Michael Rachlis MD

Happy Valentine's Day!

14 February 2010, 12:00 AM

I had a magnificent trip to Sweden Jan 8-17, 2010. I was speaking to groups of social democratic politicians about Canadian health policy. I got know a lot of Swedes, from all political perspectives. I started off in Stockholm where I spoke to some national politicians and county level politicians who are responsible for doctors and hospitals and a fair bit of community services. There are 22 Swedish counties and their responsibilities include health care, transportation and culture. They don’t have the regionalism you see in Canada or Spain. It’s a much more homogeneous country. There are non-white faces in Stockholm but not much outside.

After three days in Stockholm, I went to Uppsala 80 km north of Stockholm where my main hosts live. I met the Uppsala County social democratic health committee in October 2008 when they Ire touring Toronto. They have an annual meeting with social democratic party health care committees from five counties around Stockholm and I was the keynote speaker. One of the interesting things I noticed was the dislike of the capital (Stockholm) by the regional folks, much the way all Canadians seem to carry a dislike for Toronto as the home of the place with the money. The conference was held at a 13th century castle just outside of Uppsala.

After two nights in Uppsala and then I took a train to Tallberg about 300 km NW of Stockholm. Tallberg is small (pop 1000) but Big (1200 hotel rooms). It is a major tourist town on a large beautiful lake. It is known as the real Sweden and from the train the countryside looked like it probably looked hundreds years ago — lots of red log houses, cleared plots with small farms, and lots of forest. About 1850 some Swedish artist relocated here and restored a 17th century log house and then the town and its tourism took off. Of course I was there in low season.

The last night in Tallberg my wife and I were guests for dinner at the home of Christina. She is the step-grand daughter of Olof  Aschberg  who set up the first private bank in the USSR with Lenin’s blessings. See: http://en.wikipedia.org/wiki/Olof_Aschberg for more details. The dinner included the president of the local branch of the Moderate party (the senior member of the current ruling right wing coalition) and the mayor of Tallberg district who was a member of a party in the left wing coalition. The Moderate Party person and his wife had lived in Toronto and the US so they had a particularly interesting perspective. However, I concluded that Swedish moderates’ basic philosophy was not that much different from what most social democrats would support in Canada.

For more on Swedish health care see:

Health and medical Care fact sheet Swedish Ministry of Health and Social Affairs 2007

Quality and Efficiency in Swedish Health Care: Regional Comparisons 2007.

The Organization of the Ministry of Health and Social Affairs. 2009

For more on Swedish politics and the race leading up to this September’s election:

http://en.wikipedia.org/wiki/Swedish_general_election,_2010

Here is a presentation I gave to the five counties meeting.

Here’s a picture of me with my main hosts Bertil Kinnunen an organizer for the Social Democratic Party in Uppsala County and Lena Rönnberg who is the chair of the party’s health committee.

Sault Ste Marie leads the way!

3 November 2009, 9:32 AM

Yesterday’s blog post has been edited and today is an op ed in the Toronto Star — How one Ontario community avoided chaos at H1N1 clinics. It is always a delight for me to highlight best practices in Canada’s health system and Sault Ste. Marie is full of them. See more about the Group Health Association health centre on pages 101-105 of Prescription for Excellence.

Canadian H1N1 vaccine rollout hits a pothole

2 November 2009, 11:52 AM

I did interviews with nine CBC morning shows today on the troubled roll out of the H1N1 vaccine. Canadians are rightfully enraged at the chaos of last week’s H1N1 vaccine clinics. There must be a better way to run a vaccine program. There are two main reasons why the vaccine roll out looks like rush hour at a Mexican bus terminal.

Late last week, vaccine manufacturer GlaxoSmithKline notified the federal government that it would not meet its production quotas and would temporarily have to reduce the amount of vaccine delivered.  As a result, BC had no vaccine over the weekend and Alberta has no vaccine today.

However, there is a worldwide problem producing the vaccine. The horror stories in Canada are matched by those in the US. And the federal government has shipped 6 million doses of H1N1 vaccine which should be enough to vaccinate those at high risk — pregnant women, children 6 months to less than 5 years of age, people under 65 with chronic conditions, people who live with or care for infants under 6 months old and immuno-compromised people, and health care workers. The real problem is delivering the vaccine to those who need it.

There are some places in Canada which are delivering vaccine expeditiously to those who need it and we can learn something from these communities. For example, in Sault Ste. Marie, the Group Health Association Clinic is using its computerized appointment system to book patients for H1N1 vaccinations from throughout the Algoma Health Unit. Eighty percent of “the Soo’s”  residents get their health care from Group Health. The appointments schedulers have access to Group Health’s electronic medical record so they can ensure that the patients they book are indeed high risk. Patients arrive at the clinic and get their needle within 10 minutes. No waiting

Group Health has over 60 doctors and 300 other staff and is cooperatively run by a community board and the Algoma District Medical Group. It has been a national leader in health care innovation since it first opened in 1963. The Centre has had a computerized appointment system for 20 years and a comprehensive medical record since 1997. Roy Romanow referred to it as a “the jewel in the crown of Medicare.”

In other parts of Ontario, public health is now delivering the vaccine to selected family doctors offices. Some might ask why public health didn’t simply give the vaccine to family doctors in the beginning. In fact, Ontario Medical Association president and family physician Dr. Susan Strasberg and other family doctors have been asking this question. In fact, Ontario and some other provinces have been quietly distributing the vaccine to clinics and shelters dealing with very high risk populations such the homeless, AIDS patients, and drug addicts.

What held public health authorities back initially was the concern that much of the vaccine could be wasted in family doctors’ offices. Most Canadian family doctors still work in small offices with one or two doctors, a non-professionally trained receptionist and no electronic records. Many family doctors don’t even have adequate refrigerators to store the vaccine and with the vaccine packaged in multiple dose vials, public health authorities were understandably concerned that much of the precious vaccine would go to waste in doctors’ offices. On Friday Ontario announced that like some other provinces and distribute vaccine to certain family doctors who met criteria and requested it. As the Globe notes this morning, Ontario and BC have both (perhaps inadvertently) sent vaccine to for profit, exclusive family practices which charge their patients extortionate and likely illegal annual “club fees”.

Some family practices have the vaccine and are distributing it to their high risk patients. In the midst of Toronto’s complete chaos and confusion one of the province’s new family health teams is advertizing this week’s vaccination clinics for its high risk patients. No fuss no muss no waiting. That’s how Canada should have rolled out the vaccine if we had a decent system of primary health care. Family doctors offices and community health centres would have vaccinated the patients they knew to be at high risk from their electronic health records. Public health then could have focussed on groups like the homeless who otherwise wouldn’t have been vaccinated.

If there were a Group Health Centre in every Canadian community, our H1N1 vaccination campaign wouldn’t make us look like a third world country. We need more effective primary health care in Canada and we need to effectively link primary health care to public health. Let’s not wait 50 years for the next pandemic to make this a reality.

I coordinated a workshop for the Public Health Agency of Canada four years ago on how to improve collaboration between public health and primary health care. I’m sorry to say the previous Liberal government was lukewarm to follow up my work and the current Conservative government sees little role for the federal government in health care. No national leadership and little provincial leadership. Fortunately, there are still enough local examples of excellence to provide us with prototypes for a better future.

Thoughts about Alberta and activity based funding

25 October 2009, 12:51 PM

After being home for a week from my trip to Alberta speaking on behalf of Friends of Medicare, I have a few reflections:

Activity-based funding

Alberta is moving to pursue a policy named “activity-based funding”. Essentially ABF is fee for service payment for hospital care. Hospitals would be paid a specific free for an episode of care such as a hip replacement. The United States government moved most of its hospital funding through their Medicare program into Diagnosis Related Groups or DRGs in 1983.

Hospitals are funded through a variety of different means across Canada. In fact, in most parts of Canada, hospitals are no longer independent organizations. Rather they are operational units of regional health authorities which receive integrated funding for acute care and publicly funded long term care, home care, mental health, and public health services. In Ontario, 14 the local health integration networks (LHINs) created in 2005, have regional funding envelopes but don’t deliver services. Services continue to be delivered by independent non profit hospitals and the previous array of other providers which include many for profit corporations who are heavily involved in the delivery of long term care and home care in Ontario.

The impacts of activity-based funding or DRGs or other types of prospective payment systems are heavily dependent upon the context of their implementation and their specifics. As always the devil is in the details. For example, if hospitals are paid on a volume basis but there is no accountability for quality, then clearly hospitals would have an incentive simply to discharge patients sicker and quicker. If patients suffer complications which bring them back, then an additional fee can be charged. and how do you assess the correct fee for every patient when some hip replacement patients like marathoners are good risks, will recover quickly, and cost relatively little and some like 80 year olds with emphysema and diabetes are poor risks, will take a long rehabilitation period, and whose care will likely be expensive. If the fee paid is the same or doesn’t properly account for extra social risks such as homelessness, then the new policy can really create bad disparities.

For more on ABF, DRGs etc. see: An analysis of Activity-Based Funding by Canadian Doctors for Medicare.

Stirring up a hornet’s nest: Blunt policy endangers health care reform

My biggest concern about what’s happening in Alberta is that it violates one of health care’s key precepts, primum non nocere, “first do no harm”. The most influential reports on quality in health care are the US National Institute of Medicine’s 1999 To Err is Human and the 2001, Crossing the Quality Chasm. Crossing the Quality Chasm has a nice section on the need to treat complex systems, like health systems with respect and make change gently and deliberately.

The authors of the report, including Dr. Donald Berwick, CEO of the Institute of Healthcare Improvement, suggested focusing on frameworks and “simple rules” to drive reform instead of relying upon so-called big-bang legislative and regulatory solutions. That’s because, big changes, like Alberta dissolving all the individual health regions in 2008 and putting in place a very complicated organizational structure for Alberta Health Services with different roles, responsibilities, and reporting relationships for hundreds of senior managers can wreck big havoc. I’m not an expert when it comes to complexity theory in health care (Google Toronto’s Brenda Zimmerman and Shalom Glouberman for more information), but here’s the essence. There are simple systems, like a pulley lifting a load over a river. Then there are complicated systems which are a series of simple systems like a bunch of pulleys, gears, and wheels, like a car. Then there are complex systems like ecosystems. 

We can know pretty much everything about complicated systems — even one as gigantic as sending a spaceship to the moon. But we can never know everything about a complex system because the second, third, and even tenth order interactions might be crucial but it’s almost impossible to predict these interactions in advance. For example, you might be bothered by some insects in your garden so you kill them off with pesticides. A few years later your oak trees start falling down because those pesky insects were part of a chain of life which controlled an oak tree parasite. You didn’t know that in advance and maybe you couldn’t have known it in advance.

The Institute of Medicine suggested ten simple rules that should guide health care re-engineering.

  1.  Care should be based upon continuous healing relationships instead of mainly in-person visits.

  2.  Care should be customized for individual patients’ needs and values instead of being dictated by professionals.

  3.  Care should be under the control of patients not professionals.

  4.  Knowledge about care should be shared freely between patients and providers and between different providers. This transfer should take maximal advantage of leading-edge information technology. Patients should have unrestricted access to their records.

  5.  Clinicians should make decisions on the basis of the best scientific evidence. Care should not vary illogically from clinician to clinician or from place to place.

  6.  Safety is the responsibility of the whole system not individual providers.

  7.  The content of care is made transparent instead of being held in secret. The health system should give as much information as is required to patients and families to enable them to fully participate in clinical decisions, including where to seek care.

  8.  Patients’ needs should be, as much as possible, anticipated and not treated in a reactive fashion.

  9.  The health care system should continually decrease waste (goods, services, and time) instead of focusing on cost reduction.

10.  Providers should cooperate and work in high-functioning teams instead of attempting to work in isolation. Concern for patients should drive cooperation among providers and drive out competition based upon professional and organizational rivalries.

I think these would be good rules to follow, especially in Alberta. There is so much innovation within the public system; the question should really be why is the government making such drastic changes that risk serious untoward effects?

The answer in Alberta as well as other provinces seems to be that a lot of the Canadian elite decided about 10 years ago that our country should have the for-profit sector deliver much elective surgery. I was told this in 2001 by a senior health administrator in Alberta and recently by a senior health ministry official in another province. When I asked given the risks, given the current public sector best practices which could be easily spread, why was he pursuing activity-based funding. He said that activity-based funding was inevitable and he was resigned to trying to implement it is such a way as would cause the least harm.