By Dr. Stephen Pinney
The Canadian healthcare system is founded on great ideals: high quality care, public funding, and universal access. Ideals notwithstanding, the reality is that Canada’s healthcare system is plagued with long wait lists, lack of primary care access, inconsistent care quality, and rising costs. Can hockey, Canada’s game, provide the answer to the nation’s healthcare woes?
The past two decades have seen a movement to fundamentally reform healthcare delivery –almost everywhere except Canada. The impetus for these sweeping changes includes the realization that traditional healthcare delivery –where individual physicians working autonomously in isolated practices, leads to wide variations in care that is costly, not evidence-based, and has an unacceptably high rate of medical errors. Fee-for-service reimbursement has resulted in an emphasis on the volume rather than value of care. Failure to adequately measure the results of care has limited opportunities to continuously improve performance.
Recognizing these dysfunctional elements of 20th century healthcare, it has been proposed that 21st century health systems need to be organized differently. Key changes include:
- A primary orientation to the entire episode of care, focusing on (and measuring) patient outcomes rather than emphasizing isolated fragments of care (clinic visits, tests, etc).
- A team-oriented approach to care delivery (with an emphasis on primary care) to replace the traditional isolated physician model.
- A population-based approach where proactive strong health system leadership organized care around individual patients and
With few exceptions these changes have not occurred in Canada. The country’s vaunted system has become a prisoner of its own history.
Hockey provides an analogy for understanding how our system needs to change. Successful professional hockey teams embrace certain principles that Canadians take for granted. Successful modern healthcare systems must do the same.
Imagine treating a patient with an illness or a surgical problem as the equivalent of a hockey game. Teams focus on winning games and being successful throughout the entire season. This requires high performance levels in various skills by outstanding players in a coordinated team. Patient care requires a similar approach. For most medical problems, multi-disciplinary skilled practitioners must work in a coordinated manner under clear team leadership to ensure successful patient outcomes. Hockey coaches measure results and player performance, and make changes accordingly to improve future games. Similarly, healthcare must accurately measure care results and make progressive changes for improvement, including replacing underperforming providers or team management.
Those leading the NHL make decisions based on the best interest of the whole league. An equivalent approach is critical in modern healthcare. System leaders must work on behalf of patients and taxpayers by proactively identifying population health needs, creating programs (teams), and assembling resources to meet these needs.
However, making the essential changes that would promote integrated care delivery and a population-based approach has been challenging in Canada. Most hospitals still receive lump-sum yearly payments, which reinforce the status quo and stifles innovation. Fee-for-service physician payment rewards doctors for high volume fragmented care and precludes integrating physicians into team-based care. These historical payment methods are not based on normal patient flows and population needs. They must change.
To match reality with the ideals, take a page out of the hockey playbook and fundamentally reform the health systems organization and funding mechanisms. Rather than directly confronting the existing entrenched system head-on one option for reform is the formation of a second public healthcare system based on these principles. A coordinated outcome oriented team-based system that would supplant the existing fragmented system over time. However, major reform will only occur when citizens push their provincial and federal leaders for changes. This time is approaching as more Canadians realize that we cannot expect a different result from a system that keeps doing the same old things.
Stephen Pinney MD is the author of How Hockey Can Save Healthcare: A Principle-Based Approach to Reforming the Canadian Healthcare System.