Integrating Ontario’s Healthcare System: A Point of View
Globally, many countries are facing challenges with healthcare services, costs and overall value. The World Economic Forum has recognized these challenges which include an unsustainable rise in health and social service expenditures, variability in medical practice, disproportionate acute care infrastructure, and misaligned incentives1. The WEF has leveraged early work by Michael Porter2, positioning integrated care as a cornerstone of healthcare transformation and the delivery of value, specifically, improving outcomes at the same or lower costs.
Some jurisdictions have led the way to transform healthcare by integrating care services, moving to value-base care and population health management strategies, including Spain13, Denmark14, and US providers Geisinger Healthcare10 and Kaiser19. These jurisdictions, averaging populations in the range of 5 million people, have invested in centralized capabilities, scaled across entire populations, and are now reaping the benefits of a seismic shift in the way that health is managed, funded and measured.
Denmark recognized that shifting health expenditures from acute care to community and home-based services was key to value-based care and has reduced the total number of acute care facilities from 98 to 36, shifting this previous acute funding to community and home-based care14 . Geisinger focused on quality management and consumer engagement, reducing overall costs per patient by 11% over five years, and reducing avoidable readmission rates by over 35%10 .
The need for integration is not new to Ontario, as outlined by Leatt et al3 . We understand the key policy drivers that need to be in place4 , and frequently refer to these international examples as aspirational. However, Ontario is clearly lagging behind any shift to population health management based on integration of care delivery. We can no longer view healthcare transformation as ‘stopping hallway medicine’5 or delisting OHIP fee codes8 . We must begin to thoughtfully view transformation through the lens of these aspirational leaders, thoroughly understanding the centralized capabilities that have enabled their journey to value-based care, heavily leveraging their investments over entire populations.
Establishing Core Capabilities
Social media has been electric over Ontario Health Teams5 and the integration of healthcare in Ontario with a goal to eliminate ‘hallway medicine’. However, hallway medicine is a symptom, and not the problem. Prior to treating the symptom of hallway medicine, we must leverage the WEF1 , and international examples, including Spain13, Denmark14, and US references such as Geisinger10, Kaiser19 and Michigan9 who have clearly defined the problem as the urgent requirement to improve overall population health, supported by integrated care delivery processes. By focusing on population health and process integration, we can begin to assess the core capabilities and culture that we require to sustain the journey.
High health expenditures reduce Canada’s competitiveness relative to countries with advanced population health strategies that reduce the demand side of health services. The more we spend on health, the less we have to invest in job creation and new innovation. We must view the health industry not merely as a ‘cost’ to the Province, but as a $60 billion industry that can be a catalyst for a new digital economy in Canada, driving “jobs for our children”. We have a $60 billion burning platform that will require enormous investments in order to transform. We have to create a culture of ‘spending money to make money’.
By framing the problem as the need to improve the health of the Ontario population, we are in a better position to define integration strategies and the capabilities to reach the desired state. Specifically, based on the WEF recommendations and aspirational international leaders, we must establish the following six capabilities, via significant and rapid parallel investments. These capabilities must include
- Population Segmentation: the ability to systematically track value over time, creating insights that support new models of care that deliver outcome improvements by population segment,
- Funding Innovation: new funding programs based on end-to-end cost structures to deliver these new care models, and incent integration among organizations,
- Consumer Partnership: a culture to embrace consumers as full partners in transformation, based on extended reach and community engagement,
- Process Integration: the critical ability to automate integrated process across Ontario’s disparate digital landscape, allowing our health system to ‘appear’ integrated,
- Digital Scalability and Productivity: a strategy that places scalability and productivity at the centre of the digital discussion, enabling case management and consumer empowerment, and lastly,
- Digital Health Economy: a shift to a new digital health economy, leveraging private sector investment to fund Ontario’s digital transformation.
Other industries have used data to ‘know their consumers’, understanding their wants and needs, and shaping offerings or services that drive value for a specific segment. In a similar way, value in healthcare starts with segmentation of our consumers, and definition of improved outcomes for each sub-population. By considering patient needs relative to a group of similar patients, including co-morbidities, risk factors, social determinants of health (SDOH) and accessibility of provider services, specific care models and delivery capabilities can be established tailored to the outcome.
Spain’s Catalonia region, a leader in population health management14, has segmented their population into 320 segments, based on 8 levels of acuity along with age and sex distributions, yielding the ability to tailor care models to each segment with defined outcomes. To become comparable to Spain, we need the data management ability to segment our population by defined cohorts or sub-populations, using data to ‘know our customers’. It is critical that Ontario enable all key stakeholders to access a single Ontario health ‘data common’, based on an integrated view of acute, primary, home care, community health, municipal social and emergency services to measure the health status of our population.
Geisinger has segmented their population, developed new care models aligned with incentives, with clinical leadership supported by centralized innovation and quality support functions, a single digital strategy for consumers, and an enterprise wide data warehouse or data common10 . For each segment, value must start with the systematic tracking of health outcomes over time and the end-to-end costs required to deliver those outcomes, including health, social and municipal costs1. The International Consortium for Health Outcomes Measurement (ICHOM) is developing a set of outcome measures that would contribute to Ontario’s ability to measure value1, moving beyond our current state of measuring wait times and compliance to quality measures.
By establishing an approach to population segmentation using an integrated ‘data common’, similar to Geisinger10 and Spain14, clinical leadership will be able to develop new Ontario-wide care models to address both individual clinical lines of business as well as heterogeneous populations such as peadiatrics, women’s health or eldercare. Ontario is not short of clinical expertise and leadership, armed with the knowledge of how to improve outcomes or avoid preventable episode. We are short of the data-driven knowledge that risk profiles our populations and targets patients who may most benefit from interventions to prevent onset, improve outcomes at lower costs, or reduce preventable episodes. At a second level, we also need to move our new health ‘data common’ so that it is accessible to researchers and private sector to drive further medical innovation and emerging AI solutions, positioning data as the fuel to drive an Ontario AI economy.
Complementing the formation of the data common, we must also build a focused Ontario data science capability, leveraging AI and the Vector Institute, to derive insights from our digital health and social resources, driving iterative re-design and increasingly precise interventions for each subpopulation. Although Ontario has completed important work to categorize the top 5% of patients from a cost perspective, we need the ability to derive insights, identifying patients in the next 10% who are drifting to become five percenters. Importantly, our new care models, tailored to each sub- population, will define the required re-alignment of delivery organizations and end-to-end cost structure, aligned with funding innovation.
Based on the value sought for each segment of the population, we require the ability to rapidly launch new payment models designed to drive value – improved outcomes at the same or lower costs. The WEF clearly positions funding innovation as a critical top priority1 rapidly attacking key sources of benefit or value, such as avoidable episodes, adverse events and a holistic approach to eldercare, with benefits in the 15% range achieved by several US examples9 . We must establish the capability to define the payment model, or price, associated with the total end-to-end costs of the effort required to achieve the outcome.
Michigan’s Blue Cross Blue Shield, focused on specific segments of their population, and reduced avoidable ER episodes by 18% and achieved a 21% reduction of inpatient days9 . Others in the US according to the Primary Care Collaborative, have outlined substantial reductions in avoidable ER episodes in the 10%- 18% range by focusing on sub-populations9 . Spain recognized primary care’s critical role to be consumer-facing and leader of population health management, and established an enterprise primary care capability, incorporating multidisciplinary teams and shared resources14.
By measuring the gap between current outcomes and desired outcomes, we will be in a better position to measure potential benefit or value, and therefore, measure the size of the investment required. Specifically, the price must be greater than the costs of delivery and less than the desired benefit accrued to the Province. Our costing capabilities must recognize the multi-discipline requirements across acute care, home care, primary, community and municipal services, and accurately distribute funding across all organizations involved in the new care model, as demonstrated by leading efforts in the Netherlands7 .
Based on these new payment models, we must also have the capability to establish new partnerships, based on teaming agreements, service level management and integrated processes, both among provider organizations, as well as between providers and the end consumer. By targeting outcome improvements and new care models for each segment of our population, we are able to reshape the cost structure required to implement the new care model, allowing each organization to see a benefit where their revenue exceeds their costs. Quality improvement programs, based on a set of multi-organizational quality metrics, must be established so that all are measured equitably to achieve outcomes, improve quality or reduce avoidable episodes.
We are not short of technology innovation; however, we are short of funding innovation. We must adopt a ‘fail fast’ attitude, based on the need to ‘spend money to make money’, recognizing that we will not get this right up-front. However, we must do this as partners with consumers!
Although patient-centred care has been aspirational for three decades, Ontario consumers remain a significant untapped resource in the transformation journey. We must establish a partnership culture with consumers related to both care management as well as community engagement, and not merely selective participation on planning committees. Partnership must mean an end-to-end relationship, using the concept of extended reach, moving knowledge to the consumer rather than moving the consumer to the ‘point of knowledge’.
Other jurisdictions have forged strong partnerships with consumers10 13 14 19 , based on ‘extended reach’ in order to maintain a connection between the clinical team, the patient and family. This partnership and extended reach are supported in many ways including coaches or navigators, home nursing support or community champions, as well as through partnerships with both private sector and public organizations under a ‘team sport model’.
Unlike other industries who have focused on the ‘end consumer’, the health system has not embraced the ‘healthcare manager’ or HCM in each Ontario household, as the ‘end consumer’. We must leverage the HCM, engaging them on family health schedule management, education- based behaviour change, and care plan compliance tools. We must do this at scale across Ontario in order to enable consumers to see a seamless view of Ontario’s health system, regardless of their place of residence or OHT relationship.
Again, by framing the problem as improving the health of the population, and given the 13 million in Ontario, we have no choice but to embrace a stronger partnership with consumers, supported by extended reach. This scale of consumer engagement, supporting self-management at home as well as behaviour change and compliance, can only be enabled by digital process integration, tailored to each population segment. This must not be defined at an OHT level!
In the UK, Bradford’s Bangladeshi community has established a ”seniors show the way” project to train champions in the community, via the NHS Altogether Better Program5 . In a similar way, the Shropshire Health Authority established a network of 150 young champions to extend to the community using social media6 . The Netherlands Buurtzorg Neighbourhood model of care has received international recognition by partnering home nursing with the family and patient7 . Other jurisdictions have also recognized that resources beyond the healthcare system are required, defining partnership and extended reach as a ‘team sport’, as demonstrated by Jersey Health Call and Check Program15 in partnership with Jersey Post, or via potential private partnerships such as Best Buy’s transformation of their Geek Squad to support home monitoring devices and security in a growing elderly market.
Process Integration and Organizational Change
We must recognize that process integration is the key to integration, enabling the ability to implement new care delivery models for a specific set of outcomes. Process integration is also the key to becoming patient-centred, recognizing patient wants and needs. Four processes are cornerstones of health transformation, specifically behaviour change, care plan compliance, remote monitoring or virtual care, and case management, all supported by extended reach to consumers. By focusing on these key processes, and engaging consumers as partners, we will achieve greater levels of ‘health system integration’ based on patient-centred design. Patient-centred means designing integrated processes that connect consumers at all key steps and decision points through extended reach. To be clear, using consumer-centricity in other industries as proof-points, patient-centricity is not about being in the centre. Patient-centred is a culture statement that integrates consumers, via Design Thinking11 and Service Design12 .
Before designing new integrated processes, it is also important to understand that our current processes among provider organizations as well as between providers and consumers are highly variable and open loop, caused by open communication technologies – fax, paging or voice. Open loop and highly variable process are the single greatest barrier to integrating the Ontario health system and achieving population health at scale. We will fail if we design new processes but implement using ‘open communication technology’.
We must learn from other industries who have used a digital process automation platform (PAP) to design and manage integrated process across a variety of backend IT systems, shifting to digitally defined processes that are hardened, closed loop, and measured – if you can’t measure it, you can’t manage it! Other industries have also learned that it is imperative to ensure consistency across multiple channels including both the ‘in person’ channel as well as any new digital channels, via equivalent content and decision-steps. Healthcare is not immune from this requirement!
We often reference Catalonia or Kaiser as appropriate targets but fail to realize that the IT systems in these jurisdictions enable integration of processes that are closed loop and standardized, in other words, hardened12 19 . We have to realize that trying to replicate the best practice of these jurisdictions is virtually impossible at scale without using a digital process integration platform or PAP that integrates process across our disparate IT systems and enables Ontario to ‘appear’ integrated.
Therefore, we must leverage a digital PAP to allow the fragmented Ontario IT landscape to ‘appear’ integrated. The PAP must be complemented by regional organizational change capacity, shared across acute, community, primary and home care, using Design Thinking and the PAP to deploy integrated processes that reduce variability, establish closed loop collaboration, and allow the health system to act as a system. The result will be a culture that designs processes with consumers at the centre, supported by a digital process automation platform, whether supported by phone calls, email or self-serve digital capabilities. This is not a capability of an OHT!
Digital Scale and Productivity
The Internet of Things, wearables and other in-home devices have fueled an exploding range of digital solutions, creating a fire storm of options for virtual care, remote consultations, consumer self-management and behaviour change. The digital channel represents a new channel that enables behaviour change and care plan compliance among an empowered consumer. This all adds up to digital extended reach and digital process automation, supporting a shift to closed loop and integrated process. Digital has become a critical ingredient of healthcare transformation and population health management.
In combination with funding innovation, consumers and providers are being incented to adopt these new digital solutions, scaling new therapeutic management approaches, achieving increased productivity and improving outcomes, in other words, value! For example, the US Centers for Medicare and Medicaid Services (CMS) now reimburses for digital therapeutics for diabetes prevention and management, and millions across the US have downloaded digital therapeutics apps for medication adherence16 17 The potential of digital solutions to improve outcomes over traditional in-person channels is increasingly promising, and will be validated over time, with solutions yet to be developed superseding early entrées to this growing market.
The potential for digital to improve outcomes is not new to Ontario social media; however, Ontario needs to position scalability and productivity at centre stage in the digital discussion. Given the heavily fragmented Ontario health landscape, we have no choice but to establish a digital strategy with a core set of digital solutions, mimicking the levels of integration achieved by aspirational examples, allowing our system to ‘appear’ integrated and enabling scalability and productivity. This digital strategy must provide a seamless view for consumers regardless of their residence or employment location, integrated across all processes, and supported by extended reach, coach interaction and system navigation. We need to use digital to empower consumers via self-management, rapidly scaling new care delivery innovations to thirteen million, and avoiding care innovation to be trapped within an OHT.
Blue Cross Blue Shield Nebraska uses digital reach to not only improve effectiveness but also reach high levels of productivity for case managers16 . Post-hospitalization costs were 41% lower for patients under digital case management versus patients not enrolled in care management, compared to only 17% reduction in post-hospitalization costs when telephonic reach was utilized. Care manager productivity also increased, with a 65% reduction in time spent with patients versus a telephonic channel17 . Based on a digital platform for extended reach the US DVA has established a case management model that allows a case manager to manage 300 patients while achieving better therapeutic measures. Based on this 300:1 ratio, applied to Ontario’s highest need or 5% of patients, we would require 2,200 dedicated case managers, a tiny investment in the context of our total workforce.
By scaling new innovation across Ontario, digital will also increase the productivity of our health workforce, specifically primary care, home care, coaches, navigators and case managers, and reducing the cost of patient scheduling and administration. In addition to general productivity increases, a digital platform can reach new levels of population health management via case management, supported by virtual coaching and virtual care, predictive risk or early warning models, as well as self-care alerts to patients and families. By increasing the productivity of a case manager by a factor of 3 times compared with non-digital case managers for populations where case management is appropriate,16 17 we will open the way to assign more clinical resources to high value, in person contact for those populations where this is crucial, specifically to manage the five percenters or importantly to manage those drifting to become five percenters.
Although there is great debate over the effectiveness of case managers, it is safe to state that digital does offer an effective way to deploy case managers, coaches or navigators, and generate the data to measure success. Net is, as we see from others, not only does it make economic sense to engage consumers through case management and coaches, it makes more sense to do it digitally16 17 .
Digital Health Economy
Digital is not the core competency of our Ontario health system, further plagued by local technology decisions that propagate barriers to process integration, scalability and productivity. Although there is long standing debate on private sector’s role in Canadian healthcare delivery, there must not be debate over private sector’s role to digitally enable Ontario’s health transformation. We must leverage the Canadian private sector, both in terms of their ability to provide the massive infusion of capital needed to pull Ontario in to the 21st century, catching up to Kaiser and Catalonia, but also in terms of their know-how gained from other industries successfully addressing similar integration problems.
Ontario’s private sector has the capacity to invest and build new digital tools based on a single PAP to integrate process, including self-management, virtual care, coaching, care plan compliance dashboards, e-consults, and in the future chatbots and personal assistants. We need to foster widespread funding innovation under a single Ontario framework, that will draw in Ontario private sector investment and digital innovation all designed to scale health innovations, dramatically increase productivity and engage the consumer towards overall population health.
Private sector is also the key to create digitally enabled healthier communities focused on healthy aging, based on new skills to drive connected communities, as researched by Bolzano, Italy18 or exhibited by early use of personalized robots interacting with the elderly in Japan.20 We must leverage the final cohort of boomers - all digitally powered and now reaching their 70s – and they all want to live in their homes! We will need new community health skills, merged with smart municipal programs and infrastructure. This takes investment and new jobs!
Lastly, we must view the health industry not merely as a ‘cost’ to the Province, but as a $60 billion industry that can be a catalyst for a new digital health AI economy in Ontario, driving “jobs for our children”. We must view Ontario’s health digital expenditures as an investment in our private sector, with a goal to position Canada as a net exporter of digital health solutions, methodologies and practices. We have a $60 billion burning platform that will require enormous investments in order to transform. We have to create a culture of ‘spending money to make money’. We can and must do this!
Symptoms versus the Diagnosis
Business acumen and system theory, as well as sound medical practice, teaches the importance of root cause analysis and applying the correct level of problem solving that focuses on the ecosystem and not a symptom. Hallway medicine is a symptom, not the problem. Integration is not the destination but a means to an end. Clearly, we can and must ‘address’ symptoms, and deliver early value via defined solutions, but in the end, we must look beyond. The real problem is the need to achieve a healthier population, reducing the demand side of healthcare and managing care closer to home, via preventive measures and behaviour change across an entire population.
To achieve higher levels of population health, Ontario must transform via significant investments in all six capabilities, in parallel and at scale. We must establish a health data common to derive new insights for each segment of our population, designing new models of care and end-to-end cost structures, aligned with funding incentives. We must embrace consumer partnerships and HCMs, tailored by segment, through digital extended reach, regardless of their OHT relationship. Similar to aspirational examples, our Ontario’s fragmented health system must reach the ‘appearance’ of integration via a single digital process integration platform. We must form a digital strategy that rapidly scales care innovation to 13 million and avoid being trapped in OHTs. Enable a digital channel to reach high levels of productivity for a large percentage of the population, allowing increased resources to be applied to the in-person channel for high needs populations.
We must ensure significant additional funding in a ‘spend money to make money’ view, and position Ontario’s $60billion health industry as an economic driver of a new health digital economy, leveraging our Canadian private sector, and creating ‘jobs for our children’. We must establish these capabilities once, centrally at scale, and not scattered and diluted in multiple OHTs. We must innovate once and replicate at scale leveraging the ‘onthe- ground capabilities of each OHT – rapidly!
We are on the brink of a global workforce shortage by 2025, across the G8, fueling a competition for skills. Our most skilled physicians and nurses will retire from the Ontario workforce in the near term. We must replace these skills while concurrently reshaping a workforce from acute to community and home care resources, creating healthier communities, fostering health aging, and caring for the elderly closer to home. In addition to educating our children, we must compete for skilled immigrants to fill healthcare positions. Recognizing this shortage must be framed from the perspective of investing in education, but also with a lens to ensure the highest levels of productivity of our health workforce through digital enablement.
About the Author(s)Paul Sulkers, PRS Health Consulting
1. World Economic Forum; Value in Healthcare project session held at the World Economic Forum Annual Meeting 2017.
2. Michael E. Porter and Thomas H. Lee; The Strategy That Will Fix Health Care, October 2013.
3. Peggy Leatt, George H Pink, Michael Guierre, Towards a Canadian Model of Integrated Healthcare, March 2000.
4. Dr Robert Bell, August 2019, https://drbobbell.com/comparing-health-systems-lessons-for-ontario/
6. NHS Altogether Better Program: https://www.altogetherbetter.org.uk/
7. Netherland’s Buurtzorg Neighbourhood Care
9. Primary Care Patient Centred Collaborative https://www.pcpcc.org/results-evidence ;
10. Geisinger …. D Maeng et al. “Can Telemonitoring Reduce Hospitalization and Cost of Care? A Health Plan’s Experience in Managing Patients with Heart Failure”. Journal of Population Health May 2014.
11. Design Thinking: https://www.designorate.com/category/design-thinking/
12. Service Design. https://medium.com/design-ibm/service-design-at-a-speed-and-scale-23be71f94612
13. Catalonia Spain: http://cloud2.snappages.com/673e459e46f0ce352dfa9ad4928ac5aea6fdcbdb/CatalanHealthSystem_INTRO.pdf
14. Denmark: Australian Financial Review, https://www.afr.com/work-and-careers/management/whydenmark-is-reducing-hospitals-while-we-are-building-more-20190219-h1bg9d
15. Jersey Post Call and Check Program: https://www.jerseypost.com/about-us/news/2018/cc/
16. Case Management: Mobiheatlh News, David Muoio, January 4, 2018 http://www.mobihealthnews.com/content/positive-outcomes-welldocs-bluestar-translate-costsavings-analysis-finds
17. Productivity of Case Management: AHIP blog, Darcy Lewis, January 25, 2018. https://www.ahip.org/how-a-healthplan-innebraska-uses-mobile-tech-to-connect-with-patients
18. IBM Research, Comune di Bolzano, ASSB, Geriatric Dept. https://researcher.watson.ibm.com/researcher/view_group.php?id=6700
19. Kaiser Permanente Integrated Care Models https://www.cfhi-fcass.ca/sf-docs/defaultsource/ reports/learning-fromkaiser-permanente-townsend-e.pdf?sfvrsn=2
20. IBM Research on Loneliness https://researcher.watson.ibm.com/researcher/files/usblaese/Loneliness.pdf
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