If we can get as much information, not by the bedside, but by the ‘homeside,’ then we might be able to reduce the actual visits to [doctors and hospitals].”
Walsh says that whatever the costs may be, they must be paid because if they’re not addressed now, we’ll like the later consequences even less. She points out that $3 million is a relatively small amount of money for potentially much larger savings. “If that’s the attitude that we take—that we don’t ever want to shift resources or fund innovation, especially in health care—then we’re going to end up with a health care system that’s going to cost us 80% of our budget and that’s just not affordable.
“So we don’t have a choice. We have to fund innovations, we have to seed new ways of doing things and we have to get them in place so we can get the money out of the system that is being spent unnecessarily today without getting good results for patients and is causing more complexity than necessary.”