PROLOGUE
DeBakey had pioneered an experimental procedure U.S. Department of Veterans Affairs. (2015). Michael E. DeBakey VA Medical Center, Houston, Texas. www.houston.va.gov/debakey.asp
THE BASICS
Subcommittee on Primary Health and Aging U.S. Senate Subcommittee on Health, Education, Labour, and Pensions. (2016). Subcommittee on Primary Health and Retirement Security. www.help.senate.gov/about/subcommittees/primary-health-and-retirement-security
My remarks ended just shy of the five-minute mark National Cable Satellite Corporation (C-SPAN). (2014). C-Span – International Health Care Models. www.c-span.org/video/?c4486943/cspan-international-health-care-models
exchange between Republican Senator Richard Burr and me U.S. Senate Committee on Health, Education, Labor and Pensions. (2014). Subcommittee hearing. Access and cost: What the US health care system can learn from other countries. Transcribed from original testimony. www.help.senate.gov/hearings/access-and-cost-what-the-us-health-care-system-can-learn-from-other-countries
The Los Angeles Times picked it up under the headline Hiltzik, M. (2014). Watch an expert teach a smug U.S. senator about Canadian healthcare. articles. latimes.com/2014/mar/12/business/la-fi-mh-watch-a-canadian-20140312
net influx of physicians from the United States Canadian Health Services Research Foundation. (2008). Myth: Canadian doctors are leaving for the United States in droves. www.cfhi-fcass.ca/Migrated/PDF/myth29_e.pdf?
in those areas of Australia where private insurance Duckett, S. J. (2005). Private care and public waiting. Australian Health Review, 29(1), 87–93. www.ncbi.nlm.nih.gov/pubmed/15683360
I know that there are forty-five thousand in America Wilper, A. P., Woolhandler, S., Lasser, K. E., McCormick. D., Bor, D. H., & Himmelstein, D. U. (2009). Health insurance and mortality in US adults. American Journal of Public Health, 99(12), 2289–2295. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2775760/
national hero Chai, C. (2014, March 13). Doctor who schooled U.S. senator ‘thrilled’ by Canadian support. Global News. globalnews.ca/news/1205831/doctor-who-schooled-u-s-senator-thrilled-by-canadian-support
“Joan of Arc” Skyvington, S. (2014, May 5). Medicare’s Joan of Arc. The Kingston-Whig Standard. www.thewhig.com/2014/05/05/medicares-joan-of-arc
a 2012 Leger Marketing poll Jedwab, J. (2012). Pride in Canadian symbols and institutions. Leger Marketing poll commissioned by the Association for Canadian Studies. https://acs-aec.ca/pdf/polls/Pride%20in%20Canadian%20Symbols%20and%20Institutions.ppt
We can’t, the argument goes Simpson, J. (2012). Chronic Condition: Why Canada’s Health Care System Needs to Be Dragged into the 21st Century. Toronto: Penguin Group.
“adult discussion” Mulroney, B. (2010, October, 18). Brian Mulroney—Wanted: Regulatory Czar. The National Post. business.financialpost.com/fp-comment/wanted-regulatory-czar
“Building on Values” Commission on the Future of Health Care in Canada. (2002). Building on Values: The Future of Health Care in Canada – Final Report. publications.gc.ca/collections/Collection/CP32-85-2002E.pdf
If you understand who’s paying Evans, R. (1998). Going for gold: The redistributive agenda behind market-based health care reform. The Nuffield Trust. www.nuffieldtrust.org.uk/sites/files/nuffield/publication/Going_for_Gold.pdf
About 70 percent of Canadian health care Canadian Institute for Health Information. (2005). National Health Expenditure Trends, 1975 to 2015. www.cihi.ca/sites/default/files/document/nhex_trends_narrative_report_2015_en.pdf
every province has established a single-payer insurance scheme Parliament of Canada. (2005). The Canada Health Act: Overview and Options. www.lop.parl.gc.ca/content/lop/researchpublications/944-e.htm
A small but not insignificant number of people are not eligible Goel, Ritika, Bloch, Gar & Paul Caulford. (2013). Waiting for care. Effects of Ontario’s 3-month waiting period for OHIP on handed immigrants. Canadian Family Physician, 59(6). & Caulford, P., & D’Andrade, J. (2012). Health care for Canada’s medically uninsured immigrants and refugees: Whose problem is it? Canadian Family Physician, 58(7), 725–727.
principles of the Canada Health Act Canada Health Act (1985, c. C-6). (2012). Department of Justice Canada. laws-lois.justice.gc.ca/PDF/C-6.pdf
an estimated 18 percent of the premiums Jiwani, A., Himmelstein, D., Woolhandler, S., & Kahn, J. G. (2014). Billing and insurance-related administrative costs in United States’ health care: Synthesis of micro-costing evidence. BMC Health Services Research, 14(556). www.biomedcentral.com/1472-6963/14/556
Administrative costs are a lot higher Woolhandler, S., Campbell, T., & Himmelstein, D. U. (2003). Costs of health care administration in the United States and Canada. New England Journal of Medicine 349, 768–75. www.nejm.org/doi/full/10.1056/NEJMsa022033#t=article
hospital-based physicians like me are under much more direct control from the state Cribb, J., Emmerson, C., & Sibieta, L. (2014). Public sector pay in the UK. Institute for Fiscal Studies. www.ifs.org.uk/bns/bn145.pdf
in recent years more for-profit primary care Mehra, N. (2008). Eroding public medicare: Lessons and consequences of for-profit health care across Canada. www.ontariohealthcoalition.ca/wp-content/uploads/Eroding-Public-Medicare.pdf
this isn’t a large, investor-owned business Deber, R. B. (2002). Delivering health care services: Public, not-for-profit, or private? Commission on the Future of Health Care in Canada, Background Paper No. 17. http://publications.gc.ca/collections/Collection/CP32-79-17-2002E.pdf
Canada having a “government monopoly” Fayerman, P. (2015, February 10). Dr. Brian Day #1: Everything you need to know about him and his legal case against the government health care “monopoly.” The Vancouver Sun. http://blogs.vancouversun.com/2015/02/10/dr-brian-day-1-everything-you-need-to-know-about-him-and-his-legal-case-against-the-government-health-care-monopoly
women have more difficulty accessing some services Pelletier, R., Humphries, K. H., Shimony, A., Bacon, S. L., Lavoie, K. L., Rabi, D., Karp, I., Tsadok, M. A., & Pilote, L. (2014). Sex-related differences in access to care among patients with premature acute coronary syndrome. Canadian Medical Association Journal, 186(7), 497–504. http://www.cmaj.ca/content/early/2014/03/17/cmaj.131450
People in rural communities, those living in poverty National Collaborating Centre for Aboriginal Health. (2011). Access to Health Services As A Social Determinant of First Nations, Inuit, and Métis Health. www.nccah-ccnsa.ca/docs/fact%20sheets/social%20determinates/Access%20to%20Health%20Services_Eng%202010.pdf & Ontario Council of Agencies Serving Immigrants. (2005). Canada’s Health Care Debate – The Impact on Newcomers. http://w.ocasi.org/downloads/OCASI_health_care_policy_position.pdf & Ontario Ministry of Health and Long-Term Care. (2011). Rural and Northern Health Care Report Executive Summary. www.health.gov.on.ca/en/public/programs/ruralnorthern/docs/exec_summary_rural_northern_EN.pdf
Our provinces and territories have primary responsibility Health Canada. (2012). Canada’s Health Care System. www.hc-sc.gc.ca/hcs-sss/pubs/system-regime/2011-hcs-sss/index-eng.php
In order to receive federal funding for health care, provinces have to adhere Canada Health Act (1985, c. C-6). (2012). Department of Justice Canada. laws-lois.justice.gc.ca/PDF/C-6.pdf
agreements called Health Accords Government of Canada. (2006). First ministers’ meeting on the future of health care 2004: A 10-year plan to strengthen health care. http://healthycanadians.gc.ca/health-system-systeme-sante/cards-cartes/collaboration/2004-meeting-racontre-eng.php
For on-reserve First Nations and Inuit communities Report of the Auditor General of Canada. (2015). Report 4—Access to Health Services for Remote First Nations Communities. www.oag-bvg.gc.ca/internet/English/parl_oag_201504_04_e_40350.html
This can create divided systems of care Marchildon, G. P., Katapally, T. R., Beck, C. A., Abonyi, S., Episkenew, J., Pahwa, P., & Dosman, J. A. (2015). Exploring policy driven systemic inequities leading to differential access to care among Indigenous populations with obstructive sleep apnea in Canada. International Journal for Equity in Health, 14, 148. www.ncbi.nlm.nih.gov/pmc/articles/PMC4683910
Indigenous peoples in Canada continue to have much worse health outcomes Health Canada. (2016). First Nations and Inuit Health. Diseases and conditions. www.hc-sc.gc.ca/fniah-spnia/diseases-maladies/index-eng.php & King, M., Smith, A., & Gracey, M. (2012). Indigenous health part 2: The underlying causes of the health gap. The Lancet, 374, 76–85. http://cahr.uvic.ca/nearbc/documents/2009/lancet-vol374-2.pdf
doctors are not allowed to “extra bill” Marchildon, G. P. (2014). The three dimensions of universal Medicare in Canada. Canadian Public Administration, 57(3), 362–382. onlinelibrary.wiley.com/doi/10.1111/capa.12083/abstract;jsessionid=D4955C63362498F4201A874B29FBCA4B.f03t04?userIsAuthenticated=false&deniedAccessCustomisedMessage=
It’s set in negotiations between the government and the medical association Government of Ontario. (2016). Health Insurance Act, R.R.O. 1990, Reg. 552: General. www.ontario.ca/laws/regulation/900552
A 2015 report from the Organisation for Economic Co-operation and Development Organisation for Economic Co-operation and Development. (2015). Health at a glance 2015. Remuneration of doctors, ratio to average wage, 2013. www.keepeek.com/Digital-Asset-Management/oecd/social-issues-migration-health/health-at-a-glance-2015_health_glance-2015-en#page91
a “brain drain” of doctors south of the border Canadian Institute for Health Information. (2014). Physicians in Canada, 2013: Summary report. https://secure.cihi.ca/free_products/Physicians_In_Canada_Summary_Report_2013_en.pdf
The term Triple Aim Berwick, D. M., Nolan, T. W., & Wittington, J. (2008). The Triple Aim: Care, health, and cost. Health Affairs, 27(3), 759–769. http://content.healthaffairs.org/content/27/3/759.full
Indigenous peoples and some other marginalized groups National Collaboration Centre for Aboriginal Health. (2013). Setting the Context: An Overview of Aboriginal Health in Canada. www.nccah-ccnsa.ca/Publications/Lists/Publications/Attachments/101/abororiginal_health_web.pdf
The proportion of Canadians who say they are in good or excellent health Health Council of Canada. (2014). Where you live matters: Canadian views on health care quality. www.healthcouncilcanada.ca/content_lm.php?mnu=2&mnu1=48&mnu2=30&mnu3=56
Our average life expectancy is just over eighty-one years Organisation for Economic Co-operation and Development. (2015). Health at a glance 2015. www.oecd.org/health/health-systems/health-at-a-glance-19991312.htm
Canada comes in sixth place Nolte, E., & McKee, M. C. (2008). Measuring the health of nations: Updating an earlier analysis. Health Affairs, 27(1), 58–71. http://content.healthaffairs.org/content/27/1/58.full
When compared to thirty-four OECD countries Organisation for Economic Co-operation and Development. (2015). Health at a glance 2015. www.keepeek.com/Digital-Asset-Management/oecd/social-issues-migration-health/health-at-a-glance-2015_health_glance-2015-en#page55
Over the last ten years we’ve done much better Canada Health Infoway. (2015). The path of progress. Annual report 2014–2015. www.infoway-inforoute.ca/en/component/edocman/resources/i-infoway-i-corporate/annual-reports/2771-annual-report-2014-2015
fewer than half of Canadians Health Council of Canada. (2014). Where you live matters: Canadian views on health care quality. www.healthcouncilcanada.ca/content_lm.php?mnu=2&mnu1=48&mnu2=30&mnu3=56
The methods used to compare health care in different countries Docteur, E., Berenson, R. A. (2009). How Does the Quality of U.S. Health Care Compare Internationally? Timely Analysis of Immediate Health Issues. www.urban.org/sites/default/files/alfresco/publication-pdfs/411947-How-Does-the-Quality-of-U-S-Health-Care-Compare-Internationally-.PDF
According to the annual Wait Time Alliance report cards Wait Time Alliance. (2015). WTA Reports. www.waittimealliance.ca/wta-reports
Some countries with two-tier systems have long waits Flood, C. M. (2001). Profiles of Six Health Care Systems: Canada, Australia, The Netherlands, New Zealand, The UK, and The US. http://www.parl.gc.ca/Content/SEN/Committee/371/soci/rep/volume3ver1-e.pdf.
In 2013 (the latest year for which data are available at the time of writing) Canadian Institute for Health Information. (2015). National Health Expenditure Trends, 1975 to 2015. www.cihi.ca/sites/default/files/document/nhex_trends_narrative_report_2015_en.pdf
For every dollar we spend on health care in Canada Canadian Institute for Health Information. (2015). National Health Expenditure Trends, 1975 to 2015. www.cihi.ca/sites/default/files/document/nhex_trends_narrative_report_2015_en.pdf
U.K., where eighty-three cents Organisation for Economic Co-operation and Development. (2013). OECD.Stat: Health Status. http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT
United States, which has the highest private spending Canadian Institute for Health Information. (2015). National Health Expenditure Trends, 1975 to 2015. www.cihi.ca/sites/default/files/document/nhex_trends_narrative_report_2015_en.pdf
We have very low levels of public funding Organisation for Economic Co-operation and Development. (2015). Health at a glance 2015. www.keepeek.com/Digital-Asset-Management/oecd/social-issues-migration-health/health-at-a-glance-2015_health_glance-2015-en#page36 & Quiñonez, C. (2013). Why was dental care excluded from Canadian Medicare? Network for Canadian Oral Health Research Working Papers Series, 1(1).
Since 1998, our average out-of-pocket health care expenses Sanmartin, C., Hennessy, D., Lu, Y., & Law, M. R. (2014). Trends in out-of-pocket health care expenditures in Canada, by household income, 1997 to 2009. Statistics Canada. www.statcan.gc.ca/pub/82-003-x/2014004/article/11924-eng.pdf
has been called the Pac-Man argument Drummond, D. & Burleton, D. (2010). Charting a path to sustainable health care in Ontario. 10 proposals to restrain cost growth without compromising quality of care. TD Economics. www.td.com/document/PDF/economics/special/td-economics-special-db0510-health-care.pdf
“straight lines of death” fallacy Falk, W., Mendelsohn, M., Hjartarsen, J. & Stoutley, A. (2011). Fiscal Sustainability and the Transformation of Canada’s Healthcare System: A Shifting Gears Report. The Mowat Centre. mowatcentre.ca/fiscal-sustainability-canadas-healthcare/
Our total spending on health care is now falling Canadian Institute for Health Information. (2015). National health expenditures trends, 1975 to 2015. www.cihi.ca/sites/default/files/document/nhex_trends_narrative_report_2015_en.pdf
This made the fraction Evans, R. (1998). Going for gold: The redistributive agenda behind market-based health care reform. The Nuffield Trust. www.nuffieldtrust.org.uk/sites/files/nuffield/publication/Going_for_Gold.pdf
And these days, as citizens have pushed for better Navigator. (2016). Navigator poll shows widespread support for infrastructure spending. www.navltd.com/insights/navigator-poll-shows-widespread-support-infrastructure-spending/
we can expect to see health care costs grow by about 1 percent per year Mackenzie, H., & Rachlis, M. (2010). The sustainability of medicare. Canadian Federation of Nurses Unions. https://nursesunions.ca/sites/default/files/Sustainability.web_.e.pdf
The biggest increase in health care costs Canadian Institute for Health Information. (2015). National health expenditure trends, 1975 to 2015. www.cihi.ca/sites/default/files/document/nhex_trends_narrative_report_2015_en.pdf
Every Canadian adult, of every age group Health Council of Canada. (2009). Value for money: Making Canadian health care stronger. www.healthcouncilcanada.ca/tree/2.49-HCC_VFMReport_WEB.pdf
On average, each year we spend about C$6000 per person Canadian Institute for Health Information. (2015). National Health Expenditure Trends, 1975 to 2015. https://secure.cihi.ca/free_products/nhex_trends_narrative_report_2015_en.pdf
we’re one of the top ten spenders Organisation for Economic Co-operation and Development. (2015). Health at a glance 2015. www.keepeek.com/Digital-Asset-Management/oecd/social-issues-migration-health/health-at-a-glance-2015_health_glance-2015-en#page166
Morris Barer and Bob Evans first coined the term Barer, M., Evans, R. G., Hertzman, C., & Johri, M. (1998). Lies, damned lies and health care zombies: Discredited ideas that will not die. HPI Discussion Paper #10, University of Texas, Houston Health Science Center.
these fees deter both unnecessary and necessary care Keeler, E. B., & Rolph, J. E. (1983). How cost sharing reduced medical spending of participants in the health insurance experiment. Journal of the American Medical Association, 249(16), 2220–2222. www.rand.org/pubs/external_publications/EP19830401.html
One U.S. study looked at how employees Brot-Goldberg, Z. C., Chandra, A., Handel, B. R., & Kolstad, J. T. (2015). What does a deductible do? The impact of cost-sharing on health care prices, quantities, and spending dynamics. The National Bureau of Economic Research Working Paper No. 21632. http://eml.berkeley.edu/~bhandel/wp/Utilization_BCHK_Web.pdf
In the late 1960s the Saskatchewan government Beck, R. G. & Horne, J. M. (1980). Utilization of publicly insured health services in Saskatchewan, during and after copayment. Medical Care, 18(8), 787–806. www.jstor.org/stable/3764080?seq=1#page_scan_tab_contents
a drop most marked among people who could least afford to pay Beck, R. G., & Horne, J. M. (1980). Utilization of publicly insured health services in Saskatchewan before, during and after copayment. Medical Care, 18(8), 787–806. www.jstor.org/stable/3764080?seq=1#page_scan_tab_contents
user fees reduce usage of the kind of health care Creese, A. (1997). User fees: They don’t reduce costs, and they increase inequity. British Medical Journal, 315(7102), 202–203. www.ncbi.nlm.nih.gov/pmc/articles/PMC2127164/pdf/9253259.pdf
fail to produce significant revenues Stabile, M., & N-Marandi, S. (2010). Fatal flaws: Assessing Quebec’s failed health deductible proposal. C.D. Howe Institute. www.cdhowe.org/pdf/Working_Paper_Stabile.pdf
once you start setting fees Birch, S. (2004). Charging the patient to save the system? Like bailing water with a sieve. Canadian Medical Association Journal, 170(12), 1812–1813. www.ncbi.nlm.nih.gov/pmc/articles/PMC419770/
A study was conducted in Australia Duckett, S. J. (2005). Private care and public waiting. Australian Health Review, 29(1), 87–93. www.ncbi.nlm.nih.gov/pubmed/15683360
when Manitoba experimented briefly DeCoster, C., MacWilliam, L., & Walld, R. (2000). Waiting times for surgery: 1997/98 and 1998/99 update. Manitoba Centre for Health Policy and Evaluation. mchp-appserv.cpe.umanitoba.ca/reference/waits2.pdf
private health insurance does not improve access Canadian Medical Association Task Force on the Public–Private Interface. (2006). It’s about access: Informing the debate on public and private health care. www.cwhn.ca/en/node/27868#sthash.kPDer2x9.dpuf
the number of private clinics inside the public system is growing Mehra, N. (2008). Eroding Public Medicare: Lessons and Consequences of For-Profit Health Care Across Canada. http://www.ontariohealthcoalition.ca/wp-content/uploads/Eroding-Public-Medicare.pdf
In the United States, being admitted Devereaux, P. J., Choi, P. T. L., Lacchetti, C., Weaver, B., Schünemann, H. J., Haines, T., Lavis, J. N., Grant, B. J. B., Haslam, D. R. S., Bhandari, M., Sullivan, T., Cook, D. J., Walter, S. D., Meade, M., Khan, H., Bhatnagar, N., & Guyatt, G. H. (2002). A systematic review and meta-analysis of studies comparing mortality rates of private for-profit and private not-for-profit hospitals. Canadian Medical Association Journal, 166(11), 1399–1406. www.cmaj.ca/content/166/11/1399.full
dialysis in a for-profit Devereaux, P. J., Schünemann, H. J., Ravindran, N., Bhandari, M., Garg, A. X., Choi, P. T. L., Brydon, J. B. G., Haines, T., Lacchetti, C., Weaver, B., Lavis, J. N., Cook. D. J., Haslam, D. R. S., Sullivan, T., & Guyatt, G. H. (2002). Comparison of mortality between private for-profit and private not-for-profit hemodialysis centers: A systematic review and meta-analysis. Journal of the American Medical Association, 288(19), 2449–2457. http://jama.jamanetwork.com/article.aspx?articleid=195538
a 2015 study looked at the rates of hospitalization and death Tanuseputro, P., Chalifoux, M., Bennett, C., Gruneir, A., Bronskill, S. E., Walker, P., & Manuel, D. (2015). Hospitalization and mortality rates in long-term care facilities: Does for-profit status matter? Journal of the American Medical Directors Association, 16(10), 874–883. Epub 2015 Sep 30. www.jamda.com/article/S1525-8610(15)00414-4/abstract
Most European nations invest more public money Organisation for Economic Co-operation and Development. (2015). Health at a glance, 2015. www.keepeek.com/Digital-Asset-Management/oecd/social-issues-migration-health/health-at-a-glance-2015_health_glance-2015-en#page167
In France, having private insurance Chevreul, K., Durand-Zaleski, I., Bahrami, S., Hernández-Quevedo, C., & Mladovsky, P. (2010). France: Health System Review. Health Systems in Transition, 12(6). www.euro.who.int/__data/assets/pdf_file/0008/135809/E94856.pdf
In Germany, only 10 percent of the population Greß, S. (2007). Private health insurance in Germany: Consequences of a dual system. Health Policy, 3(2), 29–37. www.ncbi.nlm.nih.gov/pmc/articles/PMC2645182
earn more money than doctors in many European countries Organisation for Economic Co-operation and Development. (2015). Health at a glance 2015. www.keepeek.com/Digital-Asset-Management/oecd/social-issues-migration-health/health-at-a-glance-2015_health_glance-2015-en#page91
clauses that preserve the ability of Canadian governments Government of Canada. (1994). North American Free Trade Agreement. www.international.gc.ca/trade-agreements-accords-commerciaux/agr-acc/nafta-alena/index.aspx?lang=eng
BIG IDEA 1
“In hospitals, the diseases stay” Heath, I. (2006, January). Keeping the particular alive in general practice. Irish College of General Practitioners. www.icgp.ie/assets/26/D2AF6FE9-DEFF-4524-9ABEADC5FB3B7AC4_document/Iona.pdf
For many kinds of care Yeravdekar, R., Yeravdekar, V. R., & Tutakne, M. A. (2012). Family physicians: Importance and relevance. Journal of the Indian Medical Association, 110(7), 490–493. europepmc.org/abstract/med/23520678
“A death from a non-cardiac cause” Health, I. (2011). Divided we fail. Clinical Medicine, 11(6), 576–86. www.clinmed.rcpjournal.org/content/11/6/576.full
Systems that focus on good primary care Martin, D., Pollack, K., & Woolard, R. F. (2014). What would an Ian McWhinney health care system look like? Canadian Family Physician, 60(1), 17–19. www.cfp.ca/content/60/1/17.full.pdf
people are living longer Heath, I., & Sweeney, K. (2005). Medical generalists: Connecting the map and the territory. British Medical Journal, 331(7530), 1462–1464. www.ncbi.nlm.nih.gov/pubmed/16356984
one study that looked at men…with severe, uncontrolled high blood pressure Shea, S., Misra, D., Ehrlich, M. H., Field, L., & Francis, C. K. (1992). Predisposing factors for severe, uncontrolled hypertension in an inner-city minority population. New England Journal of Medicine, 327, 776–781. www.nejm.org/doi/full/10.1056/NEJM199209103271107#t=article
Study after study has confirmed Starfield, B., Shi, L., & Macinko, J. (2005). Contribution of primary care to health systems and health. Milbank Quarterly, 83(3), 457–502. www.ncbi.nlm.nih.gov/pmc/articles/PMC2690145/
A man was referred to me Barron, L. (2015, February 28). Why you need a family doctor. By a surgeon. canadianfemalesurgeon.wordpress.com/2015/02/28/why-you-need-a-family-doctor-by-a-surgeon
More than two hundred Canadian adults out of every thousand Stewart, M., & Ryan, B. (2015). Ecology of health care in Canada. Canadian Family Physician, 61(5), 449–453. www.cfp.ca/content/61/5/449.full
High-performing health care systems Baker, G. R., & Denis, J. (2011, September). A comparative study of three transformative healthcare systems: Lessons for Canada. CHSRF Commissioned report. www.cfhi-fcass.ca/sf-docs/default-source/commissioned-research-reports/Baker-Denis-EN.pdf?sfvrsn=0
approximately 85 percent of Canadians report Canadian Institute for Health Information. (2012). Health Care in Canada 2012 A: Focus on Wait Times. www.cihi.ca/en/hcic_2012_pptx_en.pptx
nearly three-quarters of those surveyed in 2013 Health Council of Canada. (2013). Where you live matters: Canadian views on health care quality. Results from the 2013 Commonwealth Fund International Health Policy Survey of the General Public. www.healthcouncilcanada.ca/content_lm.php?mnu=2&mnu1=48&mnu2=30&mnu3=56
their training enables them Huftless, S., & Kalloo, A. N. (2013). Screening colonoscopy: A new frontier for nurse practitioners. Clinical Gastroenterology and Hepatology, 11(2), 106–108. www.ncbi.nlm.nih.gov/pubmed/23142205 & Mundinger, M. O., Kane, R. L., Lenz, E. R., Totten, A. M., Tsai, W. Y., Cleary, P. D., Friedewald, W. T., Siu, A. L., & Shelanski, M. L. (2000). Primary care outcomes in patients treated by nurse practitioners or physicians: A randomized trial. Journal of the American Medical Association, 283(1), 59–68. http://www.ncbi.nlm.nih.gov/pubmed/10632281 & Ministry of Health and Long Term Care. (2016). Health workforce planning and regulatory affairs division. Mid career. New roles in nursing. www.health.gov.on.ca/en/pro/programs/hhrsd/nursing/mid_career.aspx
in Canada in the early 1990s Joschko, J., & Busing, N. (2016). Exploring the factors that influence the ratio of generalists to other specialists in Canada. Canadian Family Physician, 62(3), E122–128. www.cfp.ca/content/62/3/e122.abstract
“a robust appreciation…” Heath, I., & Sweeney, K. (2005). Medical generalists: Connecting the map and the territory. British Medical Journal, 331(7530), 1462–1464. www.ncbi.nlm.nih.gov/pubmed/16356984
“a perception of something being wrong…” Heath, I. (2010). World Organization of Family Doctors (Wonca) perspective on person-centered medicine. International Journal of Integrated Care. www.globalfamilydoctor.com/GetFile.aspx?oid=FBC397FA-3287-4E6D-9F82-E0CEE179AD6F
Primary care providers like family doctors see more illness than disease Heath, I., & Sweeney, K. (2005). Medical generalists: Connecting the map and the territory. British Medical Journal, 331(7530), 1462–1464.
the patient–physician relationship is central The College of Family Physicians of Canada. (2015). Four principles of family medicine. www.cfpc.ca/ProjectAssets/Templates/Category.aspx?id=885&langType=4105&terms=Family+medicine+is+a+community-based+discipline
“the relationship is usually prior…” McWhinney, I. R. (1996). The importance of being different. William Pickles Lecture. British Journal of General Practice, 46(408), 433–436. www.ncbi.nlm.nih.gov/pmc/articles/PMC1239699/
health care systems centred on primary care Starfield, B., Shi, L., & Macinko, J. (2005). Contribution of primary care to health systems and health. Milbank Quarterly, 83(3), 457–502. www.ncbi.nlm.nih.gov/pmc/articles/PMC2690145/
the real value and importance of the primary care relationship Devoe, J. E., Nordin, T., Kelly, K., Duane, M., Lesko, S., Saccocio, S. C., & Lesser, L. I. (2011). Having and being a personal physician: Vision of the Pisacano Scholars. Journal of the American Board of Family Medicine, 24(4), 463–468. www.ncbi.nlm.nih.gov/pmc/articles/PMC3211082/
something that happens when the door clicks shut Berwick, D. M. (2012). To Isaiah. Journal of the American Medical Association, 307(24), 2597–2599. http://jama.jamanetwork.com/article.aspx?articleid=1199158
such as screening for and treating high blood pressure McAlister, F. A., Wilkins, K., Joffres, M., Leenen, F. H. H., Fodor, G., Gee, M., Tremblay, M. S., Walker, R., Johansen, H., & Campbell, N. (2011). Changes in the rates of awareness, treatment and control of hypertension in Canada over the past two decades. Canadian Medical Association Journal, 183(9), 1007–1013. www.ncbi.nlm.nih.gov/pmc/articles/PMC3114892/
Specialists are three times more likely Allan, G. M., Kraut, R., Crawshay, A., Korownyk, C., Vandermeer, B., & Kolber, M. R. (2015). Contributors to primary care guidelines: What are their professions and how many of them have conflicts of interest? Canadian Family Physician, 61(1), 52–58. http://www.cfp.ca/content/61/1/52.full
recommended preventive services Yarnall, K. S. H., Pollak, K. I., Østbye, T., Krause, K. M., & Michener, J. L. (2003). Primary care: Is there enough time for prevention? American Journal of Public Health, 93(4), 635–641. www.ncbi.nlm.nih.gov/pmc/articles/PMC1447803/
recommended manoeuvres Østbye, T., Yarnall, K. S., Krause, K. M., Pollak, K. I., Gradison, M., & Michener, J. L. (2005). Is there time for management of patients with chronic diseases in primary care? Annals of Family Medicine, 3(3), 209–214. www.ncbi.nlm.nih.gov/pubmed/15928223
family doctor could spend between eleven and eighteen hours Pimlott, N. (2008). Who has time for family medicine? Canadian Family Physician, 54(1), 14–16. www.cfp.ca/content/54/1/14.full
RACE—Rapid Access to Consultative Expertise What is RACE? www.raceconnect.ca/what-is-race
about three-quarters of primary care doctors Canadian Institute for Healthcare Information. (2015). How Canada Compares: Results from the Commonwealth Fund 2015 International Health Policy Survey of Primary Care Physicians. www.cihi.ca/sites/default/files/document/2015-cmwf-chartpackenrev-web.pptx
primary care needs to incorporate elements Price, D., Baker, E., Golden, B., & Hannam, R. (2015, May). Patient Care Groups: A new model of population based primary health for Ontario. A report on behalf of the Primary Health Care Expert Advisory Committee. www.oma.org/Resources/Documents/primary_care_price_report.pdf
Ontario project called D2D Association of Family Health Teams of Ontario (AFHTO). (2015). D2D 2.0 report release: AFHTO members advance primary care measurement. www.afhto.ca/highlights/key-issues/d2d-2-0-report-release/
He called this the “Starfield observation” Southey, G. (2013). A Path to Greater Effectiveness, Efficiency and Equity In Ontario’s Health Care System Through Stable Primary Care Relationships, Provider Accountability And Measured Outcomes: Economic Perspectives of Controlling Health Costs and Assuring Quality. www.dorvalmedical.ca/wp-content/uploads/2012/01/Economic-Perspectives-of-Controlling-Health-Costs-2013-04-18.pdf
only about a third of family doctors The College of Family Physicians of Canada, Canadian Medical Association, & The Royal College of Physicians and Surgeons of Canada. (2013). National Physician Survey, 2013. Results for Family Physicians. http://nationalphysiciansurvey.ca/wp-content/uploads/2013/09/2013-FPGP-EN-Q6a.pdf
Ontario’s auditor general found Office of the Auditor General of Ontario. (2011). Ministry of Health and Long-Term Care. Chapter 3, Section 3.06. Funding Alternatives for Family Physicians. www.auditor.on.ca/en/content/annualreports/arreports/en11/306en11.pdf
jeopardize patient access and make waits for primary care longer Baerlocher, M. O., Noble, J., & Detsky, A. S. (2007). Impact of physician income source on productivity. Clinical and Investigative Medicine, 30(1), 42–43. http://cimonline.ca/index.php/cim/article/view/448/564
Every option encourages some behaviours Peckham, S., & Gousia, K. (2014). GP payment schemes review. PRUComm, a collaboration between London School of Hygiene and Tropical Medicine, the University of Manchester, and the Centre for Health Services Studies, University of Kent. www.kent.ac.uk/chss/docs/GP-payment-schemes-review-Final.pdf
over 40 percent of medical degrees were earned The Association of Faculties of Medicine of Canada. (2014). Canadian medical education statistics, 2014. www.afmc.ca/pdf/CMES2014-Complete-Optimized.pdf
we see fewer patients per day Cohen, M., Ferrier, B. M., Woodward, C. A., & Goldsmith, C. H. (1991). Gender differences in practice patterns of Ontario family physicians (McMaster medical graduates). Journal of the American Medical Women’s Association, 46(2), 49–54. http://www.ncbi.nlm.nih.gov/pubmed/2033207 & Roter, D. L., Hall, J. A., & Aoki, Y. (2002). Physician gender effects in medical communication: A meta-analytic review. Journal of the American Medical Association, 288(6), 756–764. http://jama.jamanetwork.com/article.aspx?articleid=195191
During our reproductive years Barer, M. L., Evans, R. G., & Hedden, L. (2014). False hope for Canadians who study medicine abroad. Canadian Medical Association Journal, 186(7), 552. www.cmaj.ca/content/186/7/552
new physicians have little interest The College of Family Physicians of Canada, Canadian Medical Association, & The Royal College of Physicians and Surgeons of Canada. (2012). The 2012 National Physician Survey for Medical Residents. http://nationalphysiciansurvey.ca/wp-content/uploads/2013/02/NPS2012-Resident-Full-EN.pdf
only 1 percent of new family medicine graduates The College of Family Physicians of Canada, Canadian Medical Association, & The Royal College of Physicians and Surgeons of Canada. (2012). The 2012 National Physician Survey for Medical Residents. http://nationalphysiciansurvey.ca/wp-content/uploads/2013/02/NPS2012-Resident-Full-EN.pdf
BIG IDEA 2
Canada is the only developed country Morgan, S. G., Daw, J. R., & Law, M. R. (2013). Rethinking pharmacare in Canada. www.cdhowe.org/pdf/Commentary_384.pdf
overmedication and inappropriate prescribing Morgan, S. G., Hunt, J., Rioux, J., Proulx, J., Weymann, D., & Tannenbaum, C. (2016). Frequency and cost of potentially inappropriate prescribing for older adults: a cross-sectional study. Canadian Medical Association Journal Open, 4(2), E346.
mostly an accident of history Boothe, K. (2015). Ideas and the Pace of Change: National Pharmaceutical Insurance in Canada, Australia, and the United Kingdom. Toronto: University of Toronto Press. www.utppublishing.com/Ideas-and-the-Pace-of-Change-National-Pharmaceutical-Insurance-in-Canada-Australia-and-the-United-Kingdom.html
one-third of Canadian adults live with at least one chronic condition Health Council of Canada. (2007). A Health Outcomes Report. Why Health Care Renewal Matters: Learning from Canadians with Chronic Health Conditions. www.healthcouncilcanada.ca/tree/2.20-Outcomes2FINAL.pdf
HIV medications for people who are HIV positive Detels, R., Muñoz, A., McFarlane, G., Kingsley, L. A., Margolick, J. B., Giorgi, J., Schrager, L. K., & Phair, J. P. (1998). Effectiveness of potent antiretroviral therapy on time to AIDS and death in men with known HIV infection duration. Journal of the American Medical Association, 280(17), 1497–1503. & Johnston, K. M., Levy, A. R., Lima, V. D., Hogg, R. S., Tyndall, M. W., Gustafson, P., Briggs, A., & Montaner, J. S. (2010). Expanding access to HAART: A cost-effective approach for treating and preventing HIV. AIDS, 24(12), 1929–1935. www.ncbi.nlm.nih.gov/pubmed/20588171
inhalers for people with asthma Rebuck, A. S. (2013). The global decline in asthma death rates: Can we relax now? Asia Pacific Allergy Journal, 3(3), 200–203. www.ncbi.nlm.nih.gov/pmc/articles/PMC3736367
cardiac medicines for people who’ve had a heart attack Flather, M. D., Yusuf, S., Kober, L., Pfeffer, M., Hall, A., Murray, G., Torp-Pedersen, C., Ball, S., Pogue, J., Moyé, L., & Braunwald, E. (2000). Long-term ACE-inhibitor therapy in patients with heart failure or left-ventricular dysfunction: A systematic overview of data from individual patients for the ACE-Inhibitor Myocardial Infarction Collaborative Group. The Lancet, 355(9215), 1575–1581. www.ncbi.nlm.nih.gov/pubmed/10821360 & Furberg, C. D., & Pitt, B. (2001). Are all angiotensin-converting enzyme inhibitors interchangeable? Journal of the American College of Cardiology, 37(5), 1456–1460. http://content.onlinejacc.org/article.aspx?articleid=1127138 & Taylor, F., Huffman, M. D., Macedo, A. F., Moore, T. H., Burke, M., Davey Smith, G., Ward, K., & Ebrahim, S. (2013). Statins for the primary prevention of cardiovascular disease. Cochrane Database of Systematic Reviews, 1. www.ncbi.nlm.nih.gov/pubmed/23440795
Low-income people with diabetes Booth, G. L., Bishara, P., Lipscombe, L. L., Shah, B. R., Feig, D. S., Bhattacharyya, O., & Bierman, A. S. (2012). Universal drug coverage and socioeconomic disparities in major diabetes outcomes. Diabetes Care, 35(11), 2257–2264. www.ncbi.nlm.nih.gov/pmc/articles/PMC3476904
the more people have to spend on their prescriptions Goldman, D. P., Joyce G. F., & Zheng, Y. (2007). Prescription drug cost—associations with medication and medical utilization and spending and health. Journal of the American Medical Association, 298(1), 61–69. http://jama.jamanetwork.com/article.aspx?articleid=207805
drug coverage becomes a factor in people’s career and job choices McGroarty, G. (2011). Benefits versus salary: Which is worth more? Sun Life Financial. www.sunlife.ca/ca/Learn+and+Plan/Money/Financial+planning+tips/Benefits+versus+salary+Which+is+worth+more?vgnLocale=en_CA
it’s called “job lock” Frakt, A. (2014). Job lock: Introduction. http://theincidentaleconomist.com/wordpress/job-lock-introduction
Nearly three-quarters of part-time workers Barnes, S. & Anderson, L. (2015). Low earnings, unfilled prescriptions: Employer-provided health benefit coverage in Canada. The Wellesley Institute. www.wellesleyinstitute.com/wp-content/uploads/2015/07/Low-Earnings-Unfilled-Prescriptions-2015.pdf
Young people and women, who are more likely Ferrao, V. (2010, December). “Paid work,” in Women in Canada: A gender-based statistical report. Statistics Canada. www.statcan.gc.ca/pub/89-503-x/2010001/article/11387-eng.pdf & Statistics Canada. (2015). Part-time employment rates, chart G.2. www.statcan.gc.ca/pub/71-222-x/2008001/sectiong/g-part-partiel-eng.htm
most Canadians with jobs are excluded Barnes, S., & Anderson, L. (2015). Low earnings, unfilled prescriptions: Employer-provided health benefit coverage in Canada. The Wellesley Institute. www.wellesleyinstitute.com/wp-content/uploads/2015/07/Low-Earnings-Unfilled-Prescriptions-2015.pdf
a patient with congestive heart failure Demers, V., Melo, M., Jackevicius, C., Cox, J., Kalavrouziotis, D., Rinfret, S., Humphries, K. H., Johansen, H., Tu, J. V., & Pilote, L. (2008). Comparison of provincial prescription drug plans and the impact on patients’ annual drug expenditures. Canadian Medical Association Journal, 178(4), 405–409. www.cmaj.ca/content/178/4/405.full
one in five Canadian households Angus Reid Institute. (2015). Prescription drug access and affordability an issue for nearly a quarter of all Canadian households. http://angusreid.org/prescription-drugs-canada
two-thirds of Canadians over the age of sixty-five Canadian Institute for Health Information. (2014). Drug use among seniors on public drug programs in Canada, 2012. https://secure.cihi.ca/free_products/Drug_Use_in_Seniors_on_Public_Drug_Programs_EN_web_Oct.pdf
22 percent of our prescription drug costs Canadian Institute for Health Information. (2014). Drug spending in 2014. www.cihi.ca/web/resource/en/nhex_2014_infosheet_en.pdf
one in ten Canadians does not fill a prescription Law, M. R., Cheng, L., Dhalla, I. A., Heard, D., & Morgan, S. G. (2012). The effect of cost on adherence to prescription medications in Canada. Canadian Medical Association Journal, 184(3), 297–302. http://www.cmaj.ca/content/early/2012/01/16/cmaj.111270
3 percent of the Dutch and 2 percent of the British Gagnon, M-A. (2014). A roadmap to a rational pharmacare policy in Canada. Ottawa: Canadian Federation of Nurses Unions. https://nursesunions.ca/sites/default/files/pharmacare_report.pdf & Schiff, G. D. (2013). A piece of my mind. Crossing boundaries—violation or obligation? Journal of the American Medical Association, 310(12), 1233-1234. www.ncbi.nlm.nih.gov/pubmed/24065007
new classes of on-patent drugs Morgan, S. G., Bassett, K. L., Wright, J. M., Evans, R. G., Barer, M. L., Caetano, P. A., & Black, C. D. (2005). “Breakthrough” drugs and growth in expenditure on prescription drugs in Canada. British Medical Journal, 331, 815–816. www.bmj.com/content/331/7520/815
goes for about $800 in Canada Ontario Ministry of Health and Long-Term Care. (2016). Ontario Drug Benefit Formulary/Comparative Drug Index. Retrieved April 2015 from www.formulary.health.gov.on.ca/formulary/results.xhtml?q=Lipitor&type=2
A year’s supply of the exact same drug New Zealand Pharmaceutical Management Agency (PHARMAC). (2016). Online Pharmaceutical Schedule. Retrieved April 2015 from www.pharmac.govt.nz/Schedule?osq=Atorvastatin&code=C0732041137
Canadians pay 30 percent more Patented Medicine Prices Review Board. (2013). Annual Report 2013, Comparison of Canadian Price to Foreign Prices. http://www.pmprb-cepmb.gc.ca/view.asp?ccid=938#1765
Drug prices in Canada are among the highest Beall, R. F., Nickerson, J. W., & Attaran, A. (2014). Pan-Canadian overpricing of medicines: A 6-country study of cost control for generic medicines. Open Medicine 8(4). www.openmedicine.ca/article/view/645/566
Some policy makers have argued that maintaining high patented drug prices encourages Government of Canada. (2015). Patented Medicine Prices Review Board: Strategic plan 2015–2017. www.pmprb-cepmb.gc.ca/view.asp?ccid=1197
The more we’ve spent on pharmaceutical products Government of Canada. (2014). Patented Medicine Prices Review Board. Annual report 2014. www.pmprb-cepmb.gc.ca/view.asp?ccid=1217#a8 & Lexchin, J. (2003). Intellectual property rights and the Canadian pharmaceutical marketplace: Where do we go from here? www.policyalternatives.ca/sites/default/files/uploads/publications/National_Office_Pubs/ipr.pdf
Compare this to the U.K., where drug prices are Kiriyama, N. (2011). Trade and Innovation: Pharmaceuticals. Organisation for Economic Co-operation and Development. www.oecd-ilibrary.org/docserver/download/5kgdscrcv7jg.pdf?expires=1442773436&id=id&accname=guest&checksum=12893DDCD318DF887B518C2F5A409AE3
Another growing factor in pricing Sinclair, S., Trew, S., & Mertins-Kirkwood, H. (2014). Making sense of the CETA: An analysis of the final text of the Canada-European Union Comprehensive Economic and Trade Agreement. Canadian Centre for Policy Alternatives. www.policyalternatives.ca/publications/reports/making-sense-ceta
generic drugs…are nearly double the median prices Government of Canada. (2014). Patented Medicine Prices Review Board. Generic drugs in Canada, 2013. www.pmprb-cepmb.gc.ca/view.asp?ccid=1122
amlodipine is 86 percent lower in New Zealand Beall, R. F., Nickerson, J. W., & Attaran, A. (2014). Pan-Canadian overpricing of medicines: A 6-country study of cost control for generic medicines. Open Medicine, 8(4), E130–E135. www.openmedicine.ca/article/view/645/566
it’s now the norm for governments to pay 18 percent The Pan-Canadian Pharmaceutical Alliance. (2016). Background: Generic drugs. www.pmprovincesterritoires.ca/en/initiatives/358-pan-canadian-pharmaceutical-alliance
especially where they competitively tender to procure Law, M. R., & Kratzer, J. (2013, September 17). The road to competitive generic drug prices in Canada. Canadian Medical Association Journal, 185(13), 1141–1144. www.cmaj.ca/content/185/13/1141
the number of pharmacies in Canada continues to go up Labrie, Y. (2015). The Other Health Care System: Four areas where the private sector answers patients’ needs. Chapter 2- Pharmacies in Canada: Accessible private health care services. Montreal Economic Institute. www.iedm.org/files/cahier0115_en.pdf
$383 million more per year for generic medications Gagnon, M-A., & Hébert, G. (2010, September 13). The Economic Case for Universal Pharmacare: Costs and Benefits of Publicly Funded Drug Coverage for All Canadians. Ottawa: Canadian Centre for Policy Alternatives. https://s3.amazonaws.com/policyalternatives.ca/sites/default/files/uploads/publications/National%20Office/2010/09/Universal_Pharmacare.pdf
$6.8 billion more in premiums Law, M. R., Kratzer, J., & Dhalla, I. A. (2014). The increasing inefficiency of private health insurance in Canada. Canadian Medical Association Journal, 186(12), E470-474. www.cmaj.ca/content/early/2014/03/24/cmaj.130913.full.pdf+html
administrative costs…8 percent in the private sector Gagnon, M-A. (2014). A roadmap to a rational pharmacare policy in Canada. Ottawa: Canadian Federation of Nurses Unions. https://nursesunions.ca/sites/default/files/pharmacare_report.pdf
General Motors CEO Richard Wagoner French, R. (2006, October 29). GM, nation losing out to health care. The Salt Lake Tribune. http://archive.sltrib.com/story.php?ref=/healthscience/ci_4567855
Warren Buffett has looked at the numbers too French, R. (2006, October 29). GM, nation losing out to health care. The Salt Lake Tribune. http://archive.sltrib.com/story.php?ref=/healthscience/ci_4567855
GM and Ford paid $1500 per vehicle in health costs Daschle, T., Greenberger, S. S., & Lambrew, J. M. (2008). Critical: What We Can Do About the Health-Care Crisis. New York: St. Martin’s Griffin. https://books.google.ca/books/about/Critical.html?id=MlweIW_sU3EC&redir_esc=y&hl=en
the insurance industry’s association has called for Hope, W. (2015). The better way—public and private sectors working together to reform pharmacare in Canada. News release. www.clhia.ca/domino/html/clhia/clhia_lp4w_lnd_webstation.nsf/page/AA2597E98A11A70085257E140047580C
We’ve seen exactly this in Quebec Gouvernement du Québec. (2015). Eligibility. www.ramq.gouv.qc.ca/en/citizens/prescription-drug-insurance/Pages/eligibility.aspx
The result has been staggeringly expensive Morgan, S. G., Daw, J. R., & Law, M. R. (2013). Rethinking pharmacare in Canada. C.D. Howe Institute. www.cdhowe.org/pdf/Commentary_384.pdf
Instead of cost containment, the Quebec approach has resulted in cost-shifting Gagnon, M-A. (2014). A roadmap to a rational pharmacare policy in Canada. Ottawa: Canadian Federation of Nurses Unions. nursesunions.ca/report-study/roadmap-rational-pharmacare-policy-in-canada & Smolina, K., & Morgan, S. (2014). The drivers of overspending on prescription drugs in Quebec. Healthcare Policy 10(2), 19-26. www.longwoods.com/content/24046
and there is less bargaining capacity Gagnon, M-A. (2015, June 26). Quebec should not be the model for national pharmacare. The Globe and Mail. www.theglobeandmail.com/opinion/quebec-should-not-be-the-model-for-national-pharmacare/article25135678/
even private insurance companies are struggling Nelson, J. (2015, July 31). The high-stakes battle of medications, insurers and the government. The Globe and Mail. www.theglobeandmail.com/report-on-business/the-high-stakes-battle-of-medications-governments-and-insurers/article25807404
increase in the number of plans adding annual or lifetime maximums Kratzer, J., Mcgrail, K., Strumpf, E., & Law, M. R. (2013). Cost-control mechanisms in Canadian private drug plans. Healthcare Policy, 9(1), 35–43. www.ncbi.nlm.nih.gov/pubmed/23968672
can’t afford drug coverage for their employees Mercer. (2011). Cost trends in health benefits for Ontario businesses: Analysis for discussion. Commissioned by the Ontario Chamber of Commerce for release at the Ontario Economic Summit. www.occ.ca/Publications/Cost-Trends-in-Health-Benefits-Report.pdf
$8.2 billion annually Morgan, S. G., Law, M., Daw, J. R., Abraham, L., & Martin, D. (2015, March 16). Estimated cost of universal public coverage of prescription drugs in Canada. Canadian Medical Association Journal 187(7). www.cmaj.ca/content/early/2015/03/16/cmaj.141564
In 1994, those federal and provincial tax subsidies Smythe, J. G. (2001, August 19). Tax subsidization of employer-provided health care insurance in Canada: Incidence analysis. Working Paper, Department of Economics, University of Alberta, Edmonton.
Up to 90 percent of new drugs Light, D. W., & Lexchin, J. R. (2012). Pharmaceutical and research development: What do we get from all that money? British Medical Journal, 345, E4348. www.bmj.com/content/345/bmj.e4348
Often called “me too” drugs Morgan, S. G., Bassett, K. L., Wright, J. M., Evans, R. G., Barer, M. L., Caetano, P. A., & Black, C. D. (2005). “Breakthrough” drugs and growth in expenditure on prescription drugs in Canada. British Medical Journal, 331, 815–816. www.bmj.com/content/331/7520/815
the cure rate is up to 96 percent U.S. Food and Drug Administration. (2014). Approval of Sovaldi (sofosbuvir) tablets for the treatment of chronic hepatitis C. www.fda.gov/ForPatients/Illness/HepatitisBC/ucm377920.htm
the price in Canada of a twelve-week course of therapy Hepatitis C Education & Prevention Society. (2014). New Canadian Developments Re: Sofosbuvir’s price and approval schedule. http://hepcbc.ca/2014/02/updates-canadian-sofosbuvir-pricing-cadth-queuing-schedule
$650 per pill CTV News. (2014, May 25). Hepatitis C drugs show promise, but price is too high for most patients. www.ctvnews.ca/health/hepatitis-c-drugs-show-promise-but-price-is-too-high-for-most-patients-1.1837917
$1000 per pill for a total cost of $84,000 LaMattina, J. (2014, August 8). Even at $900 (vs. $84,000 in US) Hep C cure Sovaldi’s cost could be unacceptable in India. Forbes. http://www.forbes.com/sites/johnlamattina/2014/08/08/even-at-900-per-cure-sovaldis-cost-could-be-unacceptable-in-india/#7a804ac419a5
price was set at $900 LaMattina, J. (2014, August 8). Even at $900 (vs. $84,000 in US) Hep C cure Sovaldi’s cost could be unacceptable in India. Forbes. http://www.forbes.com/sites/johnlamattina/2014/08/08/even-at-900-per-cure-sovaldis-cost-could-be-unacceptable-in-india/#7a804ac419a5
25 percent of people infected with the virus will spontaneously Grebely, J., Raffa, J. D., Calvin, L., Krajden, M., Conway, B., & Tyndall, M. W. (2007). Factors associated with spontaneous clearance of hepatitis C virus among illicit drug users. Canadian Journal of Gastroenterology, 21(7), 447–451. www.ncbi.nlm.nih.gov/pmc/articles/PMC2657966
In 1993, the New Zealand government introduced Grocott, R. (2009). Applying Programme Budgeting Marginal Analysis in the health sector: 12 years of experience. Expert Review of Pharmacoeconomics and Outcomes Research, 9(2), 181–187. www.ncbi.nlm.nih.gov/pubmed/19402806
led to savings of over $50 million Pharmaceutical Management Agency (PHARMAC). (2016). PHARMAC tender savings top $600 million. www.pharmac.govt.nz/news/media-2015-03-17-tender-savings
A recent study in Quebec found Equale, T., Buckeridge, D. L., Winslade, N. E., Benedetti, A., Hanley, J. A., & Tamblyn, R. (2012). Drug, patient and physician characteristics associated with off-label prescribing in primary care. Archives of Internal Medicine, 172(10), 781–788. www.ncbi.nlm.nih.gov/pubmed/22507695
Most of the solutions out there O’Brien, M. A., Rogers, S., Jamtvedt, G., Oxman, A. D., Odgaard-Jensen, J., Kristoffersen, D. T., Forsetlund, L., Bainbridge, D., Freemantle, N., Davis, D., Haynes, R. B., & Harvey, E. (2007). Educational outreach visits: Effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews, 4, CD000409. www.cochrane.org/CD000409/EPOC_educational-outreach-visits-to-change-health-care-professional-care-for-patients
the National Health Service maintains a “blacklist” Mossialos, E., & Oliver, A. (2005). An overview of pharmaceutical policy in four countries: France, Germany, the Netherlands and the United Kingdom. International Journal of Health Planning & Management, 20(4), 291–306. www.ncbi.nlm.nih.gov/pubmed/16335079
NHS makes these decisions according to evidence-based recommendations Gagnon, M-A., & Hébert, G. (2010, September 13). The Economic Case for Universal Pharmacare: Costs and Benefits of Publicly Funded Drug Coverage for all Canadians. Ottawa: Canadian Centre for Policy Alternatives. https://s3.amazonaws.com/policyalternatives.ca/sites/default/files/uploads/publications/National%20Office/2010/09/Universal_Pharmacare.pdf & Mossialos, E., & Oliver, A. (2005). An overview of pharmaceutical policy in four countries: France, Germany, the Netherlands and the United Kingdom. International Journal of Health Planning & Management, 20(4), 291–306. www.ncbi.nlm.nih.gov/pubmed/16335079
The process of academic detailing Kondro, W. (2007). Academic drug detailing: an evidence-based alternative. Canadian Medical Association Journal, 176(4), 429–431. http://doi.org/10.1503/cmaj.070072
Wise Use of Antibiotics Pharmaceutical Management Agency. (2012). Annual review 2012. www.pharmac.health.nz/ckeditor_assets/attachments/115/annual_review_2012.pdf
E-prescribing can also decrease prescription errors Durieux, P., Trinquart, L., Colombet, I., Niès, J., Walton, R., Rajeswaran, A., Rége, M. W., Harvey, E., & Burnand, B. (2008). Computerized advice on drug dosage to improve prescribing practice. Cochrane Database of Systematic Reviews, 3, CD002894. www.ncbi.nlm.nih.gov/pubmed/18646085#
effective way to improve the appropriateness of prescribing Ivers, N., Jamtvedt, G., Flottorp, S., Young, J. M., Odgaard-Jensen, J., Frech, S. D., O’Brien, M. A., Johansen, M., Grimshaw, J., & Oxman, A. D. (2012). Audit and feedback: Effects on professional practice and healthcare outcomes. The Cochrane Collaboration. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000259.pub3/abstract
despite decades of recommendations by Royal Commissions Council of the Federation. (2006, July 28). Council of the Federation communique. www.releases.gov.nl.ca/releases/2006/exec/0728n05.htm
A research study I was involved in Morgan, S. G., Law, M., Daw, J. R., Abraham, L., & Martin, D. (2015, March 16). Estimated cost of universal public coverage of prescription drugs in Canada. Canadian Medical Association Journal, 187(7). www.cmaj.ca/content/early/2015/03/16/cmaj.141564
social objective of equitable access Walkom, T. (2015). Why Canadian governments resist sensible pharmacare. Toronto Star. www.thestar.com/news/canada/2015/03/17/why-canadian-governments-resist-sensible-pharmacare-walkom.html
Public support for national pharmacare is high EKOS. (2013, May 22). Canadian views on prescription drug coverage. Press Release. www.ekospolitics.com/wp-content/uploads/press_release_may_22_2013.pdf
These economic powerhouses exert Evans, R. (2013). Concluding Remarks. Presentation at the seminar Rethinking Drug Coverage held in Ottawa, May 25, 2013.
Major change in Canadian health care is rare, but it isn’t impossible Boothe, K. (2015). Ideas and the pace of change: National pharmaceutical insurance in Canada, Australia, and the United Kingdom. Toronto, ON: University of Toronto Press. www.utppublishing.com/Ideas-and-the-Pace-of-Change-National-Pharmaceutical-Insurance-in-Canada-Australia-and-the-United-Kingdom.html
known complication of the procedure Werner, N., Zahn, R., & Zeymer, U. (2012, October). Stroke in patients undergoing coronary angiography and percutaneous coronary intervention: incidence, predictors, outcome and therapeutic options. Expert Review of Cardiovascular Therapy, 10(10), 1297–1305.
BIG IDEA 3
likelihood of ending up with a Caesarean section Alfirevic, Z., Devane, D., & Gyte, G. M. (2006). Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews, 3, CD006066. www.ncbi.nlm.nih.gov/pubmed/16856111
the explosive finding in a 2015 study Jena, A. B., Prasad, V., Godlman, D. P., & Romley, J. (2015). Mortality and treatment patterns among patients hospitalized with acute cardiovascular conditions during dates of national cardiology meetings. Journal of the American Medical Association (JAMA) Internal Medicine, 175(2), 237–244. http://archinte.jamanetwork.com/article.aspx?articleid=2038979
In the early 2000s, a new disease known as “pre-diabetes” Goldenberg, R., & Punthakee, Z. (2013). Definition, classification and diagnosis of diabetes, pre-diabetes and metabolic syndrome. Canadian Journal of Diabetes, 37, S3. www.canadianjournalofdiabetes.com/article/S1499-2671(13)00052-X/fulltext & Welch, H. G., Schwartz, L. M., & Woloshin, S. (2012). Overdiagnosed: Making People Sick in the Pursuit of Health. Boston: Beacon Press. www.beacon.org/Overdiagnosed-P925.aspx
people with sugars below 6.0 are at increased risk Welch, H. G., Schwartz, L. M., & Woloshin, S. (2012). Overdiagnosed: Making People Sick in the Pursuit of Health. Boston: Beacon Press. www.beacon.org/Overdiagnosed-P925.aspx
diseases like diabetes and high blood pressure Welch, H. G., Schwartz, L. M., & Woloshin, S. (2012). Overdiagnosed: Making People Sick in the Pursuit of Health. Boston: Beacon Press. www.beacon.org/Overdiagnosed-P925.aspx
From a population perspective, small changes to testing thresholds Welch, H. G., Schwartz, L. M., & Woloshin, S. (2012). Overdiagnosed: Making People Sick in the Pursuit of Health. Boston: Beacon Press. www.beacon.org/Overdiagnosed-P925.aspx
the definition of what constitutes “abnormal” cholesterol levels Welch, H. G., Schwartz, L. M., & Woloshin, S. (2012). Overdiagnosed: Making People Sick in the Pursuit of Health. Boston: Beacon Press. www.beacon.org/Overdiagnosed-P925.aspx
pre-dementia, pre-diabetes, or pre-hypertension Le Couteur, D. G., Doust, J., Creasey, H., & Brayne, C. (2013). Political drive to screen for pre-dementia: Not evidence based and ignores the harms of diagnosis. British Medical Journal Online, 347. www.bmj.com/content/347/bmj.f5125 & Yudkin, J. S. (2014). The epidemic of pre-diabetes: The medicine and the politics. British Medical Journal Online, 349. www.bmj.com/content/349/bmj.g4485
A recent study looked at expert panels Moynihan, R. N., Cooke, G. P. E., Doust, J. A., Bero, L., Hill, S., & Glasziou, P. P. (2013). Expanding disease definitions in guidelines and expert panel ties to industry: A cross-sectional study of commons conditions in the United States. PLOS Medicine, 10(8). http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001500.
an American campaign for migraine medicine Mintzes, B. (2006). What are the Public Health Implications? Direct-to-Consumer Advertising of Prescription Drugs in Canada. Health Council of Canada. www.healthcouncilcanada.ca/tree/2.38-hcc_dtc-advertising_200601_e_v6.pdf
We even have a set of “ankle rules” Stiell, I. G., Greenberg, G. H., McKnight, R. D., Nair, R. C., McDowell, I., & Worthington, J. R. (1992). A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Annals of Emergency Medicine, 21(4), 384–390. www.ncbi.nlm.nih.gov/pubmed/1554175
Our approaches to training physicians can reinforce Weinberger, S. E. (2011). Providing high-value, cost-conscious care: A critical seventh general competency for physicians. Annals of Internal Medicine, 155(6), 386–388. http://annals.org/article.aspx?articleid=747128
when physicians are paid for performing Shah, B. R., Cowper, P. A., O’Brien, S. M., Jensen, N., Patel, M. R., Douglas, P. S., & Peterson, E. D. (2011). Association between physician billing and cardiac stress testing patterns following coronary revascularization. Journal of the American Medical Association, 306(18), 1993–2000. http://jama.jamanetwork.com/article.aspx?articleid=1104608
Among the “Laws” passed down Shem, S. (1978). The House of God. New York: Putnam Publishing Group, p. 361.
overtesting and overtreatment are significant problems Hicks, L. K. (2015, March 24). Reframing overuse in health care: Time to focus on the harms. American Society of Clinical Oncology. www.ncbi.nlm.nih.gov/pubmed/25804988
The Canadian Association of Radiologists has estimated Health Council of Canada. (2010). Decisions, decisions: Family doctors as gatekeepers to prescription drugs and diagnostic imaging in Canada. www.healthcouncilcanada.ca/tree/2.33-DecisionsHSU_Sept2010.pdf
It’s hard to know if this estimate is accurate Fraser, J. (2013) Appropriateness of Imaging in Canada. Canadian Association of Radiologists Journal 64, 82–84
While radiation exposure…is small Peck, D. J. & Samei, E. (2010). How to Understand and Communicate Radiation Risk. Image Wisely. www.imagewisely.org/imaging-modalities/computed-tomography/medical-physicists/articles/how-to-understand-and-communicate-radiation-risk
eliminating inappropriate CT and MRI scans You, J. J., Levinson, W., & Laupacis, A. (2009). Attitudes of family physicians, specialists and radiologists about the use of computed tomography and magnetic resonance imaging in Ontario. Health Policy, 5(1), 54–65. www.ncbi.nlm.nih.gov/pmc/articles/PMC2732655/
If she has a Pap smear every year DeMay, R. M. (2000). Should we abandon Pap smear testing? American Journal of Clinical Pathology, 114(S), 48–51. www.ncbi.nlm.nih.gov/pubmed/11996169
thousands of people are having such unnecessary screening Kirkham, K. R., Wijeysundera, D. N., Pendrith, C., Ng, R., Tu, J. V., Laupacis, A., Schull, M. J., Levinson, W., & Bhatia, R. S. (2015). Preoperative testing before low-risk surgical procedures. Canadian Medical Association Journal, 187(11), E349–358. www.cmaj.ca/content/187/11/E349.full
This unanimous recommendation is based on the fact Simos, D., Catley, C., van Walraven, C., Arnaout, A., Booth, C. M., McInnes, M., Fergusson, D., Dent, S., & Clemons, M. (2015). Imaging for distant metastases in women with early-stage breast cancer: A population-based cohort study. Canadian Medical Association Journal, 187(12), E387–E397. www.cmaj.ca/content/early/2015/06/22/cmaj.150003
a recent Ontario study Simos, D., Catley, C., van Walraven, C., Arnaout, A., Booth, C. M., McInnes, M., Fergusson, D., Dent, S., & Clemons, M. (2015). Imaging for distant metastases in women with early-stage breast cancer: A population-based cohort study. Canadian Medical Association Journal, 187(12), E387–E397. www.cmaj.ca/content/early/2015/06/22/cmaj.150003
According to a newspaper article about the study CBC News. (2015, June 22). Needless breast cancer imaging common in Ontario, study finds. www.cbc.ca/m/touch/health/story/1.3122554
even three years after a false positive mammogram Brodersen, J., & Siersma, V. D. (2013). Long-term psychosocial consequences of false-positive screening mammography. The Annals of Family Medicine, 11(2), 106–115. www.annfammed.org/content/11/2/106.full
One review of all the studies on screening mammograms Gøtzsche, P. C., & Jørgensen, K. (2013). Screening for breast cancer with mammography. The Cochrane Library 2013, 6. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001877.pub5/abstract
Dr. H. Gilbert Welch explains the problem of cancer overdiagnosis Welch, H. G. (2015). Less Medicine, More Health: 7 Assumptions That Drive Too Much Medical Care. Boston: Beacon Press Books. www.beacon.org/Less-Medicine-More-Health-P1095.aspx
nearly 60 percent of men over the age of seventy-nine Bell, K. J., Del Mar, C., Wright, G., Dickinson, J., & Glasziou, P. (2015). Prevalence of incidental prostate cancer: A systematic review of autopsy studies. International Journal of Cancer, 137(7), 1749–1757. & Zlotta, A. R., Egawa, S., Pushkar, D., Govorov, A., Kimura, T., Kido, M.,…& Fleshner, N. (2013). Prevalence of prostate cancer on autopsy: cross-sectional study on unscreened Caucasian and Asian men. Journal of the National Cancer Institute, 105, 1050–1058.
likelihood that testing will turn up a “problem” Draisma, G., Boer, R., Otto, S. J., van der Cruijsen, I. W., Damhuis, R. A., Schröder, F. H., & de Koning, H. J. (2003). Lead times and overdetection due to prostate-specific antigen screening: estimates from the European Randomized Study of Screening for Prostate Cancer. Journal of the National Cancer Institute, 95(12), 868–878.
And for men who go on to have treatment for low-grade prostate cancer Heijnsdijk, E. A., Wever, E. M., Auvinen, A., Hugosson, J., Ciatto, S., Nelen, V.,…& Zappa, M. (2012). Quality-of-life effects of prostate-specific antigen screening. New England Journal of Medicine, 367(7), 595-605.
Hearing the word “cancer” understandably evokes anxiety Welch, H. G. (2001). Informed choice in cancer screening. Journal of the American Medical Association, 285(21), 2776–2778. http://jama.jamanetwork.com/article.aspx?articleid=193878
One in four Canadians report Ipsos R. (2015, April). Public awareness and attitudes towards the Choosing Wisely campaign. Commissioned by the Canadian Medical Association. www.choosingwiselycanada.org/news/2015/06/11/choosing-wisely-canadas-first-birthday/
Increased use of prescription medication Canadian Institute for Health Information. (2015). National health expenditure trends, 1975 to 2015. Data Tables, Series G—Expenditure on drugs by type, by source of finance, by province/territory and Canada. www.cihi.ca/en/spending-and-health-workforce/spending/national-health-expenditure-trends
In 2009 Canadian physicians wrote 80 percent more prescriptions Health Council of Canada. (2010). Decisions, decisions: Family doctors as gatekeepers to prescription drugs and diagnostic imaging in Canada. www.healthcouncilcanada.ca/tree/2.33-DecisionsHSU_Sept2010.pdf
They can be effective treatments for temporary sleep problems Buysse, D. J. (2013). Insomnia. The Journal of the American Medical Association, 309(7), 706–716.
not supposed to be prescribed for daily use O’Brien, Charles P. “Benzodiazepine use, abuse, and dependence.” Journal of Clinical Psychiatry, 66, 28–33. & Holbrook, A. M., Crowther, R., Lotter, A., Cheng, C., & King, D. (2000). Meta-analysis of benzodiazepine use in the treatment of insomnia. Canadian Medical Association Journal, 162(2), 225–233.
should almost never be prescribed to seniors Campanelli, C. M. (2012). American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults: The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. Journal of the American Geriatrics Society, 60(4), 616–631.
they’re frequently prescribed these medications to help them sleep Bell, C. M., Fischer, H. D., Gill, S. S., Zagorski, B., Sykora, K., Wodchis, W. P.,…& Rochon, P. A. (2007). Initiation of benzodiazepines in the elderly after hospitalization. Journal of General Internal Medicine, 22(7), 1024–1029.
Many of these people then continue being prescribed Kermode-Scott, B. (2007). Benzodiazepine prescribing to elderly people after hospital discharge can lead to chronic use. BMJ: British Medical Journal, 335(7611), 119. & O’Brien, Charles P. “Benzodiazepine use, abuse, and dependence.” Journal of Clinical Psychiatry, 66, 28–33.
Sleeping pills also increase the risk of Campanelli, C. M. (2012). American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults: The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. Journal of the American Geriatrics Society, 60(4), 616–631.
a group of patients receiving cataract surgery in British Columbia Davis, J. C., McNeill, H., Wasdell, M., Chunick, S., & Bryan, S. (2012). Focussing both eyes on health outcomes: Revisiting cataract surgery. BioMed Central Geriatrics, 12(50). http://bmcgeriatr.biomedcentral.com/articles/10.1186/1471-2318-12-50
in orthopaedic surgery, despite clear evidence Kirkley, A., Birmingham, T. B., Litchfield, R. B., Giffin, R. J., Willits, K. R., Wong, C. J., Feagan, B. G., Donner, A., Griffin, S. H., D’Ascanio, L. M., Pope, J. E., & Fowler, P. J. (2008, September 11). A randomized trial of arthroscopic surgery for osteoarthritis of the knee. New England Journal of Medicine, 359, 1097–1107. www.nejm.org/doi/full/10.1056/NEJMoa0708333#t=article
In the United States, it’s estimated that 30 percent of all medical spending is unnecessary Lallemand, N. C. (2012). Reducing Waste in Health Care. Health Affairs: Health Policy Brief. http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_82.pdf
In a 2014 survey of American physicians Perry Undem Research/Communication. (2014). Unnecessary tests and procedures in the health care system: What physicians say about the problem, the causes, and the solutions. Results from a national survey of physicians. www.choosingwisely.org/wp-content/uploads/2014/04/042814_Final-Choosing-Wisely-Survey-Report.pdf
Dr. Alberto Dolara published a call for “Slow Medicine” Dolara, A. (2002). Invitation to “slow medicine.” Italian Heart Journal Supplement, 3(1), 100–101. www.ncbi.nlm.nih.gov/pubmed/11899567
“Slow Medicine is to health care what Slow Food is to fast food” Slow Medicine. (2015). Slow Medicine History. www.slowmedicine.info/
Economic interests, as well as cultural and social pressures Houston, M. (2013). Welcome to Slow Medicine: Dr. Muiris Houston looks at a new concept for Irish medicine. Medical Protection. www.medicalprotection.org/ireland/casebook/casebook-may-2013/welcome-to-slow-medicine
To achieve that culture change American Board of Internal Medicine Foundation. (2016). Choosing Wisely: An initiative of the ABIM Foundation. www.choosingwisely.org
medical groups have created American Board of Internal Medicine Foundation. (2016). Choosing Wisely: An initiative of the ABIM Foundation. www.choosingwisely.org/clinician-lists
the campaign launched in April 2014 Glauser, W. (2014). Choosing Wisely campaign well received. Canadian Medical Association Journal, 186(8), E239–240. www.cmaj.ca/content/186/8/E239.full
at the time of writing, fifteen other countries Choosing Wisely Canada. (2016). What is CWC? www.choosingwiselycanada.org/about/what-is-cwc/
As each country develops and tests its own version Bhatia, R. S., Levinson, W., Shortt, S., Pendrith, C., Fric-Shamji, E., Kallewaard, M., Peul, W., Veillard, J., Elshaug, A., Forde, I., & Kerr, E. A. (2015). Measuring the effect of Choosing Wisely: An integrated framework to assess campaign impact on low-value care. British Medical Journal Quality and Safety, 24(8). http://qualitysafety.bmj.com/content/early/2015/06/19/bmjqs-2015-004070
Many others are using their information technology systems Howell, L. P., MacDonald, S., Jones, J., Tancredi, D. J., & Melnikow, J. (2014). Can automated alerts within computerized physician order entry improve compliance with laboratory practice guidelines for ordering Pap tests? Journal of Pathology Informatics, 5(1), 37. www.ncbi.nlm.nih.gov/pubmed/25337434
in Alberta, physicians and universities Hnydyk, W., Cooke, L., Lang, E., & Patterson, E. (2015). Choosing Wisely Alberta & Partnerships for Implementation. www.choosingwiselycanada.org/wp-content/uploads/2015/06/Spring-Newsletter-Final.pdf
At North York General Hospital in Toronto Choosing Wisely Canada. (2015). Implementation Initiatives: North York General Hospital, Ontario, January 2015. www.choosingwiselycanada.org/resources/implementation-initiatives/2014/11/20/north-york-general-hospital-ontario-oct-2014
36 percent of American physicians Wolfson, D., Santa, J., & Slass, L. (2014). Engaging Physicians and Consumers in Conversations About Treatment Overuse and Waste: A Short History of the Choosing Wisely Campaign. Academic Medicine, 89(7), 990–995. http://journals.lww.com/academicmedicine/Fulltext/2014/07000/Engaging_Physicians_and_Consumers_in_Conversations.17.aspx
four questions that can help initiate conversations about unnecessary care Choosing Wisely Canada. (2015). Four Questions To Ask Your Doctor. www.choosingwiselycanada.org/wp-content/uploads/2015/11/Four-questions-poster.pdf
a decision aid can really improve Stacey, D., Légaré, F., Col, N. F., Bennett, C. L., Barry, M. J., Eden, K. B., Holmes-Rovner, M., Llewellyn-Thomas, H., Lyddiatt, A., Thomson, R., Trevena, L., & Wu, J. H. C. (2014). Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews, 1. https://decisionaid.ohri.ca/docs/develop/Cochrane_Review.pdf
The Ottawa Hospital Research Institute The Ottawa Hospital Research Institute. (2015). Alphabetical list of decision aids by health topic. https://decisionaid.ohri.ca/AZlist.html
the use of decision aids has been shown Stacey, D., Légaré, F., Col, N. F., Bennett, C. L., Barry, M. J., Eden, K. B., Holmes-Rovner, M., Llewellyn-Thomas, H., Lyddiatt, A., Thomson, R., Trevena, L., & Wu, J. H. C. (2014). Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews, Issue 1. https://decisionaid.ohri.ca/docs/develop/Cochrane_Review.pdf
the recent EMPOWER study Tannenbaum, C., Martin, P., Tamblyn, R., Benedetti, A., & Ahmed, S. (2014). Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: The EMPOWER cluster randomized trial. Journal of the American Medical Association (JAMA) Internal Medicine, 174(6), 890–898. http://archinte.jamanetwork.com/article.aspx?articleid=1860498
Compare this to a 5 percent success in stopping sleeping pills with our usual approaches Tannenbaum, C., Martin, P., Tamblyn, R., Benedetti, A., & Ahmed, S. (2014). Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: The EMPOWER cluster randomized trial. Journal of the American Medical Association (JAMA) Internal Medicine, 174(6), 890–898. http://archinte.jamanetwork.com/article.aspx?articleid=1860498
BIG IDEA 4
“either more of the same or actually the same with higher pay attached” Decter, M. (2012). Does money buy change? National Speakers Bureau, July 4, 2012. http://nsb.com/speakers/michael-decter
Improvements for dollars invested are rapid until about US$2000 in spending per capita Organisation for Economic Co-operation and Development. (2013). Health at a Glance 2013. www.oecd.org/els/health-systems/Health-at-a-Glance-2013.pdf
we see countries like Canada spending just over CAD$6000 per capita every year on health care Canadian Institute for Health Information. (2015). National Health Expenditure Trends, 1975 to 2015. https://secure.cihi.ca/free_products/nhex_trends_narrative_report_2015_en.pdf
the U.S. spends almost twice as much by comparison Organisation for Economic Co-operation and Development. (2015). OECD Health at a Glance 2015. www.keepeek.com/Digital-Asset-Management/oecd/social-issues-migration-health/health-at-a-glance-2015_health_glance-2015-en#page167
“fix medicare for a generation” St. Hilaire, F., & Lazar, H. (2004). A fix for a generation? Policy Options. http://policyoptions.irpp.org/issues/the-2004-federal-election/a-fix-for-a-generation
five priority areas Government of Canada. (2004). First minister’s meeting on the future of health care 2004. http://healthycanadians.gc.ca/health-system-systeme-sante/cards-cartes/collaboration/2004-meeting-racontre-eng.php
Surgical-care wait times for many procedures improved Wait Time Alliance. (2015). Eliminating code gridlock in Canada’s health care system: 2015 Wait Time Alliance report card. www.waittimealliance.ca/wp-content/uploads/2015/12/EN-FINAL-2015-WTA-Report-Card_REV.pdf
Canadians received over four million CT scans Health Council of Canada. (2010). Decisions, decisions: Family doctors as gatekeepers to prescription drugs and diagnostic imaging in Canada. www.healthcouncilcanada.ca/tree/2.33-DecisionsHSU_Sept2010.pdf
less than half of the populations of P.E.I. and Alberta Wait Time Alliance. (2015). Eliminating code gridlock in Canada’s health care system: 2015 Wait Time Alliance report card. www.waittimealliance.ca/wp-content/uploads/2015/12/EN-FINAL-2015-WTA-Report-Card_REV.pdf
at least 30 percent and up to 50 percent of imaging exams Health Council of Canada. (2010). Decisions, Decisions. www.healthcouncilcanada.ca/tree/2.33-DecisionsHSU_Sept2010.pdf
side effects including sleepiness de Jong, M. R., Van der Elst, M., & Hartholt, K. A. (2013). Drug-related falls in older patients: Implicated drugs, consequences, and possible prevention strategies. Therapeutic Advances in Drug Safety, 4(4), 147–154. www.ncbi.nlm.nih.gov/pmc/articles/PMC4125318 & Miller, D. D. (2004). Atypical antipsychotics: Sleep, sedation and efficacy. Primary Care Companion, Journal of Clinical Psychiatry, 6(52), 3–7. www.ncbi.nlm.nih.gov/pmc/articles/PMC487011 & Schneider, L. S., Dagerman, K. S., & Insel, P. (2005). Risk of death with atypical antipsychotic treatment for dementia: Meta-analysis of randomized placebo-controlled trials. Journal of the American Medical Association, 294(15), 1934–1943. http://jama.jamanetwork.com/article.aspx?articleid=201714
There are other ways to control aggressive behaviour Livingston, G., Kelly, L., Lewis-Holmes, E., Baio, G., Morris, S., Patel, N., Omar, R. Z., Katona, C., & Cooper, C. (2014). Non-pharmacological interventions for agitation in dementia: Systematic review of randomised controlled trials. The British Journal of Psychiatry, 205, 436–442. http://bjp.rcpsych.org/content/bjprcpsych/205/6/436.full.pdf
it’s more than two-thirds Health Quality Ontario. (2015). Looking for balance: Antipsychotic medication use in Ontario long-term care homes. www.hqontario.ca/portals/0/Documents/pr/looking-for-balance-en.pdf
survival after stroke varies substantially from province to province Ganesh, A., Lindsay, P., Fang, J., Kapral, M. K., Côté, R., Joiner, I., Hakim, A. M., & Hill, M. D. (2016). Integrated systems of stroke care and reduction in 30-day mortality: A retrospective analysis. Neurology, 86(10), 898–904. www.neurology.org/content/86/10/898.short
We also know that people with diabetes who live in northern or rural areas ICES. (2012). Regional Measures of Diabetes Burden in Ontario Key Findings. www.ices.on.ca/publications/atlases-and-reports/2012/regional-measures-of-diabetes-burden-in-ontario & World Diabetes Foundation. (2014). Prevention of Blindness WDF07-275. http://www.worlddiabetesfoundation.org/projects/india-wdf07-275
Women with invasive breast cancer in Newfoundland Canadian Institute for Health Information. (2012). Breast Cancer Surgery in Canada, 2007–2008 to 2009–2010. https://secure.cihi.ca/free_products/BreastCancer_7-8_9-10_EN.pdf
nearly one-quarter of our country’s population will be over sixty-five Government of Canada. (2016). Canada’s Aging Population. http://publications.gc.ca/collections/Collection/H39-608-2002E.pdf
seniors represented 19 percent of the population of Nova Scotia Statistics Canada. (2015). Chart 4: Proportion of the population aged 0 to 14 years and 65 years and older, July 1, 2015, Canada, provinces and territories. www.statcan.gc.ca/daily-quotidien/150929/cg-b004-eng.htm
as people age and live longer with multiple chronic diseases Canadian Institute for Health Information. (2011). Seniors and the health care system: What is the impact of multiple chronic conditions? https://secure.cihi.ca/free_products/air-chronic_disease_aib_en.pdf
Only one in four Canadian seniors with a chronic condition Canadian Institute for Health Information. (2011). Seniors and the health care system: What is the impact of multiple chronic conditions? https://secure.cihi.ca/free_products/air-chronic_disease_aib_en.pdf
97 percent of seniors are satisfied Public Health Agency of Canada. (2010). The Chief Public Health Officer’s report on the state of public health in Canada. Table 3.2: Health of Canada’s seniors. www.phac-aspc.gc.ca/cphorsphc-respcacsp/2010/fr-rc/cphorsphc-respcacsp-06-eng.php
the highest numbers of new Canadians came from the Philippines, China, and India Immigration, Refugees, and Citizenship Canada. (2011). Facts and figures—Immigration overview. Permanent and temporary residents. www.cic.gc.ca/english/resources/statistics/facts2011/permanent/10.asp
heart disease, high blood pressure, and diabetes Chiu, M., Austin, P. C., Manuel, D. G., & Tu, J. V. (2010). Comparison of cardiovascular risk profiles among ethnic groups using population health surveys between 1996 and 2007. Canadian Medical Association Journal, 182(8), E301–310. www.cmaj.ca/content/182/8/E301.abstract
first-generation immigrant adults are generally healthier Vang, Z., Sigouin, J., Flenon, A., & Gagnon, M-A. (2015). The healthy immigrant effect in Canada: A systematic review. Population Change and Lifecourse Strategic Knowledge Cluster Discussion Paper Series, 3(1). http://ir.lib.uwo.ca/cgi/viewcontent.cgi?article=1012&context=pclc
“Instead of just looking up symptoms…” Sifferlin, A. (2015, September 10). Here’s what 6 doctors really think of Dr. Google. Time. http://time.com/4025756/google-health-issues-doctor
Let Patients Help! is a manifesto for participatory medicine deBronkart, Jr., R. D. (2013). Let Patients Help! A patient engagement handbook. CreateSpace Independent Publishing Platform. www.epatientdave.com/let-patients-help/
a generation to completely arrive at a new reality e-Patient Dave. (2015). Berci’s “My Health: Upgraded”: A futurist vision worthy of Doc Tom. www.epatientdave.com/2015/09/22/bercis-my-health-upgraded-a-futurist-vision-worthy-of-doc-tom/#more-10646
appropriate use of less expensive and more empowering self-care deBronkart, D. (2013). How the e-patient community helped save my life: An essay by Dave deBronkart. British Medical Journal, 346. www.bmj.com/content/346/bmj.f1990
Something as simple as a chair can make a big difference Glouberman, S. (2014). Small changes with impact: The third chair in triage. https://healthandeverythingblog.wordpress.com/2014/09/10/minimal-interventions-a-third-chair-in-triage
our spending is concentrated among a small group of people Rais, S., Nazerian, A., Ardal, S., Chechulin, Y., Bains, N., & Malikov, K. (2013). High-cost users of Ontario’s healthcare services. Healthcare Policy, 9(1), 44–51. www.ncbi.nlm.nih.gov/pubmed/23968673
1 percent of the province’s health care users Deber, R. B., & Lam, K. C. K. (2009). Handling the high spenders: Implications of the distribution of health expenditures for financing health care. Paper presented at the 2009 American Political Science Association Annual Meeting, Toronto, Canada. http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1450788
in Ontario, only 45 percent remained in that category Wodchis, W. P., Austin, P. C., & Henry, D. A. (2016). A 3-year study of high-cost users of health care. Canadian Medical Association Journal, 188(3), 182–188. www.cmaj.ca/content/early/2016/01/11/cmaj.150064
people whose high-intensity needs are chronic Canadian Institute for Health Information. (2011). Seniors and the health care system: What is the impact of multiple chronic conditions? https://secure.cihi.ca/free_products/air-chronic_disease_aib_en.pdf
others are frail, medically complex, or have a severe, relapsing condition Vaillancourt, S., Shahin, I., Aggarwal, P., Pomedli, S., Hayden, L., Pus, L., & Bhattacharyya, O. (2014, July). Using archetypes to design services for high users of health care. Healthcare Papers, 14(2), 37–41. www.ncbi.nlm.nih.gov/pubmed/25880862
In Canada, one in every twelve hospitalized patients Canadian Institute for Health Information. (2012). All-cause readmission to acute care and return to the emergency department. https://secure.cihi.ca/free_products/Readmission_to_acutecare_en.pdf
in the U.S., it’s one in eight Tsai, T. C., Joynt, K. E., Orav, J., Gawande, A. A., & Jha, A. K. (2013). Variation in surgical-readmission rates and quality of hospital care. New England Journal of Medicine, 369, 1134–1142. www.nejm.org/doi/full/10.1056/NEJMsa1303118
when I refer a patient with late-stage osteoarthritis of the knee. Sunnybrook Health Sciences Centre. (2007). New Assessment Model for Hip and Knee Replacement. http://sunnybrook.ca/uploads/MSK_AssessHKR.pdf
among the lowest number of beds per capita Organisation for Economic Co-operation and Development. (2014). Hospital beds: Density per 1,000 population. www.oecd-ilibrary.org/social-issues-migration-health/hospital-beds_20758480-table5;jsessionid=33dmec807jdht.x-oecd-live-03
primary health care, home care,…and rehabilitation Decter, M. (2014). Saving medicare: As costs steadily rise, we need to build a healthcare system outside hospitals. http://reviewcanada.ca/magazine/2014/09/saving-medicare
They’re solo practitioners, or they work in small groups of two or three
doctors SCOPE Project. Unpublished data.
project called SCOPE University Hospital Network. (2016). About SCOPE. www.uhn.ca/healthcareprofessionals/SCOPE
method known as hot-spotting Gawande, A. (2011, January). The Hotspotters. The New Yorker. www.newyorker.com/magazine/2011/01/24/the-hot-spotters
cheaper, simpler, or more convenient Christensen, C. M., Bohmer, R. M. J., & Kenagy, J. (2000). Will disruptive innovations cure health care? Harvard Business Review. https://hbr.org/2000/09/will-disruptive-innovations-cure-health-care
gaining a foothold by doing things in a way Christensen, C. M., Raynor, M. E., & McDonald, R. (2015, December). What is disruptive innovation? Harvard Business Review. https://hbr.org/2015/12/what-is-disruptive-innovation
during a three-year research trial Ontario Telemedicine Network (OTN). (2013). Case study—telemedicine: A tool for the rehabilitation and socialization of stroke patients in remote communities. https://otn.ca/sites/default/files/otn-telemedicine-case-study-taylor.pdf
The PATH clinic in Nova Scotia PATH Clinic. (2013). About PATH: What is PATH? www.pathclinic.ca/getting_started
most Canadians want to die either at home or in some other safe, comfortable, non-hospital setting Canadian Institute for Health Information. (2007). Health care use at the end of life in western Canada. Ottawa: CIHI, p. 22. https://secure.cihi.ca/free_products/end_of_life_report_aug07_e.pdf
more than half of all deaths occur in hospital Statistics Canada. (2012). Table 102-0509: Deaths in hospital and elsewhere, Canada, provinces and territories. www5.statcan.gc.ca/cansim/a26?lang=eng&id=1020509
from providing care “to patients” Balik, B. (2015). To—for—with: The journey to understanding partnerships with patients. www.changefoundation.ca/library/barbara-balik-to-for-with-the-journey-to-understanding-partnerships-with-patients
Consider the Northumberland Hills Hospital Canadian Institutes of Health Research. (2013). Case 6: Shared challenge, shared solution: Northumberland Hills Hospital’s collaborative budget strategy. www.cihr-irsc.gc.ca/e/47593.html & Northumberland Hills Hospital. (2010, January). Citizens’ Advisory Panel on Health Service Prioritization, final report. www.nhh.ca/LinkClick.aspx?fileticket=jpyxIoXLcDQ%3D&tabid=587&language=en-US
We used to say that 50 percent of startups fail Noble, C. (2011). Why Companies Fail—and How Their Founders Can Bounce Back. Harvard Business School Working Knowledge. http://hbswk.hbs.edu/item/why-companies-failand-how-their-founders-can-bounce-back
John Maxwell even wrote a whole book Maxwell, J. (2000). Failing Forward: Turning Mistakes into Stepping Stones for Success. Nashville: Thomas Nelson, Inc. https://books.google.ca/books?id=FzCNE9j4u1MC&printsec=frontcover&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false
targeted at patients who were being discharged from hospital Singer, H. (2014, Fall). From hospital to home: Closing the cracks in care. U of T Medicine. Toronto: University of Toronto Faculty of Medicine. www.facmed.utoronto.ca/magazine/article/hospital-home-closing-cracks-care
the results of the evaluation were disappointing Dhalla, I. A., O’Brien, T., Morra, D., Thorpe, K. E., Wong, B. M., Mehta, R., Frost, D. W., Abrams, H., Ko, F., Van Rooyen, P., Bell, C. M., Gruneir, A., Lewis, G. H., Daub, S., Anderson, G. M., Hawker, G. A., Rochon, P. A., & Laupacis, A. (2014). Effect of a Postdischarge Virtual Ward on Readmission or Death for High-Risk Patients: A Randomized Clinical Trial. The Journal of the American Medical Association, 312(13), 1305-1312. http://jama.jamanetwork.com/article.aspx?articleid=1910109
According to the business literature O’Reilly, Charles A. and Tushman, Michael L. (2004). The ambidextrous organization. Harvard Business Review, April: 74–83.
So we’re increasingly monitoring handwashing rates Health Quality Ontario and ICES. (2012). Report on Ontario’s Health System. www.hqontario.ca/portals/0/documents/pr/qmonitor-full-report-2012-en.pdf
EWB publishes a Failure Report Engineers Without Borders Canada. (2011). Failure Report. legacy.ewb.ca/en/whoweare/accountable/failure.html
more support than just education Bhattacharyya, O., Hayden, L., & Hensel, J. (2015, June 2). Health services and designing for uncertainty. Stanford Social Innovation Review, Health. http://ssir.org/articles/entry/health_services_and_designing_for_uncertainty
BIG IDEA 5
Leslie wasn’t sick with asthma. She was sick with poverty Meili, Ryan. Personal correspondence.
income is the strongest predictor of health Canadian Medical Association. (2015). Health equity and the social determinants of health. www.cma.ca/En/Pages/health-equity.aspx
Canadians are more likely to die at an earlier The Federal, Provincial and Territorial Advisory Committee on Population Health. (1999). Towards a healthy future: A second report on the health of Canadians. Prepared for the Meeting of Ministers of Health, Charlottetown, P.E.I., September 1999. http://publications.gc.ca/collections/Collection/H39-468-1999E.pdf
income affects health indirectly Marmot, M. (2002). The influence of income on health: Views of an epidemiologist. Health Affairs, 21(2), 31–46. http://content.healthaffairs.org/content/21/2/31.full.pdf+html?sid=2475f44b-f40c-402c-8c27-149a5008fdfe
You are standing on the edge of a river… Upstream. (2013). Introduction to Upstream. Online video clip. www.thinkupstream.net/about_upstream
the social determinants of health Canadian Institute for Advanced Research, Health Canada, Population and Public Health Branch AB/NWT. (2002). Estimated impact of determinants on health status of the population. www.thinkupstream.net/anniversary_blog_charles_plante
Poverty has an effect on health Currie, J. (2008). Healthy, Wealthy and Wise: Socioeconomic Status, Poor Health in Childhood, and Human Capital Development. Working Paper 13987. Boston: National Bureau of Economic Research. http://web.stanford.edu/group/scspi/_media/pdf/Reference%20Media/Currie_2008_Health%20and%20Mental%20Health.pdf
These differences are apparent in lower birth weights Paul-Sen Gupta, R., de Wit, M. L., & McKeown, D. (2007, October). The impact of poverty on the current and future health status of children. Paediatrics and Child Health, 12(8), 667–672. www.ncbi.nlm.nih.gov/pmc/articles/PMC2528796/pdf/pch12667.pdf
They may move into low-cost housing Fransoo, R., Martens, P., The Need to Know Team, Prior, H., Burchill, C., Koseva, I., Bailly, A., & Allegro, E. (2013, October). The 2013 RHA Indicators Atlas. Winnipeg: Manitoba Centre for Health Policy, Department of Community Health Sciences, Faculty of Medicine, University of Manitoba. http://mchp-appserv.cpe.umanitoba.ca/reference//RHA_2013_web_version.pdf
This is the part of the city PEG. (2015). Our city: A PEG report on health equity. www.mypeg.ca/sites/default/files/uploads/Peg%20Health%20Equity%20Report%20-%20FINAL.pdf
Those kinds of risk factors Laurie, N. Drummond, D., Maxwell, J., Milway, J. Stabile, M., Stapleton, J., Spence, A., Park, S., Bednar, V., Murphy, J., Suave, R., Barata, P., & Murphy, C. (2008, November). The cost of poverty: An analysis of the economic cost of poverty in Ontario. https://ccednet-rcdec.ca/sites/ccednet-rcdec.ca/files/ccednet/pdfs/2008-OAFB-Cost_of_Poverty_in_Ontario.pdf
If you live in Ontario, poverty costs your household Laurie, N. Drummond, D., Maxwell, J., Milway, J., Stabile, M., Stapleton, J., Spence, A., Park, S., Bednar, V., Murphy, J., Suave, R., Barata, P., & Murphy, C. (2008, November). The cost of poverty: An analysis of the economic cost of poverty in Ontario. https://ccednet-rcdec.ca/sites/ccednet-rcdec.ca/files/ccednet/pdfs/2008-OAFB-Cost_of_Poverty_in_Ontario.pdf
estimated cost of poverty in Saskatchewan Plante, C., & Sharp, K. (2014, October). Poverty costs Saskatchewan: A new approach to prosperity for all. Saskatoon: Poverty Costs. https://d3n8a8pro7vhmx.cloudfront.net/upstream/pages/241/attachments/original/1416962412/poverty-costs-sk-summary-2014.pdf?1416962412
In their book The Spirit Level: Why Greater Equality Makes Societies Stronger Wilkinson, R. G., & Pickett, K. (2009). The Spirit Level: Why Greater Equality Makes Societies Stronger. Bloomsbury Press.
the current rate in Newfoundland for a couple Government of Newfoundland and Labrador. (2015). Department of Advanced Education and Skills. Program Overview. www.aes.gov.nl.ca/income-support/overview.html
the average monthly rent for a two-bedroom apartment Canada Mortgage and Housing Corporation. (2015, Spring). Rental market report: Newfoundland and Labrador highlights. www.cmhc-schl.gc.ca/odpub/esub/64499/64499_2015_B01.pdf
“deeply inefficient, fraught with bureaucratic excess…” Segal, H. (2013, June 8). Why guaranteeing the poor an income will save us all in the end. The Huffington Post. www.huffingtonpost.ca/hugh-segal/guaranteed-annual-income_b_3037347.html
People on social assistance Torjman, S., & Battle, K. (1993, July). Breaking down the welfare wall. The Caledon Institute of Social Policy. www.caledoninst.org/Publications/PDF/488ENG.pdf
Moreover, if a mother finds a job for minimum wage Segal, H. (2012, December). Scrapping Welfare: The case for guaranteeing all Canadians an income above the poverty line. Literary Review of Canada. http://reviewcanada.ca/magazine/2012/12/scrapping-welfare/
“Our present system…” Segal, Hugh. (2012). Scrapping Welfare. The case for guaranteeing all Canadians an income above the poverty line. Literary Review Canada. reviewcanada.ca/magazine/2012/12/scrapping-welfare
Basic Income Guarantee can’t and mustn’t replace all social programs Advisory Group on Poverty Reduction. (2015). Recommendations for a provincial poverty reduction strategy. www.saskatchewan.ca/~/media/news%20release%20backgrounders/2015/aug/advisory%20group%20on%20poverty%20reduction%20report.pdf
“would not be treated as dim creatures…” Segal, H. (2012, December). Scrapping welfare: The case for guaranteeing all Canadians an income above the poverty line. Literary Review of Canada. http://reviewcanada.ca/magazine/2012/12/scrapping-welfare
The guaranteed annual income works Simpson, W. (2012). Guaranteed Annual Income (GAI), Basic Income (BI) and the Manitoba Basic Annual Income Experiment (Mincome). http://winnipegharvest.org/wp-content/uploads/2012/08/Presentation-by-Wayne-Simpson-on-Guaranteed-Annual-Income.pptx
Most versions that currently exist Hellmann, A. G. (2015, September). How does Bolsa Familia work? Best practices in the implementation of conditional cash transfer programs in Latin America and the Caribbean. Inter-American Development Bank. https://publications.iadb.org/bitstream/handle/11319/7210/How_does_Bolsa_Familia_Work.pdf?sequence=5
we may see a universal cash transfer Kansaneläkelaitos: The Social Insurance Institution of Finland (Kela). (2015). Contrary to reports, basic income study still at preliminary stage. www.kela.fi/web/en/press-releases/-/asset_publisher/LgL2IQBbkg98/content/contrary-to-reports-basic-income-study-still-at-preliminary-stage
The Dutch city of Utrecht Boffey, D. (2015). Dutch city plans to pay citizens a ‘basic income’, and Greens say it could work in the UK. The Guardian. www.theguardian.com/world/2015/dec/26/dutch-city-utrecht-basic-income-uk-greens
In the 1960s and 1970s Forget, E. (2015, October). Reconsidering a Guaranteed Annual Income: Lessons from MINCOME. Public Sector Digest, Economics and Finance. www.publicsectordigest.com/articles/view/1506
South of our border, building on the momentum Hyndman, B., & Simon, L. (2015, October). Basic Income Guarantee: Backgrounder. www.opha.on.ca/getmedia/bf22640d-120c-46db-ac69-315fb9aa3c7c/alPHa-OPHA-HEWG-Basic-Income-Backgrounder-Final-Oct-2015.pdf.aspx?ext=.pdf
They called the experiment Mincome Forget, E. (2015, October). Reconsidering a Guaranteed Annual Income: Lessons from MINCOME. Public Sector Digest: Economics and Finance. www.publicsectordigest.com/articles/view/1506
Before Mincome came along Forget, E. (2015, October). Reconsidering a Guaranteed Annual Income: Lessons from MINCOME. Public Sector Digest: Economics and Finance. www.researchgate.net/publication/282878565_
The effects extended beyond health services Forget, E. L. (2011). The Town With No Poverty: Using Health Administration Data to Revisit Outcomes of a Canadian Guaranteed Annual Income Field Experiment. University of Manitoba. http://nccdh.ca/images/uploads/comments/forget-cea_(2).pdf
On the other side of the world Remme, M., Vassall, A., Lutz, B., Luna, J., & Watts, C. (2014). Financing structural interventions: Going beyond HIV-only value for money assessments. AIDS, 28, 425–434. www.unicef.org/tanzania/Remme_et_al._2014._Financingstructural_interventions_-_going_beyond_HIV-only_value_for_moneyassessments.pdf
Some received this money Baird, S. J., Garfein, R. S., McIntosh, C. T., & Özler, B. (2012, April). Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: A cluster randomised trial. The Lancet, 379(9823), 1320–1329. www.sciencedirect.com/science/article/pii/S0140673611617091
As Hugh Segal tells the story Segal, H. (2014). Senator speaks about guaranteed annual income. Toronto: Anglican Church of Canada. www.toronto.anglican.ca/2014/05/26/senator-speaks-about-guaranteed-annual-income-at-church
Today, all Canadian seniors Emery, J. C., Fleisch, V. C., & McIntyre, L. (2013, December). Legislated changes to federal pension income in Canada will adversely affect low income seniors’ health. Preventive Medicine, 57(6), 963–966. www.ncbi.nlm.nih.gov/pubmed/24055151
Food insecurity drops from 23 percent Emery, J. C., Fleisch, V. C., & McIntyre, L. (2013, December). Legislated changes to federal pension income in Canada will adversely affect low income seniors’ health. Preventive Medicine, 57(6), 963–966. www.ncbi.nlm.nih.gov/pubmed/24055151
At the other end of the age spectrum Simpson, W. (2015, June). Basic income, guaranteed income and tax credits: What’s the difference? University of Calgary School of Public Policy. http://policyschool.ucalgary.ca/?q=content/basic-income-guaranteed-income-and-tax-credits-what’s-difference
Families that receive the child benefit Milligan, K., & Stabile, M. (2011, August). Do child tax benefits affect the well-being of children? Evidence from Canadian child benefit expansions. American Economic Journal: Economic Policy, 3(3), 175–205. http://courses.washington.edu/pbafadv/examples/child%20benefit%20IV.pdf
around one-third of the Canadian population Broadway, Robin. Personal correspondence.
If one were to use the 2016 Low Income Cut-Off Citizenship and Immigration Canada. (2016). Applying for a Visitor Visa (Temporary Resident Visa—IMM 5256) Income Table. www.cic.gc.ca/english/information/applications/guides/5256ETOC.asp#incometables & Statistics Canada. (2015). Low income cut-offs. www.statcan.gc.ca/pub/75f0002m/2012002/lico-sfr-eng.htm
According to some estimates Goar, C. (2015, March). National income floor for troubled times: Goar. Toronto Star. www.thestar.com/opinion/commentary/2015/03/08/national-income-floor-for-troubled-times-goar.html&Segal, H. (2012). Scrapping welfare: The case for guaranteeing all Canadians an income above the poverty line. Literary Review of Canada. http://reviewcanada.ca/magazine/2012/12/scrapping-welfare
Other estimates have ranged from National Council of Welfare. (2011). The dollars and sense of poverty. http://publications.gc.ca/collections/collection_2011/cnb-ncw/HS54-2-2011-eng.pdf & Roos, N., & Forget, E. (2015, August 4). The time for a guaranteed annual income might finally have come. The Globe and Mail. www.theglobeandmail.com/report-on-business/rob-commentary/the-time-for-a-guaranteed-annual-income-might-finally-have-come/article25819266/ß
The relief gained by so many other spending areas Laurie, N., Drummond, D., Maxwell, J., Milway, J. Stabile, M., Stapleton, J., Spence, A., Park, S., Bednar, V., Murphy, J., Suave, R., Barata, P., & Murphy, C. (2008, November). The cost of poverty: An analysis of the economic cost of poverty in Ontario. https://ccednet-rcdec.ca/sites/ccednet-rcdec.ca/files/ccednet/pdfs/2008-OAFB-Cost_of_Poverty_in_Ontario.pdf
In Namibia, with a basic income, self-employment jumped 300 percent Basic Income Earth Network. (2013). NewsFlash. NewsFlash 26 (70). & Krozer, A. (2010). A Regional Basic Income: Towards the Eradication of Extreme Poverty in Central America. CEPAL. repositorio.cepal.org/bitstream/11362/25938/1/lcmexl998.pdf & UNICEF. (2012). Transformative Transfers: Evidence from Liberia’s Social Cash Transfer Programme. http://www.unicef.org/liberia/Transformative_Transfers_LiberiaCashTransferProgramme.pdf
As columnist Andrew Coyne has pointed out Coyne, A. (2015, June 10). Guarantee a minimum income, not a minimum wage. National Post. http://news.nationalpost.com/full-comment/andrew-coyne-guarantee-a-minimum-income-not-a-minimum-wage
Yet in Brazil, families spend the money Guanais, F. (2011). Bolsa Familia program, funding families for development: A case study. NS World. www.pgionline.com/wp-content/uploads/2015/08/Bolsa-Fam%C3%ADlia-Program-Funding-Families-for-Development.pdf
In Kenya, when people living in poverty were given Reuters. (2015, May 11). Cash aid feeds business surge in northeast Kenya. www.reuters.com/article/2015/05/11/us-kenya-aid-idUSKBN0NW0C120150511
Would low-income Canadians spend a basic income on beer and popcorn CBC News. (2005). Liberal apologizes for saying Harper day-care bucks may buy beer, popcorn. http://www.cbc.ca/news/canada/liberal-apologizes-for-saying-harper-day-care-bucks-may-buy-beer-popcorn-1.534811
Researcher Mark Stabile at the University of Toronto and his colleagues Jones, L., Milligan, K., & Stabile, M. (2015, March). How do families who receive the CCTB and NTB spend the money? http://martinprosperity.org/media/CCTB-and-NCB-Family-Spending.pdf
“almost without exception, studies find…” Evans, D. K., & Popova, A. (2014, May). Cash transfer and temptation goods: A review of global evidence. Policy Research Working Paper 6886. Africa Region, Office of the Chief Economist: The World Bank. www-wds.worldbank.org/external/default/WDSContentServer/IW3P/IB/2014/05/21/000158349_20140521143938/Rendered/PDF/WPS6886.pdf
mothers in the U.S. who received a cash supplement Hoynes, H., Miller, D., & David, S. (2015). Income, the earned income tax credit, and infant health. American Economic Journal: Economic Policy, 7(1), 172–211. www.nber.org/papers/w18206.pdf
The Basic Income Guarantee idea is catching on Segal, H. (2013, April 8). Why guaranteeing the poor an income will save us all in the end. The Huffington Post. www.huffingtonpost.ca/hugh-segal/guaranteed-annual-income_b_3037347.html
Liberals, Conservatives, New Democrats, and the Greens Blanchard, M. (2014). Time to move to basic income guarantee. New Democratic Party of Prince Edward Island. www.ndppei.ca/time-to-move-to-basic-income-guarantee & Green Party of Canada. (2015). Vision Green 2015. www.greenparty.ca/sites/default/files/vision_green_2015_-_updated_august_2015_-_reduced.pdf & Liberal Party of Canada. (2015). 97. Basic income supplement: Testing a dignified approach to income security for working-age Canadians. www.liberal.ca/policy-resolutions/97-basic-income-supplement-testing-dignified-approach-income-security-workingage-canadians & Liberal Party of Canada. (2015). 100. Priority resolution: Creating a basic annual income to be designated and implemented for a fair economy. www.liberal.ca/policy-resolutions/100-priority-resolution-creating-basic-annual-income-designed-implemented-fair-economy
Mayors from all over Canada Benns, R. (2015, November 2). All three northern capital city mayors say it’s time to look at basic income. http://leadersandlegacies.com/2015/11/02/all-three-northern-capital-city-mayors-say-its-time-to-look-at-basic-income & Benns, R. (2015, September 28). Mayors of St. Catharines, Niagara Falls declare support for basic income. http://leadersandlegacies.com/2015/09/28/mayors-of-st-catharines-niagara-falls-declare-support-for-basic-income & King, R. L. (2015, June 5). Alberta mayors back guaranteed minimum income. Toronto Star. www.thestar.com/news/canada/2015/06/05/alberta-mayors-stick-back-guaranteed-minimum-income.html
BIG IDEA 6
Every time a kidney is transplanted The Kidney Foundation of Canada. (2012). Facing the facts. www.kidney.ca/facing-the-facts
the Highly Sensitized Patient program Canadian Blood Services. (2015, May 22). New program will improve chances of a kidney transplant for hard-to-match patients. News release. www.blood.ca/en/media/new-program-will-improve-chances-kidney-transplant-hard-match-patients
Canadians who require stem-cell transplantation Canadian Blood Services. (2015, June 25). News release. Canadian Blood Services’ Cord Blood Bank is now officially launched. www.blood.ca/en/media/canadian-blood-services-cord-blood-bank-is-now-officially-launched
a groundbreaking program that helps Moorhouse, P., & Mallery, L. (2010). PATH: A new approach to end-of-life care. The Canadian Review of Alzheimer’s Disease and Other Dementias, 4–8. www.stacommunications.com/customcomm/Back-issue_pages/AD_Review/adPDFs/2010/May2010/04.pdf
reduce wait times for hip and knee replacements Alberta’s physicians and health regions, Alberta Health and Wellness, & Alberta Bone and Joint Institute. (2008). An Innovative Made-in-Alberta Model for Hip and Knee Replacements. www.albertaboneandjoint.com/wp-content/uploads/2013/12/At-A-Glance_12_Mo_Pilot_Results_March_08_Final.pdf
“the single biggest problem…” Lewis, S. (2007). Commentary. Healthcare Quarterly, 10(2), 103–104. www.longwoods.com/content/18840
If you want a project to spread beyond the local Mittman, B. (2014). Factors that influence the scale up and spread of innovations. Agency for Healthcare Research and Quality, Health Care Innovations Exchange. https://innovations.ahrq.gov/perspectives/factors-influence-scale-and-spread-innovations
the World Health Organization’s surgical safety checklist World Health Organization. (2009). WHO guidelines for safe surgery: Safe surgery saves lives. http://apps.who.int/iris/bitstream/10665/44185/1/9789241598552_eng.pdf
They confirm the patient’s identity Urbach, D. R., Govindarajan, A., Saskin, R., Wilton, A. S., & Baxter, N. N. (2014). Adoption of surgical safety checklists in Ontario, Canada: Overpromised or underdelivered? Healthcare Quarterly, 17(4). www.longwoods.com/content/24125
the risk of that person dying decreases by roughly 50 percent Haynes, A. B., Weiser, T. G., Berry, W. R., Lipsitz, S. R., Breizat, A. S., Dellinger, P., Herbosa, T., Joseph, S., Kibatala, P. L., Lapitan, M. C. M., Merry, A. F., Moorthy, K., Reznick, R. K., Taylor, B., & Gawande, A. A. (2009). A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine, 360(5), 491–499. www.nejm.org/doi/full/10.1056/NEJMsa0810119
Very few health care improvement projects get implemented Naylor, David, Girard, Francine, Fraser, Neil, Jenkins, Toby, Mintz, Jack & Power, Christine. (2014). Unleashing Innovation: Excellent Healthcare for Canada. Report of the Advisory Panel on Healthcare Innovation. www.healthycanadians.gc.ca/publications/health-system-systeme-sante/report-healthcare-innovation-rapport-soins/alt/report-healthcare-innovation-rapport-soins-eng.pdf
“seven spreadly sins” Institute for Healthcare Improvement. (2015). Seven spreadly sins. Infographic. Cambridge, Massachusetts. www.ihi.org/resources/pages/tools/ihisevenspreadlysins.aspx
They studied 101 hospitals Urbach, D. R., Govindarajan, A., Saskin, R., Wilton, A. S., & Baxter, N. N. (2014). Introduction of surgical safety checklists in Ontario, Canada. The New England Journal of Medicine, 370(11), 1029–1038. www.nejm.org/doi/pdf/10.1056/NEJMsa1308261
When a pilot project succeeds in one environment Plsek, P. E. & Associates, Inc. (2015). Creating a culture of innovation. Agency for Healthcare Research and Quality, Health Care Innovations Exchange. https://innovations.ahrq.gov/article/creating-culture-innovation
the time to the “third next available” appointment Institute for Healthcare Improvement. (2015). Third next available appointment. www.ihi.org/resources/Pages/Measures/ThirdNextAvailableAppointment.aspx
the team secretary starts offering you appointment times Institute for Healthcare Improvement. (2015) Third next available appointment. www.ihi.org/resources/Pages/Measures/ThirdNextAvailableAppointment.aspx
When audit and feedback inspire change Ivers, N., Jamtvedt, G., Flottorp, S., Young, J. M., Odgaard-Jensen, J., Frech, S. D., O’Brien, M. A., Johansen, M., Grimshaw, J., & Oxman, A. D. (2012). Audit and feedback: Effects on professional practice and patient outcomes. The Cochrane Collaboration. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000259.pub3/abstract;jsessionid=C89E463DA632A3B6F8B3F8E74DA14321.f02t03
While those tricks don’t solve everything Kiran, T., & O’Brien, P. (2015). Challenge of same-day access in primary care. Canadian Family Physician, 61(5), 399–400. www.cfp.ca/content/61/5/399.full
In the U.S., the Centers for Medicare Centers for Medicare & Medicaid Services. (2016). Hospital Compare. www.medicare.gov/hospitalcompare/search.html
the Canadian Institute for Health Information launched a much less detailed Canadian Institute for Health Information. (2016). Explore Your Health System. http://yourhealthsystem.cihi.ca/hsp/indepth?lang=en
websites don’t always convey information that matters Jha, A. K. (2015). Health care providers should publish physician ratings. Harvard Business Review: Assessing Performance. https://hbr.org/2015/10/health-care-providers-should-publish-physician-ratings
emails a twenty-question survey to every single patient University of Utah Health Care. (2015). About the Press Ganey survey. http://healthcare.utah.edu/fad/pressganey.php
We can begin to get data reporting right Chatterjee, P., Tsai, T. C., & Jha, A. K. (2015). Delivering value by focusing on patient experience. The American Journal of Managed Care, 21(10), 735–737. www.ajmc.com/journals/issue/2015/2015-vol21-n910/delivering-value-by-focusing-on-patient-experience
When the best practice for certain knee injuries Skerrett, P. J. (2013). Physical therapy works as well as surgery for some with torn knee cartilage. Harvard Health Blog. Harvard Health Publications, Harvard Medical School. www.health.harvard.edu/blog/physical-therapy-works-as-well-as-surgery-for-some-with-torn-knee-cartilage-201303206002
a doctors’ strike tried to stop the Tommy Douglas government Macdonald-Laurier Institute. (2014). Straight Talk: With Jeffrey Simpson. http://www.macdonaldlaurier.ca/files/pdf/SimpsonStraightTalk01-14-Draft4.pdf
There is no requirement to participate in initiatives Simpson, J. (2012). Chronic Condition: Why Canada’s Health Care System Needs to Be Dragged into the 21st Century. Chapter 2: Health Care’s Early History. Toronto: Penguin Group. http://onlinelibrary.wiley.com/doi/10.1111/capa.12046/abstract
increasing its focus on the profession’s social accountability Health Canada. (2001). Social accountability: A vision for Canadian medical schools. www.afmc.ca/pdf/pdf_sa_vision_canadian_medical_schools_en.pdf
training in areas like quality improvement Baker, R. (2016). Quality improvement and patient safety. Institute of Health Policy, Management and Evaluation, University of Toronto. http://ihpme.utoronto.ca/academics/rd/qips-msc
“the system” is something from which patients must be protected Martin, D., & Whitehead, C. (2013). Physician, healthy system: The challenge of training doctor-citizens. Medical Teacher, 35(5), 416-417.
“an embrace of citizenship…” Berwick, D. M. (2009). The epitaph of profession. British Journal of General Practice, 59(559), 128–131. www.ncbi.nlm.nih.gov/pmc/articles/PMC2629825
“Now you don your white coats…” Berwick, D. M. (2012). To Isaiah. Journal of the American Medical Association, 307(24), 2597–2599. http://fhs.mcmaster.ca/surgery/isd/documents/GHJHToIsaiah.pdf