Searching for the sustainable health-care unicorn

By Dr. Jack Kitts

About a decade ago, many hospitals were having a tough time controlling a nasty form of bacteria known as MRSA.

At the time, the standard practice was to screen only high-risk patients who were transferred into hospital. At The Ottawa Hospital, our infection control experts said that, based on best practices and data, we should screen all admitted patients. Every single one. The decision wasn’t taken lightly. It meant that all patients had to have their nose, throat and rectum swabbed, no matter what they were being admitted for. This was unpopular with patients and nurses alike.

We hired more staff, which increased our costs. But, with expert opinion on my side, I was confident in my decision.

I turned out to be wrong.

This situation illustrates how complex and, yes, maddening, the subject of sustainable health care can be. It’s not merely an academic or ecological concept. There’s a lived aspect to sustainability, as our experience showed.

Two years into the universal MRSA screening program, our data surprised us. The screening program had added about $1 million to our annual costs, but we discovered it didn’t significantly reduce MRSA transmission rates. Clearly, it was unsustainable. So instead, we targeted areas with a known high risk of infection.

That was the first time in my career as a health-care leader that I had the data to revisit a decision, to see if it was the right call. And that experience left an impression. It showed me how important it is to test expert opinion with reliable data harvested from well-designed research. I realized we will never achieve a sustainable system until we get a handle on the value of our health-care interventions. It’s value that helps us navigate the many factors that drive our decisions.

Health-care leaders and government officials have been searching for the sustainability unicorn for quite some time. So far, it has been a fruitless quest.

In his final Royal Commission report on health-care sustainability in 2002, Roy Romanow stripped sustainability down to its essence: “Will Medicare be there for me, when I need it?” His answer: The health-care system was “as sustainable as we want it to be” and that it had “more to do with ‘who pays’ than ‘how much we pay.’”

After years of investments and reform, most Canadians remain significantly concerned about our health system’s sustainability and resilience. In the 2003-2004 Health Accord, the First Ministers were right when they stated that money alone cannot ensure sustainability.

So, what does a sustainable health-care system look like? It should:

  • give optimal health outcomes to individuals and populations
  • be affordable for patients, employers and governments
  • be responsive to new diseases, changing demographics, or scientific and technological discoveries

In searching for sustainability, decision-makers get bogged down by non-tangible factors that are impossible to test or measure. Or they go granular by reducing the cost of inputs while ignoring outcomes. It’s a land of false savings and unacceptable risk.

Remembering our purpose to improve the patient experience

A far better option would be to anchor sustainability on value. Michael Porter of Harvard University defines value as the health outcomes achieved per dollar spent, which maps neatly onto efficiency. Since value depends on results, not inputs, Porter says, value in health care must be measured by the outcomes achieved (e.g. a patient recovers well from hip replacement surgery, without infection), not the volume of services delivered (e.g. number of patients who receive hip replacements).

Value can be measured. It’s right there in the Triple Aim, a framework developed by the U.S.-based Institute for Healthcare Improvement and adopted by many Canadian hospitals. The Triple Aim calls for a balanced focus on achieving better health of populations, better individual experience of care, and better value by finding lower costs for better-quality care.

Shifting focus from volume to value would likely be the most revolutionary and disruptive move ever made to a publicly-funded health-care system. The value equation – benefits over costs – allows for rational evidence-based decision-making and also for engaging professionals with fact, rather than emotion. But today, planners don’t have the required data to fill in the numerator or the denominator, or the solid cause-and-effect data to determine whether an increased investment actually improved the health of Canadians. What we have is data that is easily collected or tied to billings for services performed.

Yet measuring and reporting outcomes of individual patients as well as patient populations are essential if we are to make smart investment decisions. So is the willingness to act on what the data tell us.

Framing health-system reform in sustainability terms is a way to have honest conversations about what our society wants to build together, what is worth trading off, and what must be held onto, for dear life.

Our experience years ago with MRSA screening was a telling example of how health-care sustainability can be achieved, albeit on a small scale. The innovation we can harness by applying data-driven solutions more broadly will be key to sustainability at a larger scale.

Dr. Jack Kitts is the President and CEO of The Ottawa Hospital.