OHA HealthAchieve: Wrestling with the role of patients in the system

Harvard professor Michael Porter speaking at this year’s OHA HealthAchieve.

There was an epiphany moment at this year’s Ontario Hospital Association HealthAchieve when a hospital administrator responsible for patient surveys admitted that she had been doing it all wrong. The surveys were all about the hospital’s performance, not about the patient, she said.

We are in the age of continual measurement as administrators try to reduce the business of providing health care to a series of performance data tables. One could argue that surveying patients about their care is about improving the patient experience, so one has to wonder where the sophistry ends and where practical management begins?

At this year’s conference there was plenty of angst about the role of the patient in determining how health care is delivered.

Paul Corrigan, a former health advisor to UK Prime Minister Tony Blair, made a less than convincing case that health care providers should be basing their decisions around outcomes defined by the patient instead of the health professionals. Instead of a surgeon deciding a procedure has been a success, for example, that success should be defined around whether the patient achieves his or her goal to “walk to the shops,” for example. It’s perhaps a good thing that Corrigan didn’t encounter a patient whose goal was to play piano at Carnegie Hall.

“Hearing what patients are saying would be transformative,” says Corrigan, the implication being that we don’t.

Sir Nigel Crisp, a former senior manager in the UK’s National Health Service, ramped up the rhetoric by going as far as saying “professionals need to get down from their pedestals and patients up from their knees.” Seriously?

Kingston General Hospital CEO Leslee Thompson had the best analogy, asking “could you ever plan a wedding without the bride?”

The Health Minister did tell the OHA audience that decisions should be made with the patient rather than for the patient, although we could dance around exactly what that means, especially in light of the Health Care Consent Act.

Michael Porter, the Harvard business school professor that opened this year’s HealthAchieve, suggested what patients don’t want is to be bounced around from one provider to another. Porter says the way forward is to have specialized centers that effectively become a one-stop shop for patients – or what some of us formerly called a hospital. He calls it “parallel” rather than “sequential” health care.

Porter gave the example of a West German Headache Centre which brings together specialists under one roof to help individuals with debilitating migraines. Porter says that while this specialization may be initially more expensive, it does reduce costs over time. For patients the question becomes how much further do they have to travel to see a specialist in a focus clinic (Porter calls them integrated practice units), and how does that impact the patient “experience” when such visits are frequent due to a chronic illness? Is this what patients want, especially those living in less densely populated parts of the province?

The situation gets further confused when patients have co-morbidities that no longer fit one focus clinic. Porter argues that it would be better to bounce between two focus clinics rather than a whole series of providers.

More interesting is Porter’s idea about determining value. He is correct that we evaluate costs in the context of a single provider rather than look at the full continuum of care. Might we do things differently seeing the entire patient pathway in such a cost perspective, especially when private out-of-pocket costs – such as rehab – become part of the overall calculation?

Knowing the cost of the entire pathway does not necessarily mean that funding should necessarily be assigned by pathway, as Porter recommends. The contradiction of pathway funding is that it treats all patients based on a clinical average, not as individuals. In a for-profit environment, it provides an incentive to do the minimum required, not necessarily what is most appropriate. A visit that can be avoided goes straight to the organization’s bottom line. It also provides an incentive to use less qualified practitioners who may cost the provider less but be less able to assess other co-morbidities.

“You are really good at coming up with an exception,” Porter tells his audience. “There are exceptions. We don’t organize around the exception. You create structures to meet the rule.”

Is that really what patient-centered care looks like?

During the three days there were numerous references to patient participation in planning committees. Administrators were quick to promote and endorse the participation of selected patients or family members in the process, although we failed to hear any specific idea or change in direction that resulted from their input. “The only thing I have to bring to the table is my story,” said Joanne McPhail, the patient advisor co-chair on Ontario’s Cancer Plan IV. She didn’t offer much more than that on the HealthAchieve panel either.

Garth Matheson, Vice-President of Planning and Regional Programs for Cancer Care Ontario, suggested the benefit lies in relationships, not on how many partners a health provider brings to the table. “Counting partners doesn’t mean anything,” he said.

Neither does selecting patients to fulfill an idea about community participation without a real commitment to listen and make change.

Hearing all this we couldn’t help but think about all the patient groups we do work with, that are active in protesting hospital cuts in their local community, challenging the rise of for-profit care providers within the public system, the delisting of rehabilitation services, or the difficulties of simply accessing quality health care. You don’t see these community activists serving in an advisory capacity.

Everyone purports to speak on behalf of patients these days. Drug companies fund patient groups to be advocates for their products. Others take it upon themselves to speak on behalf of patients when in fact they are speaking on behalf of themselves. Ultimately, we are all patients and all use the health system, yet we all harbour many different and sometimes opposing viewpoints.

Patient empowerment is happening. The ability to access your own electronic medical record when you want to is itself an exercise in empowerment. There are many inexpensive remote devices that can be used in the home that will likely be integrated into your electronic medical record soon to give a broader picture of what is taking place. Health care continues to top the list of voter concerns as we head into the next Federal election. In a September Vector Poll 77 per cent of Canadians said that the federal funding formula – which is based on per capita, not on age demographics or geography – is unfair.

In Ontario Health Links continue to hold out the promise that the heavy users of the health system will receive the attention they deserve and that the promise of wrapping health services around the individual will be fulfilled.

As part of the Vector Polling Coalition, we recently also surveyed Canadians on their broader attitudes towards the public health care system. Despite the negative impacts of austerity, nearly seven out of 10 still rate their health care as good or excellent.

When we specifically probed those who rated it fair (26%) or poor (4%), 52 per cent of that subgroup said it was harder to get treatment when they needed it, 10 per cent said the actual care is worse, and the remainder said it was a combination of the two. There was no mention of getting bounced around between specialists as Michael Porter asserts.

The portrait that emerges is a health care system that the majority of Canadians are satisfied with, but there are clear signs that some significant cracks in the system are emerging.

Mark Britnell, Chair and Partner with Global Health Practice, KPMG, says “we are approaching the next dislocation” within health care. Britnell believes the next wave of change will be all about patient satisfaction. We can hardly wait.