week 2 - ontario's health system

Ontario’s Health Care System

HLTH 405 / Canadian Health PolicyWinter 2012

School of Kinesiology and Health Studies

Course Instructor: Alex Mayer, MPA

Recap

Last Week• Provincial vs. Federal responsibilities• Health Accords• The Canada Health Act: 5 criteria• “Narrow but Deep” Medicare coverage• “Similar but Distinct” provincial health insurance

plans

In the News…• “Trims to health-care funding will help feds, but

hurt provinces: Budget watchdog” - The Toronto Star (Jan 12)

• “Hands off, please” – The Ottawa Citizen (Jan 13)

• “Ottawa’s new health-care approach an opportunity for provinces”

- The Globe and Mail (Jan 13)

iClicker Registration• If you have not done so already, please make

sure to register your iClicker on the iClicker website by 11PM tonight. Use your Queensu E-mail address in full as your ‘Student ID’

Use the number on the back of your iClicker as your ‘Remote ID’

• This will allow me to give you credit for your answers on Moodle.

Test Question…What is your favorite summer activity?

A) Beach Volleyball

B) Road Cycling

C) Soccer

D) Ultimate Frisbee

Themes for today’s lecture:

• How Government works

• Health Policy Development Process

• A look at Ontario’s health care governance

• Ontario’s health care providers & programs

• Health priorities for Ontario


• Ontario Government (like the rest of Canada) operates under a Westminster system

Ontario Government

• Employs a ‘first-past-the-post’ (FPTP) electoral system to choose members to represent its ridings in the Legislature

• Gives the successful party a disproportional amount of seats, relative to its total share of votes. • “Let’s the government govern”

Ontario Government

Ontario Government• Presently, Ontario is governed by a Liberal

minority under Premier Dalton McGuinty

• Last month, McGuinty laid out his government agenda (Speech from the Throne) and passed his first Confidence vote with support from the Ontario NDP

• In March, another Confidence vote will take place when Finance Minister Dwight Duncan presents the McGuinty Government’s 2012 Budget

Question• What new health priority figured

prominently in McGuinty’s 2011 electoral platform and Throne Speech?A) Improved home care services for seniors

B) Shorter emergency room wait times

C) Hiring more foreign doctors

D) Creating a universal Pharmacare program

To summarize so far,

• Ontario government follows Westminster Modelo Concentrates executive power in the Cabinet

• Politicians elected using First-Past-The-Post o Concentrates power in the hands of the dominant party

So who has the authority to set health policy in Ontario?

o The Premier charts government agenda, usually in consultation with the Finance Minister (i.e. New policy initiatives and program spending for the Budget)

o Executive authority for day-to-day matters is delegated to the Minister of Health & Long-Term Care

Ministry of Health and Long-Term Care

Minister

Deputy Minister

ADMs

Directors

What is a health policy analyst?

- Expert researcher- Uses qualitative and quantitative evidence, economic analysis,

political analysis to produce evidence-based health policies

- Prepares briefs for Minister “For information”

“For decision”

- Has two sacred responsibilities: “Speak truth to power”

“Faithfully implement government policy” (whether you

personally agree with it or not)

Ministry of Health and Long-Term Care

Case StudyWait times at emergency rooms are high, causing

hospital overcrowding, low patient satisfaction, and

leading people with injuries to leave without

receiving care.

Your job is to find ways the government can help to

lower wait times. (Reminder: You don’t control have

any direct control over hospital operations.)

How do you, as a policy analyst, approach the

problem?

Steps in Policy Development

1. Consult stakeholders and

define the problem.e.g. Are E.R. wait times a management problem? A

resource ($$$) problem? A professional shortage

problem? A perverse incentive problem? A population

health problem? Consider many perspectives

(economists, doctors, nurses, hospital admins,

CCACs, LTCs).

2. Read the scientific literature

and understand the context.What is the scale of the problem? What are the

potential causal and mediating variables? What

is the historical context in which the problem is

occurring?


3. Identify and elucidate the best

policy options.What solutions have other jurisdictions developed?

Have they been successful? What solutions are

most likely to be successful in Ontario? Would

laws need to be changed or modified? Would funds

be required? What existing Ministry/agency/actor

would we task with policy implementation?


4. Analysis (Quantitative &

Qualitative)If we implement Approach A, B or C, what is

their relative impact on E.R. wait times? At what

rate would morbidities/mortalities be prevented?

What is the impact on patient satisfaction?


5. Economic analysis (Optional)Cost-benefit: policy’s cost vs. expected benefits to

society, in economic terms (typically presented as a

ratio)

Cost-effectiveness: Cost per unit of marginal

benefit.

e.g. How much $$$/hour of wait time reduction?

How much $$$/complication avoided? How much $$

$/Life-Year (LY) gained?


6. Political analysis &

Considerations Who wins? Who loses? Will powerful interests be

upset and take to the airwaves? What is an

appropriate communications strategy to ensure

support for the government’s policy? What other

risks should government be aware of?


…And then stick all that in your briefing

note.

2 pages max.

MOHLTC’s Evolving Role• MOHLTC used to be more ‘hands-on’ in deciding

where health service funding goes (i.e. “central”

decision-making)

• In 2006, shift towards regionalization: Ontario’s

LHINs are formed to take over responsibility for:o Public & Private Hospitals

o Community Care Access Centres (CCACs)

o Mental health and addictions services

o Community Health Centres (CHCs)

o Long-Term Care Homes (LTCs)

MOHLTC’s Evolving Role• Ministry of Health increasingly focused on

policy, oversight and contract management

• MOHLTC also retains responsibility for:o Health professionals and Family Health Teams (FHTs)

o Ambulance services

o Labs

o Provincial programs (including ODB)

o Independent Health Facilities (i.e. specialty clinics

providing insured services)

o Public Health Units

Local Health Integration Networks

(LHINs)• 14 LHINs created in Ontario through the Local

Health Systems Integration Act (2006)

• Non-profit organizations that aim to make health care in the community… o More accessible, patient-centric and cost-effective

through local service integration and consolidationo More responsive to local needs and priorities

• Transfers to LHINs account for 2/3 of MOHLTC’s budget

Local Health Integration Networks

(LHINs)Responsibilities:• Must enter into accountability agreements with

MOHLTC to receive provincial $$$

• Must develop a Service Plan to show how services will be integrated and how community health goals will be met

Powers:• Can create region-specific bylaws

• Cannot shut down hospitals or other service providers

• Can integrate/relocate services to reduce duplication and improve coverage, when it is in the public interest

Question

In Ontario, health insurance through OHIP accounts for ~70 cents of every dollar spent on health care (“public financing”). Is health care in Ontario publicly-delivered?

For the most part, NO

Ontario, like the rest of Canada, has a mixed public-private system:

oMostly public financing, mostly private delivery

Important to understand the distinction between public vs. private financing

and public vs. private health care delivery

Physicians• Prime example of public financing, private

delivery • MDs ≠ government employees; they are

private contractors and business owners (if they own a clinic)

• Family physicians are primary care providers that play a ‘gatekeeping’ role in the health care system

• Historically derive large portion of their income from Fee-for-Service (FFS) payments• FFS incentivizes high level of productivity (More

patients seen, more $$$ earned)• But does FFS provide appropriate incentives to

provide high quality preventative care?• Concern that FFS leads to poor quality and waste:

Shortened patient visits Do chronic illness patients really need to book

an appointment with MD to refill a prescription?

Physicians

• In the new Family Health Teams, physicians are paid using a “blended” capitation model• 60% salary from capitation: funding envelope

based on patient roster size• Physicians earn a reduced fee (15% of regular fee

schedule) for each service provided• Substantial bonuses ($) for delivering preventative

services & meeting patient screening targets

Physicians

Hospitals

• 227 hospitals in Ontario

• Most are private, not-for-profit (NFP)

• Funded by MOHLTC by way of global funding budgets provided annually

• based on historical expenditure trends

• adjusted to reflect changes in expected service costs

Hospitals• Global funding budgets account for ~85% of hospital

revenue.

o Other 15%: Fundraising, fees for semi-private and private rooms, Worker’s Compensation payments

• While most hospitals are operate independently

(“privately”) as corporations, most are subject to the

Public Hospitals Act and report their Plans annually

to the MOHLTC. Some call them “semi-private”.

Community Care Providers

Community Care Access Centres (CCACs)• Arrange for long-term care home placements, home

care services and in-school health support services• Can include MD, nursing, occupational therapy,

speech therapy, dietician, homemaking and other services

Community Health Centres (CHCs)Provides child and family health services such as:• Domestic violence interventions, addictions

counseling, parenting education, anti-racism programs, and body image/healthy sexuality counseling services



Family Health Teams (FHTs)Provides patients with high quality, patient-centered care:• Multiple primary health care professionals including

family MDs, nurses, dieticians, pharmacists, etc., all working collaboratively under one roof.

Important ProgramsOntario Drug Benefit (ODB)

• Provides “free” pharmaceutical drugs to seniors (age 65+) and ODSP/OW recipients

• Also available to patients living in a LTC home or enrolled in the home care program

• Ontario’s catastrophic drug insurance (Trillium Drug Benefit) limits copayment for pharmaceutical products to 3-4% of annual income

Ontario Disability Support Program (ODSP)

• Provides employment and income supports to individuals who have a disability

• Benefits include drug and dental coverage, as well as reimbursement for work-related expenses

• Criticized on basis that it requires individuals to run down their assets before they can apply for support

Important Programs

Important Programs

Ontario Disability Support Program (ODSP)

• Earnings made by ODSP recipients above a certain threshold are clawed back by the province at a rate of 50%

• Given low advancement potential of ODSP recipients and loss of income/health benefits from holding down a full-time job, ODSP provides incentives for individuals not to find meaningful work (known as “poverty wall”)

Health Priorities in Ontario

• Aging at Home Strategy• eHealth• Pharmaceutical drug costs• Wait Times

RecapOntario’s Health Care System• How Government works

• Health Policy Development Process

• A look at Ontario’s health care governance

• Ontario’s health care providers & programs

• Health priorities for Ontario

Fill-In-The-Blank…• The Excellent Care for All Act is a critical piece

of McGuinty’s health policy agenda. What does it involve?o Be the first to post the answer to the HLTH 405

Facebook Wall!

week 2 - ontario's health system

Education