Health Committee on June 1st, 2006

[Dave Batters, Conservative, Palliser, SK]

Yes, unless Ms. Brown has something first.

[The Chair, Conservative, Rob Merrifield]

Do you want to go ahead? It doesn't matter. We're going to get you both in anyway, so it doesn't make any difference.

Ms. Brown, then.

[Bonnie Brown, Liberal, Oakville, ON]

I'm impressed with how much has happened around cleaning up the queue. Eliminating 15% of the wait list in one case and 33% of the referral list is pretty impressive, I would think, even from the point of view of the morale of the surgeon receiving the referral, to know that not all those people were waiting.

I was wondering who did all this phoning to find out if these people were still at the phone numbers and addresses, etc. Did you hire some people to reorganize the wait list by phoning and contacting people?

[Dr. Cyril Frank]

The institute did the entire evaluation of this whole process, and the institute is a separate philanthropic body that writes grants to get the money to do this work.

[Bonnie Brown, Liberal, Oakville, ON]

Did you hire nurses? Would they have nurses, or could it have been almost anybody? I mean, surely anybody could have found out that patient X doesn't live at that address or answer that phone anymore.

[Dr. Cyril Frank]

One of the keys was that we had to become an affiliate of all the custodians of the information in order to give the institute permission to contact people on behalf of the physicians. Not just anybody can call. These are designates of the physicians calling patients, and they work for the institute at the discretion of the physician.

[Bonnie Brown, Liberal, Oakville, ON]

Yes. But are you saying that the physicians suggested the person who would work for the institute, or did the institute hire its own staff?

[Dr. Cyril Frank]

Yes, the institute has its own staff of research associates, some of whom are nurses and physiotherapists who were doing this calling.

[Bonnie Brown, Liberal, Oakville, ON]

Some of whom are not.

[Dr. Cyril Frank]

Yes.

[Bonnie Brown, Liberal, Oakville, ON]

Yes. It would seem to me that it be would another way to save money if we could get people who weren't particularly medically qualified to simply track some of this stuff.

[Dr. Cyril Frank]

Absolutely. This was the recurring theme that we heard in all the presentations. I think Dr. Lewanczuk emphasized teams to better help and support resource physicians, in both primary care and speciality care, with lower-cost people doing a lot of the work.

[Bonnie Brown, Liberal, Oakville, ON]

Exactly. Something that should be tracked is exactly how highly priced the help was for each task and whether they were able to sufficiently accomplish it.

There's another thing that I was wondering about. With the incentive of $20 million, it was probably fairly easy to recruit these surgeons. They would know that they'd have all this support and this goal. Any kind of project often gets better results because people are motivated.

Has anybody tracked the impact on the salaries of those participating surgeons? In other words, were they able to perform more surgeries because some of the preliminary work had been done by somebody else and their salaries therefore went up? Did it go down because they were so involved with the patients or something?

[Dr. Cyril Frank]

I don't have accurate numbers, but anecdotally, yes, they made more money. They had an incentive to do this, because they certainly had the time available to do it.

We're also tracking to see what impact it's had on the rest of their practice to make sure that no one else is at a disadvantage in the process of focusing on hips and knees.

I have to say that they've all become advocates of this, not only because they had more volume, but because it's better. They're now selling it to their colleagues and in fact saying that they've got to do this central triage approach with the teams because it's better for the patients. They become the advocates for others, who admittedly see that they can make more money with the current compensation system, which still has a volume incentive. But the case rate actually gives us the ability to give them an incentive across the continuum for access, quality, and cost-effectiveness, as opposed to only volume.

[Bonnie Brown, Liberal, Oakville, ON]

I understand. I think Dr. Lewanczuk probably had the same experience. In fact, if he's only going to take 15 minutes to see a patient as opposed to the 45 minutes he used to take, he could see three patients in those 45 minutes.

Have you been tracking the impact on salaries?

[Dr. Richard Lewanczuk]

Absolutely. One of my other roles was chairing our alternate funding planning committee at the University of Alberta.

It's worked in a number of ways. If we had methods such as electronic medical records, as you point out, then we wouldn't put the specialists at a disadvantage. Organizing who we saw was one of the difficulties in the diabetes area. The specialists were now seeing more complicated patients who took longer to see, but the remuneration was exactly the same. Their incomes went down by about 25%, until we started to bring in other ways to boost that.

[Bonnie Brown, Liberal, Oakville, ON]

I understand.

[The Chair, Conservative, Rob Merrifield]

Mr. Batters, you have one last round. We'll then have five minutes for some final business of the committee.

[Dave Batters, Conservative, Palliser, SK]

Thank you very much, Mr. Chair.

Everyone has talked a lot about the importance of primary prevention, and I'm certainly a believer in it. You refer to it as “upstream patients”. I've never heard that expression; I like it.

Clearly it's very important to have good patient education. Also, in keeping with treatment guidelines, the role of pharmacology is extremely important in primary prevention. I'd ask Dr. Lewanczuk, Dr. Glasgow, and Ms. Estey to comment, please. I'd like your opinion on three different questions.

To the gentlemen, I address you because I'd like you to comment on the effect on wait lists that pharmaceuticals can have. Specifically, I'm thinking of surgical wait lists, dialysis, and drugs like statins or ACE inhibitors. I'd like to know your opinion on the effect of wait lists and the effect pharmaceuticals can have on a patient's quality of life. Third—and this gets to a broader question—we're always looking at finite resources and infinite demand in health care. I'd like your opinion on whether these drug classes I've mentioned, or similar drugs, represent a net cost or a net savings to our health care system when you consider what the impact may be on dialysis, or surgery, or time in hospital.

I'd like to get you to comment on these. They're pretty big questions; I recognize that.

[Dr. Richard Lewanczuk]

Our various professional bodies go through the evidence, and that's how we come up with the guidelines on the use of pharmaceutical agents. Obviously, if they've been recommended, they must have benefit. Other people—the health economists—will then come to do the various cost utility and cost-effectiveness studies.

I did a similar presentation to your provincial government not that long ago. We have good data from Saskatchewan, and we know that for many of the chronic conditions we could prevent through the use of effective pharmaceutical therapy, patients have difficulty in adherence. Of course, some of it may be cost-related, but some of it's just behavioural issues.

For example, we know that 60% to 70% stop taking their cholesterol-lowering medication. We might as well not have prescribed it; it's wasted money to our system. If it hasn't done anything, or if they stopped taking it, they then represent wasted lives or wasted opportunity to our system. If we had ways, through all the various strategies, to ensure and facilitate adherence, it would certainly translate into a benefit from a medical perspective.

[The Chair, Conservative, Rob Merrifield]

I'll ask Dr. Glasgow to comment as well.

[Dr. Kevin Glasgow]

Thank you.

I welcome that question, as a former medical officer of health and a public health physician and family physician by background. I'll comment briefly on the drugs. I want to get back to the concept of primary prevention.

Yes, it is important—I'll echo those comments—for care pathways that the appropriate patients be put on the appropriate medications to prevent disease from happening, and then after disease. There are care protocols. The Institute for Clinical Evaluative Sciences in Ontario has put forward on their website a number of care pathways in the cardiology field.

Let me get back to the concept of primary prevention—the upstream. It is very important to decrease intake, because once we have a wait list for a procedure, it's too late. Some of these things clearly could have been prevented. What I'm talking about is healthy public policy. I'm talking about federal and provincial anti-smoking legislation; that is going to decrease intake. Over time you'll have seen tremendous changes in the incidence of certain diseases, with healthy public policy such as this.

Cardiovascular disease—heart problems, head problems, strokes—still remains the number one cause of morbidity and mortality in our society. One third of us are going to die from a heart problem, a stroke problem, or cardiovascular disease. What we're seeing is the fall-out of some bad eating practices, lack of activity, and smoking practices. As we decrease that, people will live longer. The whole concept of primary prevention is very important.

In Ontario, CCN is partnered with the Heart and Stroke Foundation of Ontario. Last week we had a cardiovascular summit, and it really is to connect primary prevention to treatment, to secondary prevention, rehabilitation, palliation; to look at the continuum of care approach that's been here. Addressing things in isolation is still a silo approach; you need to look at the full spectrum.

In Ontario we have a cancer strategy and we have a stroke strategy, but we do not yet have a cardiac or cardiovascular strategy. We will be making recommendations to the two Ontario ministries of health--Ministry of Health Promotion, and Ministry of Health and Long-Term Care--and to the 14 local health integration networks in the near future.

Primary prevention cannot be neglected. Like family physicians...and I'm one. I still see patients every second Friday; I cover for my family doctors. I see the patients who can't get in to other family doctors and who rely on just a cookie-cutter approach. The reality is that prevention has to be raised in profile and in emphasis as well—a comprehensive solution.

That was my concluding comment: don't look at acute care in isolation; it needs to be connected for a comprehensive solution.

Thank you.

[The Chair, Conservative, Rob Merrifield]

Thank you very much.

That takes us to the end, but I'll add one last thing about Dr. Frank's study and pilot project. I have a very close friend who was diagnosed with a hip problem just before Christmas. This young man's doctor got him in for surgery on January 31, but he couldn't make it because he couldn't clear his schedule in time to make the surgery. He had to put it back a couple of weeks. That's how successful it is.

I applaud all of you for your examples. You've given us a lot of hope for our system, because really it's not sustainable the way it's going. We need this kind of innovative thought process to be able to sustain our system.

We want to thank you for coming and for sharing with the committee today.

Just before we clear out, we have one quick motion so that we can pay these gentlemen.

Madam Brown.

[Bonnie Brown, Liberal, Oakville, ON]

This is to allow the money we need to run the committee. A series of these motions will come forward.

I move, Mr. Chairman, that the proposed budget in the amount of $11,900 for the study on health care wait times be adopted.

(Motion agreed to)

[The Chair, Conservative, Rob Merrifield]

Boy, they're feeling better already.

Thank you very much. This meeting is adjourned.