On January 30th, 2012 the Ontario Government published Ontario's Action Plan To Transform Health Care (the "Action Plan").1 This was closely followed on February 15th, 2012 when the Commission on the Reform of Ontario's Public Services published its report: Public Services for Ontarians: A Path to Sustainability and Excellence (the "Drummond Report").2 Chapter five of the Drummond Report concentrates on recommendations in the health care sector. While the Drummond Report is only recommendations to the Ontario Government, the Action Plan is the Ontario Government's stated plan for the future of health care in Ontario.
This bulletin will focus on recommendations made in both the Drummond Report and the Action Plan that advocate moving patients away from hospitals by providing a greater amount of services through alternative forms of care such as community clinics, specialised clinics and home care. It is likely that shifting patients out of hospitals will be a key focus for the Ontario Ministry of Health and Long-Term Care as it contemplates how to fulfil its commitments in the Action Plan and whether to implement the recommendations in the Drummond Report.
Why Shift Services Out of Hospital?
Both the Drummond Report and the Action Plan recognize that a hospital is often the most expensive and least efficient way to deliver health care services. The Drummond Report states that the Ontario health system suffers from classic symptoms of a system built for acute care when Ontario's needs have shifted more to chronic care.3 The Action Plan argues that shifting patients will free up hospital beds, reduce pressures on emergency rooms and save money.4 According to the Action Plan, 271,000 emergency room visits could have been avoided in 2010/11.5
How Could the Ontario Government Implement the Shift?
Both reports offer some insight into the types of care that could be better offered by alternative forms of delivery. The Action Plan contemplates that routine procedures (such as cataract procedures);6 follow-up care for hospital procedures;7 and consultations for seniors could be performed in alternative care facilities or through home care.8
The Drummond Report recommends the creation of policies that shift access to health, thereby moving people away from emergency rooms and towards alternative forms of care.9 It is likely that these policies would articulate, in greater detail, the breadth of the services that would be offered by alternative forms of care.
The Drummond Report recommends that chronic health problems should be handled by community and home-based care to the fullest extent possible10 including through increased telehomecare monitoring.11 Further, the Drummond Report suggests that home-based care should be used more extensively for recovery from procedures such as hip and knee surgery.12
The Drummond Report also advocates an increased focus on home care, particularly at the community level.13 Specifically it notes that there is a need for more and varied palliative care at home and in residential hospices.14 The Drummond Report notes that funding for community-based care may need to grow at a higher rate in the short to medium term in order to build capacity to take pressure off acute care facilities.15 However, it states that until these recommendations can be implemented, the Government should not build many more long-term care homes until the impact of increased alternative care can be assessed. In other words, the Drummond Report does not seem to be suggesting that the increased funding (at least in the short or medium term) be directed at the building of long-term care homes.16
Both the Drummond Report and the Action Plan cite the Kensington Eye Institute as a delivery model for community-based services. The Action Plan notes that the Institute is renowned for providing high-quality cataract procedures paid for through OHIP.17 Both reports cite telephone and online consultations as well as expanded house calls by health care professionals as a manner in which to improve health care delivery and reduce the amount of people in hospitals.18 The Drummond Report advocates the Nova Scotia model in which emergency medical technicians provide home care when not on emergency calls as a best practice to deliver health care to patients within their homes in order to avoid hospitalization.19
Possibly the most significant difference between the Drummond Report and the Action Plan as it relates to shifting services outside of hospitals is whether the alternative care providers can be for-profit entities or whether those providers must be not-for-profit entities. The Action Plan clearly states that routine procedures can only be shifted out of hospitals and into non-profit community-based-clinics.20 While the Drummond Report advocates moving all non-acute services out of hospitals, it states that such services could be provided by private, for-profit entities, but operated within the public payer system. In the Drummond Report the focus is on ensuring that the removal of these services results in a more appropriate form of care that will be less expensive to the government, will improve the patient experience, and reduce the patient's exposure to new health risks, while operating in a public payer system.21 In the system envisioned by the Drummond Report, the Ontario Government would continue to determine what services are offered and set the fees paid by OHIP.22
To accomplish this, the Drummond Report recommends putting specialist services and service delivery to public tender based on price and quality.23 The Drummond Report argues that as long as the government remains the payer for all covered services, there should be a role for both the public and private sectors in health care delivery. It is noted in the report that publicly funded laboratory work for health care providers is provided by private companies and family physicians are usually private sector operators paid for by OHIP.24
While there will likely be some shift of non-acute procedure delivery away from hospitals and into alternate forms of care including community clinics, it remains to be seen whether this will be done only through not-for-profit clinics, or through public tender that is open to both for-profit and not-for-profit clinics. Regardless, any such shift has the potential for alternative health care providers to enter the market if they can show they can safely deliver quality health services.
For a summary of the health care provisions in the Drummond Report, please see our February 17th, 2012 Bulletin.
Footnotes
1. Ontario Ministry of Health and Long-Term Care, Ontario's Action Plan For Health Care: Better patient care through better value from our health care dollars (Toronto: Queens Printer for Ontario, 2012).
2. Ontario, the Commission on the Reform of Ontario's Public Services, Public Services for Ontarians: A Path to Sustainability and Excellence (Toronto: Queens Printer for Ontario, 2012) (Chair: Don Drummond). Commonly termed the "Drummond Report" after the Chair of the Commission, Don Drummond, former Senior Vice President and Chief Economist at Toronto-Dominion Bank
3. Drummond Report, p. 160.
4. Action Plan, p. 11.
5. Action Plan, p. 4.
6. Action Plan, p. 13.
7. Action Plan, pp. 8-9.
8. Action Plan, p. 12.
9. Drummond Report, rec. 5-52.
10. Drummond Report, rec. 5-38.
11. Drummond Report, rec. 5-97.
12. Drummond Report, rec. 5-4.
13. Drummond Report, rec. 5-74.
14. Drummond Report, rec. 5-77.
15. Drummond Report, rec. 5-7.
16. Drummond Report, rec. 5-26.
17. Action Plan, p. 13, Drummond Report, rec. 5-97.
18. Action Plan, p. 9, Drummond Report, rec. 9.
19. Drummond Report, rec. 5-100.
20. Action Plan, p. 13.
21. Drummond Report, rec. 5-3.
22. Drummond Report, rec. 5-97.
23. Drummond Report, recs. 5-97, 5-98.
24. Drummond Report, p. 171.
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