Mr. Chair, it's a great honour to be here. Thank you for the invitation.
I'm here not to rehash all the problems in health care but to propose some potential solutions, with some preliminary evidence that it is possible. I brought copies of my presentation in both English and French, to be distributed to you.
I would like to start by telling you a little bit about the Alberta Bone and Joint Health Institute, what it is, what we've done with our pilot project and what we're planning to do with our next steps, and tell you where the institute is going in the future.
The institute is a not-for-profit entity, which is a registered charity created by philanthropy in the province of Alberta. It has two key roles. It attempts to be the catalyst for positive change in our health system and to become the objective evaluator of the success of the changed system.
The central operating theme of the institute is to create cooperation between the key players in health that have been operating in relative silos--the health regions; the universities; members of the public; the bone and joint health practitioners, in our case; government; and industry.
The institute was created by Mr. Bud McCaig, a philanthropist in our community who engaged a number of community leaders to serve on a board of directors. Their names are listed for you, including Peter Lougheed, who is a special adviser to our board of directors. We also have an international advisory board of prominent people from the United States and internationally who are advising us on whether we're doing the right things to promote change in our health system and not reinvent the wheel.
The goal of the institute is to create a sustainable system of patient-centred care that efficiently provides the best quality care to all Albertans equally. It meets people's needs as the top priority. It isn't organized for doctors, it's organized for patients and the public.
The problem, as we see it in the institute, is that there are these long waiting times for various elective procedures such as hip and knee replacement, as one example, and the reasons for those long lists are not totally clear. We would propose that we need to be clear on what the problems are in order to solve them, and a systematic solution is possible if we understand what the problems are.
Central to solving the problems, we believe, is that a partnership is required between these various entities that have been operating in silos, and that's the role of the institute--to bring them back together where they're no longer adversarial but cooperate to achieve the right balance of access, quality, and cost control.
The hip and knee project that the institute championed is an example of that. The institute analyzed the problems and began implementing solutions by communicating with all those partners and securing buy-in of all the health regions in Alberta, Alberta Health and Wellness, primary care physicians, and all the orthopedic surgeons in the province. About 100 orthopedic surgeons are behind this project. The institute then worked with those partners to clean up the poor information that existed in the system, starting with the waiting lists. I'll give you some examples in a few minutes of how poor the information is.
The institute analyzed the existing way of doing business and designed a new way of doing business, called a continuum approach, which is not totally unique. There are other examples that we're going to hear about today of reorganizing the system to make it more efficient and effective.
The institute did secure the buy-in of Alberta Health with the commitment of new dollars to be able to do this, and I will talk about that in a few minutes, too. But there was $20 million allocated by the Province of Alberta to make this happen, which was obviously very important for change management, as well as doing the new joint replacements.
We then went on to test this new way of doing things, the ideal continuum. The top of the next page shows the partners involved in the project: the universities, the health regions, and all the doctors.
I want to again quickly highlight what we believe the problems are.
The system is very confusing; patients are left on their own to try to navigate this complicated system. There is a lot of redundancy, inefficiency, and waste when people are trying to navigate the system on their own, seeking care from multiple providers, recycling through diagnostic testing in a very inefficient manner, and consuming unnecessary resources and time.
There was also a critical lack of good information to fix this problem. The administrative databases do not contain the real information needed to solve this in terms of access, quality, and cost. There is a schematic here of a spaghetti-like system that has been organized around departments and doctors and hospitals. It looks very confusing to people.
Central in our whole argument is that we need accurate information to solve this. A couple of examples of cleaning up the so-called queue or the waiting times occurred when we analyzed 20 surgeons' practices. We discovered that about 15.5% of people who had already signed consent forms to have surgery by those surgeons were not really waiting for surgery at all. Many of them had already had surgery; some of them were dead, had moved away, or didn't want surgery, despite the fact that they had signed a consent form. They had done so just to have their names on the list in hopes of having surgery in the future.
A separate list of people who had been referred to these surgeons was even worse. Fully one-third of them were not really waiting to see that surgeon. Unknown to the surgeon, they had already seen others and had had their surgery. They had actually been working their way through a separate path in the system entirely, consuming unnecessary resources. These surgeons were waiting in good faith for patients to show up in their practice, whereas they had already been treated. That's just an example of poor information driving unnecessary cost, waste, and inefficiency of people's time and effort.
What the institute did was create a continuum approach with some hard guidelines around when the clock starts and stops on different parts of the continuum of care. The system was reorganized from a patient's perspective from beginning to end, from hip pain all the way through to a happy, healthy, educated patient back home again. I'm not going to go through the details of that unless you want to in the questions, but the way the system was re-engineered was through creating focused facilities with central triage clinics, multidisciplinary teams with case managers assigned to every patient and armed with standards and benchmarks of time of access, and appropriate testing. These were implemented in every patient's case.
Central to this was the creation of an accurate database of access quality, which meant satisfaction as well as patient outcomes were being measured in every case--and cost, both direct and indirect, with a costing system that has been agreed to by all three participating health regions. We were able, for the first time, to define accurate case costing of hip and knee replacements with some agreement on what that means, and have the ability, most importantly, to track it prospectively for all cases. We have a benchmark of figuring out cost.
We set this up as a randomized control trial, which is a research design in which the same surgeons send patients either into this new path or into the existing path. Then we measured access, quality, and cost.
A preliminary report released in December talked about their improved access times. Times were dramatically reduced: the waiting time to see a surgeon went down from 35 weeks to 6 weeks, and the waiting time for surgery went from 47 weeks to 4.7 weeks. Again, this was 1,200 patients in a specialized system, just to show proof of the concept that it can be done. This is a kind of best-case scenario, with new resources, new teams, and adequate pathways. It shows what can be done.
The most important part of that is the information being generated for all patients going through the system. There'll be another report coming out from the institute within the next couple of months, with more quality and cost information. That will be more revealing about the cost-benefit ratio of doing it this way.
Patients were very satisfied with this new way of doing things. They said it was better. They felt as if they knew what was required. Somebody was always looking after them in the system. They loved their case managers. So proof of concept shows this new way is better in terms of satisfaction and can provide better access.
However, you might say, “So what? This was done with new money that could have been directed to doing new hips and knees”, which is the solution in some other jurisdictions we're aware of. Well, not only did this provide better access and higher satisfaction, we think there will be better outcomes. There will be a system in place for measuring access, quality, and cost for all the patients in the province, because we're now actually spinning out this model to the entire province. We've engaged all of the orthopedic surgeons doing hip and knee replacements. Using what we've learned from this project, it's now being used for all the doctors in those three regions, and we're educating the others in the other health regions.
This also gives us the chance to now identify how much it really costs to provide care across the continuum, and for the first time ask the providers, “Can we save money and provide better care?”, which I think is critical to creating a sustainable system. They've never been asked before, “Can you imagine saving money, as co-owners of this business?” In hallway discussions I've had, every one of them believes they can.
I don't want to over-promise and under-deliver, but I'm thinking that a minimum of 10% in costs could be saved in every case, which could be reinvested in doing 10% more. It could probably be more than that with a little bit of pushing.
So the bottom line is that this gives us better information to drive change. We can drive this out with evidence-based decision-making on access, quality, and--I emphasize--cost, and create a new business model with incentives for providers, for the first time, to participate in fixing the system.
We've set up a case rate for funding hip and knee replacements that is flowing into physician groups to manage the continuum of care. I believe that will change how the physicians are actually incented to help fix access, quality, and cost with real information, knowing that somebody is paying attention and getting the right information that's going to improve their quality of care, but also incenting them to be more efficient and cost-effective.
This will allow us to project what's really needed in the future, so there will be no more hysteria about how many patients require care and how much it is going to cost. We will know accurately within the next few months what it will cost to fix this problem, for all time and eternity, for the province.
Our stepwise approach to solving this is to optimize what we have and make it as cost-effective as we possibly can by asking the providers to participate in the solution. We believe that if we don't do that as the first step, it'll never happen. We believe people will continue to order unnecessary tests and drive unnecessary cost, unless they're incented to fix it first.
Then we can transparently define what we need, discuss the options on how to fix it by stopping to do things of marginal benefit that are evidence-based--diagnostic tests, rehabilitation, and whatever is unnecessary--and reinvest that value. That's the bottom line. We propose that as a tactic going forward.
Thank you.