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the insurers are behaving appropriately the care is not being denied the people las aseguradoras se están comportando adecuadamente no se les está negando la atención a las personas the insurers are behaving appropriately the care is not being denied the people

are receiving the care they need and they are reporting to the public on how are receiving the care they need and they are reporting to the public on how

this is going and ensuring that the cost structures and payment structures are this is going and ensuring that the cost structures and payment structures are

being are being looked after and are monitoring and they're helping set pay being are being looked after and are monitoring and they're helping set pay

schedules competitively with the insurers but still monitoring and then schedules competitively with the insurers but still monitoring and then

when it comes to quality the federal government is ensuring or the state when it comes to quality the federal government is ensuring or the state

governments are ensuring that the data is available not only to the public to governments are ensuring that the data is available not only to the public to

look at based on state analyses but also available to private individuals who mirada basada en análisis estatales, pero también disponible para particulares que look at based on state analyses but also available to private individuals who

wish to go in and do their own analyses of hospital reporting so you now have a wish to go in and do their own analyses of hospital reporting so you now have a

private individual able to go and download the information on a private individual able to go and download t he information on a

respective basis you can then report and say this respective basis you can then report and say this

hospital does better at these outcomes in that hospital and the state is also hospital does better at these outcomes in that hospital and the state is also

reporting these outcomes so now the government is the monitor the overseer reporting these outcomes so now the government is the monitor the overseer

they're the protector and they're the defender of the universality they are no they're the protector and they're the defender of the universality they are no

longer the day-to-day provider of healthcare services which depoliticizes longer the day-to-day provider of healthcare services which depoliticizes

healthcare decision-making increases the time horizon for healthcare healthcare decision-making increases the time horizon for healthcare

decision-making and changes the way the healthcare system runs no longer will decision-making and changes the way the healthcare system runs no longer will

you hear a politician say well next year's a re-election year i really don't you hear a politician say well next year's a re-election year i really don't

want to do that now because i don't know what the outcome might be and it could want to do that now because i don't know what the outcome might be and it could

go sideways it's not a hospital administrator who says i don't care when go sideways it's not a hospital administrator who says i don't care when

the re-election year is i want a better hospital a year and a half from now the re-election year is i want a better hospital a year and a half from now

let's start making that change let's get down that road and treat patients better let's start making that change let's get down that road and treat patients better

because it'll attract more patients to my facility it'll increase my resources because it'll attract more patients to my facility it'll increase my resources

and revenues and the government is making sure that that is all being done and revenu es and the government is making sure that that is all being done

in an appropriate manner and that universality is protected it's about in an appropriate manner and that universality is protected it's about

getting government right it's not about getting government out it's about getting government right it's not about getting government out it's about

getting up getting government out of the things that they don't do well and we getting up getting government out of the things that they don't do well and we

know from any number of studies that there are a number of things government know from any number of studies that there are a number of things government

clearly doesn't do well but when it comes to overseeing and ensuring the clearly doesn't do well but when it comes to overseeing and ensuring the

policy construct is correct that's the role of government and it's an important policy construct is correct that's the role of government and it's an important

role so my takeaway from talking to you today role so my takeaway from talking to you today

is that yes the canada health act has created these anomalies which has is that yes the canada health act has created these anomalies which has

prevented the kind of innovation we're talking about prevented the kind of innovation we're talking about

but there is enough room within the canada health act that we could change but there is enough room within the canada health act that we could change

the most important thing which is activity-based funding and allowing for the most important thing which is activity-based funding and allowing for

a greater diversity of delivery models and if you could do just those two a greater diversity of delivery models and if you could do just those two

things you're already going to start seeing efficiencies that then creates things you're already going to start seeing efficiencies that then creates

the argument for why you might want to try incremental different approaches as the argument for why you might want to try incremental different approaches as

you go down that path there's no reason for anyone to get started there's no you go down that path there's no reason for anyone to get started there's no

reason for political politicians to fear that if they don't do those two things reason for political politicians to fear that if they don't do those two things

that somehow they're going to be punished by the federal government those that somehow they're going to be punished by the federal government those

those could be done that's that's my takeaway have i got the right takeaway those could be done that's that's my takeaway have i got the right takeaway

is there anything more am i being let am i being not ambitious enough is there is there anything more am i being let am i being not ambitious enough is there

anything more that you would recommend from an incremental approach that you anything more that you would recommend from an incremental approach that you

think could be done today no within the balance of the canada think could be done today no within the balance of the canada

health act and and notwithstanding a couple of interpretation letters in health act and and notwithstanding a couple of interpretation letters in

the 1990s and 2000 from federal health ministers that raised concern about the 1990s and 2000 from federal health ministers that raised concern about

private clinics operating under the public scheme restricting reasonable private clinics operating under the public scheme restricting reasonable

access there are letters of interpretation from the federal access there are letters of interpretation from the federal

government on that but but all that aside within the canada government on that but but all that aside within the canada

health fact the letter of the act there's nothing stopping anticipation health fact the letter of the act there's nothing stopping anticipa tion

funding and there's there's really nothing in funding and there's there's really nothing in

the letter of the act to say you can't have a broader diversity of providers the letter of the act to say you can't have a broader diversity of providers

within the universal scheme in an activity-based funded model within the universal scheme in an activity-based funded model

to to move us forward and that would have an incredible impact on the to to move us forward and that would have an incredible impact on the

healthcare of the efficiency of hospital care on the throughput of patients healthcare of the efficiency of hospital care on the throughput of patients

through the system we've seen it time and again through the system we've seen it time and again

in european countries that have reformed how much of a difference this makes we in european countries that have reformed how much of a difference this makes we

would have a better health care system as a result of reform there's a window would have a better health care system as a result of reform there's a window

to go through there's certainly it increases complexity there's a lot of to go through there's certainly it increases complexity there's a lot of

thinking to be done the canadian institute for health information has thinking to be done the canadian institute for health information has

actually been doing a lot of this work in the background there's some very actually been doing a lot of this work in the background there's some very

interesting stuff that has come out of them all the technical aspects of interesting stuff that has come out of them all the technical aspects of

activity-based funding but it could be done activity-based funding but it could be done

and it really should be done if if we're interested in the welfare of patients and it really should be done if if we're interested in the welfare of patients

and in the efficiency and the cost efficiency we're handing over to and in the efficiency and the cost efficienc y we're handing over to

taxpayers who are funding that care the only complexity i can see i'm trying to taxpayers who are funding that care the only complexity i can see i'm trying to

think of this through a political lens of why they'd be reluctant to do it think of this through a political lens of why they'd be reluctant to do it

is if your funding authority runs out of money because they've received a certain is if your funding authority runs out of money because they've received a certain

allocation 20 billion dollars in the case of alberta and probably four times allocation 20 billion dollars in the case of alberta and probably four times

that in the case of ontario what happens if you get to september and you've run that in the case of ontario what happens if you get to september and you've run

out of your allocation for the amount you can spend on knee replacements or out of your allocation for the amount you can spend on knee replacements or

hip replacements i mean does does that happen do you do you just say okay we hip replacements i mean does does that happen do you do you just say okay we

reset next year or i think that's one of the issues around reset next year or i think that's one of the issues around

rationing is everybody's afraid to like control glo go of control especially rationing is everybody's afraid to like control glo go of control especially

since we have such long waiting lists and such pent-up demands heck we might since we have such long waiting lists and such pent-up demands heck we might

end up seeing a doubling in the cost of the health care system how how do you end up seeing a doubling in the cost of the health care system how how do you

how do you control that the overall amount that's spent how do you control that the overall amount that's spent

uh there are any number of approaches the beauty of being canada i guess in a uh there are any number of approaches the beauty of being canada i guess in a

way is that we're the last country to go way is that we're the last country to go

down this road one of the very best countries going down this road other down this road one of the very best countries going down this road other

countries have have as much as 30 or 40 years of experience countries have have as much as 30 or 40 years of experience

in working with activity-based funding and how it works it's not the entire in working with activity-based funding and how it works it's not the entire

system it's a portion of the system there has to be a global budget backbone system it's a portion of the system there has to be a global budget backbone

for a number of things that occur that really don't make sense to for a number of things that occur that really don't make sense to

activity-based fund but there's also a total amount of funding very much like activity-based fund but there's also a total amount of funding very much like

physician services there are reductions in funding that can occur after a physician services there are reductions in funding that can occur after a

certain amount of services is delivered we can have competition in fee setting certain amount of services is delivered we can have competition in fee setting

which over time especially as private providers come in says the oecd will which over time especially as private providers come in says the oecd will

actually reduce the amount that is paid per surgery which increases the number actually reduce the amount that is paid per surgery which increases the number

of surgeries you provide for a given dollar amount so the outcome is not at of surgeries you provide for a given dollar amount so the outcome is not at

all certain but what is reasonably clear is that we will get more services for all certain but what is reasonably clear is that we will get more services for

the dollar and better services for the dollar that we are getting now and any the dollar and better services for the dollar that we are getting now a nd any

number of policy approaches is available for government to employ to ensure that number of policy approaches is available for government to employ to ensure that

when we hit those funding limits the limit of what has actually been when we hit those funding limits the limit of what has actually been

allocated for health care we have a mechanism to discourage further activity allocated for health care we have a mechanism to discourage further activity

or at least reduce the pace of further activity by reducing the additional or at least reduce the pace of further activity by reducing the additional

payment that goes out it could be a 30 or 50 payment up to a next limit which payment that goes out it could be a 30 or 50 payment up to a next limit which

is then a zero percent payment again to put some soft brakes on to the end of is then a zero percent payment again to put some soft brakes on to the end of

that uh global budgets are no different though when the hospital runs out of that uh global budgets are no different though when the hospital runs out of

budget it's run out of budget it has to go back to the government and ask for budget it's run out of budget it has to go back to the government and ask for

more money or deficit fund knowing that's backed by the government which is more money or deficit fund knowing that's backed by the government which is

one of the subject constraint problems that we have one of the subject constraint problems that we have

but any number of policy approaches is available i think when we look at but any number of policy approaches is available i think when we look at

simplicity though for the provincial government it changes simplicity though for the provincial government it changes

from a system where they go okay hospital you get x uh hospital you get y from a system where they go okay hospital you get x uh hospital you get y

hospital you get zed okay well we'll see you guys next year to a system where hospital you get zed okay well we'll see you g uys next year to a system where

they're now getting billing and they have to deal with what are the billing they're now getting billing and they have to deal with what are the billing

rates has this been built appropriately what are the comorbidities what are the rates has this been built appropriately what are the comorbidities what are the

complexities it is far more administratively complex for a complexities it is far more administratively complex for a

provincial government or provincial health authority to handle on the other provincial government or provincial health authority to handle on the other

hand we're now taking patients and training them from a cost to the hand we're now taking patients and training them from a cost to the

hospital to a source of additional resources and that that turn has an hospital to a source of additional resources and that that turn has an

incredible impact on how the health care system operates you know before i let incredible impact on how the health care system operates you know before i let

you go i just want to leave it because you did make one reference to certain you go i just want to leave it because you did make one reference to certain

types of services that cannot be funded on activity based i'm assuming that if i types of services that cannot be funded on activity based i'm assuming that if i

have a heart attack and keel over and i need to be taken to the hospital that's have a heart attack and keel over and i need to be taken to the hospital that's

not one thing that would be funded on activity based you still have emergency not one thing that would be funded on activity based you still have emergency

room functions of hospitals that have to be room functions of hospitals that have to be

there and available to take emergent needs am i am i right about that there and available to take emergent needs am i am i right about that

certainly emergent needs some emergent needs could be but other emergent means certainly emergent needs some emergent needs could be but other emergent means

where it's an unknown condition somebody presents to a hospital in ambulance we where it's an unknown condition somebody presents to a hospital in ambulance we

have no idea what's going on that's really not a place for activity-based have no idea what's going on that's really not a place for activity-based

funding that's a place for global budget funding that's unpredictable care that funding that's a place for global budget funding that's unpredictable care that

is where you need the big complex tertiary care hospital that is focused is where you need the big complex tertiary care hospital that is focused

on getting the patient care for that is well funded and patient focused funded on getting the patient care for that is well funded and patient focused funded

in other areas to make sure that that patient is served uh the other area in other areas to make sure that that patient is served uh the other area

where activity-based funding really might not work well is where you have where activity-based funding really might not work well is where you have

extremely complex patients or patients whose care has gone very sideways and extremely complex patients or patients whose care has gone very sideways and

now we have multiple comorbidities multiple simultaneous conditions that's now we have multiple comorbidities multiple simultaneous conditions that's

a very hard care pathway to define it's not to say that it can't be defined but a very hard care pathway to define it's not to say that it can't be defined but

if we look at the international experience that's usually where if we look at the international experience that's usually where

activity-based funding hits its limit activity-based funding is for activity-based funding hits its limit activity-based funding is for

predictable care but remember the predictable care is is the majority of predictable care but remember the predictable care i s is the majority of

what the health care system does the majority of patients are seen for what the health care system does the majority of patients are seen for

predictable services it's a small portion of patients that are seen for predictable services it's a small portion of patients that are seen for

these very complex things and i think we often don't appreciate these very complex things and i think we often don't appreciate

that we're underserving both with the construct we have now you're so right that we're underserving both with the construct we have now you're so right

what's your prospect for change this will sort of be my last conversation my what's your prospect for change this will sort of be my last conversation my

last question for you because it seems to me that i'm excited hearing last question for you because it seems to me that i'm excited hearing

about the way in which other healthcare services are delivered in other about the way in which other healthcare services are delivered in other

countries i'm excited about the innovation and the new technologies and countries i'm excited about the innovation and the new technologies and

the work environment that's created and you would think that those who are the work environment that's created and you would think that those who are

working in this existing environment and being stifled by it not seeing their working in this existing environment and being stifled by it not seeing their

ideas implemented and only being limited to one operating room space a week you ideas implemented and only being limited to one operating room space a week you

would think they would be the ones who'd be the staunchest advocates of trying would think they would be the ones who'd be the staunchest advocates of trying

something new and yet those are the forces that want to keep things exactly something new and yet those are the forces that want to keep things exactly

as they are i i don't understand why somebody wouldn't want to have multiple as they are ii do n't understand why somebody wouldn't want to have multiple

different employers that they could sell their services to and multiple different different employers that they could sell their services to and multiple different

environments in which to choose to work i i wha what what explains why it is environments in which to choose to work ii wha what what explains why it is

we're so stuck from a labors [Music] we're so stuck from a labors [Music]

we hope you enjoyed today's episode if you like what you heard be sure to we hope you enjoyed today's episode if you like what you heard be sure to

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[Music] [Music]