Ontario’s Health System is Undergoing Structural Change Again

Ontario is embarking on yet another transformation of its provincial government health care system with its creation of Ontario Health Teams which will replace the LHINs.  The LHINS (Local Health Integration Networks) were created in 2006 to create regionally integrated health delivery systems to essentially streamline services.  The move to a regional approach in Ontario at the time was a bit late given that most other provinces that had gone the regional/decentralization approach had done that in the 1990s and in the early 21^st century began to move away from the approach.  This continual restructuring of health care service delivery in Canada has if anything been quite disruptive and we are now about to undergo another round of it in Ontario.

The LHINs were to have jurisdiction over hospitals, community care access centres, various community health services as well as mental health and addiction.  However, they were not given jurisdiction over physicians, public health, diagnostics or the provincial drug spending plans.  This made the LHINs only a partial health integration network and in the end that was probably their undoing as the seamless one stop shopping system of care never really fully emerged. 

 As for the OHTs which are going to replace the LHINS, according to the provincial news release, this is “an administrative step only and not a merger of the LHIN boundaries. Further, there will be no impact to patients' access to home and community care or long-term care placement as Ontarians continue to receive the care they need from the care providers they have built relationships with at the 14 LHINs. These changes are a means of streamlining the regional oversight as an interim measure as the government continues to work toward moving home and community care supports out of bureaucracy to integrate them with Ontario Health Teams.” The Ontario Health Teams will be responsible for all of a patient’s care including primary and emergency care, home and community care, palliative care, cancer care, residential long-term care and mental health and addiction services. 

An OHT is a team of health care providers working together to deliver at least three types of health services – the initial call expressed a preference for a minimum of primary care, hospitals, home care and community care.  The aim is to create a truly integrated health care system for Ontarians with seamless transitions.  How many of these teams will ultimately emerge will depend on the population size covered.  If there are about 250,000 people per health team – a not unreasonable number given the Northwest LHIN covers that amount – then there would be about 60 teams ultimately.  Eventually, if all of this pans out,  I suspect there will be anywhere from 50 to 70 of these teams covering the entire population of Ontario and they will report to a new centralized oversight agency – Ontario Health.  Given population aging and the impact of new technologies and drugs on health care costs, part of the goal will also be to contain rising costs by eliminating duplication streamlining transactions costs and thereby slowing the rate of provincial government expenditure growth.

How is all this going to go?  Will it be effective in improving services? Good questions.  We have been reforming health care for two decades in Canada to deal with access, coverage and sustainability of the system and all the same issues still seem to be there – physician shortages, long waits for services, hallway medicine – and total spending has still grown though spending growth has moderated over the last few years. Will this time be different? We will have to wait and see.  In the meantime, this is as good a time as any to look at the Ontario health system and its spending in more detail.  Over the next few weeks, I will devote a number of blog posts to health spending in Ontario to provide some context for spending in the system as well as review where we have been over the last few decades.  Visit this page for updates.

 

Drummond and Health

A large number of recommendations in the Drummond Report have to do with health care.  There is a lot there - much of which we have heard before in terms of things like focusing more on home care, patient centered care and evidence based care.  Indeed, the first recommendation on health care made by the Drummond Report is the most likely to be adopted by the provincial government given its affinity for planning:

Recommendation 5-1: “Develop and publish a comprehensive plan to address health care challenges   over the next 20 years.  The plan should set objectives and drive solutions that are built around the following principles..."

Those principles include being patient centered, a fully integrated system-wide approach, more emphasis on chronic care and home care, disease prevention, etc...A plan to address health care over the next twenty years is definitely something that would appeal to the current provincial government and they would be able to apply the expertise acquired in doing the Northern Growth Plan - which also has a long-term horizon of decades and has yet to yield anything tangible.  Indeed, the propensity to embrace a planning rather than an action culture is one of the things that is wrong with Ontario today and in my opinion a key factor in its poor economic performance.  While planning frameworks are necessary, they appear to have become ends in themselves rather than a means to an end.  But I digress.  Back to health.

While much has been made of Drummond's recommendation to bring in a payment freeze for physicians and the remarks that they are among the highest paid in the country, one recommendation appears to have flown under the radar.  Here it is:

 

Recommendation 5-59: "Compensate physicians using a blended model of salary/capitation and fee-for service; the right balance is probably in the area of 70 per cent salary/capitation and 30 per cent fee-for-service."

The Drummond Report appears to advocate a big move away from fee-for-service.  It will be interesting to see what the reaction to this will be. 

Reorganizing Health in Ontario

As part of the Ontario government’s austerity drive, health minister Deb Matthews recently announced plans to save money by reorganizing health care.  To start with, the province’s family health teams will be placed under the control of Ontario’s Local Health Integration Networks (LHINS) so as to help plan and provide physician resources and care more effectively.  In addition, they want to move more routine procedures out of hospitals and into specialized not-for-profit clinics but with little detail as to what might happen.  All in all, there will be efforts to provide more community care and integration of that care with the main health system in an effort to rein in spending.  The health minister in her remarks to the Toronto Board of Trade earlier this week also remarked that the changes “will not happen overnight”.

Will this work?  Well, it has been tried before.  We only have to go back to the 1990s with hospital restructuring and the implementation of home and community care initiatives that nearly 20 years later are still not very well developed.  Why?  It turns out effective home care was really not that cheap after all.  As for handing over physician resource planning to the LHINs, well that suggests another complicated exercise in planning fraught with transaction and administrative costs especially given that the LHINs when they were created were never given any responsibility over core health spending resource allocations – physicians and hospitals.  For LHINs to be effective resource allocators, health budgets would need to be completely decentralized from the health ministry so that LHINs could tailor their health services to local and regional needs.  However, LHINs have evolved more into “planning” mechanisms rather than service providers.  Moreover, at this point Ontario would be a late comer to the regionalization game as other provinces – for example Alberta – have already tried it and it turns out they have retreated back to a more centralized model.  It turns out centralized budget decision-making is more useful when you are trying to cut costs across an entire health system.

It is difficult not to come to the conclusion given the vagueness of statements and pronouncements to date that the Ontario government is treading water on health care reform.  Health is contentious and the government has a minority.  True integration of the health care system in an effort to eliminate duplication of mandates and services, reorganization of physician services, billing practices and hospital human resources, the delisting of less cost-effective services and the transfer of additional procedures to not-for-profit clinics will be controversial.  Witness what happened after the health minister’s musings that reducing the number of C-section births would ease health-spending costs.  The media storm was immediate.  After several days, there was a statement that the government would not be delisting C-sections ands that the government would be encouraging new birthing centers as a better way. Taken at its word, this means keeping the current practices and introducing new ones – which means even more health spending down the road.  In health care reform, tomorrow is yesterday.