Policy Issues: Medical Wait Times

HLTH 405 / Canadian Health PolicyWinter 2012

School of Kinesiology and Health Studies

Course Instructor: Alex Mayer, MPA

Announcement

• Don Drummond speaking at the Queen’s School of Policy Studies this Thursdayo Rm. 102 at 12pm (noon).

o Presentation on his recommendations to reform Ontario’s public services.

o Good opportunity to ask tough questions!

Wait Times

Topics for today’s lecture:

Policy Issue #3: Medical Wait Times• Wait times as a policy problem

• Canadian Wait Times in a Global Context

• 2004 Health Accord: Wait Times Strategy

• 2005: The Chaoulli case

• Ontario’s progress: 2005-2011

• Remaining Challenges

Wait Times• A mainstay of universal health care

systems rationed based on medical need rather than ability to pay.oEnsures that public health care resources

are being used to their full capacity (i.e. “efficiently”) at all times.

o Imposes a time cost that discourages people from accessing care for trivial reasons.

Wait Times• Wait times can be measured for all

health care access points, including…oAccess to primary care

oAccess to hospital emergency room (ER) treatment

oAccess to surgical and imaging procedures

oAlternative level of care (ALC) placement

oReceipt of home care services

Wait Times• Not problematic so long as…

o Patients are appropriately triaged (i.e. patients with the most urgent care needs are seen immediately).

oAll patients are seen within time periods specified by clinical care guidelines, in order to prevent unnecessary suffering, complications and mortality.

oWait times meet the public’s (taxpayers’) reasonable expectations and do not undermine public confidence in the health care system.

If medical wait times are a normal part of our system,

why have they been the subject of so much

attention?

Wait Times• Not problematic so long as…

o Patients are appropriately triaged (i.e. patients with the most urgent care needs are seen immediately).

o All patients are seen within time periods specified by clinical care guidelines, in order to prevent unnecessary suffering, complications and mortality.

o Wait times meet the public’s (taxpayers’) reasonable expectations and do not undermine public confidence in the health care system.

Do Wait Times Worsen Health Outcomes?

o Coronary artery bypass:

• Between ‘91-’93, 0.4% (n=34) of Ontario patients died while in the queue. (Naylor et al, 1995)

o Hip replacement:

• Canadian patients experience higher wait times, hospital length of stay and mortality rates than U.S. patients. However, a competing risks hazards model shows that wait time is not significantly associated with mortality. (Carrier et al, 1993; Ho, Hamilton and Roos, 2000)

o Cancer Surgery:

• Only 2 of 6 studies registered a higher hazards ratios for PSA recurrence among prostate cancer patients experiencing delays ≥3 months in waiting for surgical treatment. (Saad et al, 2006)

Wait Times• Not problematic so long as…

o Patients are appropriately triaged (i.e. patients with the most urgent care needs are seen immediately).

o All patients are seen within time periods specified by clinical care guidelines, in order to prevent unnecessary suffering, complications and mortality.

o Wait times meet the public’s (taxpayers’) reasonable expectations and do not undermine public confidence in the health care system.

Wait Times Problem: Access• In past decade, Canadians have consistently

identified ‘wait times’ as the #1 barrier in accessing health services.o For laypeople, wait times are a tangible indicator

of health care quality.

o Canada’s global rankings in this regard easily becomes a flashpoint for public concern.

Global Wait Times Comparison

Global Wait Times Comparison

Wait Times Problem: Access• Excessive wait times offer an effective line of

attack for private interests that would benefit from the evolution of a parallel private-payer health care system in Canada.

"Socialized Medicine" vs "Free Market Medicine" Video

• Whether it’s the ‘grass is always greener’ appeal of two-tiered care, or the fear of losing what we have to government mismanagement (overspending, underinvestment, etc)

Wait times undermine public confidence in the system!

Are Canadians Waiting Too Long?

• For a patient, the answer is always yes.

• Medically, however, a patient’s place in line is determined by the severity and urgency of his/her case. o Severity refers to suffering, functional limitations, and risk

of premature death.

o Urgency refers to the extent to which clinical treatment is required immediately to avoid complications or death, based on the natural history of the pathology.

What the Media Sees

US Anti-Medicare Adhttp://www.youtube.com/watch?v=XwLp2KJCLOQ

Fact-Checking the Shona Holmes

Case

“Time for a Reality Check on CNN’s ‘Reality Check’ by Julia Mason, The Ottawa Citizen

… I found Holmes’ story both compelling and troubling. So I decided to check a little further. On the Mayo Clinic’s website, Shona Holmes is a success story.

But it’s a somewhat different story than the headlines might have implied. Holmes’ “brain tumor” was actually a Rathke’s Cleft Cyst on her pituitary gland.”

According to the John Wayne Cancer Centre: “Rathke’s Cleft Cysts are not true tumors or neoplasms; they are benign cysts.”

Are Canadians Waiting Too Long?

Wait Times Problem: AccessConclusion:

• Whether it’s the ‘grass is always greener’ appeal of two-tiered care, or the fear of losing what we have to government mismanagement (overspending, underinvestment, etc.) and declining quality…

Wait times undermine public confidence in the system!

Solving the Wait Times Problem

2004 Health Accord

Solving the Wait Times Problem

• 2004 Health Accord:

In response to public concern, First Ministers put wait times front and centre in the 2004 HA.o Provinces/Territories to come up with medically acceptable wait

times (i.e. ‘benchmarks’) for certain key health services by 2005.

o ‘Five in Five’ plan – provinces to receive additional funding ($5.5B Wait Time Reduction Fund) to target wait times for 5 key services in the next 5 years, and to achieve meaningful reductions by 2007.

o Provinces commit to increase % of patients treated within recommended benchmark period for cancer therapy, heart surgery, diagnostic imaging, joint replacement and sight restoration.

And Then a Curveball…

The Chaoulli case

The Chaoulli Case• 1996: Montreal businessman George

Zeliotis waits 1 year for hip replacement surgery. While waiting, he asks to purchase private insurance to skip the queue.

• When he learns this isn’t possible, he takes his case to court.

• He is accompanied by Dr. Chaoulli, who had previously failed to establish a private hospital in Quebec that would charge for publicly insured services.

The Chaoulli Case• The plaintiffs asked the Supreme Court of

Canada to strike down sections of the Quebec Hospital Insurance Act barring citizens from purchasing private insurance for publicly financed services.

• The Court agrees that wait times are “unreasonably long”.

• By a 4-3 decision, the Court rules to strike down the provincial policy (June 2005).

The Chaoulli Case• Asked whether the policy violated the

rights of Canadians to “life, liberty and the security of the person”, the Court did not come to a majority decision (3-3, with one abstention).

• Would have raised serious legal (and practical) questions about the CHA.

Post-Chaoulli Discourse

Patient ‘right’ to reasonable wait times

Harper’s Wait Times Strategy Announcement

http://www.youtube.com/watch?v=JrePOsVHVgc

Solving the Wait Times Problem

• August 2005

Wait Time Alliance release their final report “It’s About Time” that outlines medically acceptable wait times based on medical consensus and, where available, research evidence, for the 5 clinical focus areas (cancer therapy, heart surgery, diagnostic imaging, joint replacement and cataract surgery).

.

Solving the Wait Times Problem

• Provinces Commit to Set Targets for Wait Time Benchmarks by 2007o Early on, different provinces focused on different clinical areas.

o All would publicize benchmarks and wait times on provincial websites.

o All would report on progress annually.

• In SK, people can visit Saskatchewan Surgical Care Network website to determine the wait time for their level of clinical priority. o E.g. Level 3 surgical patient (out of 6 levels) will know that the

provincial target is to treat 90% of such patients within six weeks.

Solving the Wait Times Problem

• In ON, cardiac patients are assessed according to clinical guidelines and assigned a maximum recommended wait time of 6 months, depending on seriousness of their condition. o Targets and Wait times to be found on the Cardiac

Network Care of Ontario website.

o In MB, median wait time for surgery was 2 weeks.

• For oncologist appointment, wait time benchmark in ON is 21 days. o As of 2005, wait times ranged from 5 - 34 days, depending

on the type of cancer. For 10 out of 12 types of cancer, wait times were within benchmarks. For lung cancer (24 d) and myeloma (34 d), wait times exceeded benchmarks.

Solving the Wait Times Problem

Prior to the agreed-upon 2005 Benchmarks, there was a clear lack of nationwide standards in reporting wait times.

e.g. cardiac surgery

The 2005 Benchmarks

Solving the Wait Times Problem

• Today, pan-Canadian standards for measuring waits and collecting data exist for all focus areas, except for diagnostic imaging where there are still informational gaps.

Solving the Wait Times Problem

• Today, pan-Canadian standards for measuring waits and collecting data exist for all focus areas, except for diagnostic imaging where there are still informational gaps. o Challenges

• Many imaging facilities are outside of hospital facilities

• Difficult to build consensus on medical urgency

Wait Times in OntarioHow has Ontario successfully managed to reduce wait times in all clinical focus areas?

• Developing data measurement protocols in accordance with Wait Time Alliance specifications

• Reporting data and sharing results online Available at: http://www.health.gov.on.ca/en/public/programs/waittimes/default.aspx

Promotes efficiency, transparency, accountability

Wait Times in OntarioHow has Ontario successfully managed to reduce wait times in all clinical focus areas?

• Pay For Performance program In Ontario, this involves tying compensation to hospitals’

senior management to performance (‘Excellent Care for All Act’), which include setting aggressive goals to meet all Ontario Wait Times Strategy (OWTS) benchmarks.

“Targets without incentives are not taken seriously”.

UK research shows that pay-for-performance improve worst areas of performance most quickly.

• Pay 4 Performance videohttp://www.youtube.com/watch?v=Q8Wn22I32UQ

Wait Times in OntarioWhy pay hospital management to show up to work, and then pay them a little more to do a good job? (Shouldn’t they do this anyway?)

“Targets without incentives are not taken seriously.”

- Alan Hudson, Lead on Ontario Wait Times Strategy

UK research shows that pay-for-performance improve worst areas of performance most quickly, especially for low SES areas.

Wait Times in Ontario

Wait Times in Ontario• To date, Ontario government has spent $1.5B on

funding additional procedures, system redesign, reducing bottlenecks, tracking and publicly reporting on progress.

• The result:

Wait Times in OntarioIn 2008, Ontario decided to roll ‘emergency room (ER) wait times’ into the Ontario Wait Times Strategy.• As of 2010, Ontario hospitals are using CIHI’s Level 1 NACRS

database to report on ER wait times.

• Covers about 90% of the population.

• Tracks time waiting in ER minus the time spent to register/triage a patient.

Wait Times in OntarioIs pay-for-performance enough?

• Don Drummond’s Feb 2012 report suggests that the best strategy for reducing ER wait times is to bring FHTs under the LHINs o To standardize best practices and offer better quality

primary care for complex cases (e.g. mental health, diabetes management, elder care, addictions)

o To involve Family Health Teams in LHIN quality improvement plan

o To identify costly patients and fast-track cost-effective interventions that connect them with community resources that meet their needs

Case StudyAn 80-year-old woman lives alone, has diabetes, arthritis, a colostomy from a previous bout with bowel cancer and is a little forgetful. She has trouble getting an appointment with her family physician as the phone system is tiered and confusing (“press 1 for this, 3 for that”). Her daughter who lives far away gets her an appointment when she visits. The mother trips on a rug one evening and falls, breaking her wrist. She cannot get up and is found the next day by a neighbour and is taken to the ER.

Case StudyShe gets a cast on her wrist, but feels unable to go home alone. As a result, she is admitted after spending 36 hours on a gurney in the ER. Due to a mixture of pain medications, sleeplessness and unfamiliarity, the patient gets confused and is prescribed anti-psychotics. She then gets C. difficile and is placed in isolation. The daughter is advised that her mother needs a nursing home (LTC) bed.

Case StudyThe daughter’s wish for her first choice of an LTC home and the C. difficile, now complicated by the patient calling out in the middle of the night, result in the patient being on a waiting list for weeks. Eventually the patient gets to the LTC home, where the cancer returns. The patient is sent back to the hospital, where she dies.

Wait Times in OntarioWhat should the next area of focus be…

• Next-day primary care appointments, perhaps?

• Wait for LTC bed? Home care?

• Bariatric surgery? (skyrocketing demand)

How would you decide?

Have a great week!