Ottawa’s Most Innovative Hospital

July 12, 2016 1:30 pm
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Tom Schonberg has been the President and CEO of Queensway Carleton Hospital (QCH) in Ottawa since 1998. He has played a big part in helping QCH become one of the top medical institutions in Ontario. Now celebrating its 40th anniversary, QCH serves a population of over 400,000 each year. It is the secondary referral centre for the Ottawa region, but its mission is to constantly strive to be first in community care. Schonberg has overseen the transformative change and immense growth of the hospital’s facilities in the past decade that has been a boon to Ottawa’s community, influencing a significant improvement in health and medical treatment in the region.

The hospital now employs 1,900 employees and over 300 physicians on staff. It relies heavily on the help of the community, with 575 volunteers who donated over 45,000 hours of their time last year. Schonberg is quick to credit his team and the staff at the hospital and notes that one of the reasons for the hospital’s growth and continuing success is the commitment of its volunteers. “There are some exceptional people who volunteer their time to help us every day,” says Schonberg. “They really are the soul of this place and we genuinely appreciate their help.”

As for the mechanics of the hospital, QCH has state-of-the-art facilities including: two MRI units, two CT scanners, cutting-edge surgical suites with 10 operating rooms, a 12-bed ICU, a 15-bed dialysis unit, an acute rehabilitation unit and an Emergency Department and Ambulatory Care complex. Schonberg also established the Irving Greenberg Family Cancer Centre as well as the James Beach Health Care Centre.

Schonberg’s latest QCH venture is participation in the Acute Care for the Elderly (ACE) initiative. The ACE program aims to serve the growing elderly population in Canada. It is a collaborative enterprise that includes 18 hospitals across the nation, one of which is the QCH, making it one of the leading institutions for geriatric care in Canada.

About 15 per cent of the city’s population is over the age of 65 and that number is expected to double over the next 20 years.

Schonberg told Ottawa Life that in light of those statistics, “an innovative approach was required in Ottawa when it came to geriatric care. What you don’t want is a risk of overcrowding hospitals especially with an ageing population, so it’s important to be respectful and to provide the appropriate care that is patient focused first.”

Schonberg noted that the cost of health care is a constant concern for any hospital, but it is essential at QCH that these concerns don’t trump proper patient outcomes.

The ACE unit at QCH is scheduled for completion by the fall of 2016.It has 34 beds, an interdisciplinary team to care for the various needs of aging patients, and a homey and comfortable environment.

“ACE is meant to address its patient’s particular needs efficiently so seniors and their families can avoid drawn out hospital stays. We have a plan for discharge that begins upon admission and allows for elderly patients to continue their care in the comfort of their own homes,” says Schonberg.

Another big challenge facing hospitals in Canada has been addressing the increase in mental health admissions. QCH has seen a 30 per cent increase in mental health admissions, a 55 per cent increase in substance abuse visits and a 25 per cent increase in patients diagnosed with mental health issues in the past decade.

Schonberg assures that Queensway Carleton is not shrinking from this challenge and will be there for patients in the community who require help.

“We have a campaign we just launched called Hopes Rising. I am hopeful that our community will support the campaign to raise $5 million to help the hospital continue to serve the growing mental health needs of the city.”

Based on his track record and relationship with the community, it’s probably a sure thing.

** Prior to coming to Ottawa, Schonberg was CEO of Bowmanville Memorial Hospital and Senior Vice-President of Toronto’s Riverdale. In recognition of his contributions to Queensway Carleton Hospital and broader community, he was awarded with the Order of Ottawa in 2014. In 2012, Queensway Carleton was awarded an “Accreditation with Exemplary Standing”, the highest honour given by Accreditation Canada.

What Kind of Health Workforce Will Be Needed to Serve Our Aging Population?

June 23, 2016 9:55 am
Nurse and elderly man spending time together --- Image by © Jose Luis Pelaez, Inc./Blend Images/Corbis

By Gregory Huyer and Ivy Lynn Bourgeault

We know that Canada’s population is aging. Among the many statistics that have been reported is how in 2015, the proportion of Canadian seniors surpassed that of youth under 15 for the first time. The gap will continue to widen over the next 20 years.

There has been much discussion about how to prepare for this bulge of aging baby boomers. Indeed, there has been no shortage of media and policy reports on this topic.  These include aging strategies, dementia strategies, aging-at-home strategies; home care strategies, integrated care strategies, end-of-life strategies and more.  While most of these are well thought out, they frequently overlook one very important implication: what kind of health workforce will be needed to deliver on these strategies?

If we are serious about preparing for an aging population, we need to get the health workforce right and ensure the capacity of caregivers to deliver the care that is needed.

The health workforce is the “elephant in the room” at health policy tables – a large, pervasive issue that unfortunately often goes unaddressed.  The health workforce is a pillar of the health system and so like the foundation of our homes, it can sometimes go unnoticed. But if we plan on reforming services (i.e., renovating our home), we are going to have to attend to whether the health workforce foundation can support the changes. Failing to address foundational health workforce issues can leave otherwise thoughtful policy initiatives without a basis from which to succeed.

A common theme in recent policy initiatives is the promotion of aging at home to reduce the pressure on institutional long-term care. This also responds to a general preference in the aging population to stay at home as long as possible.  While this is a laudable goal, shifting the delivery of care from institutions to the home has significant impacts on the health workforce in terms of who will provide this care, how they work and the number of workers needed to provide the care required.

Ivy Lynn Bourgeault -- expert advisor with EvidenceNetwork.ca, Professor in the Telfer School of Management at the University of Ottawa and the CIHR Chair in Gender, Work and Health Human Resources.

Ivy Lynn Bourgeault

The health workforce for both institutional long-term care and home care includes nurses but largely includes care workers that are known either as personal support workers or health care assistants or other similar titles. Informal or unpaid caregivers – spouses, children and friends – also play a significant role, filling the gaps left by the formal care system.  The vast majority of caregivers (both paid and unpaid) for older adults are women, so gender issues are important considerations that need to be taken into account.

Taking care to the home can increase the burden on informal caregivers, exacerbated for those in the “sandwich generation” who are supporting their own children while caring for aging parents.  The social and economic implications of overburdened informal caregivers are rarely acknowledged in any tangible way and yet represent a very important element of health workforce planning for our aging population.

What of the formal health workforce? Do we have sufficient numbers and competently trained workers to meet the care needs in the community? The health needs of seniors are getting more complicated because people are living longer, resulting in higher rates of dementia and multiple chronic conditions. We need a workforce that can keep up with this.

Undertaking such thoughtful health workforce planning is complicated by the dearth of information about the health workforce, particularly when it comes to unregulated health workers who provide the bulk of care.  Only two provinces – British Columbia and Nova Scotia – have registries for their unregulated health workers to track information on employment and training.  Ontario’s registry was shut down earlier this year due to concerns about data quality, and Alberta is planning to launch a registry this fall.

Gregory Huyer is a Masters student in the Health Systems program in the Telfer School of Management at the University of Ottawa.

Gregory Huyer

And for health professionals such as doctors who are not used to making house calls, it means an important culture change in practice habits as well as revised payment models to encourage these changes.

So, how can we get policymakers to recognize the elephant in the room and take health workforce considerations into account when developing and implementing policy changes?

One solution is a health workforce impact assessment tool that can be applied to all new health policies.  Such a tool could be structured around two guiding questions: (1) does the policy mention/address health workers, professionals, caregivers? and (2) are the health workforce implications of the policy highlighted, including recruitment, training, distributing, retaining, motivating and managing?

A useful precedent for such a tool comes from Australia, where a health workforce impact checklist was created to apply to all health policies as they are developed. A call for greater health workforce impact assessments was also a key element of the Global Human Resources for Health Strategy 2030, recently passed in the 69th World Health Assembly this past week.

If we really want to be prepared for the care needs of our aging population, we need to get better at addressing the health workforce foundation of our care system.

Gregory Huyer is a Masters student in the Health Systems program in the Telfer School of Management at the University of Ottawa. 

Ivy Lynn Bourgeault is an expert advisor with EvidenceNetwork.ca, a Professor in the Telfer School of Management at the University of Ottawa and the CIHR Chair in Gender, Work and Health Human Resources.  Gregory and Ivy are members of the Canadian Health Human Resources Network 

Inner City Children’s Vision Is Being Left Behind

June 22, 2016 12:40 pm
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Why Ontario needs a universal vision screening program for preschool children

By Anand Bery and Wynn Peterson

We can remember many of them, leaning forward, almost off their tiny kindergarten-sized chairs, squinting with one eye to try and make out a rather large ‘H’ or ‘O’ on a chart across the room. We saw them try to cheat by uncovering their other eye or slyly turning their head to one side.

They are frustrated that this letter game is so difficult, and so are we. How could it be that we, volunteers at an outreach vision screening program in Toronto, are the first to pick up potentially significant vision problems in these children?

The program we run, Kids2See, is one of the few community vision screening programs for kindergarten-aged children in Ontario. Kids2See is a volunteer-based program run through the University of Toronto’s Faculty of Medicine which aims to screen kindergarten children primarily for amblyopia.

Amblyopia, sometimes called “lazy eye,” is a relatively common condition present in up to five percent of children that develops when the eyes are misaligned or one eye needs glasses much more than the other. It can lead to permanent vision loss if not treated early in life.  With early treatment, children can easily regain much of their vision.

This is where our screenings come in. They are run entirely by volunteer medical students, under the supervision of a licensed optometrist. Each of us is concerned with the lack of accessible vision care in our city and we donate time out of our schedules to try and fill this gap. Our annual funding budget consists of only $350, which the medical student society provides to all outreach groups.

While we are screening principally for amblyopia, we also pick up on children’s general vision difficulties, which can markedly impair their social and cognitive development. Up to 80 percent of learning in the preschool age is visually-driven, and children are highly unlikely to realize their own vision is poor.

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Anand Bery, contributor to EvidenceNetwork.ca, a second-year medical student at the University of Toronto, he is also co-director of Kids2See.

At the small number of inner city schools we target, all of which are deemed high needs by the Toronto District School Board, a staggering 41 per cent of the children we screen have never had any type of eye examination.

As part of our program, we are conducting a research study to better understand barriers to vision care in early childhood. While this work is still in progress, we have noticed a disturbing – and statistically significant – trend. Children from low-income families are less likely to have ever had their vision checked than children from high-income families.

The Canadian Pediatric Society recommends a sequence of eye examinations throughout childhood up to the age of 18. Children with regular access to family doctors, pediatricians or optometrists may be receiving this kind of care, but the results of our survey suggest that this is far from a universal reality.

Why doesn’t Ontario’s supposedly universal healthcare system include vision screening for amblyopia?

Ontario lags behind other provinces, such as British Columbia and Nova Scotia, which have universal screening programs in place to detect amblyopia in young children. Ontario could also follow the example of Sweden, which has a well-thought-out nationwide screening program for amblyopia in preschoolers and has an uptake of over 99 percent.

Many resources exist in Ontario via our publicly-funded system to address vision health, but they are a messy patchwork – disorganized and uncoordinated. For example, the Toronto District School Board has programs for screening children in Grades 4-6, but by that age, while it may be helpful for simple near-sightedness or far-sightedness, it is too late to effectively treat amblyopia.

OHIP covers eye exams for all children under 19 years of age, but parents need the time, resources, and awareness to know that these examinations are an important part of promoting their child’s health. As we have experienced first-hand, most parents at the Kids2See visits are not managing to make use of these resources – with potentially serious consequences for their children.

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Wynn Peterson. Contributor to EvidenceNetwork.ca, second-year medical student at the University of Toronto, she is also co-director of Kids2See.

In decades past, nurses from Toronto Public Health would visit schools to check every child’s vision. But now, like the school nurse and cafeteria milk programs, that initiative is a relic of a bygone era.  Provincial budgets not focused on preventative care are to blame.

An article in the medical journal, The Lancet from last year advocates for population-wide screening for amblyopia at age four or five. We could not agree more.

Ontario needs a universal vision screening program for preschool children.  Maybe then so many children in Toronto wouldn’t have to rely on volunteers to check their vision.

Anand Bery and Wynn Peterson are contributors to EvidenceNetwork.ca and second-year medical students at the University of Toronto.  They are co-directors of Kids2See, along with Omri Arbiv and Heather Dunlap. 

From Hockey Player to Chiropractor

June 1, 2016 1:51 pm
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For a short time in chiropractor Karlo Pavich’s life, playing hockey was all he ever wanted to do.

During his youth, Pavich lived that dream. From the age of 16 until the age of 23, Pavich skated his way into the professional hockey circuit. In his early years, Pavich played in minor hockey and eventually broke into the Central Canada Hockey League as a #1 pick and the Quebec Major Junior Hockey League. Pavich turned his junior career into a professional career in Europe. After living there for a few years, Pavich received an invitation to try out for the Montreal Canadiens.
Hockey Player to Chiropractor – image 3As a child, the Ottawa South team Pavich was playing for went on an exchange to play a Montreal team under the chaperone Jean Beliveau. That evening, Pavich watched his first and only NHL game and met player Mario Tremblay. He promised himself at that tender age that the next time he was in the Forum, he would be wearing a Montreal Canadiens jersey. Ten years later, he kept that promise and wore that jersey, albeit only for a few weeks.

Not long after, Pavich began studying at the National University of Health Sciences in Chicago and graduated at the top of his class. After his studies, Pavich returned to Ottawa and immediately opened his practice, Atlas Chiropractic and Massage Therapy.

Pavich’s practice is welcoming and open. The waiting room walls are adorned with backstage passes for bands he has worked on, along with autographed sports memorabilia. Pavich’s patients typically hear about his clinic by word of mouth. While he has worked on big names, Pavich takes pride in being a family-friendly clinic.

“Chiropractors adjust and rid the spine and extremities of subluxations or distortions,” Pavich explains. “These distortions in the supporting structures of the body that support spinal vertebrae cause a stress response in the brain. Every time we adjust a patient, there’s a direct effect on brain chemistry, which allows the brain-body connection to adapt and heal. The body is a self-healing and self-regulating entity.”

Pavich adds that his practice uses gentle hands-on techniques, as well as additional modalities to add to the patient’s experience and treatment value, including the use of Intersegmental Traction and Hydromassage tables.

“EVERY TIME WE ADJUST A PATIENT, THERE’S A DIRECT EFFECT ON BRAIN CHEMISTRY, WHICH ALLOWS THE BRAIN-BODY CONNECTION TO ADAPT AND HEAL.”

Pavich is passionate about providing quality care for his patients. He tells the story of a young patient who was having difficulties learning and concentrating at school. With the help of a chiropractic treatment plan,  Pavich worked on the child to develop better focusing skills. Today, the now-teenaged patient is an aspiring golf player.

“My patient’s story is one of many little miracles, as I like to call them, that happen daily across this city and this country in chiropractic offices,” Dr. Pavich says. “Having a healthier community is what really motivates me to assist my patients, their families, friends, and coworkers. We all have a purpose in life, and hockey was my stepping stone to hone my eye-hand coordination and concentration to do and practice what I do today, and that’s being a Chiropractic doctor.”

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You can find out more about Karlo Pavich at atlaschiro.ca.

Health Systems Around the World

October 30, 2015 10:20 am
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By Kathleen O’Grady

Comparing the performance of health systems around the world just got a little easier.

One morning, the media headline pronounces Canada’s health system should model that found in the Netherlands; the next week, we should follow Germany’s example, and yet another says Australia is leading the pack. Then there are the inevitable comparisons to the U.S. health system.

Think-tanks, politicos and pundits regularly weigh in with perennial favourites for how to improve Canadian healthcare. Such media coverage is often weighted with viewpoints steeped in ideological or economic vested interests. So, who can we believe?

Health systems are complicated. Journalists covering the issue often struggle – on short timelines – to gain enough knowledge of complex international health systems to ask the critical questions. But that’s about to change.

Now, health journalists from several countries are teaming together to create a free resource for journalists covering health systems and health policy issues from around the world. It’s journalists helping journalists, in other words.

The Panel of International Journalists was the brain child of U.S. health journalist, Trudy Lieberman. Liberman partnered with Dr. Noralou Roos, Professor of Health Policy at the University of Manitoba, and founder of EvidenceNetwork.ca, a non-partisan resource that creates original content for the mainstream media on health policy issues by bringing together health policy academics and journalists in partnership.

“Health reform is always a hot topic in Canada,” says Roos, “and often journalists are required to assess the quality of a source or a resource that compares our health system to those in other countries. It’s not an easy task, and certainly not on a deadline.”

Lieberman, who took part in a cross-Canada speaking tour at the invitation of EvidenceNetwork and as part of her Fulbright Fellowship in 2013, had a solution. Instead of just using the expertise of health policy experts, who aren’t always media savvy or available on media timelines, why not create a learning opportunity with seasoned health journalists working in the field around the world?

“The idea is for journalists covering healthcare to begin a dialogue with colleagues in other nations and learn from each other,” says Lieberman. “We also hope that this international exchange will foster the development of deeper and more informed health news stories.”

The Panel of International Journalists, with representation from Portugal, Italy, the United States, the United Kingdom, Australia, the Netherlands and Canada, have volunteered with EvidenceNetwork.ca to serve as resources for other journalists covering health systems they may not be familiar with. The individuals on the Panel are able to provide support and information on topics about patient safety; the rising cost of medical care; the marketing, pricing, and regulation of drugs and medical devices; and the workings of health insurance arrangements in their home countries.

The Panel is also available to health experts who are non-journalists, but who are searching for information about healthcare in other countries.

“It’s part of our on-going effort to raise the quality of health policy journalism,” says Roos, “by bringing academics and journalists together so they are on the same page, (they) understand each other’s needs and can inform each other’s work.”

Evidence Network has previously brought health policy experts and journalists together by creating original content for the mainstream media, including publishing hundreds of op-eds every year since their inception in 2011, in the largest media outlets in the country and internationally. They also have a regular podcast series on health policy issues and create media backgrounders on controversial health policy topics “so that journalists can quickly find the facts without the spin,” says Roos.

As with other EvidenceNetwork.ca projects, any material created from the International Panel is posted to their website with a Creative Commons license so that anyone can reprint the material with proper attribution.

“There is so much misconception about other nations’ health systems,” says Lieberman, “this Panel of International Journalists can be a resource for helping to set the record straight.

unnamedKathleen O’Grady is a Research Associate at the Simone de Beauvoir Institute, Concordia University and Managing Editor, EvidenceNetwork.ca. She lives in Ottawa, Canada. You can follow her on twitter at @kathleenogrady

 

The Digital Expert Will See You Now

September 9, 2015 11:01 am
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Why doctors and digital experts should work together to improve patient health 

As a family doctor, I have seen a dramatic shift in the range of people I work alongside every day – all for the better. When I was in training, most family doctors worked only with other family doctors and registered nurses. Today my health care team is rich with a variety of skilled people, including social workers, psychologists, chiropodists and dieticians. There are even examples of primary care teams engaging lawyers and accountants to help with health-related issues, such as housing and income.

But what’s missing – and should be an essential part of any healthcare team – is the digital expert. Here’s why.

Health care has been consistently changed by technology for decades. Historically, however, the change has been driven from within the healthcare system. PET scans, laparoscopic surgery, interventional radiology, digital imaging and electronic medical record systems are just a few examples of technological changes we now use routinely.These advances have been large scale, top down and expensive.

Now three relatively low cost, consumer owned, technological innovations are changing the game.

First, smartphones with a plethora of apps devoted to healthcare improvement, including those related to exercise, diet, chronic disease management and mental well-being, are ubiquitous among almost every demographic. Second, medical devices such as glucometers, scales and blood pressure cuffs are increasingly digitized and able to hold significant amounts of patient specific data. Finally, wearable technology, including watches, exercise bands, clothing and glasses, is exploding in popularity.

These technologies are even starting to merge as smartphones become medical devices capable of monitoring a person’s heart rate, heart rhythm, respiratory rate and oxygen saturation, among other critical health indicators.

Yet these important new technological innovations exist outside of my day to day family practice. The thousands of health related data points captured by these three types of personal technologies are not yet part of the health system. They should be.

Currently I rely on isolated data points and rough estimates. I take a blood pressure reading the day I see a patient, and I ask them how much alcohol they drank that week, what they tended to eat that month and push them to estimate how often they have exercised since our last visit. What I get are data points that reflect moments in time and the best efforts of an individual’s memory. Yet the information I need to help guide their care is often already nested in their smart phones, medical devices and wearable technologies.

But here’s the problem. Despite a steady growth in electronic medical records – and, simultaneously, patients investing in health-related personal technologies — the two worlds of technology can’t routinely talk to each other. Currently I may have a patient print out the results from their medical devices or apps and then scan the information into the medical chart as a static document.

Here’s what the future needs to look like: When patients come for their regular appointments, the first person they meet with should be a digital expert on the healthcare team. She has the ability to securely and quickly upload all the data from their various devices into the medical record in a manner that can be appropriately integrated, searched, displayed and programmed to show trends over time.

When the doctor – or any other member of the healthcare team – sees the patient a few minutes later, we now have days, weeks and months of helpful health information.

The digital expert on the team would offer far more than just synching devices at the appointment. They would be available to help link devices and apps remotely to a medical record without the patient even needing to come into the office. They could also act as a resource to help guide patients through the growing morass of choice in the wearable, digitized and app laden world of health care. They could also be key leaders in the research and evaluation of this emerging area.

Better data can improve healthcare decision-making and contribute to better quality care.

Patients already believe this, which is why they invest time and energy in collecting their health data. It’s time to take better advantage of their efforts – and a digital expert on the health team can help.

Tepper_Joshua_HIGH RESJoshua Tepper is a family physician at St. Michael’s Hospital and Associate Professor at the University of Toronto.

It Shouldn’t Matter Where You Go To School, But For Kids With Diabetes, It Does

August 11, 2015 12:00 pm
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Provinces, school districts need to adopt comprehensive diabetes policies now

Summer is a time to put thoughts of school aside, but some families are already worrying about September.  For parents of kids with diabetes, the beginning of each new school year brings not only the usual preparations, but also fears for their child’s health and safety.  This is especially true if their school or school district does not have a policy to ensure staff are knowledgeable about diabetes, know how to prevent emergencies, and are able to assist students with daily diabetes tasks, when needed.

Type 1 diabetes affects more than 34,000 Canadian children under the age of 19; another 1,800 have type 2 diabetes. Type 1 diabetes is when the body is unable to produce insulin, a hormone that controls blood sugar. It has no known cause or cure and usually begins in childhood.  Type 1 diabetes is the most common diabetes in children.

Type 2 diabetes is the most common among all people with the disease, where the body either cannot effectively use or produce enough insulin. Type 2 diabetes usually develops in adulthood, although more children and adolescents are being diagnosed.

Most students can manage their diabetes independently or with minimal support, and they can fully participate in school activities, including gym classes, field trips and celebrations. However, some, especially very young children with type 1 diabetes, may need trained personnel to help administer insulin, monitor blood sugar levels or supervise food intake and activity. Students with diabetes may also need flexibility in school rules to prevent low or high blood sugar, and may also need help with recognizing “lows” and “highs.”

A supportive school environment is critically important for keeping children with diabetes safe and healthy.

Proper diabetes management reduces the risk of life-threatening emergencies, prevents or reduces the risk of serious long-term complications such as heart disease, limb amputation, kidney failure and blindness. It also ensures that students with diabetes are able to learn and participate fully in all school activities. Yet only five provinces have guidelines for children with diabetes at school:  Newfoundland and Labrador, New Brunswick, Nova Scotia, Quebec and British Columbia.

Ontario recently formed a working group to address this issue and other jurisdictions have signaled their interest in forming such policies, but change has not been implemented as of yet. At the school-board level, some boards and even individual schools have developed policies, leading to a patchwork of different care standards among school districts, and even among schools in the same district.

Many schools and districts have no diabetes policies in place at all.

It is important that all children with diabetes be afforded the same protections and given the same opportunities to succeed, no matter where they live or attend school.

It is a team effort to enhance the health, safety, emotional well-being and participation of each student with diabetes. Parents and guardians need to notify the school of the diagnosis and meet with the school to develop an Individual Care Plan (ICP). School personnel need to participate in annual diabetes education, training and resource review to learn how to manage diabetes, including emergency procedures. Healthcare providers act as resources to the schools and assist in creating the student’s ICP.

But perhaps, most importantly, our provincial governments need to make proper diabetes management at school a priority now.

Every province and territory should establish clear standards of care that school boards can follow to ensure the safety, health and optimal education for children with diabetes. In the interim, school boards can begin the process of creating pragmatic guidelines such as those outlined by the Canadian Diabetes Association so that diabetes care across regions is equitable, safe and organized. Clear and consistent policies are better for the schools, better for families and provide an open and transparent process for communities to work with.

Finally, everyone should work to prevent students with diabetes from experiencing stigma and discrimination by promoting a positive, caring and inclusive learning environment through communication, education and cooperation.

By Jan HuxJan Hux

Dr. Jan Hux is an expert advisor with EvidenceNetwork.ca and Chief Science Officer for the Canadian Diabetes Association.

 

 

 

Is Waiting Longer for New Prescription Drug Approvals Necessarily a Bad Thing?

July 30, 2015 3:00 pm
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Why Canada’s ‘slow and low’ approach to new pharmaceuticals may be the prudent approach.

The newest report from Canada’s brand name drug makers on access to new drugs has one key message: compared to other countries, Canada goes slow and low.  New drugs are slower to be covered by our provincial drug plans and the numbers of people who get access to new drugs are lower than in other countries.  The report is undeniably negative: Canadians are suffering because our governments don’t provide timely access to new medicines.

Produced by Rx&D (the association of Canada’s brand name drug manufacturers), the report ranks Canada 17th out of 18 industrialized nations in terms of new drug reimbursement—with only 23 percent of new medicines covered across the country (it is closer to 90 percent in the U.S.).  As far as the time it takes between when a drug gets approved by Health Canada and when the provinces start paying for it, Canada ranks 16th of 18 countries.

Canada’s drug makers believe that drug plans in Canada should be more generous and access should be simplified so when new and innovative medications come along—those to conquer cancer, heart disease or other life-threatening conditions—government health plans should quickly pay for them.  After all, if they extend the length and quality of our lives, we citizens deserve them, right?

But here’s the rub: what prescribers know about the potential benefits and harms of a new drug when they arrive on the market is often uncertain or problematic. Often new drugs are studied for a shorter period of time and with a very specific population, so end up with biases, there’s sometimes unpublished data and frequently we don’t have a full sense of the overall safety of the drug in the real population.

Canada is not wrong to be prudent in taking our time to decide how, or if, a new drug needs to be covered—a precautionary approach is just the smart way to go. Take for example the widely prescribed arthritis drug Vioxx, which caused as many as 60,000 excess heart attack deaths in North America according to some estimates.  Those Canadian provinces who were more restrictive in covering it (such as BC) likely had proportionally fewer deaths caused by the drug.

Lately we’ve heard a lot about cancer in Canada from a new report that says the number of new cases of cancer will rise dramatically over the next 15 years.  The rise in cancer rates will be due mostly to baby boomers acquiring more diseases of aging, says the report—and this will drive the demand for more and more effective cancer drugs.

But there is plenty to suggest caution in approaching this new reality.  A recent article in the British Medical Journal by two noteworthy pharmaceutical industry analysts, Donald Light and Joel Lexchin, made the case that cancer drugs are often rushed to market and have faster approvals even when they provide very little gain for patients.

Their study, “Why do cancer drugs get such an easy ride?” examined  nearly 9,000 oncology clinical trials conducted between 2007 and 2010 and compared those studies to drugs for other diseases. They found that cancer drugs were almost three times less likely to be evaluated in randomized studies or tested against comparator drugs, and were more likely to be ‘fast-tracked’ in approvals than other drugs, casting doubt on the long-term benefit and safety of the drugs.

Then there’s a little bit of sleight of hand around what’s being measured.  Does it matter if a clinical trial of a new cancer drug gets approved because it changes a surrogate outcome (that is, it shrinks a tumour) as opposed to doing something meaningful (such as making the patient live longer or healthier)?  The reality is that many cancer drugs can shrink tumours quite effectively (and expensively) but may not change the length of a person’s life, while possibly turning the last few months of a person’s life into medically-intensive misery.

There is some good news here because the age-standardized death rates from cancer have been falling quite rapidly in Canada. Compared to other industrialized countries, Canada has relatively good cancer care outcomes: above average survival and generally about average mortality compared with other OECD countries.

We all want access to newer and better drugs but could we better spend our cancer budgets towards an array of non-drug options that improve the lives of people with cancer?  Do we want to continue to allow expensive drug intensive therapy to eclipse all the other things we could do for cancer patients and their families?

Wildly expensive new cancer drugs are eating a growing share of our healthcare dollars and provinces are clearly voting with their budgets, going slow and low on approvals and coverage of new therapies.  Canada’s drug manufacturers are condemning us for this approach, but they’re wrong — regardless of how strenuously they try to paint Canadians as poor suffering underdogs with stingy and heartless healthcare systems.

Cassells_Alan_new high res-apr2012 5x7Alan Cassels is a pharmaceutical policy researcher in Victoria and an expert advisor with EvidenceNetwork.ca.

Why We Should Think Twice Before We Institutionalize National Pharmacare

July 17, 2015 11:30 am
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Amalgamation always seems like a good idea.  Greater Victoria has 13 municipalities, 13 councils, oodles of separate fire and police departments and multiple separate teams of garbage-persons, road fixers, parks maintainers and others that you need to keep our cities humming.  Which makes everyone ask:  Wouldn’t it be easier (and cheaper) if we just had one of each?  That’s right, “Let’s amalgamate.”

I don’t know much about municipalities amalgamating, but joining forces, preventing duplication and saving money has been suggested with something I do know about — pharmacare programs. Canada has at least 16 separate drug public plans – each of the provinces, plus ones for the RCMP, veterans, aboriginals and others, as well as hundreds of private drug plans.

Wouldn’t it also be easier – and cheaper — if we just had one national drug plan?

Earlier this summer, at least eight provinces got together to discuss a national drug plan. Cost-efficiencies, a better ability to negotiate drug prices and other economies of scale make it a compelling idea.  I agree.  Yet, I also agree that if done poorly, a national drug plan could be an utter disaster, characterized by waste, political coverage decisions and even more irrational and unsafe pharmaceutical use than we’ve got now.

Bigger does not always equal better; sometimes bigger means dumber.

Let’s take a major new drug to see how we might fare with a national drug plan. The diabetes drug Januvia (generic name: sitagliptin) globally earns about $6 billion per year for its manufacturer, Merck.  It costs about $3.50 per pill in BC and lowers blood sugar on par with older, cheaper diabetes drugs.

Proponents of a national drug plan would assert that with the buying power of one big agency, we’d negotiate much better prices for Januvia. Instead of paying $3.50 per pill maybe we could get it for $2 a pill which is about what Australia pays, seeing as they have national buying power.  Sound good?

It would be good only if Januvia had advantages over older, cheaper diabetes drugs.  Sadly, independent experts say that drugs like Januvia are less effective than older diabetes medications.  So are they more dangerous?  A trial published in early June tested the drug in 14,000 people over three years and found it wasn’t any more harmful than “usual care” plus placebo.  This “non-inferiority” trial suggested that over three years Januvia won’t increase your risk of heart failure, heart attacks, death or cancer compared to placebo.  Hmm. Hardly a slam dunk.

Taxpayers in Ontario and in Quebec pay tens of millions a year for this drug.  And Canada’s private plans?  It’s a good chance if you get drug benefits through your employment, then you’re paying for Januvia as well.

For my tastes, the first priority of a national drug plan wouldn’t be price, but evidence.

If the best available evidence suggests that a new, more expensive drug like Januvia is in the “not better or worse than comparator drugs” category, you’d have strict rules to make sure the drug was only covered for the subset of people who can’t tolerate other diabetes drugs.  You’d use the money you saved to expand coverage for drugs that are cost-effective so that more Canadians can be covered for high drug costs.  These are the types of hard decisions you have to make when you’re facing the political power of one of the world’s biggest drug companies.

The BC government, just recently, made a hard decision when it decided BC Pharmacare won’t pay for Januvia.  Why?  Maybe given little evidence the drug could extend the quality or the length of a diabetic’s life and the fact that Merck refused to lower the price to bring it on par with the other DPP-4 inhibitors, the government made the decision not to kowtow to the lobbying pressure.

That’s the kind of spine that would be essential in a national drug plan.

Yet if you look at other federal health-related organizations (Health Canada, CIHR and CADTH) you find very poor models of national spine.  We have a watchdog that doesn’t bite, a national health research funder that encourages Canadian researchers to “partner” with drug companies and a technology evaluator that takes money from drug companies  in the form of ‘fees,’ thus making them beholden to the very industry they are supposed to assess.

Any national pharmacare program would need an absolute firewall to protect it from the inevitable politics of drug coverage, otherwise you’d be left with even more irrational and expensive drug coverage decisions.

Amalgamation in Victoria and a national pharmacare program both sound great in theory. But in practice?  Hmm, I am usually optimistic about doing things collaboratively and working for efficiencies but I’d hate to see Victoria lose its character or Canada to accidently create a national form of institutionalized drug coverage that can’t make hard, politics-free and evidence-based decisions.

Cassells_Alan_new high res-apr2012 5x7Alan Cassels is a pharmaceutical policy researcher, author and expert advisor with EvidenceNetwork.ca.  He lives in Victoria, BC.

Provincial Health Ministers Right to Push for National Pharmacare Program–But What Kind?

July 14, 2015 10:12 am
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Quebec’s outdated drug coverage policies should not be model for rest of Canada

In spite of very high expenditures for drug coverage, one in 10 Canadians cannot afford to fill their prescriptions. The current patchwork of public and private plans across the country means that Canadians are covered for their prescription drugs based on where they live or work, rather than on their medical needs.

Eight provincial health ministers organized a roundtable with healthcare professionals and academic experts on June 8 to discuss how we should transform drug coverage in Canada and several are now calling for a national pharmacare program. The question now is, what kind?

The suggested reforms discussed were based on international best practices, which overwhelmingly emphasize a single payer universal public drug coverage system equipped with the institutional capacity to ensure value for money. The evidence consistently shows that such a system would provide better access while substantially reducing costs.

Nevertheless, private insurers, the drug industry and some think tanks are advocating for the implementation of Quebec-style hybrid private-public drug coverage for the rest of Canada. Here’s why this won’t work for Canada–because it no longer works for Quebec.

In 1997, Quebec created a drug coverage system where it is mandatory for workers to enroll in private plans when they are available. Those for whom no private plan is available end up on the mandatory public plan. Thus, all Quebecers are covered by some form of drug insurance. Premiums can be very expensive, and patients still have to pay out-of-pocket a maximum copayment of 32.5 per cent when purchasing prescriptions, which can add up to more than $1,000/year.

What has been the result of Quebec’s hybrid model? Access to medications improved when the plan was implemented, but by keeping a fragmented system based on multiple public and private plans, Quebec has not developed the needed institutional capacity to contain costs. Canada has the world’s second-highest per capita costs for prescription drugs (only after the United States), and Quebec has the highest costs per capita among all provinces.

Twenty years ago, Quebec’s system was a great step forward, but it is certainly not a model for the 21st Century. While it did provide better access to prescription drugs, the system remains inequitable, inefficient and unsustainable, according to a recent official report by Commissaire à la santé et au bien-être.

Inequity persists in the Quebec system because the prices of drugs vary between the public and private plans. The public plan tends to balance its budget by shifting costs onto the shoulders of private plans rather than containing its costs. Since insurance companies are paid as a proportion of spending, they rarely complain.

So who pays? Employers and employees end up paying steep premiums. This increases labour costs and reduces the competitiveness of Quebec’s businesses.

Mandatory private coverage is also not related to income, so the costs can be substantial for some — especially the working poor. I was shocked when a student working part time told me that she had to pay $190 of her $514 net monthly income on drug premiums.

There’s also the systemic issue of institutional ‘skimming’ between “good” and “bad” risks. Seniors, people on social assistance, or unemployed end up on the public plan while those with a “good job” (the wealthier and healthier population) enrol in private plans.

Then there’s the inefficiency. For decades, private plans remained fixed on the idea that a “good drug plan” covered all new drugs at any cost, even when a lower cost alternative was available. Considering that the majority of new drugs do not provide therapeutic benefits over existing therapies, drug plans without the capacity to evaluate cost-effectiveness become a major source of waste. A good drug plan also requires the capacity to negotiate with drug companies to obtain better prices. Can you really negotiate prices if from the start your position is to pay for any product whatever the price?

When you look at the numbers, it really is surprising that all public employees in Quebec are required to enrol in costly private coverage given that administration costs account for 1.7 per cent for Quebec’s public plan, yet 18 percent for private insurers. In fact, more than 30 per cent of all people enrolled on private plans are public employees. This is a massive indirect subsidy to insurance companies, in addition to tax subsidies offered by the Federal Government, which represent 13 per cent of expenditures by private drug plans.

In a presentation last November, former health minister Jean Rochon, who implemented Quebec’s drug regime 20 years ago, said that, at the time, such a hybrid model was the right thing to do, but added that the system is now outdated and we needed to move on to tackle the new challenges relating to drug coverage.

The question, he said, is not “if,” but “how” we should implement universal public drug coverage for everyone.

Corporate lobbies and doubt manufacturers are working very hard, however, to tout Quebec as a model for the rest of Canada – against the best evidence.

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Marc-André Gagnon is an expert advisor with EvidenceNetwork.ca and assistant professor with the school of public policy and administration, Carleton University. Follow him on twitter at @MAG_Rx.

 

 

 

What Do Canadians Need from Pension Reform?

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A gentle policy nudge to enhance coverage and pension contributions—here’s how.

 Pension reform continues to hold interest across the country, especially given the willingness of the federal Conservatives to at least talk about expanding the Canada Pension Plan (CPP). Pundits and politicos are weighing in now with blunt talk of ‘voluntary’ or ‘mandatory’ enhancements to CPP. Neither may be exactly what Canadians want. Here’s why.

What do Canadians want out of a national pension system?old-people-616718_1280

I think it’s safe to guess they want at least the following: a system that
can be trusted, the lowest cost possible, high rates of return on investments, but within a range of prudent safety, transparency and a governing process that puts the interests of the plan participant (and not agents) first and foremost.

More importantly, perhaps, they want a system that will stay with them even if they change jobs and employers — turning savings into monthly cheques in retirement, until death.

So who is at retirement income financial risk today? A large number of workers.

We know only 32 per cent of workers have workplace pensions of any type. In the private sector, only 24 per cent of workers have anything. Further, the superior Defined Benefit Plan coverage is down everywhere.

We also know that very poor workers should not be forced into a mandatory system. Why? Because, after paying their mandatory contributions, they will receive very little to no extra benefits because of the claw back provisions in our Guaranteed Income Supplement (GIS) (usually alongside provincial supplements). In fact, the working poor can easily lose a full dollar for every new dollar of monthly income they produce on their own. Not to mention that the Old Age Supplement (OAS) and GIS benefits, now payable at age 65, will not be paid until age 67 starting in 2029.

Can we provide Canadians with a better system? The answer is a hearty, YES, although it will take some will on the part of legislators, both federal and provincial, since Pension Benefits Acts and the Income Tax Act will have to be amended.

Here is how it would work. The government makes it possible for institutions and agencies to create large pooled Retirement Income Funds to which any worker can contribute (within some tax limits). After a very short establishment period, these funds must achieve a minimum size (at least $10B in short order but even larger later). The funds must have a Board of Directors of experts who will guarantee good governance and guarantee that the plan participants’ needs are paramount and more important than any agent within the system. Expense ratios will be capped (and policed). 40 basis points (0.40%) seems appropriate since many larger pension plans today operate with expense ratios below 25 basis points.

You would be automatically enrolled, with an automatic payroll deduction if you are not in a Registered Pension Plan — but you can take action to opt out. This ‘nudge’ (according to the evidence) should result in ultimate participation rates in the 80 to 90 percent range. But, it will also allow poorer workers to opt out, as they should.

You and the fund will decide on your retirement income goal stated as a Defined Benefit. From this goal, one would subtract the benefits anticipated from OAS and CPP. The balance is what the fund is meant to provide.

Using slightly conservative actuarial assumptions as to rates of return and life expectancy, the fund will decide what contributions are necessary to attain your goal. Every year you will get a statement showing the record of the fund over the past year and whether you are ahead or behind the projected values necessary to reach your goal.

At retirement, you will continue in the fund and it will pay your monthly benefit cheques. Behind the scenes, the fund can carry the longevity risk of the group (not very volatile given the size requirements of the fund) or they can buy annuities (on a group basis — more competitive than for individual annuities).

Your benefits will be highly probable as to their attainment, but they will not be fully guaranteed. If we have another 2008 financial meltdown, you may face a short- term decrease in benefits. Note that what you get is a monthly benefit for life, not a lump sum at retirement.

Who can offer such a fund? Anyone who can meet the capital requirements – likely any banks, insurance companies that exist today could expand into this activity. But, also, large pension funds would be invited to offer this product.

It can be done. It just requires some imagination and a few (but important) tweaks to existing pension and income tax laws. Canadians want this. They deserve no less.

Brown_Rob.High resBy Robert L. Brown

Robert Brown is an expert advisor with EvidenceNetwork.ca, a Retired Professor of Actuarial Science, University of Waterloo and Immediate Past President of the International Actuarial Association.

 

Canadians Care About Healthcare—So Why Don’t We See More Health Policy Coverage in the News?

July 8, 2015 10:03 am
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For the last 30 years or so, Canadians have repeatedly flagged healthcare as the most important national concern and the issue they want their political leaders to prioritize. Surveys and studies and polls and panels—there have been plenty—all come up with the same finding: Canadians care about healthcare.

That doesn’t mean we are satisfied with the healthcare system we have. These same data sources show that Canadians often have concerns over health care quality, timeliness and availability, and we frequently believe we are not getting the best healthcare bang for the buck. But one thing holds fast: Canadians want their health system to remain universal, publicly financed and based on need, not income.

How healthcare is delivered in this country, to whom, where, and even how health providers are paid for health services is often the subject of vigorous debate. Whether it be public delivery, private, for-profit delivery or variations on private-public-partnerships—this is the stuff of heated polemic. This debate can be partisan with preferences frequently drawn down party lines and with differing perspectives across regions. But polls show that the vast majority of Canadians—across the political spectrum—continue to value our single-payer system (medicare) to cover the costs for essential health services for all Canadians. Many pundits have pointed out that this viewpoint is so pervasive and long-standing that it is no longer just a Canadian preference, it has become a Canadian value.

Nevertheless, we’ve had some significant changes to our health system in recent years. These include court challenges on how medicare operates, substantial alterations in federal government funding formulas used to determine critical healthcare dollars and a variety of changes in what is classified as an “essential health service” from provincial and territorial governments. There have also been systemic reforms in hospital funding in many regions—not to mention shifts in health human resource availability and changes in technology (screening and pharmaceutical) that disrupt the traditional healthcare landscape. Then there’s the perpetually evolving social and economic terrain that indirectly affects both our public policies and our health status, such as our aging population, growing economic inequities, challenges for affordable housing and childcare, among others.

All of this should be big news, right? Not so fast. It is terrifically strange to see health policy issues so important to Canadians frequently absent in media coverage. So where’s the news?

Changing media landscape

The media landscape has changed dramatically over the last several years with legacy media outlets being elbowed from the front of the pack by new online media sources with agile operations (unhampered by the restrictions and costs of a print medium) and nimble economic restraints (frequently engaging non-unionized, young recruits). At the same time, Canadian patterns for media consumption are changing in a now predictable fashion: the dwindling of print broadsheets and magazines, particularly in the youngest demographics, and a steady upswing in the use of tablet and mobile devices to access both traditional and new media stories.

But there are some constants. Turns out, Canadians continue to be immersed in media stories about sports, the economy and the weather, in that order. How much might surprise many.

According to 2014 metrics, there were 10.9 million news items last year in Canadian media outlets (across mediums), and a whopping 37 per cent of those stories were sports-related. (Perhaps less surprising is that coverage of the NHL constituted 44 per cent of all Canadian sports news). Measured another way, of the top 50 news stories of 2014, 21 were related to sporting events.

Canada also has the dubious honour of covering weather in the news 229 per cent more frequently than other countries. Let’s not forget the economy and mostly national and regional (not international) politics. Nearly half of all of our media stories last year were about sports, politics and the economy. You throw weather in there, and there’s not room for much else.

Why does this matter? It’s when you get to the bottom layer of data–the scrapings on the floor–that you find that the least covered news stories in Canada might be the most important. Turns out, we spend the least amount of media time on stories that address poverty, the elderly, education, childcare and aboriginal issues. These five issues amount to less than one tenth of the space devoted in the Canadian media to cooking, says one recent report.

Health content does slightly better, but constitutes a minor blip of just over two per cent of all media stories.

In other words, we are all too frequently entertained—and not educated—by our media outlets. The stories that help us understand what influences public policy and the factors that determine our health status—the so-called social determinants of health—are left largely untold. ‘Health policy’ writ large may be a topic of interest to Canadians, but it is not an easy sell for the media.

On the whole, it seems health policy issues are absent or thinly covered by the bulk of media outlets (television, radio, print and online) now available to the public. This is not the fault of journalists; Canada has some exceptionally talented public health reporters, including the Globe and Mail’s André Picard, Vox’s Julia Belluz, the National Post’s Tom Blackwell, Hamilton Spectator’s Steve Buist, Winnipeg Free Press’ Mary Agnes Welch and freelancer Ann Silversides, to name just a few.

But since media outlets are struggling for survival, competing for precious ad dollars and strapped to meet the changing demands of a highly techno-savvy audience, policy rich stories are often left by the wayside. It is a constant struggle for health policy stories to compete for space in the media with sports, celebrity, economics and the weather — and ‘clickbait’ stories with snappy headlines and ever shorter, punchy narratives too often take over.

EvidenceNetwork.ca has tried to mitigate this reality and inject more health policy content into the news. How?

Partnership between journalists and health policy academics

Since 2011, we’ve worked to create a dialogue between Canada’s journalists and academic health policy experts to enrich the quality and quantity of health policy stories in the Canadian media. We work with a Media Advisory Board made up of journalists and professors of journalism from across the country who let us know what their needs, constraints and objectives are from a journalistic perspective. We also have a network of more than 80 health policy academics who are ready and available to be interviewed by the media and provide a non-partisan, evidence-based perspective from their areas of expertise.

Working together, we have created a number of tools for enabling media coverage of health policy issues in Canada, including the preparation of media backgrounders, infographics, posters, podcasts and videos that highlight the evidence, and we conduct webinars, seminars and conferences by and for both journalists and academics alike.

But our most successful initiative thus far has been having our academic experts author Op-Ed articles on health policy issues—highlighting the evidence; they work with a professional editor to follow specific media guidelines, and then we publish the commentaries in the biggest media outlets across the country. The table below illustrates how successful this strategy has been and how receptive media outlets have been to these stories—increasingly so.

OpEds by Media Category HUFF POST CATEGORY B_APRIL 2015 2011 - 2012 OpEds by Media Category_Apr 13 2015-jpeg2013 - 2014 OpEds by Media Category_Apr 13 2015-jpeg

Do op-eds make a difference? Well, we are trying to track key outcomes. But we can say already that as a result of the publication of the op-eds, some of our academic experts have been invited to give testimony at court hearings, provide evidence at government proceedings, give presentations to royal commissions, invited to international conferences—real world consequences, in other words (and there are more). We’ve also seen published op-eds in one paper instigate stories in other media outlets, creating a kind of domino effect, and thus expanding the coverage of the topic further. We’ve also had several major broadsheets endorse a position in their editorial pages that was originally outlined in one of our op-eds. Social media sharing for many of our top stories has been in the thousands, ensuring an audience reach of several million for a single story. This hasn’t happened once or twice, but multiple times, indicating that there’s an appetite in our country for rigorous, meaty policy content on health policy issues.

With our project, we hope to engage and enrich the dialogue and debate on a healthcare system that’s so important to Canadians. As we head into a federal election year in 2015, it seems certain that many of these issues will come to the fore, and it serves our democratic system that they be aired and discussed with evidence as the foundation. With journalists and academics in partnership to communicate health policy in the news, we can help navigate the evidence together.

A version of this essay appears in the new free ebook: Navigating the Evidence: Communicating Canadian Health Policy in the Media edited by Noralou Roos, Kathleen O’Grady, Shannon Turczak, Camilla Tapp and Lindsay Jolivet. Available in Kindle, Apple, Google and PDF formats:

1276991_588866957837667_1084464500_o KathRoos_Noralou_2007leen O’Grady is the Managing Editor of EvidenceNetwork.ca and a Research Associate at the Simone de Beauvoir Institute, Concordia  University, Montréal, Québec.

Noralou Roos is a Professor in the Department of Community Health Sciences, Faculty of Medicine, University of Manitoba and Director of EvidenceNetwork.ca.

Aging In The Right Place Is What Many Canadian Seniors Want And Need

June 29, 2015 10:08 am
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Here’s how to make it happen

A shift in thinking on seniors’ care issues is taking place across the country, and it’s making our government leaders sit up and take notice.

The opportunity to provide cutting edge seniors’ care has never been more within reach. Worldwide, there is a movement to take better care of aging adults and this is reflected in exciting technology, design and conceptual communities—which completely flip the notion of what it is to age on its head.

We know now seniors’ issues include more than just better health-care coverage. It’s about more than just beds for long-term care, more money for care-providers and the obvious need for updating older seniors’ facilities with sprinklers and other mobility-related accommodations so people who don’t move as easily as they once did, can get around and out as needed.

But it’s also about more than providing in-home supports and retrofits to allow seniors to, so called, “age-in-place.”

Those of us in the industry who are committed to providing quality seniors’ housing and care—many of whom also deal with the reality of aging parents—believe there is a long overdue conversation Canadians should be having with their families. It’s also a conversation our governments should be having with every single one of us, as most of us will live longer than generations past, but will need greater supports.

These discussions should be based on having all of the options and information available for our aging seniors—which should include the more appropriate goal of “aging in the right place.”

When most people think of seniors’ care, they skip a step or maybe two. They might think resentfully of the hospital bed being taken up by a senior who is waiting for appropriate supports to be able to go home or to some draconian long-term care institution we imagine with horror.

Thinking about end-of-life quickly moves us to think of something else, and so we cling to the notion of staying in the family home as the best place to be. This may not be true for all.

Unfortunately, statistics and surveys describe a sometimes different reality, where seniors living alone wait for the kids to call, become isolated, depressed and under-nourished. For many elderly, living the dream of aging-in-place can instead mean their world becomes a seniors’ Bermuda triangle: moving alone between the bedroom, the fridge, the TV and back.

The home that once worked for the family, may not exactly be fulfilling or suitable as we age.

It turns out most people’s notions of seniors’ care facilities are outdated. These outdated notions may also not reflect the value of the supports that are available in congregate living.

Seniors’ housing options are no longer just one-stop-fits-all. The move to ‘supportive living,’ for example, can offer greater safety, more balanced meals, increased access to home care, with the added value of engagement with a vital social community.

Eventually when the time is right and when it’s needed, there is also ‘full support’ available in the senior housing sector. All of these may be more finely tuned, responsive, efficient, cost effective, and most importantly, appropriate housing options for seniors than staying in the family home.

There is an industry of professionals who are organized, armed with research, prepared and excited to assist with respect to providing better housing and care for aging Canadians. Seniors’ issues may not be the ‘squeaky wheel’ that drives the revenue of our economy; however, if not supported, it will drive costs.

For the growing number of seniors and for those with an aging family member, we need to keep the foot on the pedal.

Arlene AdamsonArlene Adamson is CEO of Silvera for Seniors, a charitable non-profit organization which provides homes to over 1,500 lower-income seniors. She is also co-chair of the Seniors and Special Populations Sector Housing Committee and is on the Board of the Alberta Seniors Communities and Housing Association.

Four Things you Should Know About the Pending Charter Challenge Against Medicare

June 25, 2015 10:00 am
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A long-running dispute between Dr. Brian Day, the co-owner of Cambie Surgeries Corporation and the British Columbia government may finally be resolved in the BC Supreme Court this year – and the ruling could transform the Canadian health system from coast to coast.

The case emerged in response to an audit of Cambie Surgeries, a private for-profit corporation by the B.C. Medical Services Commission. The audit found from a sample of Cambie’s billing that it (and another private clinic) had charged patients hundreds of thousands of dollars more for health services covered by medicare than is permitted by law. Dr. Day and Cambie Surgeries claim that the law preventing a doctor charging patients more is unconstitutional.

Dr. Day’s challenge builds on the legacy of a 2005 decision by the Supreme Court of Canada overturning a Quebec ban on private health insurance for medically necessary care. But this case goes much further, not only challenging the ban on private health insurance to cover medically necessary care, but also the limits on extra-billing and the prohibition against doctors working for both the public and private health systems at the same time.

A trial date was set to begin in 2012, but was adjourned until March 2015 so that the parties could resolve their dispute out of court and reach a settlement. It now appears such a resolution has not been reached and the court proceedings may resume in November.

Here’s why this case matters.

1. Legal precedent: Whatever way the case is decided at trial, it is likely to be appealed and eventually reviewed by the Supreme Court. A decision from this level will mean all provincial and territorial governments will have to revisit equivalent laws. The foundational pillars of Canadian medicare–equitable access and preventing two-tier care — could well be vanquished in the process.

2. Wait times: Day will likely argue that Canada performs poorly on wait times compared to other countries, and that other countries allow two-tier care; thus, if Canada is allowed two-tier care, our wait times would improve. But this approach is too simplistic.

Common comparisons to the English health system, for example, fail to recall that despite having two-tiers, they have in the past suffered horrendously long-wait times. Recent efforts to tackle wait times have come from within the public system, with initiatives like wait time guarantees and tying payment for public officials to wait times targets.

By looking to England we are not measuring like to like but apples to oranges. English doctors are generally full-time salaried employees while most Canadian physicians bill medicare on a fee-for-service basis. Consequently, the repercussions for permitting extra billing in Canada could eviscerate our publicly funded system, whereas this is not the case in England. Imagine if most doctors in Canada could bill, as those at the Cambie clinic have done, whatever they want in addition to what they are paid by governments?

3. Conflict-of-interest incentives: Evidence suggests there is a danger in providing a perverse incentive for physicians who are permitted to work in both public and private health systems at the same time. Wait times may grow for patients left in the public system as specialists drive traffic to their more lucrative private practice.

Sound improbable? Academic studies have noted this trend in specific clinics that permit simultaneous private-public practice. And recent UK news reports have profiled a case where a surgeon bumped a public patient in need of a transplant for his private-pay patient.

4. Competition: Proponents of privatized health services often claim that it would add a healthy dose of competition, jolting the “monopoly” of public healthcare from its apathy. But free markets don’t work well in healthcare. Why? Because public providers and private providers won’t truly compete if the laws Dr. Day challenges are struck down. Instead, those with means and/or private insurance will buy their way to the front of queues. Public coverage for the poor will likely suffer, as is clearly evident in the U.S., with many doctors refusing to provide care to medicaid (low-income) patients in preference for those covered by higher-paying private insurance.

Of course, this is all based on an outcome that is not yet known. It may be that the Charter challenge in B.C. is unsuccessful but clearly the stakes for ordinary Canadians are very high. Sadly Dr. Day is not bringing a challenge for all Canadians. Isn’t it long past time our governments and our doctors work to ensure all Canadians – and not just those who can afford to pay – receive timely care?

Flood_ColleenO'Grady_KathleenColleen M. Flood is Professor and University Research Chair in Health Law & Policy at the University of Ottawa and an expert advisor with EvidenceNetwork.ca

Kathleen O’Grady is a Research Associate at the Simone de Beauvoir Institute, Concordia University and Managing Editor of EvidenceNetwork.ca.

We Have Built a Sickness Care System Rather Than A Health System

June 24, 2015 11:58 am
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We have designed that system for the convenience of practitioners, not patients: Convocation speech delivered to graduating MDs at the University of Manitoba on the receipt of an honorary doctorate.

Mr. Chancellor, Mr. President, distinguished guests, soon-to-be MDs and their deeply indebted family members. I’m touched and humbled to receive an honorary degree from the University of Manitoba. Thank you for letting me share this special moment with you.

I’m not a doctor. I never will be. I’m a lowly journalist. I tell stories.

For almost 30 years I’ve tried to help Canadians understand their health system and their medical care.

In that time, I’ve seen tremendous advances in medicine and I’ve met, quite literally, thousands of health professionals, from students to Nobel Prize winners — and patients, from those with rare genetic mutations to those with everyday ailments, from those cured miraculously to those who died needlessly.

Today, I’d like to take few minutes to share some of what I’ve learned from telling their stories.

One of the greatest privileges in our society is to have the letters M.D. after your name. Those two letters confer great power. And with that power comes great responsibility, to quote Voltaire — or Spiderman, depending on your literary predilections.

Shortly, you will be taking the Hippocratic oath. You’ve probably all heard that it says: “First do no harm.” It doesn’t actually – that’s just bad media reporting.

But it does say a lot of important things. I think the line that matters most in the oath is this:

“Whatsoever house I may enter, my visit shall be for the convenience and advantage of the patient.”

Sadly, too many physicians fail to honor that part of the pledge.

We have built a sickness care system rather than a health system. We have designed that system for the convenience of practitioners, not patients.

Modern medicine has become so specialized that many physicians treat specific syndromes and body parts, and the patient herself gets lost in the process. We have filled our temples of medicine with such bedazzling hi-tech tools that we’ve forgotten that we should treat people where they live.

In our desire to cure, we over-treat.

We fail too often to say the three most important words in medicine: “I don’t know.” We see death as a failure, instead of aspiring to make patients’ comfortable and at peace at end-of-life.

In our unrelenting quest for efficiency and measurement, we too often lose sight of what really matters. The patient.

What does your patient want? What are his or her goals? Those are the questions that must guide your practice.

For some of your patients, the goal is to repair their acute woes, to help them live long. But most of your patients will be older, and have a number of chronic conditions and be nearing the end-of-life. Their goals are different.

They’re not going to be cured. You have to focus on their quality of life.

They want to be at home. They don’t want to fall. They don’t want to be in pain. They don’t want to be a burden. They don’t want to be alone. They don’t expect miracles – but they would like respect.

They don’t fear dying. They fear losing their autonomy and their dignity. They don’t care about your metrics, or your age-adjusted mortality rates, or your fancy new genomic test. They want to be listened to, and heard.

We hear a lot these days about personalized medicine, about drugs and treatments that can be tailored to specific genomic and epigenetic markers. But you know what people really long for: personal medicine, not personalized medicine.

They crave a human connection. Not just care, but caring.

The very best medicine you can offer your patients is a listening ear. The very best treatment you can offer them is a compassionate heart.

Now you may be sitting there thinking, this is all feel-good nonsense. It’s not. The more sophisticated and complex medicine becomes, the more the basics matter.

What did you learn in medical school? Anatomy, biochemistry, genomics, countless mnemonics to help you remember bits of knowledge; you know how to deliver babies and treat cancer and diabetes and depression and asthma, take out people’s appendix and do MRIs and PCIs, and countless other things.

What you’re going to learn now, in the real world, is that physical woes are the least of patients’ worries. Their health problems aren’t strictly caused by mutating cells, opportunistic pathogens and poor genes, but by poverty, lack of education, poor housing, stress and social isolation.

You’re going to, sooner or later, learn humility. And, the earlier you do, the better the doctor you’re going to be.

In this, the Internet age, we are drowning in information, but starving for wisdom. I urge you, as you forge long, successful and prosperous careers, to not just be smart, but be wise.

In every interaction you have, embrace the ancient wisdom of Hippocrates: “Whatsoever house I may enter, my visit shall be for the convenience and advantage of the patient.”

A version of this speech was delivered May 14, 2015 to the graduating class at the University of Manitoba.

Globe and Mail business journalist Andre Picard poses in the Montreal offices on September 6, 2012. For Promotions (Christinne Muschi for The Globe and Mail)

André Picard is a health reporter and columnist at The Globe and Mail, where he has been a staff writer since 1987. He is also the author of three bestselling books.

Pros and Cons of an Expanded Canada Pension Plan

June 23, 2015 10:00 am
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A new report came out this week that reiterates what we’ve heard from other sources a few times now: Canadians aren’t saving nearly enough for retirement. The Deputy Chief Economist of the CIBC warns that without pension reform now, younger workers today will see a steep decline in living standards as they retire.

The Conservative government has recently announced it would like to have a dialogue with Canadians about a potential expansion of the Canada Pension Plan (CPP). While this, in itself, is a purely political action–since it commits the government to nothing–it is worth looking at what the possible outcomes might be.

We know 76 per cent of workers in the private sector have no pension plan at all. They are left totally to their own initiative. They are not trained in this “retirement-income-security” science. They can get retirement savings products but have to pay extremely high fees (e.g., 250 to 300 basis points or a full 2.5 to 3 per cent of their cash flow) for this expert management. And sometimes, their agent does not even work on their behalf, but rather acts to maximize the income of the agent.

Might it thus be wise to finally consider an expansion of the CPP at a time when both the CPP and its investment arm (the Canada Pension Plan Investment Board—CPPIB) are riding high in the polls?

The answer is not obvious. Far from it.

Amendments made to the CPP in 1996 state that any new benefits must be fully-funded. That means you only get back what you have paid for in full. Under current rules, it takes 39 years at a minimum to earn a full benefit. So if you make a contribution today (2015) you would only have earned 1/39 of a full benefit. Full benefits would not be available until 2054.

So if we think we have a problem in terms of people who plan to retire in 2054 not saving enough today, then we must amend the CPP now.

The CPP is currently organized and administered like a Defined Benefit plan. Moving to Voluntary Contributions, as the Conservatives wish, would force it to be administered much more like a Defined Contribution plan.

Why does this matter?

If workers can move their money in and out of the CPP fund freely, this will create the potential for anti-selection on the part of the participants (move in when the times are good and out when bad), resulting in the need for the CPPIB to move toward much more liquid shorter-term assets with lower rates of return. It would also mean much higher administrative costs for the CPP (especially the investment arm, the CPPIB, as they would have to track the cash flows of individual accounts).

This would be on top of the high expense ratio for the CPPIB–estimated in the range of 90 to 100 basis points (i.e., 0.90 to 1.00 per cent) which is multiples of what other very large plans cost (e.g., HOOPPs, BC Public Service and even some private sector plans like Bombardier) which run with expense ratios closer to 25 basis points.

It would also make all Canadian workers much more dependent on the investment capabilities of the CPPIB and the decisions they make versus the myriad of private managers now being used. So, the word “voluntary” cannot be taken lightly.

Further, the CPPIB is having problems keeping all of its $265 billion invested in safe, but high yield investments today. What will it do with another tier of contributions?

Finally, one can certainly expect a vehement push-back from the private sector that caters to retirement savings today at a nice profit margin.

So, what if the contributions are mandatory? That will result in serious problems for very poor workers (and their employers).

Consider forcing low-income workers (and their employers) to contribute to a new tier of the CPP. Not only do they not receive full benefits for another 39 years, but when they do get their extra CPP benefits, they will lose the impact of these extra payments as they see their Old Age Security (OAS) Guaranteed Income Supplement (GIS) benefits clawed back.

Since GIS payments are often matched by provincial schemes (e.g., GAINS in Ontario), many poor workers will lose $1 of OAS/GIS and provincial supplements for every new dollar of CPP benefits. So, they, and their employers, contribute out of money they need for higher order needs now (like food and rent) and they get no new net benefits at all. That is regressive. And we know that employers, such as those represented by the Canadian Federation of Independent Business (CFIB) will aggressively oppose any such mandatory imposition.

In summary, we are faced with a myriad of questions and not only do we not have any good answers, we have no answers at all. It’s time our governments started looking at the complexity of the issue with some serious attention.

Brown_Rob.High resRobert Brown is an expert advisor with EvidenceNetwork.ca, a Retired Professor of Actuarial Science, University of Waterloo and Immediate Past President of the International Actuarial Association.

The Real Costs of Informal Caregiving in Canada

June 15, 2015 11:13 am
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National strategy needed for unpaid caregivers in the workplace

The phenomenon is not exactly marginal: according to a recently released government report, one in every three workers in Canada is assisting a chronically disabled person–many of them seniors–with transportation, household maintenance or day-to-day tasks. The 6.1 million employed workers who are providing such care, free of charge, to a family member or friend are more likely to experience interruptions at work and to arrive late or even be absent from work. Many are less available than they would otherwise be to work overtime, travel for work or advance their careers.

Without a doubt, the impacts of informal caregiving commitments do not remain confined to the home: they are felt in the Canadian workplace and reduce productivity. They translate into 2.2 million hours of reduced effort in the workplace every week and cause an estimated $1.3 billion productivity loss annually, says the report.

With the anticipated growing numbers of seniors requiring care, the costs of unpaid caregiving and reduced productivity will likely expand over the next two decades. What should we do about them?

As Canadian employers are increasingly confronted with the reality the work of informal caregiving has on their employees, it only makes sense that they should be the first to recognize and support informal caregiving. Some of them already offer flexible arrangements (e.g., compressed work weeks, work from home, unpaid and even paid leaves) to employees with caregiving commitments. This said, not all employers are equally supportive, if at all, and many Canadian workers with caregiving responsibilities are paying the price: reduced income, career limitations and exit from the labour force.

A year ago, the federal government established the Employer Panel for Caregivers which consulted with employers to help them find ways to better support their employee caregivers. The consultation was premised on the (realistic) assumption that unpaid care will remain the main source of long-term care in this country.

The most significant insight it gained is this: while employer support to employee caregivers may foster engagement and greater retention in the workplace, there might not be a business case for many employers to voluntary engage in this. Put another way, moral appeal and compassion for employee caregivers will not translate into a massive, spontaneous movement in the Canadian workplace to address the issue any time soon.

What else is needed? Should the costs of caregiving and reduced productivity belong uniquely to caregivers and their employers?

It is becoming increasingly difficult for Canadian policymakers to ignore their own essential role–beyond that of offering limited and sporadic supports–to address the issue.

Confronted with a similar situation, the United Kingdom, Australia and New Zealand have, in recent years, adopted national caregiver strategies. At home, Manitoba and Nova Scotia are leading in many ways, but efforts across the country remain fragmented and inconsistent.

Canada can do better.

Needed as part of a national strategy are integrated policy instruments to support caregivers and their employers. First, Canada’s workplace legislation, which is primarily a provincial jurisdiction, needs to ensure minimum standards to protect workers with caregiving commitments. Second, we also need a comprehensive set of financial instruments–possibly a combination of private or public programs–to better protect the workers’ incomes and their employers’ productivity losses. Third, more substantial coverage of homecare, nursing care and supportive services (e.g., adapted transportation or supervised day centers) for the disabled is an essential component that would benefit everyone.

Is this financially realistic? Policymakers still need to recognize the undeniable costs of unpaid caregiving. So the real question should be instead: How should these costs be shared?

Caregivers are already contributing a lot: A study estimated that if governments had to pay for caregiving provided free of charge by people 45 and over in this country, it would have cost about $25 billion in 2009.

Some argue that governments should compensate caregivers. I don’t think they should. But governments do need to ensure that while providing unpaid caregiving, workers never incur catastrophic income losses or lose their jobs as a result.

Financial and in-kind supports are critical especially when caregiving commitments extend to several hours a week over a long period of time. This should be covered by public programs.

Instead of having a situation where we have some employers who provide workers with coverage and some not, only a coherent national strategy will allow Canadian workers looking after a spouse or relative to better focus on their work, their employers to better focus on their mission and disabled persons to get the care they need.

Bernier_NicoleNicole F. Bernier is an expert advisor with EvidenceNetwork.ca and research director of the Faces of Aging program at the Institute for Research on Public Policy.

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