Chronic Disease and Aging: Health Policy Implications

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1 Chronic Disease and Aging: Health Policy Implications Penny Ballem MD FRCP Clinical Professor of Medicine University of British Columbia Former Deputy Minister of Health, BC

2 Aging and Chronic Disease Context of Policy Development Key policy issues : Disposition Drugs Death Conclusion

3 The Canadian Construct for Funding Health CHA Services Non-CHA Services Doctors care in hospital & out of hospital Services provided in hospitals Inpt/outpt Lab services Inpt/outpt Imaging Private clinic services contracted by Hospitals/Health Authorities Community based services: OTs, PTs, chiropractors, etc Non hospital/physician addictions/mental health programs Pharmacare Ambulance Home care Residential care Dental Care Non-medically necessary services (cosmetic surgery, IVF) No user fees/co-payments Medicare premiums allowed Co-payments, user fees allowed Social Determinants of Health

4 Government Priorities Other needs Emerging issues commitments

5 Federal Provincial Territorial Activity: Evolving Strategies for Chronic Disease in Canada: Investments in Prevention programs: Obesity Physical activity Tobacco reduction initiatives School health initiatives (Consortium for School Health) Mental Health Commission Public access to information/ opportunities for self-care through and on-line resources (eg: BC Nurseline, Sask Health-Link, etc) Funding of national and regional Healthy Living Alliances Primary Care strengthening with initiatives focused on enhanced chronic disease management and interdisciplinary care Some physician pay-for-performance for enhanced chronic disease management Provincial targeted funding of targeted chronic disease initiatives (eg. Ontario Diabetes initiative) Quality/Safety Organizations (national agency; provincial councils) Investments in electronic health record, chronic disease registries Research and surveillance: targeted funding initiatives

6 Disposition Quality Care in the Right Place at the Right Time by the Right Provider

7 Policy Challenge: Optimizing and Enhancing the Capacity of Regionalized Health Service Delivery and Related Sectors Education Private Sector Clinics Home & Community Care Community Labs Community Radiology Community MH&A Programs Inpatient Outpatient Labs X-ray Drugs Rehab & CCC Facilities Emergency Services Mental Health Facilities Long-Term Care Homes Social Services & Housing Police Justice Corrections Primary care and Specialists Services Public Health Including Promotion and Prevention Special Provincial Programs Ambulance / EMS Public Drug Plan Local Govt

8 Policy Challenge: Enabling Primary Care Providers to Align with Needs of Community and Patients Increase Comprehensiveness Degree of Comprehensiveness All FP/GPs Participating of Practice in Other Models versus Days Worked Number of Categories of Care Family Practitioners Activities and Work Days FP/GPs if full-time work equivalent to 200 days Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile Days Physicians Billed >$500 Increase Activity Note: FP/GP Quintiles have been calculated by the number of days where over $500 were billed. Shadow Billing Included SRP Master File, which has been used for Primary Care calculations has not been validated Source: This data has been derived from FFS Database and SRP Master file provided by MOHLTC

9 Policy Challenge: Optimizing Quality and Best Practice in Primary Care 100% Percent of people with diabetes receiving care according to guidelines 80% Percent 60% 40% 20% 0% 1999/ / / / / /05 Year

10 Policy Challenge: Optimizing Use of E-Health

11 The Need to Involve the Patient, Family and Peers

12 High Resource Hospital Patients: 2/3 are Seniors Majority go home after hospitalization; Account for up to 80% of ALC days; 30%-40% have a mental health co-morbidity Health Region: Hospital Inpatient Data 06/07 100% 80% 60% 40% 697,073 1,827 1, ,713 5% 4,996 42,298 11% 97, ,992 36% Complex Inpatients Other Inpatients 20% 0% Population Inpatients Discharges Bed Days Source: DAD database 1Defined as discharges not coded as emergency, direct or clinic; excludes stillborns, newborns and day surgery

13 Policy Challenge: Transforming Models of Care Medicine Hospitalists CDM Shared Care Geriatrics Elder care Primary Care CDM Shared care Home Care Home Support functional relationships and physical space; skilled care providers Start with Focus on Most Resource Intensive Patients End of Life Complex Care Rehab

14 Policy Challenge: Planning for Continuum of Services for Frail Seniors RESIDENTIAL CARE COMPLEXITY (BC) Most complex care level / / / / / / / / / / / /2002 Less complex care levels

15 Creating the Continuum of Seniors Housing in Canada Private Home Supported Housing Assisted Living Residential Care Ground level Apartment Congregate care developments group homes family care homes respite care hospice Home care (including Mental Health) adult day centres Increasing acuity, intensity and cost of services

16 Drugs One of the Key Enablers of Transformation of Care and Improved Outcomes

17 Policy Challenge: Maintaining Access to Key Classes of Drugs Population Beneficiaries # of Paid Rx per Beneficiary Expenditure per Beneficiary Paid Prescriptions PharmaCare Expenditure 0% 50% 100% 150% Source: Public Accounts Plan Expenditures (1995/96 to 2004/05) and Utilization Data from Ministry of Health, HNData (1995 to 2004)

18 Key Policy Issues Affordability for public Ability to fund breakthrough drugs Ensuring access to important classes of drugs: Therapeutic substitution Generic substitution Special authorities Post listing surveillance Enabling best practice in prescribing

19 Policy Challenge: Optimizing the Potential 100% 80% 60% 40% Theoretical vs Actual Use: Post MI >65 yr 97/98-99/00: B BLOCKER, ACEI, STATIN drugs 1 drug 2 drugs 3 drugs 20% 0% Theoretical Actual Pilote L et al, Canadian Cardiovascular Outcomes Research Team, Can J Cardiol Jan 2004; 20(1):

20 Death

21 Policy Challenge: Need for End of Life Strategy Rates of Acute Care In-Hospital Death for Patients that Died of Cancer in Ontario, Source: Cancer Care Ontario Cancer Registry; Canadian Institute for Health Information Discharge Abstract Database

22 Slow Progress on Key Policy Issues For Seniors at End of Life Legislation: Trustee/guardianship Substitute decision-makers Advance directives, living wills Legislative/regulatory clarity re community hospice care Coherent end-of-life programs: Drug plans and assistive equipment 24/7 Access to skilled providers across all disciplines in community Logical funding formula

23 Conclusion

24 Educational Institutions National Colleges RCPSC, CCFP, etc Accreditation Agencies Quality Councils Optimizing Outcomes in Chronic Disease: Legislated Accountability Structures Ministers & Ministries of Health Health authorities/regions/lhins Acute Care Hospitals MAC s Other Ministries Provincial Health Officers Provider/Patient interface in other health facilities (eg:residential care/addictions programs) Provincial Self Regulating Colleges Provider/Patient interface in Hospitals Provider/Patient interface in Community

25 Key Considerations The impact of chronic disease in our seniors population is driving transformation in our health system Policy tends to lag behind models of service and practice; service delivery and practice are not changing fast enough Governments have few levers which are effective in creating transformative change; the health and social sector has responsibility for change management The academic community is key to enabling and providing the platform for change Translation of research has to reflect the reality of health service delivery in Canada Strong support for difficult public interest policy decisions is helpful Democracy creates imperfect policy decisions helping inform the public of rationale for change and a new approach can significantly raise chance of success