Healthc Pap
· 2019 Dec · PMID 31901065
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The population that undergoes pediatric surgical procedures in high-resource settings such as Canada primarily comprises healthy patients who undergo low-risk, elective surgeries and fewer higher-risk patients who requir...The population that undergoes pediatric surgical procedures in high-resource settings such as Canada primarily comprises healthy patients who undergo low-risk, elective surgeries and fewer higher-risk patients who require more complex surgeries. Given this variability, there is a relatively low incidence of traditionally measured "critical" outcomes within any single pediatric surgical system or even pediatric surgical subspecialty, rendering the currently available quality measurement tools inadequate to provide sensitive measures of quality. In an era when scalable solutions are required to improve health outcomes across entire populations, there is an urgent need for more holistic measures of a child's well-being to benchmark and measure changes in quality of care. This article discusses opportunities for enhanced performance measurement in pediatric surgery using a value-based framework to identify and measure patient and family outcomes of importance over the full care cycle, from initial presentation through surgery and recovery to sustainability of health. In suggesting new avenues for performance measurement, we highlight how these measures can be used to develop, evaluate and refine surgical system innovations such as bundled care pathways and perioperative care homes.
Healthc Pap
· 2019 Dec · PMID 31901064
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Healthcare reforms that do not address outcomes of importance to patients may not be poised to successfully deliver the ultimate objectives of improved outcomes and quality of life for patients. Value-based healthcare is...Healthcare reforms that do not address outcomes of importance to patients may not be poised to successfully deliver the ultimate objectives of improved outcomes and quality of life for patients. Value-based healthcare is a distinct approach to aligning diverse health-system stakeholders, including healthcare professionals, health system administrators and the pharmaceutical and medical devices industries, on delivering outcomes that matter to patients at the same or lower cost. This article examines existing pan-Canadian infrastructure, including quality improvement and data initiatives, to demonstrate a path forward for this international healthcare transformation movement in Canada.
Healthc Pap
· 2019 Dec · PMID 31901063
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Across Canada's provinces and territories, healthcare policy discussions are often focused on the attributes of the health services delivery system that are most easily measured and monitored. The obvious examples are sp...Across Canada's provinces and territories, healthcare policy discussions are often focused on the attributes of the health services delivery system that are most easily measured and monitored. The obvious examples are spending growth, number of beds and wait times. In turn, this orientation tends to induce a focus on the volume of healthcare rather than its value. Yet it is increasingly clear that value from healthcare improves when patients' health goals are prioritized and addressed in a cost-efficient and effective manner.
Healthc Pap
· 2019 Oct · PMID 31642806
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International health system comparisons reveal that Canada ranks poorly in several measures when assessed against comparable countries, despite the fact that billions of dollars are spent on the Canadian healthcare syste...International health system comparisons reveal that Canada ranks poorly in several measures when assessed against comparable countries, despite the fact that billions of dollars are spent on the Canadian healthcare system every year. Canada is among one of the highest spenders on health care, yet value for our investment is not always clear. To sustain Canadian health care, it is essential that innovations and process transformations that improve health outcomes and value for our investment are implemented in the health system. Following the movement of other organizations that are experimenting with innovative models of funding, the Canadian Institutes of Health Research partnered with four Canadian provinces to pilot the Rewarding Success Initiative. This initiative rewards and incentivizes research teams to develop effective partnerships with health system payers and, together, implement innovative solutions in the health system that will enhance value-based care, health system sustainability and health outcomes.
Healthc Pap
· 2019 Oct · PMID 31642805
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There is broad consensus that achieving a "value-based" healthcare system requires a shift toward "value-based payment," but less agreement on what this entails beyond moving away from fee-for-service reimbursement. Opin...There is broad consensus that achieving a "value-based" healthcare system requires a shift toward "value-based payment," but less agreement on what this entails beyond moving away from fee-for-service reimbursement. Opinions diverge on the ideal end-state payment model, and the evidence base remains equivocal. We propose a framework for Canadian payers interested in pursuing value-based payment reforms that draws lessons from two widely recognized examples of paying for value in healthcare: the US Center for Medicare & Medicaid Innovation and Canada's own experience using health technology assessment to inform payment policy.
Healthc Pap
· 2019 Oct · PMID 31642804
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Value in health is a concept that has been used in many different contexts. It is used in debates about priority setting, pricing of pharmaceuticals and payment systems. In the Norwegian context, value in health in prior...Value in health is a concept that has been used in many different contexts. It is used in debates about priority setting, pricing of pharmaceuticals and payment systems. In the Norwegian context, value in health in priority setting is officially defined as the quality-adjusted life-years produced by an intervention. However, the value of an intervention is also adjusted based on the severity of the disease. Importantly, the value does not include gains in productivity. In the context of price setting, there is a movement toward value-based pricing. Although generally supportive, I argue that the approach is limited by noisy and incomplete indicators of outcome and that full value-based pricing of pharmaceuticals has important consequences for the distribution of costs.
Healthc Pap
· 2019 Oct · PMID 31642803
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Value-based healthcare has entered the lexicon of health service managers and policy makers over the past decade. But translating the idea from a rhetorical device or concept for use in the United States into a policy or...Value-based healthcare has entered the lexicon of health service managers and policy makers over the past decade. But translating the idea from a rhetorical device or concept for use in the United States into a policy or action elsewhere is difficult. It has obvious appeal - who can argue against value? In this paper, I discuss the utility of value-based care as a rhetorical device and the complexity of operationalizing it and identifying patient perspectives on value.
Healthc Pap
· 2019 Oct · PMID 31642802
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Value in healthcare is often defined as the patient outcome relative to the resources or costs employed in attaining the patients' outcome. But just defining value in the healthcare delivery system is a vexing challenge....Value in healthcare is often defined as the patient outcome relative to the resources or costs employed in attaining the patients' outcome. But just defining value in the healthcare delivery system is a vexing challenge. Defining value requires clarity on what factors, features or attributes are valued and the value attached to each. This commentary dissects this approach and offers some hopefully useful principles and conclusions. I argue that improving value requires an appreciation not only of patient value but also that of providers, organizations and companies and values associated with health system goals and society. I then propose principles for the measurement of value and policies to incentivize high value care. The most important message is that single actions or actors will not do much to improve healthcare value and we must value coordinated activities with shared accountability.
Healthc Pap
· 2019 Oct · PMID 31642801
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Canada's high level of spending on healthcare and lagging performance are leading policy makers and system managers to explore the concept of value. The concept, applied to healthcare, is appearing in medical media and p...Canada's high level of spending on healthcare and lagging performance are leading policy makers and system managers to explore the concept of value. The concept, applied to healthcare, is appearing in medical media and policy documents with increasing frequency and is being used to describe patients' outcomes vis-à-vis the costs of achieving the outcomes. A uniquely Canadian interpretation of value is needed that recognizes that patients', providers' and society's perspectives of the value of the same health service or medical technology differ. This issue of Healthcare Papers presents complementary articles whose authors explore options for improving the value from public spending on healthcare. Commonalities among the articles indicate that improving value from healthcare should focus on understanding what matters to patients and their caregivers and measuring health and health outcomes and that changes in financial incentives are overdue to support a higher degree of integration between providers and their organizations.
Socially disadvantaged groups are more likely to have poor mental health and experience inequities in mental health service use, quality of care and health outcomes. A promising practice is the development of health equi...Socially disadvantaged groups are more likely to have poor mental health and experience inequities in mental health service use, quality of care and health outcomes. A promising practice is the development of health equity-focused impact assessment tools that help planners and other people in developing policies, programs and services to identify and address health inequities. This paper presents and reviews Health Equity Impact Assessment (HEIA), a decision support tool developed by the Ontario Ministry of Health and Long-Term Care. The tool has the potential to incorporate health equity into mental health service planning and improve access to and quality of care for marginalized and vulnerable populations.
Global mental health explores cultural differences and context-specific conditions. It deals with the epidemiology of mental disorders, their treatment options, mental health education, the structure of mental healthcare...Global mental health explores cultural differences and context-specific conditions. It deals with the epidemiology of mental disorders, their treatment options, mental health education, the structure of mental healthcare systems and human rights issues. Specifically, this paper focuses on community-based mental health approaches that may be useful for marginalized and excluded populations, for example, frail elderly, francophone minorities and refugees. We explore the delivery of mental health support and care, psychoeducation, narrative therapies and trauma-informed approaches for these populations. We focus on lay persons, peer workers and community-based primary care practitioners and shared mental healthcare workers. We provide examples of these approaches and therapies and explore the central role of narrative approaches and proximity of care.
Psychotherapies are a fundamental part of mental healthcare. These have been shown to be effective treatments for a wide range of mental disorders, from anxiety and depression to psychoses such as schizophrenia. However,...Psychotherapies are a fundamental part of mental healthcare. These have been shown to be effective treatments for a wide range of mental disorders, from anxiety and depression to psychoses such as schizophrenia. However, there is evidence that the effectiveness of psychotherapies may vary, and these may need to be adapted to work optimally for different cultural groups. In addition, some diagnoses that are more common in refugee populations may require specific interventions. This paper examines the effectiveness of psychotherapeutic techniques for immigrant, refugee, ethno-cultural and racialized populations.
This commentary explores the Immigrant and Refugee Mental Health Project at the Centre for Addiction and Mental Health as a promising practice in equity in mental health. The Immigrant and Refugee Mental Health Project i...This commentary explores the Immigrant and Refugee Mental Health Project at the Centre for Addiction and Mental Health as a promising practice in equity in mental health. The Immigrant and Refugee Mental Health Project is a nationally funded project providing free, accredited, evidence-based online training, tools and resources. It is designed to enhance settlement, social and health sector professionals' knowledge, skills and networks for working with immigrants and refugees. The barriers to services, the social determinants of health and the healthy immigrant effect are referenced as key factors addressed by the project. The commentary discusses key components of the course, such as accessibility, capacity and content. It further discusses some of the innovation and evaluation that are planned as we move forward and explore expansions to the project.
Indigenous peoples, immigrants and refugees and racialized groups, as well as some long-established ethnic, linguistic, cultural and religious communities, experience inequities in mental health in Canadian society. Thes...Indigenous peoples, immigrants and refugees and racialized groups, as well as some long-established ethnic, linguistic, cultural and religious communities, experience inequities in mental health in Canadian society. These inequities result from social structural determinants of health that are embedded in the cultural knowledge, values and attitudes of the specific group as well as those of the larger society. Culture shapes the experience and expression of mental health problems, modes of coping, pathways to care and the effectiveness of treatment and prevention, as well as the processes of resilience and recovery. Systematic attention to culture in the provision of mental health services can improve access, utilization and health outcomes. We review models to address diversity in mental healthcare and identify key areas in which we believe policy innovation is urgently needed: 1. Cultural competence, safety and anti-racism training and accreditation standards for practitioners and for healthcare education, service systems and institutions; 2. National regulations and quality assurance standards to ensure use of language interpreters; 3. Development of a cadre of culture brokers to improve clinical communication; and 4. Integration of attention to culture in service systems design, as well as clinical practice.
Mental health problems are common and have a significant impact on people and their families, communities and the economy. Sixty percent of the population risk of illness is linked to the social determinants of health, a...Mental health problems are common and have a significant impact on people and their families, communities and the economy. Sixty percent of the population risk of illness is linked to the social determinants of health, and immigrant, refugee, ethno-cultural and racialized (IRER) groups have more exposure to these social factors. But one size does not fit all; the actual rates of mental health, mental illness or substance misuse for any IRER group depend on a complex interplay between risks and resilience. Disparities in rates of mental health, rates of illness and service use exist for IRER populations in Canada. Moving toward equity requires action on the social determinants of health to promote mental wellness as well as targeted action to prevent mental illness and increase the rates of recovery. Equitable mental health services require culturally competent staff, with interventions that work effectively for differently cultural groups and a system that allows equitable access.
The respondents all raised valuable, informative points in response to our Invited Essay. There was convergence around the need to alter governance structures at the same time as payment arrangements for physicians to ac...The respondents all raised valuable, informative points in response to our Invited Essay. There was convergence around the need to alter governance structures at the same time as payment arrangements for physicians to achieve higher-performing health systems within Canada. At the same time, there were different views on how best to address the disconnect between levels of physician remuneration and accountability for healthcare performance and delivery. In addition to ongoing efforts to improve governance, such as the recent amendments to the government-physician agreement in Alberta, individual provincial governments can and should take the lead in initiating and evaluating further payment and governance experiments.
Understanding physician remuneration and its growth is extremely complex, much more so than for a typical worker. Highlighting one narrow aspect of this issue, this paper focuses on governments' increased incentives for...Understanding physician remuneration and its growth is extremely complex, much more so than for a typical worker. Highlighting one narrow aspect of this issue, this paper focuses on governments' increased incentives for physicians to incorporate and the ensuing physician response in the period 1996-2011. Nationally, incorporation rates increased for both general practitioners and specialists between 1996 and 2011. We observe that the largest changes in provincial regulation were in Ontario, and incorporation increased from 18% in 2001 to 54% five years later. Incorporation is less common in Quebec, where the incentives were the weakest. Married male physicians, middle-aged physicians (regardless of sex), physicians with higher incomes and physicians born outside of Canada are all more likely to incorporate their practices. On average, incorporated physicians realized a 4% reduction in personal income taxes and accumulated retained earnings of at least $10,000 per annum in their Canadian-controlled private corporations in our data period. The benefits of incorporation stem largely from retained earnings and income splitting. Many physicians benefit from one or both; however, the benefits of incorporation are not equally distributed. Sex, marital status and income affect the magnitude of the financial benefit of incorporation.
This commentary responds to Marchildon and Sherar's (2018) paper, "Doctors and Canadian Medicare: Improving Accountability and Performance," in which they explore questions around governance and physician accountability...This commentary responds to Marchildon and Sherar's (2018) paper, "Doctors and Canadian Medicare: Improving Accountability and Performance," in which they explore questions around governance and physician accountability in Canada. This response situates the issues raised in a northern context by sharing experiences with primary care reform in the Northwest Territories and exploring the implications these changes have had for physician accountability and reported system improvements. Physician leadership and accountability are further explored in the northern context, where health systems for Indigenous communities include multiple jurisdictions and transitions in governance advance the self-government, land claims and treaty rights of Indigenous peoples.
The Marchildon and Sherar (2018) paper provides some useful insights: the role of primary care, improved approaches to physician compensation and the importance of accountability and governance. But their approach of foc...The Marchildon and Sherar (2018) paper provides some useful insights: the role of primary care, improved approaches to physician compensation and the importance of accountability and governance. But their approach of focusing on doctors, including their compensation, misses the boat. Canada's healthcare system needs a major overhaul to improve integration and reward good performance for patient care going beyond medical practitioner compensation.
Marchildon and Sherar's (2018) "Doctors and Canadian Medicare" presents a specific dilemma for healthcare reform: the ability of physicians to negotiate ever-increasing incomes without reference to the consequences to he...Marchildon and Sherar's (2018) "Doctors and Canadian Medicare" presents a specific dilemma for healthcare reform: the ability of physicians to negotiate ever-increasing incomes without reference to the consequences to healthcare costs or provincial budgeting. This commentary situates that discussion in the broader debate of the challenges to healthcare reform as exemplified by studies such as Paradigm Freeze (Lazar et al. 2013) and the ability of provincial medical associations to act as both system insiders (gatekeepers) and outsiders (with no responsibility for system finances). The resolution to this dilemma may be to follow the lead of the Alberta government by negotiating a stewardship role for physicians that requires them to take broader governmental goals into account. There is evidence to suggest that physicians may be the best actors to insist on and enforce changes in physician behaviour. Furthermore, adding physicians as stewards of the system may help create better checks and balances in the currently dysfunctional dynamics between federal and provincial stewards.