Health Committee on June 1st, 2006

[Dr. Cyril Frank]

Thank you for the question.

We actually saved money in acute care by decreasing lengths of stay, and some of the in-hospital costs and spending more money at the front end in terms of optimizing patients, educating them, and preparing them for surgery. The case costs were about the same per case across the continuum, from time of presenting with hip and knee replacement all the way through, including rehabilitation and home care costs. That's what we call the case cost. I said that I think we could, over the next year, save 10% per case with a focus on saving costs.

We were trying to optimize the experience--improve the efficiency and quality of care--as our top priority. We believe it is still the top priority. If we carefully look at saving money, where across the continuum could we save and then invest in maintaining a high-quality experience? We believe that the saving could then drive increased volume for the same envelope of funding.

[Christiane Gagnon, Bloc, Québec, QC]

I also want to know whether any patients had been pressured in any way to assume costs that would normally have been paid by the health network. Some patients even had to assume costs in order to become more eligible for surgery or to qualify for follow-up after surgery.

Now you said that you are in charge of all the steps preceding surgery.

[Dr. Cyril Frank]

This was entirely publicly funded. There were no incremental costs beyond the normal system of care; there were no incremental costs. This was entirely covered by the new funding I mentioned.

I believe there is some limit on the number of physiotherapy visits that people get post-operatively; they may have to pay a small amount, but I actually don't think it's an issue for these people, who recover quite quickly.

[Christiane Gagnon, Bloc, Québec, QC]

For example, there are vulnerable persons who cannot necessarily afford a follow-up on top of a preparation process and who could find it difficult to follow your program. Some kinds of health care may not be provided for by drug coverage or, in Quebec, by the Régie de l'assurance-maladie. In any case, I was talking about the prevailing situation in your province.

[Dr. Cyril Frank]

In Alberta, everything was covered. There were no incremental costs beyond the normal health care system. And patients were randomized into the system, so that in fact two-thirds of the people we treated were in the low socio-economic group, and their cost of care was entirely covered.

[The Chair, Conservative, Rob Merrifield]

Thank you very much for the questions, Madame Gagnon. Your time has expired.

Mr. Fletcher has a quick statement, and then we'll have the rest of the time for Ms. Davidson.

[Steven Fletcher, Conservative, Charleswood—St. James—Assiniboia, MB]

Thank you, Mr. Chair.

I just want to say to the panel, thank you very much for your presentation today. The Government of Canada is looking at each of your activities closely, and we look forward to using your ideas and innovations to help us meet our wait time guarantee.

I'm yielding the rest of my time to Ms. Davidson.

[Patricia Davidson, Conservative, Sarnia—Lambton, ON]

Thank you.

First of all, thank you to our panel.

It's difficult to understand how we can have a problem with our health care system after listening to you four gentlemen. I think there are some very innovative solutions out there, and each of you in your own area has worked towards making them successful.

My first question is to Dr. Reed. I found it alarming to hear your statistics on the number of radiologists we have today. I think you said in 2004 we were 500 radiologists short, and over the next six years our number of tests is going to be increasing 30%, but our number of radiologists is only going to be increasing 5%. Is that correct?

[Dr. Martin Reed]

Less than 5%.

[Patricia Davidson, Conservative, Sarnia—Lambton, ON]

So those figures are certainly very alarming, and I think we all, in our own communities, have seen that trend building over the last few years.

I found this guideline project that you chair extremely interesting, to listen to you speak of that.

The 10% of unnecessary procedures could even be low, I would think.

[Dr. Martin Reed]

Yes.

[Patricia Davidson, Conservative, Sarnia—Lambton, ON]

Many years ago I was an X-ray technician, and I would say that at that time over 10% were unnecessary, and I think that trend has only increased.

These guidelines that you have embraced are certainly intriguing. Did they go to each family physician, or to each physician? How did you distribute those, and are they only guidelines? I guess guidelines are guidelines and don't carry a whole lot of weight. So that's one question.

Second, could you talk a little bit more about your pilot project?

Third and last, is there a parallel education program for the public? I firmly believe a huge part of our problem is public expectation and what they feel they are entitled to.

Could you answer those questions for me?

[Dr. Martin Reed]

On your first question, I would agree with you. We feel that 10% is a low estimate of the number of unnecessary examinations that are done, so we're certainly hoping there will be an even greater reduction in the number of diagnostic imaging studies when the guidelines are widely circulated.

The CAR itself has distributed electronic versions of these guidelines to all the medical schools, all provincial radiology societies, and I believe all provincial colleges of physicians and surgeons.

We've also, through the national specialty societies, distributed versions to all the specialty societies in Canada. We feel this is very important, because these guidelines will only work if we have the support of the specialty societies.

We've also provided them to the College of Family Physicians of Canada and have their support. We've distributed them at some meetings--a national internal medicine meeting, for instance.

We have made them available for sale, so various people have purchased them for distribution. I have to say, we're not sure where they have all gone, but those are the methods we've used to distribute them currently.

You were asking about the demonstration project. I'm assuming you're talking about the project in my hospital.

[Patricia Davidson, Conservative, Sarnia—Lambton, ON]

Yes, it was at the Winnipeg Children's Hospital.

[Dr. Martin Reed]

We are initially starting with four sites in Children's Hospital where there are physicians or pediatricians who are very keen on using these guidelines. We'll implement them there. We will make sure that all the bugs are out of the system, that the software is working the way it should, and that the clinicians are happy with using the software. Then we hope to spread it throughout the hospital, so that by this fall, all the diagnostic imaging studies ordered in the hospital will be ordered through Percipio. In that way, we can collect quantitative data on who is using the guidelines. If physicians get a guideline, get a suggestion, do they follow it? That kind of data will let us know how we need to change the guidelines or change physicians' behaviour.

It is the same situation everybody has been talking about. We need hard data.

There is also a clinic of pediatricians, the biggest pediatric private group in Winnipeg, that wants to use this software, and we hope to implement it there too in the fall. This project will last about a year. We hope to collect about a year's data, then analyze it and report on it.

[The Chair, Conservative, Rob Merrifield]

Our time is gone, actually. We may get back to that subject as well, but thank you.

Ms. Keeper, you have five minutes.

[Tina Keeper, Liberal, Churchill, MB]

Thank you very much.

I would like to ask Dr. Lewanczuk a question.

I was really interested in this restructuring you're talking about. I represent a riding with a large aboriginal population, and I have 33 first nations in my riding. We actually have a backgrounder here from AFN on the health crisis. Of course, diabetes is a chronic issue in our community.

One of the interesting comments you made was that you're responsible for patients who are not showing up for appointments, that you need to treat disease and risk in the community. Can you share with us how you approach that? How do you work with those patients or doctors, and what is the impact?

[Dr. Richard Lewanczuk]

We do it in a number of ways. Would you like me to comment on some first nations issues while we are on that? We have some specific strategies there as well, and we have done considerable work.

One way we do that is by knowing all the people in our jurisdiction who have diabetes or a particular chronic disease. We do this in the capital region. We basically, electronically, know who everyone is, and all their information is accessible. If we do that, and by interacting with the family physicians' electronic records, and by using strategies.... For example, we know that people who have diabetes must have a high blood sugar record somewhere in the laboratory that would be available electronically. So if we search through the laboratory, we can pick out all the people with diabetes. In fact, that is what we have been doing through the Canada Health Infoway project.

Because we have this integrated electronic system, we can then see that these people have diabetes. Have they visited a physician in the last year? Have they had the yearly urine test? If they haven't, we can remind them. We find that it is most beneficial and works best if we remind patients. We remind them by letter. If they don't respond after three letters, we can give them a phone call. And we have a community team that will even go knock on the door.

We use other strategies. Some of our community health nurses go to seniors' centres--there are about 47 of them in our region. They are there ostensibly to measure blood pressure and check blood glucose, but what they are really there for is to ask, while they're doing that, if there is anybody in the building or the centre who might be ill and who has not seen a doctor. We actually try to ferret out the patients.

We use community resources as well. Particularly with first nations, we rely, in the case of diabetes, for example, on people with diabetes serving as mentors to newly diagnosed patients. I have gone out on many trips. They will say that so-and-so is at home and has a problem with his foot. He has an ulcer on his foot. We will actually go out to the home and see him.

We really use the community and try to develop community spirit. We have various programs that develop patient empowerment, that get the communities empowered to look after each other. So there is a host of strategies we use to engage the public to pick out the people who don't go to physicians regularly.

In the inner city, we offer free lunch. Patients come in for the free lunch, and we capture them there for health care reasons.

[Tina Keeper, Liberal, Churchill, MB]

Are there any problems with jurisdictional issues or privacy issues related to jurisdiction?

[Dr. Richard Lewanczuk]

That question commonly comes up, and we ask it ourselves. But when the providers get together and we ask the question of each other, we haven't been running across any.

One of the strategies and techniques we use is we point out to the patient that this information is available, but here's the benefit. It means that if you're hit by a bus and you show up in emergency, we know everything about you. We know your allergies. We know what medication you're on. We can be a bit proactive; we can help you.

So we work with the patient. We tell them right up front what we're doing. They have the option of opting out of some of these systems, and amazingly, when they realize the benefits, patients are very engaged.

[The Chair, Conservative, Rob Merrifield]

Thank you very much.

Mr. Batters.

[Dave Batters, Conservative, Palliser, SK]

Thank you very much to each of you for coming before this committee. I think I join the other members in saying that it's clear you've done some great work on this in your respective fields and hospitals and areas of influence. You're to be commended for that, and certainly this committee and this Parliament can learn a lot from you.

First of all, we know this issue is extremely important to Canadians. It's extremely important to the Government of Canada. As all of us in this room and most of the Canadian public know, it's one of the five priorities identified by the government to have this health care wait time guarantee for patients.

I come from Saskatchewan, where under the provincial NDP government we have the longest wait times in the country for diagnostic and surgical procedures. My time doesn't permit me to get into examples of that. I want to talk a little about general practitioners and the shortage of GPs in this country.

Dr. Lewanczuk, you talked about one of the strategies that you've employed being to empower general practitioners. I wonder if you could comment quickly--and it's certainly not just limited to Dr. Lewanczuk--on the shortage of GPs, how best to address that problem.

Many GPs in this country are not taking new patients. At least that's the case in my home city of Regina, where it can be difficult to find a general practitioner taking new patients. Often you have to go to medi-centres and seek care in those venues. How best can we address this problem?

And this is one I'm sure you'll want to comment on. Is there a problem with how we pay doctors in Canada? There's clearly an incentive for the quantity of patients that our GPs can see. It's obvious, when you go to the doctor's office. I have the utmost respect for our general practitioners, but the reality is that there are significant incentives to see 60 patients a day as opposed to 35. You see the signs up in the doctor's office: “One complaint only”. Hence, our wait times. It's no surprise that the same patient is back a week from then, because they've got only one complaint out and they had six.

I wonder if you could talk a little bit about the shortage of GPs, the difficulty getting in to see your GP. You're talking about empowering them. You talked about GPs doing diabetes education, for example. That probably takes an hour a patient.

How do you complete that circle?

[Dr. Richard Lewanczuk]

I will give you a short answer to a long problem.

One of the difficulties, as mentioned, is that we provide no resources to our family doctors. We like to beat up on them, and often as specialists we tell them, you're doing a poor job, look at the poor levels of blood pressure control, the poor levels of diabetes control, and yet we do nothing to help them.

Some of the primary care reform strategies...for example, now in Alberta the primary care reform strategy is having family physicians get together in groups in what are known as primary care networks, and they're provided with extra funding to hire nurses, pharmacists, and other health care professionals to help them, and so now they don't have to personally deliver the diabetes education. A nurse may help them. A nurse may get the height, weight, the blood pressure, do the initial screening for the family physician.

We've done a tour around the world to see how it's done in other countries. New Zealand uses this model very effectively, for example. Over time we've put our resources into the acute care hospital specialist-based system, and so now the patients, as has been mentioned earlier, expect that they need to see the specialist and at the cocktail party it's, I see an internist for my thyroid, or, I see an endocrinologist. But what about the family doctor?

So we provide this expectation, and in fact the family doctors can do a lot with help from the specialists. In fact, the specialist is somebody the family doctor should use as a tool. We should be there to support the family doctors with advice and in multiple other ways. So we have to elevate the status of the family physician.

The remuneration model, you're right, is not aligned with the behaviour that we want. It does force high volumes of patients through. If we get another health care worker and they do some of the work, the family physician under the current funding models across Canada usually doesn't get paid for that. So alternate funding mechanisms are another mechanism.

In terms of this emphasis on the acute care system, in one university of Canada that I'm aware of, in the last two years not one family medicine graduate has set up a family medicine practice, because they can get paid more money by working as a hospitalist, with no overhead, and at 5 o'clock they're done. And so again it's not only the method but the magnitude of the remuneration for family physicians. We've put them at the bottom of the heap in terms of respect and resources, and we need to turn the pyramid upside down.

[The Chair, Conservative, Rob Merrifield]

Maybe we'll get another round.

Madame Demers.

[Nicole Demers, Bloc, Laval, QC]

Thank you, Mr. Chairman.

I would like to congratulate you, ladies and gentlemen, for all the work you have done up to now.

Dr. Reed, I appreciated your straightforwardness when you mentioned that we did not have enough radiologists. You are right.

Dr. Frank, at the outset, when you began to describe your success, I thought that you had found another use for petroleum. I thought that knee and hip replacements were perhaps made from oil, because you and your team have done some outstanding work. I thank you for it.

However, with good ideas like those, if you can accomplish the feat of reducing wait times from 47 weeks to 4.7 weeks, has anyone thought of sharing this information with our colleagues in the other provinces? Has anyone thought of sending this information out so that it can be used by other physicians in other places? This is very important.