Week 2 - Ontario's Health System

Ontario’s Health Care
System
HLTH 405 / Canadian Health Policy
Winter 2012
School of Kinesiology and Health Studies

Course Instructor:
Alex Mayer, MPA

Recap
Last Week
• Provincial vs. Federal responsibilities
• Health Accords
• The Canada Health Act: 5 criteria
• ‚Narrow but Deep‛ Medicare coverage
• ‚Similar but Distinct‛ provincial health insurance plans

In the News<
• ‚Trims to health-care funding will help feds, but hurt
provinces: Budget watchdog‛
- The Toronto Star (Jan 12)

• ‚Hands off, please‛
– The Ottawa Citizen (Jan 13)

• ‚Ottawa’s new health-care approach an opportunity for
provinces‛
- The Globe and Mail (Jan 13)

iClicker Registration
• If you have not done so already, please make sure to
register your iClicker on the iClicker website by 11PM
tonight.
 Use your Queensu E-mail address in full as your ‘Student ID’
 Use the number on the back of your iClicker as your ‘Remote ID’

• This will allow me to give you credit for your answers
on Moodle.

Test Question<
What is your favorite summer activity?
A) Beach Volleyball
B) Road Cycling
C) Soccer
D) Ultimate Frisbee

Ontario’s Health Care System

Themes for today’s lecture:
• How Government works
• Health Policy Development Process
• A look at Ontario’s health care governance
• Ontario’s health care providers & programs
• Health priorities for Ontario

Ontario Government
• Ontario Government (like the rest of Canada)
operates under a Westminster system

Ontario Government
• Employs a ‘first-past-the-post’ (FPTP) electoral
system to choose members to represent its
ridings in the Legislature

• Gives the successful party a disproportional
amount of seats, relative to its total share of
votes.
• ‚Let’s the government govern‛

Ontario Government
• Presently, Ontario is governed by a Liberal minority
under Premier Dalton McGuinty

• Last month, McGuinty laid out his government
agenda (Speech from the Throne) and passed his
first Confidence vote with support from the Ontario
NDP

• In March, another Confidence vote will take place
when Finance Minister Dwight Duncan presents the
McGuinty Government’s 2012 Budget

Question
• What new health priority figured prominently in
McGuinty’s 2011 electoral platform and Throne
Speech?
A) Improved home care services for seniors
B) Shorter emergency room wait times
C) Hiring more foreign doctors
D) Creating a universal Pharmacare program

To summarize so far,

• Ontario government follows Westminster Model
o Concentrates executive power in the Cabinet
• Politicians elected using First-Past-The-Post
o Concentrates power in the hands of the dominant party

So who has the authority to set health policy in
Ontario?
o The Premier charts government agenda, usually in
consultation with the Finance Minister (i.e. New policy
initiatives and program spending for the Budget)
o Executive authority for day-to-day matters is delegated to the
Minister of Health & Long-Term Care

Week 2 - Ontario's Health System

Ministry of Health and
Long-Term Care
Minister
Deputy Minister

ADMs

Directors

Ministry of Health and
Long-Term Care
What is a health policy analyst?
- Expert researcher
- Uses qualitative and quantitative evidence, economic analysis, political
analysis to produce evidence-based health policies

- Prepares briefs for Minister
 ‚For information‛
 ‚For decision‛

- Has two sacred responsibilities:
 ‚Speak truth to power‛
 ‚Faithfully implement government policy‛ (whether you personally
agree with it or not)

Case Study
Wait times at emergency rooms are high, causing hospital
overcrowding, low patient satisfaction, and leading people
with injuries to leave without receiving care.

Your job is to find ways the government can help to lower
wait times. (Reminder: You don’t control have any direct
control over hospital operations.)

How do you, as a policy analyst, approach the problem?

Steps in Policy Development
1. Consult stakeholders and define the
problem.
e.g. Are E.R. wait times a management problem? A resource
($$$) problem? A professional shortage problem? A perverse
incentive problem? A population health problem? Consider
many perspectives (economists, doctors, nurses, hospital
admins, CCACs, LTCs).

2. Read the scientific literature and
understand the context.
What is the scale of the problem? What are the potential
causal and mediating variables? What is the historical
context in which the problem is occurring?

3. Identify and elucidate the best
policy options.
What solutions have other jurisdictions developed?
Have they been successful? What solutions are
most likely to be successful in Ontario? Would laws
need to be changed or modified? Would funds be
required? What existing Ministry/agency/actor
would we task with policy implementation?

4. Analysis (Quantitative & Qualitative)
If we implement Approach A, B or C, what is their
relative impact on E.R. wait times? At what rate would
morbidities/mortalities be prevented? What is the
impact on patient satisfaction?

5. Economic analysis (Optional)
Cost-benefit: policy’s cost vs. expected benefits to
society, in economic terms (typically presented as a
ratio)
Cost-effectiveness: Cost per unit of marginal benefit.
e.g. How much $$$/hour of wait time reduction? How
much $$$/complication avoided? How much $$$/Life-
Year (LY) gained?

6. Political analysis & Considerations
Who wins? Who loses? Will powerful interests be upset
and take to the airwaves? What is an appropriate
communications strategy to ensure support for the
government’s policy? What other risks should
government be aware of?

<And then stick all that
in your briefing note.

2 pages max.



MOHLTC’s Evolving Role
• MOHLTC used to be more ‘hands-on’ in deciding where
health service funding goes (i.e. ‚central‛ decision-
making)

• In 2006, shift towards regionalization: Ontario’s LHINs
are formed to take over responsibility for:
o Public & Private Hospitals
o Community Care Access Centres (CCACs)
o Mental health and addictions services
o Community Health Centres (CHCs)
o Long-Term Care Homes (LTCs)

MOHLTC’s Evolving Role
• Ministry of Health increasingly focused on
policy, oversight and contract management
• MOHLTC also retains responsibility for:
o Health professionals and Family Health Teams (FHTs)
o Ambulance services
o Labs
o Provincial programs (including ODB)
o Independent Health Facilities (i.e. specialty clinics providing
insured services)
o Public Health Units

Local Health Integration
Networks (LHINs)
• 14 LHINs created in Ontario through the Local Health
Systems Integration Act (2006)

• Non-profit organizations that aim to make health care in
the community<
o More accessible, patient-centric and cost-effective
through local service integration and consolidation
o More responsive to local needs and priorities

• Transfers to LHINs account for 2/3 of MOHLTC’s budget

Local Health Integration
Networks (LHINs)
Responsibilities:
• Must enter into accountability agreements with MOHLTC to
receive provincial $$$
• Must develop a Service Plan to show how services will be
integrated and how community health goals will be met

Powers:
• Can create region-specific bylaws
• Cannot shut down hospitals or other service providers
• Can integrate/relocate services to reduce duplication and
improve coverage, when it is in the public interest

Question

In Ontario, health insurance through OHIP
accounts for ~70 cents of every dollar spent
on health care (‚public financing‛).
 Is health care in Ontario publicly-delivered?

Ontario, like the rest of Canada, has a mixed
public-private system:
o Mostly public financing, mostly private
delivery

 Important to understand the distinction between
 public vs. private financing
and
 public vs. private health care delivery

Physicians
• Prime example of public financing, private
delivery
• MDs ≠ government employees; they are private
contractors and business owners (if they own a clinic)

• Family physicians are primary care providers
that play a ‘gatekeeping’ role in the health care
system

Physicians
• Historically derive large portion of their income
from Fee-for-Service (FFS) payments
• FFS incentivizes high level of productivity (More patients
seen, more $$$ earned)
• But does FFS provide appropriate incentives to provide
high quality preventative care?
• Concern that FFS leads to poor quality and waste:
 Shortened patient visits
 Do chronic illness patients really need to book an
appointment with MD to refill a prescription?

Physicians
• In the new Family Health Teams, physicians are
paid using a ‚blended‛ capitation model
• 60% salary from capitation: funding envelope based on
patient roster size
• Physicians earn a reduced fee (15% of regular fee schedule)
for each service provided
• Substantial bonuses ($) for delivering preventative services
& meeting patient screening targets

Hospitals
• 227 hospitals in Ontario
• Most are private, not-for-profit (NFP)
• Funded by MOHLTC by way of global funding
budgets provided annually
• based on historical expenditure trends
• adjusted to reflect changes in expected service costs

Hospitals
• Global funding budgets account for ~85% of hospital
revenue.
o Other 15%: Fundraising, fees for semi-private and
private rooms, Worker’s Compensation payments
• While most hospitals are operate independently
(‚privately‛) as corporations, most are subject to the
Public Hospitals Act and report their Plans annually to
the MOHLTC. Some call them ‚semi-private‛.

Community Care Providers

Community Care Access Centres (CCACs)
• Arrange for long-term care home placements, home care
services and in-school health support services
• Can include MD, nursing, occupational therapy, speech
therapy, dietician, homemaking and other services


Community Health Centres (CHCs)
Provides child and family health services such as:
• Domestic violence interventions, addictions
counseling, parenting education, anti-racism
programs, and body image/healthy sexuality counseling


Family Health Teams (FHTs)
Provides patients with high quality, patient-centered care:
• Multiple primary health care professionals including
family MDs, nurses, dieticians, pharmacists, etc., all
working collaboratively under one roof.

Important Programs
Ontario Drug Benefit (ODB)
• Provides ‚free‛ pharmaceutical drugs to seniors (age
65+) and ODSP/OW recipients

• Also available to patients living in a LTC home or
enrolled in the home care program

• Ontario’s catastrophic drug insurance (Trillium Drug
Benefit) limits copayment for pharmaceutical products
to 3-4% of annual income

Important Programs
Ontario Disability Support Program (ODSP)
• Provides employment and income supports to
individuals who have a disability

• Benefits include drug and dental coverage, as well as
reimbursement for work-related expenses

• Criticized on basis that it requires individuals to run
down their assets before they can apply for support

Important Programs
Ontario Disability Support Program (ODSP)
• Earnings made by ODSP recipients above a certain
threshold are clawed back by the province at a rate of
50%
• Given low advancement potential of ODSP recipients
and loss of income/health benefits from holding down a
full-time job, ODSP provides incentives for individuals
not to find meaningful work (known as ‚poverty wall‛)

Health Priorities in Ontario
• Aging at Home Strategy
• eHealth
• Pharmaceutical drug costs
• Wait Times

Recap
• How Government works
• Health Policy Development Process
• A look at Ontario’s health care governance
• Ontario’s health care providers & programs
• Health priorities for Ontario

Fill-In-The-Blank<
• The Excellent Care for All Act is a critical piece of
McGuinty’s health policy agenda. What does it involve?
o Be the first to post the answer to the HLTH 405 Facebook Wall!

Week 2 - Ontario's Health System

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