Physicians must lead in integrating Canadian health care

By Barbara Sibbald | CMAJ | Aug. 24, 2016

Integrating care can reduce the health system’s cost, while improving results and patient satisfaction, said experts Dr. Carl Nohr (standing) and Dr. Chris Stanley. (B. Sibbald)

The silos in Canadian health care are seemingly impenetrable: provincial and federal, primary care and hospital care, providers and patients. Reducing the system’s cost, while improving results and patient satisfaction, requires an integrated approach led by physicians, experts told delegates to the Canadian Medical Association (CMA) General Council in Vancouver today.

Dr. Carl Nohr, president of the Alberta Medical Association, highlighted the Canadian dilemma.  “Innovation in Canada looks like this: We have a problem, we create a commission which generates a report which results in pilot projects. A few years go by, then we create a commission which generates a report which results in a few projects. Then a few years go by and you’re starting to get the picture.”

“We need to get better at making excellent reports and excellent direction stick,” said Nohr. Calls for an integrated health system were emphasized in a 1997 report from provincial and territorial health ministers, in the 2000 Health Accord and, 15 years later, in the Advisory Panel on Healthcare Innovation final report. None of these has so far stuck.

According to a CMA report, integrated care provides an accessible and seamless experience for the patient in a financially prudent manner.

This requires a high degree of communication, collaboration and coordination among providers to meet the needs of the whole person, said Nohr. This “is the best, if not only, approach to deal with social determinants of illness, to deal with fiscal sustainability and to deal with patient-centred care.”

“To move to integrated care we need to shift from viewing health care as a commodity that is produced by providers in a system managed by providers, to a collection of services, coproduced by patients and providers, based on values of the patients in a coordinated system. And this is the path to patient-centred integration,” said Nohr.

Integrated care is already underway in the United States, where there are incentives for integrated care and penalties for failures, said Dr. Chris Stanley, vice-president for population health, Catholic Health Initiatives. The Bundle Payment for Care Improvement (BPCI) “means an organization like us has financial and other incentives to improve and coordinate care during an episode.”

A patient undergoing a knee replacement, for example, is admitted to hospital, physicians are paid, the patient goes to post-acute care and is sometimes readmitted.

“There was never an historical reason to tie all that together,” said Stanley. Under BPCI, the organization was reimbursed, coordinated and incented to provide coordinated care. This decreased 90-day readmission for joint replacement by 50% and boosted the patient experience by 10%.

In addition, physicians “came off much, much better financially, though that wasn’t their primary driver,” said Stanley. “They wanted to do better…we removed some of those barriers.” Value-based reimbursement is a growing US trend. “Value of care and the physician experience is going to be much much better under this model,” said Stanley.

A strong primary care base and a connected organization are vital, but a very strong physician base is the primary determination of success, he added. “This is very hard work that really requires significantly different levels of thinking for physicians, and for others as well. Physicians have the leadership and responsibility to make that change.”

Stanley advised Canadian physicians to test, innovate and stop doing things that don’t work and expand those that do.

To move to integrated care we need to shift from viewing health care as a commodity that is produced by providers in a system managed by providers

The US Centre for Medicaid and Medicare Innovation (CMMI), a national think tank, runs pilot projects aimed at decreasing total cost while improving quality of care and patient experience in Accountable Care Organizations. Of the 11 pilots since 2015, two have been exemplary. “The most important factor in success in its pilots is strong physician leadership,” said Stanley.

The CMA must get involved, said CMA Board Member Dr. Pierre Harvey of Quebec. “We have the responsibility to come up with an answer. … Can you ask government to create a new system all by themselves? … We have to be responsible and move ahead. That’s a fantastic mission and task for CMA.”

Delegate Dr. Intheran Pillay of Saskatchewan concurred. “In Canada, we have 14 siloed approaches to the health system. The CMA has a really integral role to play … to create the single unified vision that will be a tremendously useful catalyst for change in the country.”

The CMA Board of Directors is slated to come up with policy and direction. “We all know there is a need to rethink how we deliver health care in this country and that physicians need to be leaders in this discussion,” said CMA President Dr. Cindy Forbes at the conclusion of the hour-long discussion.

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