Differing opinions
Canadian physicians and the general public don’t quite see eye-to-eye on whether doctors should be evaluated — and the results made public — or on whether patient satisfaction should be a measure of hospital performance.
These disparities are but two of the areas where physician and public opinion differed significantly with respect to the Canadian Medical Association’s proposed initiative to “transform” the national health care system, according to surveys conducted by IPSOS-Reid.
But the comparative surveys of 2268 Canadian physicians and 1201 members of the general public do indicate that both groups see the transformation initiative in a positive light because it offers “something for everyone.”
The two groups also generally agree that independent reviews of hospital performance should be conducted (70% of physicians and 73% of the public); that hospital funding should be based on the number of patients served (56% and 63%); and that health care would be improved if there was more competition between facilities (38% and 35%). An equal percentage of each group (54%) agreed that the Canadian system is underperforming compared to its European counterparts.
Wider differences emerged, however, when it was proposed that all doctors, hospitals and pharmacies should be independently assessed and the information made public. Some 71% of Canadians thought that was a good idea, but only 52% of doctors approved of the proposal.
As for patient satisfaction being a measure of hospital performance, 77% of Canadians, but only 51% of doctors, thought that was a capital notion. Some 94% of doctors, as compared to 79% of the public, said Canada’s shortage of long-term care facilities puts pressure on hospitals.
The physician survey also indicates that outside of a belief that far more must be invested in bolstering the capacity of the health care system (85%), there appears to be relative polarization within the medical community as to the merits of many of the specifics contained within the transformation blueprint.
Only 51% of doctors thought “moving toward patient-focused care” was a step in the right direction, while 48% approved of “accountability and evaluation,” 51% endorsed “partial activity based funding for hospitals,” and 51% supported “protecting health care funding — arms length insurance.” A scant 34% endorsed the notion of more “competition and incentives for quality care.”
While there was general support for the transformation measures, the results also indicated that they “will be met with resistance by Canadians because of fear of privatization, (and) by physicians because of fear of evaluation.”
The survey also indicated that transformation will take time “because of the complex nature of health care and the need for a significant shift in how Canadians and governments view health care.” — Wayne Kondro, CMAJ
Liability fees rising
Medical liability insurance fees for all doctors in Canada, except those in Ontario, will increase in 2010, delegates to the Canadian Medical Protection Association’s (CMPA) annual meeting were told on Aug. 19 in Saskatoon, Saskatchewan.
Fees for doctors in Ontario will drop 8% to $3835 from $4178, while charges for doctors in Quebec will rise 9% to $3899 from $3578.
Doctors in all other parts of Canada will absorb the largest hike, as their fees will soar 23% to $2405 from $1956.
Despite the fee increases, levies in all provinces still fall below those paid by Canadian physicians midway through the past decade, Executive Director Dr. John Gray repeatedly stressed as CMPA released its annual report.
Delegates were also informed that the economic recession carved a sizable chunk out of CMPA’s investment portfolio, reducing its general reserves to $201 million at the end of 2008, as compared with healthier bottom lines of $930 million in 2006 and $859 million in 2007.
In 2008, the value of CMPA’s investments dropped to $2.457 billion from $2.631 billion in 2007, while outstanding claims liabilities rose to $2.152 billion from $1.986 billion, reported Stephen Campbell, director of finance and investments.
The CMPA’s annual report indicates that of 884 legal actions commenced in 2008, 88 went to trial but only 13 of those saw an outcome favouring a plaintiff. Some 341 actions were settled, while 574 were dismissed, discontinued or abandoned. CMPA membership rose to 75 833 from 73 271. — Wayne Kondro, CMAJ
Alberta proposes activity-based funding
Alberta may move to an activity-based funding system for hospitals as early as Apr. 1, 2010, the head of the province’s health system says.
Currently, hospitals in Canada receive yearly lump sums to cover expenses, a model known as block funding or global funding. Under an activity-based system, hospitals would be paid for each service provided to patients.
Stephen Duckett, president and chief executive officer of Alberta Health Services — who helped introduce activity-based funding in Victoria, Australia, in 1993 and claims it provides many benefits to hospitals — indicated in late August that the province is assessing whether to introduce the model next spring.
Earlier this year, Duckett wrote that “introduction of a system such as this would mean that arguments about over-funding, unfair treatment, favorites etc. would be wiped away and would also reduce the likelihood of service reductions as a budget strategy.” He added in a report presented to the Institute of Health Economics Innovation Forum II in Edmonton, Alberta, that “holding hospital Vice-Presidents to account through activity based funding would enable Alberta Health Services to measure their progress in improving the efficiency of the services for which they are responsible” (http://www.albertahealthservices.ca/files/org-2009-05-25-health-economics-speech.pdf).
In May, Alberta Health Services changed its organizational structure and created a new unit responsible for activity-based funding. The unit will work with other groups (finance, health information, reporting) to design an activity-based funding and auditing system.
“In a time of tight budgets, it is critical that we pursue all potential opportunities for efficiency and reduce variation in efficiency across the province,” Duckett writes in the report. “It is therefore important that this consideration of the potential for activity based funding is completed relatively quickly so that we will be able to address efficiency variations by introduction of an activity based funding model by the 2010/2011 financial year.”
Supporters of having funding “follow the patient” say it provides an incentive for hospitals to be more productive and more efficient. Critics of activity-based funding say it will lead to hospitals that focus on increasing patient volume instead of bettering care, and that it will cause hospitals to favour simple cases over complex, time-consuming cases (CMAJ 2008;178[11]1407-8). — Roger Collier, CMAJ
Ten ways to save lives
Ten simple health care reforms could prevent more than 85 000 deaths and save the United States more than US$35 billion a year in treatment costs, according to a report by the consumer advocacy group Public Citizen.
The US Department of Health and Human Services could implement most of the reforms by making some modifications in the federal Medicare program, states the Back to Basics report.
The report recommends:
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Implementing safeguards and quality-control measures to reduce medication errors. (Solutions include computerized order entry of prescriptions, bar code error-prevention systems and reduced use of certain medication abbreviations.)
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Increasing nurse staffing.
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Permitting standing orders to increase flu and pneumococcal vaccinations in the elderly.
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Using beta-blockers after heart attacks.
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Increasing advanced care planning.
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Using a checklist to:
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Reduce avoidable deaths and injuries resulting from surgical procedures (NEJM 2009;360 [5]:491–99).
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Prevent catheter infections. (NEJM 2006;355[26]:2725–32).
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Applying best practices to:
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Prevent ventilator-associated pneumonia, which accounts for an estimated 36 000 deaths a year in the United States.
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Prevent pressure ulcers.
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Prevent patient falls in health care facilities.
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— Ann Silversides, CMAJ