1. Service Integration The Canadian Way Presentation to the King’s Fund Study Tour September 17 th, 2007 Cathy Fooks President and CEO The Change Foundation

2. Presentation Overview Structure of Canadian health system Regionalization in Canada Ontario version of integration Implications for patient outcomes Predictions for the future

3. Structure of Canadian Health System Health care delivered by provinces and territories with some federal funding Amount of federal funding negotiated and subject of much argument The Canada Health Act gives funding authority and covers physician care and services delivered in hospital. Different ways that private care is dealt with across jurisdictions. Everything else is up to p/ts thus significant variation across the country

4. Structure of Canadian Health Care System Physicians are largely in private practice, on a fee for service basis – gradually changing to more group practice based on capitation and program funding Drugs are privately covered, often through employment benefits with some public funding for elderly or low income individuals Very little quality oversight, public reporting of outcomes Very little experience with purchasing service, contracting or commissioning

5. Expenditure per capita by source of funding, 2004

6. System Design “Canada has a series of disconnected parts, a hodge-podge patchwork, health care industry comprised of hospitals, doctors offices, group practices, community agencies, private sector organizations, public health departments and so on.” Toward a Model of Integrated Care, 2000 Leatt et al.

7. Reform Reviews in All Provinces Common themes – need for: –Primary care reform –Regionalization –Reigning in of drug expenditures –Increased spending in home care/community –A focus on non medical determinants of health

8. Move to Regionalize – mid 1990s Everywhere but Ontario Ontario had at the time District Health Councils – Ministerially appointed local individuals to provide advice to the Minister Health Services Restructuring Commission – legal authority to mandate merger/closure of hospitals – saw some amalgamation at governance level but most physical plants were kept and/or redeveloped

9. Timing Initial efforts at reform coincided with multi year reductions in the federal transfers (which have subsequently been increased up to previous levels) Choices for provinces to cut, cover the federal portion or reorganize Ontario chose to cover, the rest of the country reorganized

10. Lessons from the Initial Regionalization Experience 1a) Had to fiddle with the numbers – BC went from 9 to 5 Alberta went from 17 to 9 Saskatchewan went from 32 to 12 Nova Scotia went from four regional boards to 9 district authorities 1b) still need provincial authority to tertiary care (eg, cancer, transplants)

11. Current Numbers Against Population

12. Lessons from the Initial Experience 2) Experimented with Public Participation – quick decision to dump it Saskatchewan elected 2/3rds of its Boards but moved to wholly appointed Boards Quebec had elected Boards by representative assemblies but moved to wholly appointed Boards Alberta had directly elected Boards but moved to wholly appointed Some form of advisory council or committee created in some jurisdictions

13. Lessons from the Initial Experience 3) Lack of clarity around roles and responsibilities Survey done by the Centre for the Analysis of Regionalization and Health (2003) found that: –Majority of respondents found that division of responsibility was unclear –CEOs felt that residents had a tendency to bypass the Boards and present issues to the province –Boards felt they had less authority than they should –Ministry felt the RHAs were not restricted in their authority and that special interests had too much influence in decisions

14. Made in Ontario Ministry of Health and Long Term Care is steward LHINS- regional planning and eventual resource allocation (although Ministry has already set three year budgets) CCACs – purchase for home care and LTC Providers – maintaining separate governance for now Physicians outside any accountability system other than professional self regulation and some performance targets with financial incentives for family health teams

15. LHINS and Regions: Key Differences (S. Lewis, 2007)

16. Critical Differences

17. Physician Report Use of Multi Disciplinary Teams and Non- Physician Clinicians, 2006

18. Primary Care MDs Use of Information Technology, 2006

19. Quality Measures, 2006