Beyond Decision Support

1. Beyond Decision Support Rationing Rationalizing and Renewing Radiology in the New Era of Canadian Health Care Greg Butler MD FRCPC FACR May 2013

2. Planning is Everything

3. Plumber of the Year

4. Who put that door there?

5. Every problem has a solution

6. Hi traffic washroom

7. Long arms are sometimes an asset

8. Disclosure • Chair • Real Time Medical Inc.

9. CHANGE IS COMING…AGAIN • The successful metamorphosis of radiology as a profession will stand on two successful strategies: • Radiologists will embrace and lead in methods of cost containment and quality within the PUBLICLY funded system • Radiologists will lead a moveinto a parallel PRIVATE world where patient access and satisfactionALONG WITH QUALITY arethe primary goals

10. QUALITY WILL BE THE GIVEN • QUALITY IS HERE. • QUALITY IS NOT ENOUGH • Quality will ensure that patients receive what they need • Quality will not always give patients what they want

11. QUALITY AND THE FALL TOWARDS MEDIOCRITY • We risk a preoccupation with mandated quality and accountability at the expense of compassion and accessibility • Outcomes and evidence based analysis will trump patient and physician expectations • Radiologist professionalism will decline as self identity as “employees” increases

12. Cab Driver Back to Pakistan • Not happy with Canadian Educational system • Wants better for his kids

13. Time For Transformative Change* • Senate Committee has recently re examined the 2004 Health accord and concludes (among many other things) • System change has stalled. Canada no longer looked upon as a model of innovation in health care (currently rated 30 among OECD countries by WHO) • Funding is adequate • The system has suffered from remarkably low levels of innovation. Innovation based transformation is essential. * With thanks to Senator Kelvin Ogilvie, Chair

14. Federal funding after 2014 will increase at 6% per year until 2016-2017, after which it will increase by a three year moving average of GDP, not less than 3% • This will not likely keep up with the expectations of the public

15. GDP vs Health Care costs • Health care costs are rising at an annual rate of 6.7% while the GDP rises at <1.5% • The Aging population contributes to about 1% of the health care cost rise • Health care is utilizing an increasing proportion of budgets in all provinces • “The wall” is here.

16. Radiology Costs are on the Federal Radar Screen • Diagnostic Imaging Meeting February 2012 • The Canadian Institute for Health Information and the Institute for Health Economics • BOTTOM LINE: DATA ON DI IN CANADA IS LIMITED AND NOT YET SUITABLE FOR ANALYSIS • It is coming….

17. WHERE IS THE INNOVATION NEEDED IN RADIOLOGY? • Difficult to innovate in an environment over which we have little control

18. RADIOLOGY STRATEGIES FOR SUSTAINABILITY OF OUR CURRENT SYSTEM • COST CONTAINMENT IN PUBLIC SPENDING ON IMAGING • Effective utilization control • Improved efficiency and elimination of waste • ?Will these prevent fee reductions? • INCREASE THE ROLE AND OUR ENDORSEMENT OF PUBLIC/PRIVATE COLLABORATION

19. UTILIZATION CONTROL • Distinction between essential and non essential services extremely difficult. • Decision support with application of guidelines does reduce utilization * (23% decrease for MRI spine, MRI for headache, and CT for sinusitis). • But how aggressive can guidelines get? • Will evidence become a threshold for public pay? • The Manitoba Project *Blackmore et al JACR 2011

20. Aggressive Utilization Control • The validity of many imaging procedures has not been demonstrated with evidence, but only with expert opinion • Expert opinion may be directed at the older objectives of peace of mind, diagnostic confidence, medical legal avoidance, patient expectations • What if we eliminated public pay for all imaging that is not validated with hard evidence? • E.g.. What is the evidence to support the average chest Xray?

21. OK… • We need to innovate • We need to offer more to patients than the current system can • We will have reached the Quality destination in the next few years.

22. Seriously…We have to consider the Private Alternative • Public vs private one of the longest, most passionate, and confusing debates in Canadian history • Leadership and government has waffled, and inconsistent in enforcement, and policy statements • Generations convinced that our existing way of providing health care is a sacred trust that speaks to our patriotism as Canadians.

23. Public Private Partnership • Private funding of insured services has been forbidden by the Canada Health Act as a means of the Federal Government preventing federal transfers from subsidizing private delivery of services • Considerable ambiguity among providers and the public of the meaning of private.

24. Further Ambiguity • Provincial policy adds to the complexity and confusion of the intent of the CHA • For example: • “Private” (non institutional) imaging facilities in Ontario are funded (T fees) • Private imaging facilities in other provinces are technically forbidden, but allowed • Some facilities charge only technical fees to the patients, while others charge the full amount. • Physicians working in private facilities may be opted in or opted out.

25. Disincentives for MDs to go Private • In 3 Provinces (NB,NS,ONT) MDs cannot charge beyond the fee schedule • If opted out, cannot do any services for public reimbursement • Patients cannot recover fees from the public system (NS)

26. Restrictions on Full Private • Canada Health Act does not forbid entirely private facility, provided no public money is used in its operation. • Some provinces (e.g. Nova Scotia) forbid billing above professional tariff (e.g. no technical fee) • Some provinces (e.g. NB and Saskatchewan) forbid MDs working these clinics from doing any publicly funded services.

27. Government Objections to Private • Will allow “Queue Jumping”.. (pts get faster access to diagnosis, and then jump ahead in the public system for treatment) • If too many providers opt out, the public system will suffer (the “thin edge of the wedge argument”) • Kickbacks for referral • Self Referral

28. Technical Barriers to Privatization in Imaging • Integration of flow of information between public and private repositories • What killed our clinic ultrasound project • Achieving public administration and accountability over private facilities

29. Advantages of Private • Efficiency • Adding total $$ to the system through discretionary spending • Industry standards and competitive consequences • RADIOLOGIST CONTROL ALLOWS THE ADDITION OF THE IMPROVED ACCESS, AND TURNAROUND PATIENTS WILL DESIRE,WHILE RETAINING QUALITY, APPROPRIATENESS AND PUBLIC ACCOUNTABILITY

30. Success in the Private World • Public demand and government scrutiny will ensure and demand highest quality services • Lower quality providers will not survive • Competition in the private sector will depend on the best combination of “value add” quality items, particularly accessibility, at the lowest price. • Forgo your trip to Florida this season. Pay for insurance that will provide rapid and pleasurable imaging and therapeutic experience

31. CONCLUSION: PUBLIC HEALTHCARE • Publicly funded services limited to providing radiology services at the lowest cost and highest quality affordable. • Radiology leadership will gain traction when providing cost saving strategies like more aggressive utilization controls and evidence based practices. • Commoditization of radiology services to the public system will likely occur

32. CONCLUSION:PRIVATE HEALTHCARE • The new opportunities will be on the private side • We must pursue opportunities to influence legislation barriers (national and provincial) • ENHANCED ACCESS AND SUPERIOR PATIENT EXPERIENCE • RADIOLOGIST CONTROLLED POLICY AND STAFFING • Business level Efficiencies • Positioned as an aid not a threat to, principles of a strong public system

33. What Kind of System do Canadians Want? • Do we know what we want? • What we do know…We want sustainability, accessibility, value AND the experience of our preference. • Recent Environics poll (Globe and Mail, Jan 2013) states that 55% of Canadians believe that “inefficient management” is the culprit as to why our health care system has stalled. 55% also said they approved of a private health care system to improve access to health care. • A blended public/private system is what we both need and want.

34. butler.gj@gmail.com