Evidence of meeting #76 for Health in the 41st Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was patients.
A recording is available from Parliament.
Conservative
Patrick Brown Conservative Barrie, ON
Thank you, Madam Chair.
Thank you for the testimony so far.
First, to Dr. Guirguis, you did a lot of emphasis on obviously obesity management. I want to know what you think the consequences are of obesity on the health care system. I think it's important to realize the types of savings that could be found through innovation.
Do you have any figures in terms of the cost consequences?
General and Cosmetic Surgeon, Lakeview Surgery Centre, As an Individual
I do. In general it's obviously in the millions. The lead conditions associated with obesity—high blood pressure, type 2 diabetes, sleep apnea, cardiac disease, heart attacks—are massive components of health care costs.
There are actually specific cost-analysis studies that look at the cost savings. I didn't present them today, but the cost savings with lap band surgery and gastric bypass surgery are in the millions.
Keep in mind that these are chronic conditions that are constantly taxing health care dollars and health care energy with family physicians. Looking at this model, once you have patients in your program and you're able to get their BMIs under control, their conditions decrease quite substantially, along with their reliance on medication. Lost time off work is another issue as well.
So it's millions. I can get specific numbers for you, but it's definitely in the millions.
Conservative
Patrick Brown Conservative Barrie, ON
You mentioned lap band surgery, and the answer made me think of the whole issue of medical devices. In 2011 the audit of Health Canada by the Auditor General's office said that one thing that needed to be addressed was the approval of medical devices in a timely manner. That was an area that needed improvement.
I think that's important to talk about here, because obviously new medical devices are one of the tools for innovation. What have your observations been, Emad and then Jason, about barriers we have with the federal government? Do you have concerns about the process we have for the approval of medical devices?
General and Cosmetic Surgeon, Lakeview Surgery Centre, As an Individual
Speaking personally, there haven't been any issues raised with the efficiency of approving the lap band as a medical device. It was approved initially by Health Canada in the late eighties. In 1993 the first laparoscopic, or less invasive, procedure was carried out.
The band has undergone several modifications. It is a process that generally takes one to two years for FDA approval in the States and Health Canada approval in Canada. It does take between six to 12 months on average, if you have an existing device that is modified, to approve the modification as well.
Conservative
Patrick Brown Conservative Barrie, ON
In terms of your device, has it been more challenging to have it approved in Canada as compared with other countries?
General and Cosmetic Surgeon, Lakeview Surgery Centre, As an Individual
For the lap band, there's no evidence that Health Canada has been slower at approving it than in Europe and the United States.
We actually just came back from Mont-Tremblant, where we had a lap band meeting. The actual innovator of the lap band was there, and we had a dialogue over dinner. There was no mention of any difficulties as far as getting it approved.
Conservative
Patrick Brown Conservative Barrie, ON
Jason, do you have any observations on the regulation of medical devices?
Assistant Professor, Centre of Health Services and Policy Research, University of British Columbia, As an Individual
I'm sorry, I don't have insight into medical device evaluation.
Conservative
Patrick Brown Conservative Barrie, ON
One direct question I had for you, Jason, was in regard to your research with CIHR. I've asked this question before about CIHR. Do you believe there's an adequate level of collaboration in the type of research we're doing that leads to innovation?
I think of juvenile diabetes, where they're doing research in both Canada and Australia on an artificial pancreas. I know that in the case of JDRF, they were pooling their research.
Do you notice that's happening pretty broadly at CIHR, being someone who has worked with them?
Assistant Professor, Centre of Health Services and Policy Research, University of British Columbia, As an Individual
I do know that many of my faculty colleagues do have international collaborations, but it is also hard to know. Having worked in the NIH a little bit as well, with grant funds from there, they actually tend to be a little more insular and have fewer international collaborations.
However, I believe there is certainly space for trying to develop, identify, and then scale up effective strategies or policies much more quickly than is done now. I know that CIHR effectively tries to implement a knowledge translation component into each research project. However, I think there is a central role that could be played in identifying effective strategies, pushing them out, and scaling them up with resources much more quickly than leaving it to individual investigators or researchers such as myself, where the payoff in terms of my time disseminating research, rather than creating it, is very low.
So I think there's a role for central agencies to identify good ideas, evaluate them, and scale them up.
Conservative
Patrick Brown Conservative Barrie, ON
Emad, I want to ask one question just to play devil's advocate. I remember when we studied obesity here at the health committee, one thing I asked about was that obviously people are exercising less and less. There are more distractions with video games and TV, with 300 channels instead of two, and there are fewer kids at the park across the street. Given that challenge, do you think we should be relying on innovation to combat obesity or are there other things the government should be doing to address that? Do you have ideas regarding possible innovation other than something surgical?
General and Cosmetic Surgeon, Lakeview Surgery Centre, As an Individual
That's an interesting point.
As with any health care policy, prevention is always prime above treating the disorder. However, we're here now. The evidence shows that if you can get children exercising at an early age and prevent childhood obesity and prevent early obesity, then you're winning. If you can sustain that lifestyle, combined with portion control and exercise, then you're going to have great success in keeping the population at a healthy weight.
However, the problem is that once patients are obese, it's a whole different equation. These patients feel anguish over losing their weight. We see them in consultation. They are exercising aggressively. They're trying portion control. They yo-yo back and forth among multiple diets.
Now the evidence shows that once a person is obese, they have a new set BMI that's like a spring. No matter how hard they diet, they spring right back to that BMI and often one that is higher, so it becomes very difficult to lose weight and keep the weight off. That's the big challenge with obesity. Once a patient becomes obese, it turns into a chronic condition.
General and Cosmetic Surgeon, Lakeview Surgery Centre, As an Individual
You bring up an excellent point, but to reverse obesity with exercise and diet alone is virtually impossible. From the studies that show us it can be done, usually 1% or 2% of the population can keep the weight off after two years.
February 28th, 2013 / 4:05 p.m.
Liberal
Hedy Fry Liberal Vancouver Centre, BC
Thank you very much, Madam Chair.
I want to start with a question on the obesity piece. I know that in fact not every province funds the innovative surgery you do with a lap band. Is there a guideline that says you have to be over a certain weight, that your BMI has to be over a certain number in order for it to be fundable, or is it never fundable?
General and Cosmetic Surgeon, Lakeview Surgery Centre, As an Individual
The lap band has variable funding across Canada. Alberta funds the lap band. Quebec funds the lap band. The challenge, though, is the amount of funding required to fund a procedure like the lap band, because it really is a chronic condition. It requires very intense follow-up and care.
The gastric bypass and another surgical procedure called the gastric sleeve are publicly funded in all provinces.
Liberal
Hedy Fry Liberal Vancouver Centre, BC
Thank you.
Dr. Sutherland, I think what you're talking about is really extraordinarily important for us as we look at how we spend appropriately. I know that many of us who have been in the health care field for the longest time have always felt that hospitals are rewarded for spending badly, because the next year they get a bigger budget, as opposed to what you're suggesting, which is activity-based funding.
Is activity-based funding in this project that's going to go on in B.C.—and we're looking at this as a best practice—going to be based on everything, or only on the five areas for bringing down wait times? Is it open to any kind of activity funding?
Assistant Professor, Centre of Health Services and Policy Research, University of British Columbia, As an Individual
If we're going to limit the discussion to the experience in B.C., there are several different initiatives within their patient-focused funding there. One of them is the activity-based funding. Another of them is called the procedural care program, which does bulk contracting with hospitals for incremental surgical volume.
Activity-based funding is across the board, so it weights all hospital activity equally. However, it's for only a small portion of the health authorities' or hospitals' activity. It's about 17% of the health authorities' or hospitals' funding. It applies to only the largest hospitals since they feel that the hospitals can achieve economies of scale without jeopardizing access in smaller communities. It's not across the board, and it probably should not be applied across the board for everyone. They've sensibly, as have many other countries, restricted it to the largest ones.
Liberal
Hedy Fry Liberal Vancouver Centre, BC
You talked about the quality-based incentives that are going on in Ontario, for example. Can you give me an example of how that is working? Is everyone building up some sort of outcomes-based analysis that says this is achieving these results in certain areas? Can you talk to me a little bit about whether there is data supporting this and what the quality-based incentives are in Ontario?
Assistant Professor, Centre of Health Services and Policy Research, University of British Columbia, As an Individual
The British Columbia experiment with activity-based funding is essentially intended to provide more care. It is about decreasing length of stays and decreasing wait-lists. There are no outcome measures in terms of patient-reported outcome measures or patient outcomes, although we are looking at readmission rates and mortality rates to see if we detect changes.
The program in Ontario, the quality-based procedures initiative, is a very new initiative. It is essentially pulling together clinical panels of expert clinicians in every field, identifying for that condition what the best practices should be and how to line up the funding behind them, and then matching the funding cross-continuum to that. They currently are just compiling their clinical panels. Some of them have met, including those on chronic heart failure, congestive heart failure, hip fractures, knee replacements.
So a number of them have already met, and they are developing these guidelines. They intend to match the funding, but it has not actually been implemented to the degree that they've been able to delineate what the best practices are. They are doing so now.
Liberal
Hedy Fry Liberal Vancouver Centre, BC
Thank you.
My concern is that if we don't have some outcome measures, we won't know whether this is working or not or whether it's just based on a grand idea. That's the first thing I would like to see, then, if there's an ability to build in outcome measures.
Second, I would like to ask if there is a look at not only funding activity-based incentives and, as Ontario is doing, quality-based incentives; is there also a way in which even within the hospital you can look at the appropriate person to do the care? Is there any work on that?
For instance, do you need to use a physician to do something that, say, a nurse could do, or a midwife could do, or somebody else could do with the same results but at a more cost-effective value? Is that being looked at?
Assistant Professor, Centre of Health Services and Policy Research, University of British Columbia, As an Individual
I'll try both of those.
To the first point, one of my recommendations, and one that I think is really important, is to start to collect outcome measures and patient-based outcome measures that we can tie these results and these initiatives to.
In fact, I'm actually running the only population-based, patient-reported outcome measures, funded by the Canadian Institutes for Health Research, in the Vancouver Coastal Health authority right now. I think it's a great initiative to understand how the dynamics of preference-sensitive and supply-sensitive care are affected by these funding mechanisms, but I would like to see that expanded. I think there's definitely a role for pushing out standards and identifying what standards are in terms of outcome so that we can compare between and within procedures, and between and within provinces, in the allocation of resources.
There are many people working on the efficiency and the health human resource question you're bringing up. I'm less familiar with that, but I know a lot of efforts are ongoing in the field.
