The Castonguay report

The ongoing debate surrounding health care in industrialized economies did not spare Québec. My home province is facing growing health expenditure well beyond the growth of its GDP : the former has grown at 6%, while the latter has recently grown at around 4%. From 1980 to 2007, health expenditures have grown from 30.6% of the overall budget to 44.3% (see report referred to below). It is estimated that this proportion could reach almost 50% over the next decade if nothing is done.

Quebec's population faces a high tax rate, and many feel we do not get what we pay for. There might be no free lunch, but this one is especially expensive! This situation has led the province's government to formulate various reforms over the last 2 decades, and ordering multiple reports has resulted, sadly, in minimal changes to face the trend of increasing health expenditures (HE). Today, the "father of health insurance" in Québec (RAMQ), Claude Castonguay, and the Task Force on the Funding of the Health System, have published the awaited report "En avoir pour notre argent" ("Getting our money's worth").

It was, obviously, a much required exercise. Taxes can't be increased much beyond their actual level for Quebecers to be happy. Moreover, it is difficult to limit the availability of medical interventions, even with rigorous economic evaluations . Such evaluations limit the opportunity for patients to choose their preferred options, it can be subjective (thresholds are often subjective... how much is a life worth? QALY vs ageism?), and is ultimately political as lobby groups can pressure governments to change their minds (Herceptin) or challenge them in court (Aricept and other Alzheimer's drugs). And incentivizing intelligent and imaginative people is not always straightforward and can produce unforeseen results...

As a society, however, we still need to take serious actions to ensure the survival of our health care system in Québec. The "Castonguay report" is a move in the right direction, as it shows a profound understanding of the issues at stake. Moreover, the objectives and principles described in the report are right. Unfortunately, the main propositions and recommendations aimed at improving access are inappropriate, and I disagree with the report conclusions on these matters. Note that the vice-president of the Task Force, Michel Venne, has also expressed a dissident position. I'll summarize the key points of the report first, and will provide a critical analysis in my next blog.

If you are lazy, you may prefer to listen to Mr. Castonguay : Français or English

• Values on which the report is based :
  
  • Universality
    
  • Solidarity
    
  • Equity
    
  • Efficacy
    
  • Responsibility (accountability)
    
  • Freedom and choice
    
• Stakeholders involved and what they should aim for :
  
  • Citizens : responsible
    
  • Medical profession : right service to the right patient at the right time
    
  • Health managers : guardians of efficiency
    
  • Lobby groups : need for them to give the government some flexibility
    
  • Government : need to be coherent
    
  • Private sector : increasing role (it is currently virtually absent)
    
• Quantitative limit : adjust the growth rate in health expenditures to GDP growth.
  
• Qualitative limit : restrict public coverage and define priorities through a systematic review of public coverage è suggest a permanent, credible and legitimate mechanism : "L'institut national d'excellence en santé" (NICE equivalent)
  
• Service delivery : the right service by the right professional
  
• Focus on prevention and primary health care
  

From these objectives, the task force has come to 4 major propositions to improve access to healthcare

• Transparent relationships with affiliate medical clinics
  
• A well delimited extension of medical practice to the private healthcare sector
  
• Increase the possibility for patients to contract health insurance
  
• Increase the use of hospital assets, by giving access to private healthcare to public hospitals' resources
  

According to the report, the focus of the Ministry of Health should be to regulate and evaluate the health care system regularly from different perspectives (stewardship role)

• Clinical
  
• Economical
  
• Patient satisfaction
  
• Transparent and publicly available
  

Other themes are also discussed :

• Specificities of the ageing population (ch 8) : 6 propositions
  
  • Support to live at home despite decreasing autonomy levels
    
  • Ensure universality of professional services at home
    
  • Admissibility to a tax credit through a revenue test
    
  • Nursing home operations è concession to the "appropriate resource"
    
• Improved utilisation of pharmaceutical treatments (ch9) : 2 elements
  
  • Cost effectiveness
    
    • Reinforce the rules of the "exceptional medication"
      
    • Create a unique organism to evaluate : "L'institut national d'excellence en santé"
      
  • Improved financing rules for the Medication Insurance Scheme : each beneficiary group should finance their costs
    
• Governance (ch 10) : 4 principles (with 2 as bonuses)
  
  • Distinguish the Ministry of Health from service providers : stewardship role
    
  • The regional agencies should translate the ministerial orientations è strategic implementation
    
  • Increase autonomy and accountability of service providers
    
  • The health care system should be based on rights and obligations of every stakeholders (contractual engagements)
    
  • Every regional agency (administrative entity similar to the NHS trusts) and hospital should have a board composed of independent members (competent and paid)
    
  • Involve citizens
    
  • Monitor performance
    
• Resource allocation (ch 11)
  
  • Abandon historic budgets è services will be bought
    
• Service provision (ch12)
  
  • Promote efficiency and dynamism
    
  • everyone should have access to a family physician by 2013
    
    • registered clinic will have the right to charge annual fees to registered patients
      
• Create "L'institut national d'excellence en santé" (ch 13)
  
• Develop the IT infrastructure to serve the patient and the manager (ch14)
  
  • "Dossier de Santé du Québec"
    
  • Opt-out approach
    
• Financing : promote a durable financing mechanism for the long term
  
  • Durable and diversified revenue sources (ch 15)
    
    • For the portion corresponding to GDP growth : general taxation revenue (solidarity through fiscality)
      
    • For the portion above the GDP growth : a Stabilisation fund dedicated to health care and modulated based on :
      
      • Fiscality (solidarity) è a portion of TVQ (sales tax)
        
      • Service utilisation (individual responsibility) è deductible
        
    • Over ≈10 years, the task force estimates that HE growth will be reduced to GDP growth
      
  • Other sources
    
    • Eliminate accessory fees in primary care
      
    • Regulate (negotiate) accessory fees in specialist care
      
    • Rationalization and payment of services (?)
      
  • Health account (ch 16) is explored
    
    • The ministry should produce its annual health account for review in Parliamentary Commission
      
• Legal context : the Canada Health Act would require some changes.
  

TBC...

Think lean

For the course "Managing people and healthcare", which is (kind of) a revelation from the clinician's perspective, we went to Kingston Hospital to investigate process redesign in healthcare. After going through doubts concerning what to address (the topic is quite vast...), and contacting the trust's STD clinic (just ask how Carole ended up being asked if she needed a Chlamydia screen...), we got into lean thinking and its various tool. It is a quite simple concept behind the success of Toyota, and the aim of lean thinking is to create an organizational culture that identify and eliminate waste wherever it occurs in business processes. While it has been developed for the manufacturing sector, it can be applied to the service industry, and healthcare is no exception. As a clinician, inefficient pathways of care (read business processes) drive me crazy, and that's what brought me to this health management course.

Many tools are available to "get lean", and a fast and (almost) easy way to produce changes is rapid improvement events. It is quite easy to understand for key stakeholders and simple to implement. I'm already dreaming of applying it to our inventory management in Québec (CHUL)

If you too want to eliminate waste from your processes (whatever they are...), I'd recommend the excellent report "Going lean in the NHS" published by the NHS Institute for Innovation and Improvement (you will need to register). You could also go for the original book or just have a look at this brief video... If you're lazy!

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Stéphane Lemire is licensed under a
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