TORONTO – Dr. Danielle Martin is a family physician and innovative vice-president at Women’s College Hospital, whose firm grasp and defence of Medicare, Canada’s beloved universal healthcare system, famously won her the day at an inquisition-like U.S. Senate committee hearing in Washington last year.
Dr. Martin recently made a convincing case back home in Toronto that to fix our still admirable but admittedly flawed Medicare system, it’s high time our healthcare leaders stopped grasping at straws.
We need, she says, to reduce wait times and improve outcomes with technological innovation certainly but also with bold, necessarily risky, non-techie approaches – like making all prescriptions in Canada free.
Dr Martin, charming and approachable despite such strongly held views, got a chance to air them at the second in a series of Distinguished Speaker Series hosted by Telus Health, this one over lunch at the downtown Toronto Region Board of Trade offices.
There, another executive with a good grasp of Canadian healthcare and its troubles, Janet Da Silva, the Board of Trade’s president and CEO, set the scene for the over 100 luncheon guests who paid to hear Dr. Martin’s talk and her subsequent discussion with Paul Lepage, Telus Health’s president.
“Our healthcare system doesn’t come cheap, and our costs are rising,” said the well-informed Ms. Da Silva, a former Western University dean of the Ivey Asia business school in China. “According to the OECD (Organization for Economic Co-operation and Development, in Paris ), Canada has one of the most expensive universal healthcare systems in the world. And in 2011, a TD Bank economics report estimated that by 2030 our healthcare costs could well rise to be 80 percent of provincial spending!”
Da Silva further pointed out that a recent report from the Ontario Health Innovation Council (ohic.ca) made clear that if we are to create more sustainable healthcare, we rather desperately need to innovate new ways of doing things and consequently abandon the old.
Such as costly, unneeded, dangerous tests.
Dr. Martin, early in her after-lunch talk, told the story of a world-ranked athlete she knew who followed a private clinic’s recommendation that he undergo a stress test and a follow-up angiogram “just in case” something was truly wrong: “The angiogram confirmed he was not suffering from heart disease, but not before he suffered a stroke on the table. This athlete will never play his beloved sport again because he is paralyzed on one side of his body, as a direct result of a completely unnecessary and inappropriate medical test.”
Dr. Martin went on to say that many Canadians are harmed every year by improper, wasteful or harmful tests and prescriptions, naming mammography for young women, PSA testing for men not at risk, colonoscopy after five years instead of 10, among the leading culprits.
Also, such errant testing, she pointed out, lengthen an already over-long queue of people who truly need the tests.
In order to get better hold of such dysfunction in our healthcare system, Dr. Martin says the Canadian medical community together with its patients need to undergo a fundamental cultural change. And encouragingly, there’s already a movement to bring that about underway in Canada.
“It’s called the Choosing Wisely campaign which is a physician-led attempt to get doctors and patients talking more together about things they both need to question,” said Dr. Martin. “When that occurs, two good things happen: the patients usually end up healthier; and resources are freed up for others who truly need them.”
Beyond earnest discussion, Dr. Martin believes that all innovations aimed at giving Canada a stronger handle on its healthcare, be they cultural or technical, should leverage what she terms the “Medicare Advantage”. “We have one health insurance plan for all, making widespread innovation relatively easy to implement. So we can make changes at low administrative costs.
“Our costs our impressively low by comparison,” Dr. Martin told her audience over after-lunch coffee. “Administration accounts for 31 percent of healthcare expenditure in the United States, for example, but in our public insurance plans in Canada, administration costs are just 1.3 percent.”
So it hasn’t cost all that much to make some sweeping changes by applying the Medicare Advantage in coming to grips with a long-standing bugaboo in Canadian healthcare – wait times for surgery. Dr. Martin finds the innovations Ontario has made in reducing those times encouraging for both her as a physician and for her patients.
Ten years ago when she first started practicing, even if Dr. Martin referred a knee-replacement patient to an orthopaedic surgeon she knew well, the patient might still just go on wait list and have nothing done while the surgeon, say, went off to vacation for the month of August.
“Ontario has since introduced Centralized Intake and Assessment centres across the province,” said Dr. Martin, “so now if I refer a patient with late stage osteoarthritis of the knee, that patient is seen within a week or two, first by an advanced practice nurse and then a physiotherapist.”
In the course of those encounters, reports Dr. Martin, the two caregivers educate the patients about their disease; demonstrate exercises to improve pre-operative strength, give weight-loss advice, and use an evidence-based checklist to determine whether surgery is actually required. If it is, then the patient can book an appointment with a surgeon of their choosing, or wait for the next available one.
“The Intake Centres are good examples of the evidence-based cultural shift in the healthcare system I have been saying we need to make,” said Dr. Martin. “It’s a shift that moves us away from thinking of the surgeon as the personal owner of referral bases and wait lists – to one that puts access for patients first.”
For Dr. Martin, the first among all patients needing a change are those paying for their own prescriptions.
“Canada is the only developed country with universal health insurance that doesn’t include prescription drugs,” Dr. Martin pointed out. “The result is many Canadians do not take the medication they need, simply because they can’t afford to.”
The well-known upshot is that neglected medications often lead to more serious and thus far more costly patient care for both public and private health insurance schemes to bear.
“The need to expand our public insurance plans to include coverage of medically necessary prescription medicine is absolutely clear,” said Dr. Martin, adding that it would save tax-payer dollars as well as stimulate the economy.
A study Dr. Martin co-authored and was published in the Canadian Medical Association Journal showed that implementing universal drug coverage would save private sector health insurers with drug coverage plans for their employees a whopping $8.2 billion annually. “Think how much more competitive our industries could be without that burden,” she said at the Telus luncheon.
This notion, said Dr. Martin, of a universal drug Pharmacare, is, as she termed it, a good news story about opportunity: “It turns out that innovations we need in our system don’t require that we turn our backs on our healthcare values, nor do they require a lot more money.”
But they could do with much more help from technology.
Just how much help, became clearer after Dr. Martin’s formal address in an informal on-stage chat with Telus Health President Lepage. Here’s a synopsis of much of that conversation:
Lepage: As a practising physician Dr. Martin, I am wondering what you are gaining from technology generally and from the electronic medical record in particular?
Dr. Martin: Well Paul, it’s a matter of stages. The first stage that technology has taken us to is getting our record keeping off paper and into the computer.
The second stage or level we need to get to is getting our systems to talk to each other, and we’re not there yet. For example, I am in a family medicine clinic at Women’s College on one electronic medical record, but the rest of the hospital just across the street is on a different EMR. The one we have is more appropriate to what we do in the clinic and the one in the hospital is more appropriate to their needs. So, if I want to see what happened to my patient in the gastroenterology clinic across the street, I need to laboriously exit my EMR and then log into theirs – and that is absurd.
Once we get systems talking to each other, the third level up is to use IT to drive improvement in population health – but I don’t think any healthcare system in the world has figured out how to do that yet.
Lepage: Speaking of IT, the balance of power seems to be shifting to the cell phone-toting patient. How does that affect the physician, would you say?
Dr. Martin: That’s a tricky issue. But what I find helpful is to look at it as part of the shift from doing healthcare things for the patient to doing things with the patient. Remember that patients are their own care provider 99.999 percent of the time. But if you give them stuff they don’t use, can’t understand, or doesn’t fit into their world, you’re not going to be much help to them. However, we are seeing a shift from traditional care in two forms: in one the patient sees the provider then goes home to use technology and manage themselves independently; in the other, both patient and provider stay in some form of two-way electronic communication. So there’s a lot of research going on right now, to see which works best.
Lepage: That raises questions about access to the records and about who owns them, as well as the transparency and openness of the whole caregiver-patient record-producing process.
Dr. Martin: I am all for openness and transparency, but I do think it is sort of sad that we feel this need to declare to people that they actually own the information about their own health. Also, patients need access to more than just their own health data. We need transparency for them at the physician level too, about the quality of their physician’s individual work, about their physicians’ incomes – who is paying them, and how much their physicians are taking from industry in the work they do on behalf of businesses.
Lepage: So we can’t just think about healthcare if we are going to solve its problems, can we?
Dr. Martin: That’s what I think is so exciting about healthcare today, especially when you start trying to solve the many problems connected with high-end users, like those who have chronic diseases. Many of them are socially and economically challenged, so they are not only sick, but usually have multiple challenges extending well beyond the medical sphere. That means, unless you are solving problems with their housing say, or unless you are thinking about their mental health, or wrestling with their language issues, you are not going to move the yardsticks on population health very much.
Indeed in our healthcare universe, where you have so many moving parts like we have in chronic disease and so many other variables that are particular to one individual, it’s enough to make your head burst. It’s so hard to know what to even try, exactly.
But what we’ve learned at Women’s Hospital, in what we call our Virtual Clinic, is to think of “rapid cycle” development. That means we try something, evaluate it, often fail, but learn from it, and try again, kill that one if necessary and try something different, kill it again if needed, and just keep moving on to the next one until something works.