beyond decision support

Beyond Decision Support

Rationing Rationalizing and Renewing Radiology in the New Era of Canadian Health Care

Greg Butler MD FRCPC FACRMay 2013

Planning is Everything

Plumber of the Year

Who put that door there?

Every problem has a solution

Hi traffic washroom

Long arms are sometimes an asset

DisclosureChairReal Time Medical Inc.

CHANGE IS COMING…AGAINThe successful metamorphosis of radiology as a

profession will stand on two successful strategies:

1. Radiologists will embrace and lead in methods of cost containment and quality within the PUBLICLY funded system

2. Radiologists will lead a move into a parallel PRIVATE world where patient access and satisfaction ALONG WITH QUALITY are the primary goals

QUALITY WILL BE THE GIVENQUALITY IS HERE. QUALITY IS NOT ENOUGHQuality will ensure that patients receive what

they needQuality will not always give patients what

they want

QUALITY AND THE FALL TOWARDS MEDIOCRITYWe risk a preoccupation with mandated

quality and accountability at the expense of compassion and accessibility

Outcomes and evidence based analysis will trump patient and physician expectations

Radiologist professionalism will decline as self identity as “employees” increases

Cab Driver Back to PakistanNot happy with Canadian Educational systemWants better for his kids

Time For Transformative Change*Senate Committee has recently re examined the 2004

Health accord and concludes (among many other things)

1. System change has stalled. Canada no longer looked upon as a model of innovation in health care (currently rated 30 among OECD countries by WHO)

2. Funding is adequate 3. The system has suffered from remarkably low levels of

innovation. Innovation based transformation is essential.

* With thanks to Senator Kelvin Ogilvie, Chair

Federal funding after 2014 will increase at 6%

per year until 2016-2017, after which it will increase by a three year moving average of GDP, not less than 3%

This will not likely keep up with the expectations of the public

GDP vs Health Care costsHealth care costs are rising at an annual rate

of 6.7% while the GDP rises at <1.5%The Aging population contributes to about 1%

of the health care cost riseHealth care is utilizing an increasing

proportion of budgets in all provinces“The wall” is here.

Radiology Costs are on the Federal Radar ScreenDiagnostic Imaging Meeting February 2012

The Canadian Institute for Health Information and the Institute for Health Economics

BOTTOM LINE: DATA ON DI IN CANADA IS LIMITED AND NOT YET SUITABLE FOR ANALYSIS

It is coming….

WHERE IS THE INNOVATION NEEDED IN RADIOLOGY?Difficult to innovate in an environment over

which we have little control

RADIOLOGY STRATEGIES FOR SUSTAINABILITY OF OUR CURRENT SYSTEM

COST CONTAINMENT IN PUBLIC SPENDING ON IMAGING1. Effective utilization control2. Improved efficiency and elimination of

waste3. ?Will these prevent fee reductions?

INCREASE THE ROLE AND OUR ENDORSEMENT OF PUBLIC/PRIVATE COLLABORATION

UTILIZATION CONTROLDistinction between essential and non essential services

extremely difficult.Decision support with application of guidelines does

reduce utilization * (23% decrease for MRI spine, MRI for headache, and CT for sinusitis).

But how aggressive can guidelines get?Will evidence become a threshold for public pay?The Manitoba Project

*Blackmore et al JACR 2011

Aggressive Utilization ControlThe validity of many imaging procedures has not

been demonstrated with evidence, but only with expert opinion

Expert opinion may be directed at the older objectives of peace of mind, diagnostic confidence, medical legal avoidance, patient expectations

What if we eliminated public pay for all imaging that is not validated with hard evidence?

E.g.. What is the evidence to support the average chest Xray?

OK…We need to innovateWe need to offer more to patients than the

current system canWe will have reached the Quality destination

in the next few years.

Seriously…We have to consider the Private AlternativePublic vs private one of the longest, most

passionate, and confusing debates in Canadian history

Leadership and government has waffled, and inconsistent in enforcement, and policy statements

Generations convinced that our existing way of providing health care is a sacred trust that speaks to our patriotism as Canadians.

Public Private PartnershipPrivate funding of insured services has been

forbidden by the Canada Health Act as a means of the Federal Government preventing federal transfers from subsidizing private delivery of services

Considerable ambiguity among providers and the public of the meaning of private.

Further AmbiguityProvincial policy adds to the complexity and

confusion of the intent of the CHAFor example:

“Private” (non institutional) imaging facilities in Ontario are funded (T fees)

Private imaging facilities in other provinces are technically forbidden, but allowed

Some facilities charge only technical fees to the patients, while others charge the full amount.

Physicians working in private facilities may be opted in or opted out.

Disincentives for MDs to go PrivateIn 3 Provinces (NB,NS,ONT) MDs cannot

charge beyond the fee scheduleIf opted out, cannot do any services for public

reimbursementPatients cannot recover fees from the public

system (NS)

Restrictions on Full PrivateCanada Health Act does not forbid entirely

private facility, provided no public money is used in its operation.

Some provinces (e.g. Nova Scotia) forbid billing above professional tariff (e.g. no technical fee)

Some provinces (e.g. NB and Saskatchewan) forbid MDs working these clinics from doing any publicly funded services.

Government Objections to PrivateWill allow “Queue Jumping”.. (pts get faster

access to diagnosis, and then jump ahead in the public system for treatment)

If too many providers opt out, the public system will suffer (the “thin edge of the wedge argument”)

Kickbacks for referralSelf Referral

Technical Barriers to Privatization in ImagingIntegration of flow of information between

public and private repositoriesWhat killed our clinic ultrasound projectAchieving public administration and

accountability over private facilities

Advantages of PrivateEfficiencyAdding total $$ to the system through

discretionary spendingIndustry standards and competitive

consequencesRADIOLOGIST CONTROL ALLOWS THE

ADDITION OF THE IMPROVED ACCESS, AND TURNAROUND PATIENTS WILL DESIRE,WHILE RETAINING QUALITY, APPROPRIATENESS AND PUBLIC ACCOUNTABILITY

Success in the Private WorldPublic demand and government scrutiny will

ensure and demand highest quality servicesLower quality providers will not surviveCompetition in the private sector will depend on

the best combination of “value add” quality items, particularly accessibility, at the lowest price.

Forgo your trip to Florida this season. Pay for insurance that will provide rapid and pleasurable imaging and therapeutic experience

CONCLUSION: PUBLIC HEALTHCAREPublicly funded services limited to providing

radiology services at the lowest cost and highest quality affordable.

Radiology leadership will gain traction when providing cost saving strategies like more aggressive utilization controls and evidence based practices.

Commoditization of radiology services to the public system will likely occur

CONCLUSION:PRIVATE HEALTHCAREThe new opportunities will be on the private sideWe must pursue opportunities to influence

legislation barriers (national and provincial)ENHANCED ACCESS AND SUPERIOR PATIENT

EXPERIENCERADIOLOGIST CONTROLLED POLICY AND

STAFFINGBusiness level EfficienciesPositioned as an aid not a threat to, principles

of a strong public system

What Kind of System do Canadians Want?Do we know what we want?What we do know…We want sustainability,

accessibility, value AND the experience of our preference.

Recent Environics poll (Globe and Mail, Jan 2013) states that 55% of Canadians believe that “inefficient management” is the culprit as to why our health care system has stalled. 55% also said they approved of a private health care system to improve access to health care.

A blended public/private system is what we both need and want.

butler.gj@gmail.com