Essays

Essays September 2011

Will Falk Comments on John Ronson’s essay “LHINs at Five years – What Now?” Part 2 of 2

Will Falk

John Ronson sets out a compelling vision of a new system of 30-40 Integrated Health Organizations (IHOs). Each IHO would have full responsibility and accountability for primary care, acute care and homecare for their population. Primary care physicians would be formally affiliated with an IHO, the CCAC functions and part of the LHIN functions would be rolled into the IHO.  A series of 7-8 super regions would oversee the IHOs and would contain the other half of LHIN functions and many Ministry functions.  The Ministry would be downsized by 50%.

This is a compelling and comprehensive vision.  I have some quibbles with the details and might have put the number of IHOs at 80-90 and the mega-regions at five (both based on recent reports from ICES) but these are details. Ronson achieves many goals in his model which are important ones for improving patient care:

  • Primary care is integrated into the health system
  • CCACs are integrated with LHIN and acute care systems.
  • Silos among system sectors are (on paper) broken down through a regional funding envelope.

Ronson has described a workable model of centrally planned regionalization and one that would have made good sense in 2003 instead of LHINs.  He says that the best Hospitals and their Boards will be the foundation for IHOs.  Because the regions would be the primary planning and delivery vehicle, the IHO Boards would likely be publicly appointed by Queen’s Park. Partisan interests might well intervene and make these positions compensated.  They would soon no longer have the ownership and history of hospital boards of directors and become creatures of the centre.

For 2012, IHOs represent a comprehensive vision of regionalization that goes beyond what was contemplated in Alberta in 96 and 03.  A government pursuing such a path would be “betting its mandate”.  The implementation path would be long and complex with room for error:

  • It will take two full years to design the details, consult, legislate and begin the IHOs.  Probably, at least another three before they could be well-functioning.
  • Detailed system design, consultation processes, 30-40 board appointments, CEO searches followed by full executive team appointments across the province would require a team of 150+ professionals working diligently for more than two years (note the LHIN implementation team was over 60 people).  An estimated set-up cost of $50+ Million
  • Successful implementation will require the reorganization of the machinery of ABC appointments. LHINs made the mistake of paying Board members which made these appointments attractive to partisans and lessened their prestige value relative to Hospital Boards.  Political pressures within the governing party for appointments would be intense and could result in the politicization of health governance — a very undesirable outcome.

In the meantime, the health system would be in chaos with several interest groups likely beginning rear-guard battles to undo the “reform” process.  Certainly the OACCAC, and likely both the OHA and the OMA would have significant problems and would seek to alter the proposal.  It is possible, even likely, that the results emerging from public consultations would look nothing like Ronson’s well-conceived IHO plan.  In terms of the impact of starting health reform with another major restructuring:

  • Sustainability innovations would either have to wait for the new structure or be undertaken using our existing structures as they were being disbanded. 
  • The existing systems would face a huge morale crisis as all executives feared job loss and repositioned for the new system. 
  • Health reform would become an election issue for the 2015 campaign with the possible outcome of a re-reform and the beginning of Alberta-like continuous reform.
  • Citizens tire of incomprehensible infighting and restructuring which they see as being meaningless in terms of improving patient care.

Ronson has done a huge service by putting his well-conceived proposal out for discussion. It is a good plan at the wrong time in our history. He has defined the most comprehensive of the structural options and given a workable and thoughtful approach. 

There are at least three other structural options that sit between “sticking with the LHINs” and Ronson’s “Integrated Health Organizations”.  We will examine these three middle options each in turn in the remainder of this essay:

  1. Strengthen LHINs (aka Replace LHINs)
  2. Strengthen specialty care networks
  3. Support and encourage organic mergers and acquisitions

Strengthen (or Replace) LHINs: This option has been floated both internally within the MOHLTC and by Ontario politicians. The Hudak proposal starts with the decommissioning of the existing structures and is silent on what will replace them.  This is desirable for two reasons: 1) it decommissions the existing partisan and paid Boards and 2) it creates a fresh canvass on which to redraw the geographic boundaries. Mr. Hudak is (understandably) silent on what will replace the LHINs but it is reasonable to assume that he knows that something will need to replace them (as they replaced the DHCs),  There are actually functions such as accountability agreements which need to be completed. 

The discussions in and around the Ministry appear to have three main dimensions:

  1. Reduce the number of LHINs from 14 to 9, 7, or 4. (As I understand them: Nine is combining for scale, seven is returning to the old regional office boundaries and 4 is mega-regions),
  2. Combining the CCAC functions into the LHINs and using this as a basis for expanding purchasing of clinical services, and
  3. Giving LHINs an expanded role in the funding and organization of the primary care system.

A name change makes the Ministry proposals complementary to the Hudak proposal as they would “eliminate LHINs”.  Whatever party wins power, LHINs will be restructured; there is very broad consensus on this.

Strengthen Specialty Care Networks and/or Create a Multi-Specialty Agency: Cancer Care Ontario has successfully integrated the provincial cancer system across more than 80 sites of service.  It is a planning and purchasing organization co-located with its downtown Toronto clinical hub at PMH.  In 2006, Dr. Alan Hudson wrote a thought piece (the Hudson Report) on how to combine CCO with the Cardiac Care Network, Trillium Gift of Life (Organ transplantation), and other small specialty networks into a multi-specialty agency (MSA).  Further white papers were later prepared by Terry Sullivan in 2007/8 and Steini Brown in 2009. All explore the expansion of provincial programs as a way of further integrating care around patient groups

The MSA idea is to extend the knowledge and procedures around purchasing and quality management that have been built for cancer to other disease states and organize care across the continuum for patients by disease state.  Hospitals and doctors are left in place but the MSA plans, purchases and coordinate patient navigation. Both the Diabetes and Chronic Kidney Disease strategies currently being pursued by the McGuinty government have their roots in this thinking.  The Minister and MOHLTC continue to support elements of this approach to the extent that it does not fundamentally shift power away from the central authority. A much more complete devolution to specialty care agencies should create active clinical service purchasing and change agents that can cut across health silos and integrate care. The specialty agencies would build upon ECFA and the CCO experience to create the data and the capacity to interpret it so that we can fund against needed access and required quality standards.

Support and encourage organic mergers and acquisitions: The UHN acquisition of Toronto Rehab, the formation of the St. Joseph’s Health System in Hamilton, and the merger of Credit Valley and Trillium Health Centre are recent examples of an organic consolidation that is happening outside of LHIN or Ministry control.  These organizations are now sophisticated and large scale health systems and have a mission to provide a continuum of services to identified patient populations.  In many ways, they are starting to look a lot like the IHOs that Ronson describes and like US Accountable Care Organizations.   But they are not the result of central planning or top down Ministry instructions. 

They are the result of strategic vision, diligent execution and a passion for delivery excellence.  You can’t centrally plan these consolidations from Hepburn because the Ministry doesn’t have the human resources or the capabilities. Bob Bell, Mark Rochon, Michelle Di Emanuelle, Janet Davidson, and Kevin Smith don’t exist in the MOHLTC and they don’t exist in the LHINS.  Those five leaders are representative of excellent deep teams that have put together these deals.  There are literally hundreds of senior experienced caregivers involved in this consolidation trend and they each have a passion for delivery excellence and understand in detail how to reorganize care processes for their communities.  Without those skills it is folly for the Ministry to try this kind of restructuring in a top-down planning fashion.

The role that the Ministry can and should play is to:

  • Encourage boards of the great community health care institutions to actively consider consolidation options
  • Get boards and management teams to assess their performance on horizontal and vertical integration through accountability agreements and other eprocesses
  • Provide capital, planning and some operational supports to consolidation
  • Remove legislative and regulatory barriers to consolidation.
  • Bring the physicians to the table. Accelerate the evolution of the FHT to take on more of the community coordination and really, truly be the custodians of care for our aging population
  • Change compensation systems to reward integrated institutions through the aggressive implementation of:
    • Bundled payments for all VAP procedures that cross the continuum
    • 30 day readmission bonuses (and penalties) for all VAP surgeries.

These three middle options are not mutually exclusive and an incoming government will pick among the three to create a coherent program that builds on the successes of ECFA,  Access to Care, and CCO quality initiatives to strengthen hospital governance of quality and access.  The next government will also be measured against the sustainability standard.  While quality and access are important, the reformed healthcare system structure should be in place to drive costs from the system for the 2012/13 fiscal year.  This is a short implementation timeframe and demands that we focus on what is achievable and realistic.

Ronson’s vision for integrated health organizations is an excellent one.  It provides a clear and well-articulated description of goals and some concrete approaches.  However, it is too grand and requires too much change to implement given the very real sustainability challenges that face a new regime.  A combination of reforms that includes realigning LHINs, strengthen specialty care, and investing in consolidated vertically integrated delivery systems is more likely to succeed.

Click here for part one.

About the Author

Will Falk (@willfalk) is an Executive Fellow in Residence, Mowat Centre for Policy Innovation, School of Public Policy & Governance and Adjunct Professor, Rotman School of Management, University of Toronto.

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References

John Ronson's original essay started quite a debate. Follow it here:
 
 
 
 

John Ronson responds: LHINS at 5 Years – Further Thoughts 

Comments

Stephen Crotty wrote:

Posted 2011/06/09 at 12:07 PM EDT

Will Falk's critique of John Ronson's proposal proposes three options to the IHO approach that purports to offer the in-coming provincial government an ability to "pick and choose and the three to create a coherent program. Taken together, the three proposed options are fundamentally flawed because they would result in a system that is even more hospital-centric than the current system. Creating larger hospitals through voluntary mergers will result in institutions with significant policy influence and impact, as will the expansion of the CCO model to other care domains. What will lose ground in the process is a meaningful policy role for family medicine and for public health initiatives. Both of these areas have lost influence in the policy process for health care because they are represented at policy tables by large, influential institutions like UHN and Sick Kids.

Will Falk needs to use his considerable policy acumen in health care to devise proposals to expand the influence of family medicine and public health in the policy process. His proposals for larger and fewer LHINs will not accomplish this.

 

Will Falk wrote:

Posted 2011/06/09 at 03:28 PM EDT

Interesting comment. Certainly do not agree that CCO (or CCN) are hospital centric. Mainly physician driven. Because the oncologists and cardiologists are in control. I think this is generally the case and that Bringing physicians into these organizations is what is needed. Often, Docs should be running them (IMHO). Having Primary Care outside of LHINs is one of the biggest issues with LHINs. Can't integrate the delivery system without doctors!!

Hope that helps.

Will

 

Will Falk wrote:

Posted 2011/06/09 at 03:29 PM EDT

PS: Thanks for the "considerable policy acumen" Sweet! 3:16

 

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