On February 15th, 2012 the Commission on the Reform of Ontario's Public Services (the "Commission") has released its much anticipated: Public Services for Ontarians: A Path to Sustainability and Excellence (the "Drummond Report").1 The recommendations contained within the Drummond Report have the potential to fundamentally change how the public health care system is organized, how provincial funding is allocated, and how patients receive their care. Accordingly, the Drummond Report may constitute a turning-point for Ontario's health care system. However, much of the Drummond Report's impact will be determined by the provincial government's reaction to the report – specifically, in whether they choose to accept or reject the recommendations contained therein.
Background: the Drummond Report
The Commission was established in the spring of 2011 by the provincial government prior to the latest provincial election. The stated purpose of the Drummond Report is to provide recommendations to the provincial government in order to eliminate the provincial deficit and balance the budget by 2017-2018. While the Drummond Report seeks to fulfill this promise by recommending cost-saving measures across all provincial sectors, the large burden imposed by health care spending is targeted by the numerous recommendations directed at the health care sector. The recommendations generally focus on finding efficiencies and cutting needless spending from within the current system, which is not overly surprising given that the Commission was specifically mandated to avoid making recommendations that would lead to the privatization of health care.2 In any event, the report recommends significant changes to the public health care sector, providing new opportunities and challenges for health care providers.
Fiscal Issues
Prior to the release of the Drummond Report, the provincial government had already planned to limit annual increases in health care spending to 3%. However, the report suggests limiting annual increases of aggregate government spending across all sectors to 0.8%,3 and suggests a limit of annual increases in health care spending to 2.5% through 2017-2018.4 While these recommendations are likely to have an effect on all future health care spending decisions, they will be especially pertinent for the pending negotiations between the Ministry of Health and Long-Term Care (the "Ministry") and the Ontario Medical Association regarding physician payments through the Ontario Health Insurance Plan ("OHIP").5
"Patient-Centred Care": Increased Home Care and Primary Care Integration
A number of the Drummond Report's recommendations focus on "patient-centred care" by developing systems of coordinated and integrated care that support the patient throughout the various health care settings. The ultimate goal is to maximize the prevention of illnesses that lead to hospitalization, in order to decrease health care costs and increase overall patient well-being.
The goal of reducing hospitalization would, according to the Drummond Report, be partially achieved by increasing the amount of health care provided in patients' homes.6 Home care informs a number of recommendations, including those aimed at the costs associated with an increasingly senior population,7 the use of telehomecare for patients with serious chronic health problems8 and those in remote communities,9 and the increased role that community-based care should play.10 The Drummond Report states that these proposed changes would create increased opportunities for health care workers to deliver services that are flexible and customized to the patient's needs.
There is likely to be an increased integration of family health care into the community health care model in further hopes of minimizing hospitalization. The Drummond Report specifically recommends that primary caregivers be given the mandate of tracking their patients as they move through the health care system (including while in hospital).11 In addition, Community Care Access Centres and Family Health Teams and are both identified as systems that should be given larger roles in the overall provision of care.12 These changes would accord with the Minister of Health and Long-Term Care's (the "Minister") previously announced "Action Plan For Health Care" (the "Action Plan"),13 which contemplates the integration of Family Health Teams into the Local Health Integration Networks.14
Expanding Scope of Practice
In line with the push to reduce costs, recommendations are made to help ensure that services are performed by lower-cost health practitioners, where appropriate. Specifically, recommendations target a net shift in responsibilities from physicians to nurses and physician assistants (on procedures such as vaccinations)15 and an increased role for the LHINs in ensuring that hospitals are utilizing staff to their maximum scope of practice.16
Through its focus on maximizing the scope of practice of regulated health professionals within hospitals, the Drummond Report may open the debate on expanding the scope of practice for certain practitioners. It specifically recommends expanding the scope of practice of pharmacists,17 and recommends that the provincial government generally play a more active role in working with the province's health regulatory colleges to make decisions regarding scope of practice.18 These changes would provide a great opportunity for all health care professions to conduct a review to: (i) ensure that they are maximizing their scope of practice in the developing health care sector, and (ii) potentially identify areas where their scope of practice may properly be extended.
Community-Based Clinics
One of the likely consequences of the Drummond Report is an increased push for the use of specialized community-based clinics for procedures that do not require hospital facilities.19 While this recommendation accords in some respects with the Action Plan, there is a significant difference. The Action Plan specified that such clinics must be not-for-profit; the Drummond Report envisions for-profit clinics that would operate in the public payor system.20 While specifics have not been released as to the exact procedures that should be provided at such clinics, specialized, repeatable procedures would likely be targeted (such as diagnostic imaging, dialysis, mammograms, colonoscopies, cataract surgery and hip and knee replacements).
Funding Paradigms
The Drummond Report also specifically addresses a number of inefficiencies that have developed in the current system as a result of the current funding models. A number of changes recommended by the report focus funding on the provision of quality service in the appropriate setting (for both OHIP coverage and other funding issues) rather than the quantity of services performed.
While there are no recommendations that specific procedures be delisted from OHIP coverage, the way in which procedures qualify for coverage may change if certain recommendations in the report were accepted. The most significant change would be the expansion of the mandate of Health Quality Ontario to enforce evidence-based directives to guide coverage, which the report suggests would ensure that costs are being incurred only when there is evidentiary support for the procedure's need.21
A number of recommendations also promote the use of the Health-Based Allocation Model ("HBAM")22 to ensure that resources are properly allocated within the system. The HBAM would effect differential funding for services across regions,23 set appropriate compensation for procedures (in contrast to the current system of using average costs),24 and promote the removal of incentives to perform medical interventions without due consideration to the quality and efficiency of care.25
Conclusion
While the Drummond Report recommends significant changes to the provision of health care in Ontario, it remains to be seen whether any of the recommendations will be adopted by the provincial government. Though a number of the changes correspond to announcements already made by the provincial government, some recommendations entail cost-cutting measures that are unlikely to be politically popular. In any event, Ontario's public health care sector is destined to face significant changes in the near future, and providers of services in all health care related industries will benefit from ensuring they are primed to take advantage of these changes.
Footnotes
1 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
2 Ibid at p 124.
3 Ibid at p 101-102.
4 Ibid, recommendation 5-6 at p 176. After 2017-18, annual increases in health spending would be limited to a maximum of 5%.
5 Ibid, recommendation 5-60 at p 189 specifically suggests setting a goal of "no increase in total compensation" in the negotiations.
6 See generally, ibid, recommendations 5-3 and 5-4 at p 175, and 5-52 at p 187.
7 Ibid, recommendation 5-26 at p 182.
8 Ibid, recommendation 5-40 at p 184.
9 Ibid, recommendation 5-71 at p 191.
10 Ibid, recommendation 5-74 at p 192.
11 Ibid, recommendation 5-32 at p 183.
12 Ibid, recommendations 5-33 at p 183 and 5-62 at p 189.
13 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).
14 Ibid at p 9.
15 Supra note 1, recommendation 5-18 at p 181.
16 Ibid, recommendation 5-23 at p 182.
17 Ibid, recommendations 5-24 at p 182 and 5-94 at p 198.
18 Ibid, recommendation 5-19 at p 181.
19 Ibid, recommendation 5-97 at p 199.
20 Supra note 13 at p 13. The Drummond Report, ibid envisioned that the model could include private for-profit clinics.
21 Supra note 1, recommendation 5-46 at p 186.
22 The HBAM is a tool to allocate funding for services across communities in the province. Allocations estimate the demand and costs of these services based on clinical and demographic information such as age, health status, patient flow, and rural geography.
23 Supra note 1, recommendation 5-17 at p 180.
24 Ibid, recommendation 5-50 at p 187.
25 Ibid, recommendations 5-72 and 5-73 at pp 191-92.
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