• Lower wait times for a set of 5 high-priority surgeries and procedures (radiation therapy, hip/knee replacement, cataract surgery, cardiac bypass surgery, and diagnostic imaging tests);

• Improve access to acute home care (i.e., post discharge) and end-of-life home care;

• Provide Canadians with catastrophic drug coverage to limit the financial impact that costly treatments would have on patients; and

• Improve access to primary care.

So was the Health Accord a success? Well, I’m sure based on our current healthcare climate, you know the answer to that question.

The Health Accord was well-intentioned — who doesn’t want lower wait times, better access to primary care and home care, and coverage for expensive drugs?

Unfortunately, for multiple reasons, it was set up to fail from day one. Firstly, the goals were either too narrow or too broad. When you set out a goal to reduce wait times for 5 procedures, you are treating downstream symptoms, not upstream causes. So although some progress was made on lowering wait times for the target areas, the progress was inconsistent across the country and wait times for basically everything else went up.

On the opposite end of the spectrum, when you set a goal of improving primary care, you better be clear on what “improving” means, and you better have some good data and clear goals to hold everyone accountable. Of course, none of that was the case.

The Health Council of Canada was a federal body stood up to monitor progress against the Health Accord, but it had neither the data, the power, nor the required level of independence to do its job properly. How was a federal watchdog supposed to monitor progress, when it had no power to force provinces to share data, and in many cases, the data that was needed was information that the provinces did not even have/track. If you did not already guess, the Health Council of Canada no longer exists.

Healthcare’s Groundhog Day

Fast forward to today and we are again at a tipping point in many of the same areas of focus from 2003/2004: wait times, primary care, home care. In a sick, dark, depressing sort of way, it is funny that after two decades, several administrations (both federal and provincial), a Toronto Raptors championship, and a global pandemic, we find ourselves in the same position: with our collective health system in crisis and our PM and premiers in a room together trying to figure out how to solve it.

All signs point to another Health Accord-esque agreement being struck, but to make sure we don’t make the same (really) expensive mistake twice, there are a few principles I’d like this powerful group to adhere to as decisions are being made.

1. Focus on root causes, not symptoms

Any healthcare investment that is made is going to have downstream impacts. In 2004, when we put a lot of money into reducing wait times for things like cataracts and hip replacements, those downstream impacts were negative — we made mild progress in one area while other areas deteriorated further. That is because an investment focused on reducing cataract wait times isn’t upstream enough to make a broader positive impact.

We want investments to be as upstream as possible so that the trickle-down impact is positive, not negative. For example, investments into primary care make an outsized impact because of all the secondary benefits that come from high-performing primary care, like earlier and better detection of diseases, more cost-effective use of healthcare dollars, and overall healthier populations.

A lot of our issues today also sprout from a broken primary care system. I’ve seen a lot of folks talk about this as well, but one way to improve primary care would be to focus efforts on scaling up team-based care models across the country. This will be expensive in the short-term and the benefits will not be immediately evident, but when you take a macro view of the impact that team-based primary care can have on a health system and economy, the evidence is clear that it is the best way forward.

Fix primary care, fix healthcare.

Beyond primary care, you can apply this root cause logic to a lot of the major issues these days.

2. No investment without accountability

I’d argue the biggest flaw of the 2004 Health Accord was the lack of accountability and tracking on how the money was spent. In my opinion, if you are asked if you’ve reached a goal, the only answer worse than no, is I don’t know.

At least with a no, you know where you stand. When you legitimately have no idea how you are tracking towards something, you are hoping for the best, and we all know the famous phrase: hope is not a strategy.

In order for the provinces to receive any extra dollar from the feds, firstly there needs to be a clear way of knowing how that money is being spent, and secondly, there needs to be a way to eventually tie that money to performance as well.

This 2011 Healthy Debate article is a great example of where we don’t want to be in a few years: reviewing whatever comes from these 2023 meetings and having no idea what progress has been made.

3. Encourage and incentivize innovation

For all its foundational, disgusting flaws, there are many things that I’m actually jealous of within American healthcare. One of the things that I think we can learn from the US is the idea of always experimenting with new care models and ways to fund them.

The CMS Innovation Center is a US government agency that does just that; it supports the development and testing of innovative health care payment and service delivery models.

Although a federal agency, it has partnerships and delivery at the state, county, and local levels across the country.

Where is Canada’s version of this?

This is definitely more of an item on my personal wishlist, but I would love for a similar centre to be stood up in Canada. Imagine there was a national body with both power and funding that was purely focused on care and funding model innovation in Canadian healthcare. This group could function both in a top-down (i.e., they come up with a new model and offer funding to groups within the provinces that are interested in piloting it) and bottom-up way (i.e., regions/provinces have an idea they want to test and submit a proposal to the Innovation Centre for approval).

Healthcare investment has always had a culture of more (i.e., we need more doctors, more beds, more money, etc.). This needs to shift to a culture of different, and I believe we have never had a better opportunity for the federal government to take the lead on igniting this shift with a more hands-on, national focus on healthcare innovation.

4. All investments should have a clear connection to at least one of the following areas: quality, access, cost

Yes, I’m aware that the Triple Aim became the Quadruple Aim and is now the Quintuple Aim, but to me, it all boils down to improving quality, improving access, and lowering costs. I personally believe that improvements in the patient and provider experience are direct byproducts of improvements in these three areas.

As such, any initiative or focus area being discussed should be directly tied to improvements in at least one of these areas. It shouldn’t be difficult, but now is not the time to overcomplicate health policy, or get so far into the weeds that we end up (again) with a largely symptom-based investment agenda.

Everyone in that Ottawa room is old enough to remember what the 2004 Health Accord accomplished — or more importantly, what it didn’t accomplish.

Although a “fix for a generation” might be a bit too aspirational of a goal, if they abide by the principles above, I’d like to think they can come up with something that at a minimum resembles a more achievable “modest improvement for a generation” instead.

For once, let’s put progress (and principles) over politics.

Unfortunately for Premier Doug Ford, people have placed him square into the latter category.

I am by no means a Ford loyalist as I think there is much he has done/is doing that is worthy of major criticism, but the recent healthcare announcement about the province’s focus on scaling up community surgical and diagnostic centres is not one of those things (as of now).

For those that haven’t been following, Ontario announced that the province is going to further leverage surgical and diagnostic centres in the community to reduce our eye-popping surgical backlog. The idea of shifting services out of the hospital has been something we’ve been working towards as a health system for a long time. It is also a trend that the entire international healthcare community has long agreed with.

Subscribe now

So why the backlash? Well, inclusive in this announcement was the most dreaded word in Canadian healthcare. The absolutely TRIGGERING P-word.

Private.

As part of this roadmap, there will be increased public funding for private delivery of applicable surgeries, procedures, and diagnostic imaging tests.

And when you put the word “private” directly before the word “healthcare” in Canada, reporters and opposition politicians bring out the hyperbole.

“Doug Ford is introducing American-style healthcare.”

“This is how public healthcare dies.”

“We as Canadians need to reject moves like this, where doctors won’t see you until you hand over your credit card.”

This is politics, the media, and Twitter all at their respective worst. People create sensationalist narratives that are largely inaccurate and do nothing but capture fear-driven attention. And in the process, they further polarize society and reduce the already-shrinking common ground we have across our modern political spectrum.

So with all the negativity and uproar surrounding this news, I decided to take a closer look at some of the common criticism and provide a perspective on what’s valid and what’s not.

1. “There shouldn’t be any private clinics offering these services, only public or not-for-profit.”

A lot of people assume that anything private is instantly bad or evil when it comes to healthcare, or that private healthcare equals American healthcare. This is far from the case, and this is an example of folks conflating private delivery with private payment.

Much of our healthcare is already privately delivered, but publicly paid for. This announcement is just another example of that — no credit card required, just your health card.

The public/private debate is distracting as neither are inherently good or bad. They are tools, but it is the funding, policies, and regulations around them that decide how useful those tools can be.

I believe that these clinics don’t need to be private, but they shouldn’t be restricted from being private either. As long as there is a universal accountability framework in place that ensures quality and consistency across all participating organizations — both public and private — the corporate structure shouldn’t matter. If a clinic can consistently meet a set of process, quality, and experience targets at a competitive reimbursement rate, I don’t care who owns it.

2. “Why not invest this money into untapped hospital capacity instead?”

To me, this argument completely misses the bigger picture.

Long before this backlog and long before the pandemic, there was a growing international sentiment that we need to become less hospital-centric in how we deliver care.

Inclusive in this global shift is the concept of appropriately shifting day surgeries and procedures from hospitals to specialized facilities in the community. Many countries have been doing it (and are looking to do more of it), and there are even multiple Canadian provinces that have been doing it for a few years now, including BC, Alberta, Saskatchewan, and Quebec. In this regard, Ontario is a late adopter province within a late adopter country.

Now, back to the problem at hand — if we just dumped more money into hospital operating room time, that would effectively be doing more of the same and ignoring the broader shift we need to be working towards. Sure, it could maybe help to alleviate some short-term pain, but it would deepen our reliance on hospitals when we need to be doing the opposite.

The hospital of the future should be a place reserved for emergencies and complex surgeries that require hospital-level resources. Lower risk procedures like cataract surgery, hip/knee replacement, colonoscopies, and MRI and CT scans generally don’t need to be done in large acute facilities, but unfortunately the overwhelming majority of them are.

3. “Why are these Independent Health Facilities (IHFs) getting reimbursed a higher amount than the current hospital rates?”

This all stems from some Twitter bickering I came across, but the long-and-short of it is that the ambulatory surgery centres (AKA IHFs) are apparently getting paid more than hospitals for the same procedure. For example, ambulatory centres are getting $605 for each unilateral cataract surgery, while the average rate for this procedure in a hospital — via something called a quality-based procedure (QBP) — is $455.

So the IHFs are getting paid over 30% more per procedure than their hospital counterparts. Now you might be asking yourself, I thought ambulatory centres were supposed to be cheaper, and it is a valid thought.

I am by no means a QBP expert, but I think there are few things to consider here. Firstly, we need to make sure we are comparing apples to apples. A QBP is a pre-set payment that a hospital receives for managing a patient with a specific diagnosis/procedure — like a cataract surgery.

Using cataracts as an example, I’ve seen some say that this hospital QBP payment is meant to cover all direct costs associated with the cataract surgery (i.e., supplies, housekeeping, nursing staff time required for the operation), while I’ve seen others say that the QBP payment is flawed and doesn’t effectively account for some of those things, as they are already covered through the hospital’s global budget.

I tried to find some more detailed information on what goes into a QBP from a bottom-up, line-by-line costing perspective, but it looks like the Ontario Case Costing Initiative (which was used to inform QBP pricing) isn’t publicly accessible — A+ for transparency!

But let’s just say the critics are right and it is an apples-to-apples jump from $455 to $605 for the IHFs. Something to consider is that there is almost always a premium attached when you are trying to change the status quo in healthcare.

If you have a goal of making people do more of something that they currently don’t do, you’ll likely need to dangle a carrot of some sort to overcome that initial change management inertia. This rings true in all parts of society, and it is no different than what we’ve historically seen in healthcare (i.e., high Ontario capitation rates to incentivize primary care providers to join FHTs, higher guarantees in early years for value-based care arrangements in the USA to spark adoption, the massive pay bump that family docs in BC just got to promote recruitment/retention).

All this being said, it would still be helpful to know how the government came up with the $605 figure for cataracts — was there another bottom-up exercise and this was the number they came to? Is it simply a higher amount to incentivize participation? Or is it something else entirely?

These are questions that you’d hope the government would’ve already had addressed, but alas, we are left with nothing but debates on Twitter with no definitive answers (yet). How $605 was decided, how it is meant to be spent, and how it evolves over time all need to be fully transparent so that we can ensure value for money and not further erode trust in public institutions.

4. “This is going to suck more staff out of hospitals when we are already dealing with a health human resource crisis.”

This is a valid concern, and it is probably going to happen to some degree if I had to take a guess.

However, if we were to see a shift of staff from public to private, that would suggest they aren’t happy in the public system to begin with (which based on the rate of burnout/early retirement/career transitions, I think we already know).

Nurses should have the right to find work where they feel safe and valued. Brian Golden, the Sandra Rotman chair in Health Sector Strategy at Rotman, said it best in a recent Healthy Debate article: Why in the world would we feel comfortable restricting the job mobility of nurses? Good question.

A lot of folks tend to get siloed in their evaluation of new initiatives. Yes, in a vacuum, this could take some staff out of hospitals, but that doesn’t mean the government can’t be doing more to prepare for that. Increasing ambulatory surgical capacity is not mutually exclusive from trying to improve working conditions in our hospitals.

To combat this risk, I think there are some things that the government should be doing in tandem, starting with repealing Bill 124 so that nurses and other healthcare workers can be paid more competitively and commensurate with the effort they have been putting in throughout the pandemic.

5. “The private clinics are just going to get all the easy cases to avoid risk and leave the complex cases to the hospitals.”

I don’t know if people are trolling when they say this, but this is literally why you stand up ambulatory surgical centres. As a health system, you want “easy” cases to be handled where they are most cost-effective and least disruptive to the patient’s life. You also want them to be handled in a place where precious OR time doesn’t have to be shared across all acuity and complexity levels.

Right now our hospital ORs are acting like our hospital EDs — they are everything for everyone, and filled with a lot of people that should’ve been able to access care elsewhere. In the ED, that elsewhere is primary care. In our ORs, that elsewhere should be IHFs.

As long as the ambulatory centres are well-integrated with the local hospital to appropriately deal with complications and continuity of care, they should absolutely be relieving our hospitals of the least complex cases — that is what they are there for.

Now, a recipe for success

Like most things, the devil will be in the details.

Ford has already said this is not a temporary solution, which is great, but to minimize any initial flaws that could compound into some of the irreversible issues that critics have flagged, there are items that need to be put in place to make this successful.

1. A comprehensive accountability framework

We have largely abstained from tying reimbursement to metrics, but there need to be strong enough guardrails in place to limit bad actors — either public or private — from abusing this system. As such, there needs to be a framework that holds participating organizations contractually accountable across a variety of categories:

• Quality: For example, penalties for higher than expected post-op complications, committing to certain follow-up SLAs, meeting patient reported outcomes and satisfaction goals.

• Value: Even though the province has set initial rates, providers should be able to compete on price so we can get more value out of taxpayer dollars, as long as they continue to meet the minimum quality metrics.

• Equity: Ensuring access to services are within a reasonable range across income groups and geographies.

• Transparency: I don’t think the idea of upselling patients on non-medically necessary features should be prohibited, but there can never be instances of clinics trying to confuse patients or forcing them to purchase some private component to access what is publicly covered. To me, this is where this initiative thrives or dies, and the penalty for any players caught acting in bad faith needs to be swift and severe.

2. Integration with the broader system

The last thing we need is another siloed group in our health system, so it is imperative that these ambulatory centres are better integrated into whatever regional planning is occurring within their geography. This could include having these centres represented at OHT planning committees, centralizing regional waitlist management so folks are more swiftly and accurately matched for surgical/DI services, and integrating pre- and post-op care with the local hospital/primary care to enable better handoffs and continuity.

3. Public and private, not public versus private

The emphasis from this announcement has thus far been on the private sector, but as our overall focus continues to shift towards community and ambulatory services (and we hopefully get out of a pandemic state), we should be striking a balance between building up capacity in the public and NFP sectors, while appropriately encouraging private sector participation at the same time. As I said, the public/private concept is a tool, not a solution, so we shouldn’t give preferred treatment to one tool over the other — or propagate the narrative that they cannot co-exist. We are all working towards the same goal of creating a better, more sustainable health system, so we should be creating an ecosystem where both can play a role in achieving that mission.

At a minimum, it is great that this announcement has at least accelerated the conversation about ramping up ambulatory capacity outside of hospitals — something that is long overdue in Ontario. Given Doug Ford’s reputation, there is ample reason to be skeptical of what’s to come, but nothing that he or anyone else has said thus far raises any major red flags in my mind, perhaps just some yellow ones.

That doesn’t mean we are in the clear.

If done poorly and in secrecy, this could further sour trust and spiral into something resembling the more problematic side of private healthcare.

If done well and in the public eye, this could be a great step towards eliminating longstanding fears around the private sector’s role in healthcare, and also a great step forward for our health system as a whole.

In the words of the evil, microchip-injecting Bill Gates, we always overestimate the change that will occur in the next two years and underestimate the change that will occur in the next ten.

In that spirit, I wanted to take a longer view with a predictions post — 10 years longer to be exact.

I could do a 2023 predictions post, but with the pace of change in Canadian healthcare, do we really think a whole lot will be different this time next year? This year was basically like last year, just slightly (drastically?) worse. I guess my only prediction for 2023 is that the year ahead of us turns out to better than the year behind us. Look at that optimism! New year, new me.

Now back to our 10-year outlook.

Despite the pace of change, there are several trends across our country that I believe will continue to pick up steam — for better or for worse — and our health system might look quite different come 2033.

Subscribe now

1. Every province/territory will move to a single, centralized health authority

There are 10 provinces and 3 territories in Canada, for 13 total jurisdictions (thanks Canadian Geo 101).

Right now, 7 of those 13 them have a single, centralized health authority.

Of those 7, three of them moved to this centralized model within the last decade (Ontario, Saskatchewan, and Nova Scotia).

It appears that bureaucratic centralization is the movement, with Newfoundland and Labrador set to be the latest to go down this path. A centralized health authority makes sense in many cases, as long as there are tangible reasons (and evidence) for doing so. Where it doesn’t make sense, is when it is being done as a politicking facade to create the illusion of change, even though it is nothing more than a card-shuffling headache.

A centralized health authority sounds good (in theory): cost savings (in theory), reduction of duplicative roles/services (in theory), better ability to make system-wide improvements (in theory).

But a seismic move like this doesn’t generate quick wins. Even if executed in a very thoughtful way, it is actually more likely to generate the opposite. Ontario Health now has a full Doug Ford term under its belt, but with what to show for it? Ontario Health Teams? Well, having spoken to dozens of them, at this time they are generally “Teams” in name only and are years away from doing anything meaningful.

And I don’t say this to criticize the move; I say this to say that you need to be patient with massive structural changes, and patience and politics don’t mix well.

Alberta Health Services (AHS), perhaps the provincial poster child for health system centralization, was introduced ~15 years ago and many healthcare folks in Alberta would say they are still very much so figuring things out. However, say what you want about AHS, their provincial implementation of Epic has a lot of promise if rolled out and optimized properly, and wouldn’t have been possible without a centralized body. And for all of the criticism that I and many others throw at Epic, let’s not forget that the digital backbone of the highly-recognized (and envied) Kaiser Permanente system in the US is Epic.

Ultimately, if this 2033 prediction fully materializes, I hope our governments are patient enough to not (re)introduce a decentralization mandate for 2043.

2. The federal government will take on a larger role in healthcare policy (Canada Health Act modernization) and financing (Canada Health Transfer modernization)

As we all know, healthcare is largely a provincial responsibility in Canada. The federal government via the Canada Health Transfer (CHT) currently provides about 22% of funding for healthcare, but is largely hands-off otherwise. I think this will significantly change over the coming decade.

Today, the provinces (largely Conservative-led) are in a battle with the feds (Liberal-led) to bump this 22% up to 35%. There is reason to believe this ask has some merit, but the provinces are asking for this increase to be unconditional, which both I and the federal government see as problematic. Funding without accountability is a big reason why we find ourselves in the mess we are in today.

The ongoing provincial-federal battle speaks to a larger question of what the federal government’s role in healthcare should be, and in my opinion it is only a matter of time before the feds start kicking in more, while also expecting more.

Related to this, I think we will finally see a full modernization of the Canada Health Act (CHA). Whether that be a change in its principles, more prescriptive language, or clearer ties between the CHA and CHT, this is a necessary step if we are going to preserve the spirit of public healthcare and create a more meaningful and productive role for the feds moving forward.

3. Employers will start to offer coverage for more “medically necessary” services

Attracting and keeping talent via comprehensive benefits has always been a focus of the traditional HR function, but these ain’t your grandpa’s benefits packages. What was traditionally built on dental coverage has now expanded into things like fitness reimbursements, mental health coverage, and access to on-demand virtual care. And the three examples listed above progressively inch into a grey area in terms of what is/isn’t covered by our publicly-financed Medicare plans.

We are already seeing this with what I’ll call low-acuity primary care; employees at many companies these days have virtual access to doctors and/or NPs to service their primary care needs, even if those employees already have family doctors. A lot of people take issue with this, but if a traditional primary care practice can’t keep up with modern consumer expectations around convenience, availability, and reliability, it should be on the legacy organizations to speed up, not on the trailblazing organizations to slow down.

As the race for talent heats up and our public system continues to struggle, employers will push benefits coverage further into what has traditionally been the territory of publicly-covered healthcare services until a powerful someone/something tells them to stop. And in a decade’s time, we could very well have even more private delivery of public services (i.e., full-scope primary care, private specialist clinics) that employers could look at as another premium benefit to offer to their employees.

4. Direct primary care will takeoff

According to the American Academy of Family Physicians (AAFP), direct primary care is “a practice and payment model where patients/consumers pay their physician or practice directly in the form of periodic payments for a defined set of primary care services. DPC practices typically charge patients a flat monthly or annual fee, under terms of a contract, in exchange for access to a broad range of primary care and medical administrative services.”

Effectively, it is a private, subscription model for primary care (i.e., One Medical). Our version of this comes in the form of what we call “executive health” clinics. However, executive health clinics are more excessive, and as the name suggests, made for executives (AKA prohibitively expensive). Some Canadian employers provide coverage for executive health clinics, and many American employers provide coverage for direct primary care, but I believe made-for-the-masses direct primary care is coming to Canada; in fact, Telus is already dipping its toes in doing this and has stirred the pot in the process.

Done well, a direct primary care model offers digitally-enabled, team-based care, that is focused on quality over quantity. My hope is that our public system will eventually get to the point where we can offer something similar by default, but over the next decade, private primary care alternatives will become more and more common, especially in major cities.

“But isn’t that two-tier healthcare?”

Yes and no.

If these clinics are offering a like-for-like service to your average family clinic, then yes, that is two-tier healthcare and illegal. But if these clinics are layering things that go beyond what is publicly covered (i.e., 24-hour coverage, asynchronous messaging, care coordination services, limitless access to allied health professionals), all of a sudden a subscription model is fair game and the physician doesn’t have to privately charge/bill for a typical visit, which is where the illegal extra-billing line gets crossed.

Hate it or love it, versions of direct primary care are already here, and I think they are just getting started.

5. Primary care will be increasingly led by NPs

This leads me to my final prediction, which is that the concept of a traditional family physician will continue to be minimized and replaced by the NP.

We have been seeing it for a while now; the scope expansion of non-medical providers eating away at — at least from a scope of practice perspective — what makes a family doctor a family doctor.

In addition to NPs, pharmacists already have broad clinical privileges in many parts of the country, and Ontario is the latest with the announcement that pharmacists can now independently prescribe for a list of common ailments.

Nurse practitioners are increasingly used by our provinces (and virtual care companies) to deliver primary care to those that consistently struggle with access. From 2020 to 2021, the number of licensed NPs in Canada jumped 10.7%, making it one of the fastest growing health professions in the country. I’ve seen many family physicians voice their concerns about these developments. They see them as threats; not just to their profession, but to the quality of patient care as well.

That could be the case, but quality of patient care will also continue to suffer if we stick to our antiquated 1:1 patient/family doctor primary care model which doesn’t fit in a digital age, or in an age where patient demand constantly outstrips physician supply.

Over the next decade, I believe there will be a lot more NP-led models that are piloted, evaluated, and potentially scaled. If they prove to be successful, we will see the scope and sheer number of NPs continue to expand to the point where they will be used completely interchangeably with family doctors.

So there you have it — a few Canadian healthcare-specific predictions to stew over for the next decade. The best part about a predictions post that is a decade out is that no one (except for perhaps my true enemies — or “opps” as the kids say) will be able to call me out for being wrong. But best believe if this newsletter is still kicking around in 10 years and I go 5-for-5, you will most definitely hear about it.

Until then, here’s to a 2023 filled with more progress and less COVID/RSV/flu.

Subscribe now

On one hand, I get the hype. Who doesn’t want to have advanced technology that can beautifully support more accurate diagnoses and treatments, streamlined workflows, and accelerated medical discoveries?

On the other hand, healthcare still uses fax machines.

This type of juxtaposition has always been present in healthcare. You can somehow have the most advanced, groundbreaking research happening within a hospital ward that looks like a diorama from the 1980s.

However, there are few, if any, developments in healthcare that hold potential as profound as AI/ML. Yes, we’ve all heard ad nauseam phrases like AI will replace radiologists in x years for the last decade, but at its core, the idea of using smart, predictive, and always-learning technologies in healthcare truly is a new frontier.

To date, much of the technological advancement in healthcare (i.e., EMRs, virtual care, e-prescribing) has largely led to the replication of in-person artefacts and processes in the digital world. I understand there is a natural crawl-walk-run progression to most things, but transformational value is not unlocked by doing things the same way just in digital form.

AI/ML is different…if we allow it to be.

In that spirit, as I’ve gone through my own amateur self-discovery in this space, I wanted to share my findings and shed some light on what the most exciting use cases for AI/ML in healthcare are, what Canadians companies are leading the charge, and what are the barriers we need to overcome if we are to fully realize the potential of this polarizing category.

Subscribe now

Why you should be excited

I’m sure there are countless ways AI/ML will/could impact Canadian healthcare beyond what I can currently imagine, but from my research (and my need from consulting to put things into pretty buckets), I see there being three main categories, all of which contributing in their own way to the north star goal of improving patient care.

Augment clinicians

Although there are few who would call me an eternal optimist, I’m a glass half-full guy when it comes to the impact that AI/ML will have on our clinician population. I think it will be incredibly transformative and it will supercharge, not replace clinicians, as some more dystopian outlooks hypothesize.

Almost like clockwork, every couple of months I will see a study showing that an algorithm was able to outperform human doctors at detecting cancer or some other disease from a medical imaging review. But what is often lost in these headlines is that the best performing group is usually not the AI or the doctors, but the doctors supported by AI. Thus, these tools will not replace clinicians, but clinicians that use these tools will likely replace the clinicians that don’t.

In addition to improved diagnostic accuracy like the example above, the augmentation of a clinician’s abilities via AI/ML can also be in the form of earlier problem identification (i.e., Signal 1 for inpatient care, Swift Medical for wound care, MetaOptima for dermatology), or more effective treatments and procedures (i.e., Future Fertility for reproductive care). Ultimately, AI/ML can equip clinicians with the valuable information and insights they need to start delivering personalized medicine at scale.

Automate administration

Almost in lockstep with our progressive digitization in healthcare is our progressive need to inundate healthcare workers with administrative tasks. Whether it is clinical documentation, billing requirements, filling out random forms, schedule management, or a range of other administrative actions in healthcare, more and more time is being spent on non-clinical tasks instead of direct patient care.

When Medical Economics asked American doctors what contributed most to their feelings of burnout, 31% cited “paperwork” — more than twice the percentage of the second-leading cause, poor work-life balance. I couldn’t quickly find a similar survey in Canada, but from the physicians I’ve spoken to over the years, I would bet the percentage is similar, and growing.

In specific relation to AI/ML, it is a bit of a catch-22 because these models need good data to learn and ultimately be useful, but the more we try to collect good data, the more we are pulling healthcare workers away from patient care, and taking the joy and fulfillment out of healthcare in the process.

However, developments in the space can help to alleviate this burden by doing such things as automating (or at least simplifying) clinical documentation (i.e., FirstHx for medical histories), and removing a lot of the manual effort required for things like staffing and scheduling (i.e., Mesh AI for optimizing physician shifts) and health information management (i.e., Semantic Health for diagnostic coding).

If technology can be used to reduce the amount of non-clinical work that currently bogs down our workforce, more time can be spent on the higher-value, patient-facing activities in healthcare that require a human touch.

Accelerate breakthroughs

I have to admit, the life sciences sector is a bit of a mystery to me. I’ve never worked in it, I’ve never had clients in the space, and my general curiosity has rarely led me into this realm because quite frankly, it can very quickly become overwhelming and way too science-y for me.

That being said, I fully appreciate that this is arguably where AI/ML is already having the largest impact, and where it will continue to have the largest impact moving forward.

New and better drugs, new and better cures, new and better ways of doing things — these are all possible in a world where AI/ML is properly unleashed on the world of healthcare research and development.

BenchSci and Deep Genomics are post Series C Canadian companies that are leading the way internationally in this regard, with BenchSci using AI to help pharma companies make quick, evidence-based decisions on what to include/exclude in experiments, and Deep Genomics focusing on the rapid discovery and development of genetic medicines.

I encourage you to look into all of these companies further because what they are doing or trying to do is truly exciting. It may be a disservice to categorize these companies like I have, and some of them aren’t necessarily true AI/ML solutions yet, but the table below summarizes — from my limited perspective — where they all fit across this loosely defined use case spectrum.

When you look at the picture painted above, it looks like the future is bright for healthcare AI in this country, and it might very well be. When I asked Matt Johnson, who is the Director of Industry & Health Innovation at the Vector Institute, what excited him most about AI in healthcare, he simply said that there are still so many hard questions yet to be answered that we are just starting to scratch the surface in terms of what AI/ML can help us uncover or discover — the possibilities are what excite him (and probably most of us).

But…

Given healthcare’s track record when it comes to technology and innovation, there is lots to be concerned about as the AI/ML field matures as well.

Why you should be skeptical

Where to start?

Maybe as an overall preface, it is important to highlight that most of today’s ML models in healthcare are trained in closely controlled learning environments. This effectively means the information being fed into these models is highly manicured, structured, and clean — none of which are adjectives I would use to describe the data that is captured on the real frontlines of healthcare. So despite the promising advances we hear about, this preface is meant to highlight how early we really are in this space, which isn’t necessarily a bad thing, but is good context in terms of what our realistic expectations should be over the next few years.

Garbage in, garbage out

As I alluded to above, healthcare is notorious for unstructured, incomplete, and overall messy data. There is lots and lots of it, but it is often unusable in the context of AI/ML. How can you make accurate predictions when the input data being analyzed is garbage? If we are to ever progress out of the infancy phase, we will need to figure out how to fix this underlying data problem, which as I further describe below, is multi-faceted.

Access to data (at a single organization)

Sheena Melwani, a Deployment Manager at Signal 1, says that although still a barrier, it is pulling data out of systems that is arguably more challenging than the cleanliness of the data itself.

According to Melwani, part of Signal 1’s philosophy is that the introduction of an AI/ML solution into a hospital shouldn’t require the organization to collect a bunch of net new data points to feed a model. “The output of a model should definitely influence workflow and be an input into care planning, but we don’t want Signal 1 to be part of the paperwork problem that so many clinicians already complain about.”

So although a company like Signal 1 is actually able to work solely with whatever data is already captured in a client’s EMR (no small feat), they still need to navigate the technical and privacy challenges to access that data in the first place, which adds lots of complexity and time to implementations — just a day in the life of a digital health startup!

Access to data (across multiple organizations)

It is one thing to get data from a single hospital EMR; it is another to get data from multiple hospitals or full health systems. Models are only as good as the quality and quantity of data they are fed, and unfortunately limiting a model’s learning to a single hospital is like capping a Formula 1 car at 40km/h — why drive it if you aren’t going to use it as intended?

This is one of the main barriers that Matt Johnson called out when it comes to deploying AI/ML technologies at scale.

“It will be critically important to have the right data governance and stewardship in place so that these legacy silos can be knocked down and researchers can have better access to data.”

The pace of learning (and indirectly, the belief in AI/ML’s potential) will be greatly impacted if every new project needs to go through a lengthy data request/integration process with every single participating organization. We are doing ourselves a disservice — not just in AI/ML — by limiting the flow of health data across organizational boundaries.

I think this is where concepts like federated learning hold a lot of potential as it allows a model to be trained across multiple servers/organizations without ever having to transfer data from the local source to another location. This is in contrast to traditional models where everything gets centrally uploaded to a single server/data centre and the model is trained from there. However, the adoption of a federated learning model in Canadian healthcare comes with its own set of different, yet equally powerful barriers to overcome so it isn’t exactly the panacea for data sharing roadblocks in AI/ML.

Biases in data

A naive hope with AI/ML is that because it is largely math-based, it can remove bias from its predictions — something that humans can’t do, whether we want to admit it or not.

Unfortunately, this is not the case.

If you train a facial-recognition model on datasets dominated by pictures of white men, it probably won’t be as accurate for women or people with different skin tones.

The same type of biases are leaking into the training of healthcare models as well.

ML models for skin lesion classification are often trained with samples of white patients. As a result, evidence has shown they have half the claimed diagnostic accuracy when tested with images of black patients.

Another example is in cardiology, where heart attacks have been shown to be overwhelmingly misdiagnosed in women, meanwhile prediction models for cardiovascular disease are trained in predominantly male datasets. All CV disease is not created equal, and so an algorithm that is trained on men may not be as accurate in diagnosing women.

AI/ML may be math-based, but these are still models made by humans. As the field matures, we will need to make concerted efforts to train models with more diverse, representative data, while ensuring the teams designing these models are more diverse themselves to remove unconscious bias from the start. If not, we risk even greater divides between the various haves and have-nots in healthcare.

Gaps in education and awareness

“Machine learning? Is that like robots?” - Somebody somewhere.

Maybe the biggest barrier of all is educating the average person on what AI/ML is and what it is not. Or rather, what it can/should do and what it can’t/should not do.

“Healthcare has used rules-based composite scores to assist in clinical decision-making for years; AI/ML is no different, but the fear of the new/unknown is real,” said Melwani. I think this is an important point to consider, and it is akin to how Avi Goldfarb, the Rotman Chair in Artificial Intelligence and Healthcare, describes AI/ML, in that it is simply a method to reduce the cost of prediction — and healthcare is a field filled with predictions. The more we can explain AI/ML in simple terms, the better it will be for education and adoption in this country.

If you roam in the same Twitter circles as I do, you may have come across ChatGPT over the last few weeks. If you don’t roam in the same Twitter circles as I do, here is what ChatGPT is, as described by ChatGPT:

I typed in that question, ChatGPT wrote that answer back to me.

It is incredibly impressive with a wide range of use cases, but the reason why I bring it up is that OpenAI has a great blog describing what it is and how it works. They effectively built this technology in the open. If we are to ever build the necessary level of trust and understanding within the healthcare community to implement AI/ML at scale, we will need to do a similar job when it comes to transparency (how it was developed), education (how it works), and impact (how it can help).

Closing thoughts

When it comes to our collective AI/ML journey in this country, Johnson preaches a combination of optimism, diligence, and patience. “People can be rightly frustrated and impatient with the current state of our health system, but with AI/ML we need to think long-term.”

We have an expectation that any groundbreaking technology is automatically adopted quickly, but as we’ve seen countless times, health is fundamentally different, and rightly so.

Trust takes years to build; however, it can be shattered in an instant. The scale of this field’s impact in healthcare is huge, so the models we develop need to not introduce broad, unexpected risk, and need to be thoughtfully deployed to create a more equitable system.

As someone who touches all parts of the AI/ML ecosystem in Canada, Johnson understands that steering this ship is no small feat, but it is an exciting (and necessary) one.

“Where the patient value is real, it is inevitable that [AI/ML] will find its way into widespread, practical use throughout our health and life sciences sector — it just won’t be tomorrow.”

Given the desperate state we find ourselves in today, I almost wish it was.

Subscribe now

I want you to imagine you were a salesperson.

Not only a salesperson, but imagine you were a salesperson that was purely commission-based with a base salary of $0.

Now imagine your commission wasn’t based on closed deals, but only on the number of calls you made — so any outcome from your work didn’t matter at all, only the sheer volume of it.

Perhaps you are thinking that this would be a pretty sweet gig. For some, I’m sure it would be. But now imagine the commission that is paid out per call is typically cut every couple years in the name of lowering costs for the business. Not so great now, is it? And as a business, how are you going to succeed long-term with a commission structure that is in no way tied to the actual value your sales team is bringing to your organization and customers?

What I’ve described is basically how most Canadian physicians have historically and currently get paid. We have fee schedules that are filled with thousands of codes and our physicians get exclusively paid based on the type and volume of these codes that they bill — with no connection to the quality/outcome of the service being delivered and also no salary safety net for physicians to fall back on if volumes are low, or they just need to take some time off. And on top of that, whenever these fee schedules are renegotiated, I can’t remember a time when the majority of physicians left the bargaining table happy.

Many academics have been critical of fee-for-service (FFS) for years, but so have physicians. And ironically, physicians largely have themselves to blame for FFS being the dominant physician payment model in Canada.

Subscribe now

A brief history lesson

When the idea of a universal, single-payer system first arose in our country back in the mid-20th century, the strongest opposition actually came from physicians. In fact, when Medicare was being implemented in Saskatchewan (where Canadian Medicare was born), the doctors in the province went on strike because they were in opposition to the plan.

So much for first, do no harm.

The original Medicare plan called for physicians to become salaried employees, but physicians hated that idea. So to get Medicare over the finish line, the compromise was to allow physicians to remain independent contractors and to pay them via a FFS model.

Fast forward to today, and most physicians hate the very payment model they originally fought so hard to get.

Why our FFS system is so problematic

The obvious one — which I went into detail on in my previous post on value-based care — is the flawed incentivization of volume over everything. However, our current FFS system fuels imbalances in other parts of our system as well that might not be as obvious, but are just as problematic.

FFS exacerbates physician shortages (and pay gaps) across certain specialties

When you are a med student figuring out what type of physician you ultimately want to become, for many people, prestige and earning power play a huge role in that. But those two aren’t mutually exclusive. We have a system that has slowly, but consistently let earning power dictate the level of prestige attached to different medical disciplines. And based on how fee schedules are structured, the highest paid physicians — and thus most prestigious — are generally hospital-based surgical specialists.

In 2020, the average surgical specialist in Canada received $497,000 in gross payments, while the average family doctor received $287,000.

Just a tiny gap there…

Note that I said gross payments because these numbers don’t represent what the physician ultimately takes home, as they have to cover some level of their own overhead which in many cases leaves doctors with a lower net income than you may think.

There is limited literature on true overhead costs for physicians in Canada, but the general belief is that if you work in a hospital, your overhead is mostly covered, and if you are a family doctor running your own practice, everything from supplies to admin staff to office space needs to come out of your gross billings.

So just to make it crystal clear, a family doctor’s gross payments are significantly less and their expenses are likely significantly more. It is no wonder we have a family physician shortage in many parts of the country.

FFS does nothing to address the growing gap between how health resources are distributed between urban/rural and high income/low income areas

In addition to shortages by discipline, our current fee schedules do nothing to address geographical and socioeconomic shortages either. There are a range of incentive programs across the country to recruit and retain physicians in rural communities, but they are often plagued by one or more of the following: difficult to understand, not effectively marketed to the medical community, short-term in nature, and/or not lucrative enough. And because these incentive programs are handled completely separate of our fee schedules, they also represent more non-clinical administration for interested physicians to deal with (AKA another barrier).

In the same vein, our current FFS system contributes to the creation of health deserts in lower income areas as well, agnostic of rurality. All else being equal, a family doctor setting up shop in the wealthiest neighbourhood in Toronto will make the same as the family doctor who opens a clinic in the poorest. If our goal is to create a more equitable healthcare system, we should be doing all we can to drive physician capacity to our areas that need it the most, and I believe a more integrated physician payment model (instead of a hodgepodge of rural incentive different programs) can be a powerful tool to encourage that.

What is the solution?

We’ve established that a pure FFS model is not ideal, namely because it only incentivizes volume, it creates, perpetuates, and worsens shortages and pay gaps between specialties, and it also contributes to the growing divide between how well our system serves urban/rural and rich/poor communities.

There is no single payment model out there that perfectly addresses these problems, but a thoughtful combination of a few of them could be exactly what the doctor ordered.

Before I go any further, please note that I’m well aware that there would be more administrative, legal, and change management hurdles to get over than I could ever imagine to make sweeping changes to how physicians are paid. And by no means is the framework presented below immune to nitpicks or flaws, but I’m primarily doing this as a somewhat simple and provocative thought exercise to spark some ideas and necessary conversation around how we could/should change our outdated payment practices.

With that preamble out of the way, in my mind, the ideal end state of any overall physician compensation framework is one that balances reliability (salary), activity (FFS), and performance (outcome-based bonuses), and is also strategically designed to recruit physicians to high-need specialties/areas. I’ll go into detail on each of these elements below.

1. Reliability = A dynamic salary

I believe every working physician in this country deserves to make a living that isn’t purely predicated on how many visits/surgeries/reviews they perform. A safety net like this could reduce burnout amongst our physician population, which is currently a growing problem that threatens the very ability of our health system to function. As such, I think the time has come for all physicians to become more like the rest of us and make a salary of some kind.

This salary would be made up of three elements:

1. The Physician Minimum: This would be a flat base rate that would act as the starting point for every physician. Basically if you are a licensed, actively practicing physician, you are instantly eligible for the Physician Minimum which is the same regardless of your specialty (and would be adjusted on an FTE basis based on the number of hours/days per week that you work).

2. Specialization Modifier: Although I think the income gap is too extreme, I understand why surgical (and medical) specialists make more money than those in family medicine. They require more years of education and training up front, they need to utilize more specialized tools and medical equipment, and quite literally have life-or-death in the palm of their hand on a daily basis (of course, so do family physicians, but not in the same acute way). To account for all of these factors, each specialty would be assigned a Specialization Modifier which would be applied on top of the Physician Minimum to adjust the salary amount.

3. Demand Modifier: I don’t have first-hand knowledge of this, but I’d like to think we have sufficient data to roughly understand where we have physician shortages, how severe those shortages are, what kind of physicians are in short supply in those areas, and how all of these factors are expected to evolve over time (something like this). If we do have this information, why don’t we use it to create an evidence-based salary modifier to better meet expected demands in a more nuanced way? By creating a regularly-updated, demand-based modifier that is built to account for expected gaps in physician coverage, we can create a more logical, easy-to-understand, and data-driven way to attract physicians to high-need areas and disciplines (plus it also more explicitly highlights to physicians where they have the potential to make the highest social impact).

A quick illustrative scenario to show what this would look like in practice.

Let’s say you were a med student who loved family medicine, but didn’t love the idea of likely making 25-50% as much as some of your soon-to-be surgical specialist classmates (or potentially even less). You didn’t get into medicine purely for the money, but at the end of the day, you likely have massive student debt to pay off and you want to start building financial security for you and your family.

The dynamic salary framework has just been implemented and you learn that all full-time physicians are guaranteed to at least make the Physician Minimum at $75k per year. That’s a neat sign of appreciation — and there’s more!

With an easy-to-use tool accompanying the new framework, you can also quickly see that a family doctor (relatively low Specialization Modifier) practicing in X community where family doctors are set to be in short supply (relatively high Demand Modifier) has a total dynamic salary that is in the same ballpark as the total dynamic salary of a neurosurgeon (relatively high Specialization Modifier) in Big City Y where there isn’t a need for additional neurosurgeons (relatively low Demand Modifier). Suddenly the balance of earning power (and over time, prestige) shifts and perhaps more new grads start targeting high-need family medicine jobs because the financial potential is no longer in a completely lower bracket, and the social impact is communicated in a clearer, better way.

Some jurisdictions that use capitation for paying family physicians already do a version of this with comprehensive risk adjustment, where a family physician might get pre-paid $150 per year to manage the primary care of a 25-year-old male in a wealthy community, but $250 per year to manage the care of a 25-year-old male in a poor community. This dynamic salary is built on a similar logic, but applies to all physicians, accounts for the added investment required to specialize, and isn’t necessarily based on the exact number of patients in one’s care, but on the overall population health needs of a community.

The beauty of a dynamic salary approach like this is that it could theoretically be done on a national (spicy!) or provincial scale (like how physicians currently negotiate — boring!). If we ever got to the point of being able to develop a national physician license, then I don’t see why we shouldn’t be able to develop a national approach to physician reimbursement as well, and the modifier-based foundation outlined above could be a good framework to start from.

2. Activity = Good ol’ FFS

As much as I’ve ripped FFS in my last few posts, my hate towards it only applies when it is the sole method used to pay physicians; if it is part of a broader payment framework, then I actually think it can promote a commitment to a healthy amount of volume. The only difference in this model is that the dollar value attached to all our beautiful fee codes would be significantly lower than what they are now because much of a physician’s income would ideally be coming from their dynamic salary and their performance-based pay.

Over (a long) time, I think it would be possible (and in my opinion, preferred) to phase out the activity component entirely because if you establish and perform well against a well-designed set of KPIs, that should theoretically imply that there is the optimal level of activity taking place, but I also don’t think there is anything wrong with incentivizing some level of volume so I’ve left it in for now to make this fantasy framework slightly more realistic.

3. Performance = Bonuses based on patient-centric scorecards

Flat out, we need to start paying physicians based on the experiences and outcomes they create for patients. Some of the alternative payment models in Ontario for family physicians have introduced small bonus payments for things like providing better after-hours coverage and reaching certain immunization rates for specific diseases, but these are only scratching the surface and are not nearly substantial enough in scale to effect change in a meaningful way.

Reserving a pool of “at-risk” money dedicated to performance-based pay would encourage evidence-based physician behaviours, which could improve patient experience/outcomes and lower system costs. Eventually a physician could also be penalized for poor performance, which doesn’t happen now other than through some weak and poorly-designed policies (i.e., family doctors getting reduced capitation rates when one of their patients uses a walk-in clinic or ED for a primary care-related concern). Ultimately, including a performance-based element adds some necessary accountability to the mix.

Although the metrics and weightings could differ by specialty, ideally performance would be evaluated across three main buckets: outcomes (i.e., HbA1c levels, 30-day readmission rates, patient-reported outcomes), process (i.e., percentage of population screened for mental health conditions/eligible cancers, ability to get primary care appointment within 48 hours, referral times), and patient experience (i.e., patient satisfaction, NPS, level of comfort with provider).

I included some example metrics and concepts for illustrative purposes, but I’m sure you are already seeing how performance across some of these things are at least partially out of a physician’s control. That is totally true, but I believe we need to start being more provider-led as a whole, and thus we need to be focused on rewarding/penalizing providers, not organizations like hospitals, to make transformational change in healthcare. If we start to hold physicians more financially accountable to a well-designed, patient-centric scorecard, I think we will see more willingness (and urgency) to collaborate across all parts of the system, and the growth of a culture that increasingly prioritizes continuous improvement over don’t-rock-the-boat-too-much.

Ok, but how the hell would you implement this?

No idea (kidding…sort of).

The short answer is it depends, but it for sure would need to be phased in over a generation (or longer — assuming humanity as we know it is still around then). You could start small by looking at past FFS billings and replace a fraction of this total with a guaranteed dynamic salary, and then over time decrease the overall proportion of a physician’s income that comes from pure FFS. And then, you can start introducing the opportunity to make some performance-based pay on top of everything.

The diagram below provides a high-level illustration of what this could look like.

The longer answer is we would first need to have a real dialogue around the relationship between physicians and government. And with that comes maybe my spiciest take yet: I think the time has come to drop the physician-as-an-independent-contractor model in Canada.

There would no doubt be pushback to this because it gives physicians more perceived independence and an incredible range of tax benefits/flexibility, but with the right structure, you can make physicians more traditional employees without removing their autonomy. Although the tax benefits would be hard to replace 1-to-1, there are other things that can be done to lighten this blow such as programs to cover physician overhead, providing more employer-style benefits, and even making physicians pension-eligible.

I think the growing administrative headaches that come with being a modern-day physician — especially one in family medicine — are at the point now where they outweigh the benefits of the independent contractor lifestyle. If we can empower physicians to do more of what they should do (and love), which is clinical care, while removing as much of the “business” side from their plate that is a constant source of stress and frustration, I believe there would be general support for making this big shift (as long as net income doesn’t take a significant hit).

In replacement of the independent contractor structure, physicians in each province (or nationally) could come together to form large medical corporations, which would essentially be a more powerful, physician-led, and employer-style version of our medical associations. These corporations would formally employ the physicians within their jurisdiction and receive pre-payment from government to fund the dynamic salaries of the physicians. Think of it as a Canadianized version of how the Permanente Medical Groups at Kaiser Permanente are structured — a model that would allow physicians to form medically-led organizations, retain professional autonomy, and not become government employees (which was, and might still be, their worst fear).

Ok Peter, wrap it up

If you’ve made it this far, thank you and congratulations, as you are officially a bonafide healthcare nerd and I welcome you to the club with open arms.

What I’ve written above might very well leave you with more questions than answers (as I think it even has with me), but I think the spirit of this framework could be beneficial to patients, provider, and the system as a whole.

If we want to show our physician workforce that we value them, we need to do whatever we can to make their lives less chaotic. A way to do this is by transitioning them away from the current carrot-based system that only rewards more instead of better, and introducing a fair financial safety net that values all physicians, while still offering more appropriate incentives for specialization and social impact.

Subscribe now

“Value is defined as the health outcomes achieved that matter to patients relative to the cost of achieving those outcomes.”

When Michael Porter and Elizabeth Olmsted Teisberg authored what is effectively the bible of value-based care back in 2006, a new and necessary lens was applied to how we deliver and fund healthcare services.

Since then, we’ve seen a lot of action in the broadly-defined area of value-based care. It has by no means been a purely smooth and positive journey — in fact, some would argue it has thus far been a large and expensive distraction — but there have been pockets of excellence that keep us all (or maybe just the CMS Innovation Centre) coming back for more.

I am a huge believer in the concept of value-based care because, in theory, it reinforces much of what I think is critical to designing, delivering, and funding a high-quality health system:

1. It forces you to explicitly identify what metrics matter most to patients, and rigorously build a culture around doing well against those metrics;

2. It moves systems away from pure fee-for-service (FFS) models and properly aligns financial incentives for all parties — patients, providers, payers, and even vendors; and

3. It requires the effective and sustainable deployment of technology to support information sharing across organizational borders and the achievement of clinical goals.

I don’t always read about healthcare, but when I do, I find myself gravitating towards articles on the promises and pitfalls of value-based care. And as part of this weird and nerdy hobby, there are definitely some commonalities amongst the models/programs that have found some semblance of success. Unfortunately for us, these examples largely come from outside of Canada, and doubly unfortunate for us, our Canadian health systems are heavily lacking across these commonalities.

Subscribe now

Below is a semi-deep-dive into some noteworthy ingredients that seemingly make for a successful value-based program/system, and what the delta looks like when compared to what we currently practice in the Great White North.

1. Patient-centred and provider-led

Successful value-based programs put the patient at the middle and design everything around patient goals and priorities. A truly patient-centric value-based program will establish performance metrics at the very beginning that are jointly created alongside patient representatives so that the behaviours being measured, evaluated, and incentivized are built around what is important to the patient, not just the system.

Once you have established patient-centric goals, it is essential that providers have a leadership role in how a program is delivered and governed. A 2019 analysis of a large value-based program in the US looked at over 500 accountable care organizations (ACOs) and found that ACOs that were physician-led produced almost 7x the amount of savings per patient when compared to ACOs that were hospital-led. This is not an insignificant number, and although this is only from one program, I think it shines light on a broader trend that you need to look beyond the walls of a hospital (or government agency) for system-level leadership, and if you equip providers with the tools and autonomy to sit at this type of table in a meaningful way, everyone wins.

Canada’s Grade: D+

We have been preaching patient-centricity in this country for years, but at best, we practice a patient-informed system. Lots of patient/family advisory councils have been formed to incorporate more of the patient’s voice into strategic planning discussions, but this is still largely performative and when you look at how care pathways and clinical programs are developed, they are largely made in a top-down, medicalized way.

When it comes to being provider-led, we are a system that is becoming increasingly driven by administration, and non-clinical administration at that. I don’t mean to shit on hospital CEOs or other senior leaders that don’t have a clinical background, but it is a bit rich to constantly hear about our shortage of physicians and nurses due to burnout, while Ontario Health seems to be creating a new high-paying Director/Sr. Director/VP administration job every week. If you need concrete evidence of bureaucratic bloat in this country, between February 2020 and July 2022, net job creation in Canada was only 0.4% in the private sector, compared to 9.4% in the government sector.

Some provinces do a better job than others, but we need a culture that creates more opportunity and empowers providers to play a strategic system-level role, as opposed to their current role where they are largely helpless recipients of whatever policy-du-jour is coming from the government in power.

2. Alternative payment models for providers

We’ve long known that FFS is a flawed way to pay providers and in hopes of slowly moving folks away from it, successful value-based programs always include some form of alternative payment. To state the obvious, a thoroughbred FFS model will never be value-based, because payment is retroactive and based on the delivery of a service, not the outcome; so volume is incentivized, not value.

At a minimum, successful value-based programs layer some pay-for-performance elements on top of FFS, but some shift the paradigm entirely and move to a prospective payment methodology. Kaiser Permanente (KP) is often cited as an exemplary model of an integrated health system and when you look at how they are structured, all of their physicians are salaried with the opportunity for some pay-for-performance bonuses. Not to say this is the ideal model, but if one of the highest performing health systems on earth (that happens to exist in the most competitive, market-oriented jurisdiction on earth as well) can leverage a prospective payment model for primary care providers and specialists, why can’t we?

Dr. Bob Bell, former UHN CEO and Deputy Minister of Health in Ontario, wrote a great article on KP a few years ago evaluating the feasibility of adapting some of what they do to the Ontario context. I agree with much of his analysis, but at one point, he writes the following:

It is unlikely that doctors in Ontario would readily agree to a Kaiser model of capitation without substantial increases in pay and benefits possibly including pension benefits. It is not clear whether physicians would generally accept a Kaiser compensation model … and very unlikely that the province could afford the model.

Why wouldn’t Ontario (or other Canadian) doctors agree to this? Maybe aside from a few specialists that are making absolute BANK, physicians I’ve spoken to are almost universally against our current FFS system and would welcome a model that has more predictability to it.

And why couldn’t we afford the model? Dr. Bell calls out that the KP model is too expensive ($6,533 USD per capita in KP versus $3,264 USD per capita in Ontario at the time of his post). Yes, at face value, KP’s system is way more expensive, however, I think the more important takeaway is that according to his own numbers, KP’s health system is actually significantly less expensive when compared to the rest of the US (per capita costs in the US were just under $12,000 USD in 2020). To me, that says KP has potentially found a way to deliver high-quality care at a lower cost in a jurisdiction where this is next to impossible. And they have moved away from a volume-driven system and physician payment model in the process.

Canada Grade: C

We have some capitated primary care providers and salaried physicians throughout the country, but FFS is still the overwhelming majority and as such, we are still a volume-driven system. I’m going to do a whole other post on reimagining provider reimbursement because it fascinates me, but the crux of the problem in Canada is this: if Doctor A does surgeries on 10 patients and 5 of them end up with life-threatening complications, they will get paid the exact same as Doctor B who also did 10 surgeries, but with zero complications. At least to me, that is problematic.

I’m not saying FFS needs to be fully abolished in Canada as I think there is validity to incentivizing a base level of activity, but it can’t be the primary (and in many cases, only) driver of provider payment — and I think that stance holds true regardless of the speciality.

3. Integrated health record

If you were to run a million simulations on how the EMR market would evolve from its inception to today, it wouldn’t be a hot take to say our current state would be amongst the worst-case scenarios. The major players in today’s market were initially built to optimize billings, not patient care (and we are still dealing with the pains associated with that today); they are constantly cited as a major cause for burnout amongst clinical and administrative users; they are prohibitively expensive; and the different systems don’t talk to each other unless they are absolutely forced to. Put that all together and it is no wonder why we still heavily rely upon fax machines and our healthcare siloes are as strong as ever.

However, in spite of these fundamental flaws, it is still possible to cobble together a serviceable integrated health record with enough top-to-bottom buy-in and political will. There are a few ways of doing this, but at a high-level, there are two main avenues:

1. Using a single system/vendor across the entire continuum of care within a jurisdiction/health system; or

2. Allowing different organizations to use whatever system they want, as long as they adhere to a robust set of standards that enable information to seamlessly and securely flow between them.

Our aforementioned friends over at KP have opted for #1, through their Epic-based KP HealthConnect. To their credit, they have seen great benefits with this system, but a major lesson learned from their implementation isn’t necessarily the vendor or single-solution route they went, but the fact that they fully committed to its implementation for over half a decade, and have stayed fully committed to constantly improving it since its initial go-live was completed in 2005. From day one through to today, KP HealthConnect has never been an IT initiative; it has been positioned as a transformational platform to better position KP to pursue its clinical, operational, and financial goals, which is why it has had such a positive impact across the enterprise.

Having an integrated health record — like KP HealthConnect — allows you to create and work from a standard data model, which in turn enables streamlined workflows and transitions of care, exceptional reporting and analytical capabilities, and better ways to engage and manage patients remotely — all of which are absolutely critical for delivering effective value-based programming.

Canada Grade: F

Although some political folk may say otherwise, there are no examples of a working, fully integrated health record at scale in our country. Alberta might be the closest as they are currently in the pursuit of option #1 from above, creating their own KP HealthConnect-esque integrated health record with a provincial deployment of Epic called Care Connect; however, Care Connect already has a major gap as it doesn’t include primary care due to the Primary Care Networks in Alberta not being part of Alberta Health Service’s portfolio. As such, even when Care Connect is fully rolled out, all of the primary care practices across the province will still be operating with whatever EMR system they have (for now), which could create major holes in the vision for a truly integrated health record.

In a definitely not-by-design way, many other provinces have opted for option #2, letting healthcare organizations procure what they want for years and are now trying to insert connective tissue across organizations to create some semblance of integration. To put it gently, this is very much so a work in progress.

Collectively as a country, we are unfortunately still very far away from realizing any of the potential that is unlocked via a well-designed, well-utilized integrated health record.

4. A continuous willingness to challenge norms

Beyond the realm of value-based care (or healthcare in general), a common trait of any high-performing organization is an ethos of innovation. Even in the good times, the most successful team or organization is always looking to find a better way of doing things. At a system-level, this mindset is generally absent in healthcare, as “because that’s how we’ve always done it” is a response that we all hear far-too-often.

Shifting to value-based care requires a culture that is built on constantly challenging the status quo, which goes against the historical make-up of healthcare. Although challenging and awkward, some organizations are successfully making this shift.

In 2010, Cleveland Clinic started implementing team-based care. Still fairly novel today, 10+ years ago, the idea of incorporating roles like primary care coordinators, transitional care management hub caregivers, and population health medical assistants into your core primary care delivery model was virtually unheard of, and as a result, risky. How would patients respond to not always talking with a physician? How would physicians respond to a significant change in practice style? How is Cleveland Clinic going to pay for all these extra people? With some bumps along the way, Cleveland Clinic found out that patients care more about how they are treated versus who is treating them, physicians want to focus more on the parts of the job they enjoy most, and team-based care increases productivity and reduces burnout and turnover, making the model financially advantageous as well.

Since then, Cleveland Clinic has rolled out their “team of teams” culture to a number of clinical areas, and it also has formed the base of the value-based programs they are enrolled in, namely the Medicare Shared Savings Program where they currently participate in a two-sided risk model (an advanced value-based model where providers can both earn and lose money based on performance). Had they never challenged the status quo, they would’ve never deployed a care model that has allowed them to achieve industry-leading quality scores, improvements in patient and provider experience, and millions of dollars in savings.

Canada Grade: F

Unfortunately, and as I called out in my last post, people in Canadian healthcare are great at writing about what’s wrong, but terrible at changing what’s wrong. We love to talk about challenging the norms, as long as someone else is cool with actually doing it. Since I started my career, I’ve heard a lot about what needs to change (i.e., less FFS, less hospital-centric, more team-based care, better technology) and quite frankly, none of it has. Aside from virtual care — which we have a global pandemic to thank for, not our own volition — our healthcare system at its core has remained largely unchanged since the early 2000s, and if anything it has gotten notably worse in several areas. A willingness to challenge norms needs to come from the top, be encouraged at all levels of the system, and persist beyond our election cycles; none of this is happening today.

As evidenced by my incredibly rigorous, detailed, and evidence-based report card (sarcasm), a lot needs to change.

The good news for us: value-based care is still in its relative infancy everywhere.

The bad news for us: we are still somehow very far behind.

But our delayed development in this area gives us the advantage of being able to learn from the experiences of our peers to avoid some growing pains in our own value-based care journey.

The common success factors I outlined above are definitely starting to regularly emerge in the literature, and I think with the overwhelming amount of criticism being thrown at our health system on a daily basis, there has never been more universal buy-in and need to shake things up in a big way; a meaningful pivot towards value-based care requires just that, and might be the big shake we all need.

Subscribe now

If you have an assignment due in two weeks, you will find a way to spread out (or delay) the work so that it gets completed in two weeks, even if that same assignment could be done by tomorrow.

Since its conception, this adage has also been adapted into a well-known mental model: you will work faster or prioritize more effectively when you impose a shorter deadline on a task.

In healthcare, we are subconsciously exhibiting the bad side of Parkinson’s Law every day — we are an industry filled with brilliant thinkers, who also happen to be brilliant procrastinators (not to call myself a brilliant thinker, but ironically, I’ve been putting off writing this for weeks).

We are very good at identifying problems and developing thought leadership about what needs to be done to reduce/eliminate them, but the execution side is often lacking. And at least in part, I think that is because we rarely institute meaningful deadlines or create a necessary level of urgency to get shit done.

There are many examples of problem areas in our system that we’ve known about for years and have countless reports telling us how we should change course; two that jump to my mind (that we are acutely feeling the repercussions of today) are public health and home/community care.

Subscribe now

Healthcare’s fringe guy: public health

If you are unfamiliar with the concept of a fringe guy, it is a person no one is that close with, but they still find a way to always get the invite to the pre-drink/house party (or at my more mature age, the invite to the book club or group dinner). You’ve probably known them for a long time and perhaps were close at one point, but that is no longer the case and they have effectively been grandfathered into the group for better or for worse.

For as long as I’ve worked in healthcare, public health has been the fringe guy AKA the afterthought of the overall healthcare ecosystem. However, at the same time, there has always been some guest lecturer or research study or newspaper article stating that our chronic underinvestment in the space was eventually going to catch up with us.

In 2017-2018, Canada spent $7.2 billion on public health/prevention and promotion. To put that into perspective, we had approximately $264 billion in total health expenditures in 2019. That’s less than 3% of our overall health spend going towards public health initiatives. Keep in mind, this is is the part of our health system that is supposed to be focused on preventing disease, promoting good physical and mental health, and most topically, responding to public health threats.

I want you to read this excerpt from a 2009 brief written to the House of Commons Finance Committee:

Public health in Canada is underfunded and not adequately resourced. Many local public health units are under considerable strain to respond to the “normal” demands for public health services, much less additional demands. Canada is presently facing two issues that have implications for our health system and the health of our country’s citizenry: the international economic situation; and, the potential resurgence of H1N1 influenza. Any additional demands for public health services that result from the present economic situation, an episodic public health emergency, or a pandemic influenza outbreak, could result in the collapse of the health system and have repercussions for Canada’s economy and national well-being.

You could replace H1N1 with COVID-19 and that paragraph would almost perfectly apply today — which is equal parts amazing, scary, and depressing.

That brief was written over a decade ago and funding for public health relative to other line items unsurprisingly continued to decrease in the years leading up to the pandemic. And here we are.

Investing in public health is like buying toilet paper: it isn’t the sexiest item in your cart, but you are going to be absolutely devastated if you need it and it’s not there. There is no way to fully quantify how much better our overall pandemic response would’ve been better had we not underinvested in public health for a generation, but I can confidently say it almost definitely would’ve been a helluva lot better.

We knew about our public health challenges for years, we indefinitely put off doing what we knew had to be done, and it came back to bite us in the worst way possible.

And now the same is happening in home and community care, where the pandemic has exacerbated pre-existing problems that we’ve long known about.

Home is where the care isn’t available

The aging of our population is well-documented, as is the impact it will have on the health system. We have not only seen an increase in the number of individuals requiring home and community care, but an increase in the number of high needs individuals who require more intense care for a longer period of time.

This increase in demand is happening in a home and community care system that has always lacked coordination, integration, and true accountability, resulting in many challenges for patients, families, and home care providers alike. Sprinkle in a global pandemic which has led to a mass exodus of healthcare workers — disproportionately from the home care sector — and you are left with the wickedest of wicked problems.

According to Home Care Ontario, before the pandemic, home care providers fulfilled requests for nursing care 95% of the time. At the end of 2021, that number dropped to 56% (and I don’t even want to know what that number is today, or what that number is for PSW hour fulfillment).

Just like with public health, there have been calls to build up our home and community care systems across the country for years, even before the term “silver tsunami” was a thing.

Here are a couple blurbs from separate Ontario reports on home care:

Home care needs to be seen as a strategic service, since its adequacy, quality, and safety has a direct impact on our system as a whole and its total cost. The home care system described in the public hearings process revealed worried and even frightened clients, exasperated citizen and public interest groups, demoralized workers and a seriously destabilized provider community.

There is too much variability in access to services and too little accountability for outcomes. Everyone – clients and families, providers and funders – is frustrated with a system that fails to meet the needs of clients and families.

This first blurb is from the Ontario Health Coalition from a 2008 report. The second is from a 2015 report from the Expert Group on Home and Community Care that was appointed by the then Ministry of Health and Long-Term Care to evaluate the province’s home care system and come up with recommendations on how to improve it.

Two different reports. Two different groups. Same rhetoric. Seven years apart. And the same problems persisting (worsening) today.

More beautiful reports to describe beautiful tragedies in our health system.

Time to put our money where our reports are

At all levels of our health system, we develop these flashy strategies and say all the right things at the big conferences, but there is rarely a deadline, and thus rarely any accountability to achieve the goals set out in these documents. We are decades away from implementing and truly realizing the potential of value-based care in Canada, but a small interim step we can take to overcome this systemic procrastination and become more value-driven as a whole is to have financial rewards (and penalties) attached to the strategies developed by our hospitals and health systems.

For example, a small proportion of a hospital’s funding should always be “at-risk” and if a hospital achieves 50% of the KPIs outlined in their strategic plan, they should only receive 50% of the government funding from that at-risk pool. As long as our strategies have no real accountability attached to them, they will remain great marketing tools, but not great catalysts for change. And as long as we pay to maintain the status quo, we will continue to impressively call out our problems, but do nothing about them until it is too late.

When it comes to fixing foundational flaws within our system, we need to acknowledge that we are stuck in a perpetual we’ll do it later attitude cycle. We have operated under the assumption that there will always be more time available to complete something, but when you never define or measure against later, it never gets done.

Now, as we are well over two years into the pandemic whilst relying on a health system that is hanging on by a thread, we need to take a close look at Parkinson’s Law and realize that Mother Nature (and our apathy) has imposed a shorter deadline on all of us. The question is, are we finally willing to act like it?

We’ve all heard this saying, but very rarely is it used to describe a truly desperate time and/or measure.

However, when taking an objective, system-level look at what is happening in healthcare across Ontario (and Canada), it is hard to argue that these aren’t desperate times.

As such, a couple weeks ago, Doug Ford’s government introduced Bill 7 — also known as the More Beds, Better Care Act — which based on its contents and the uproar it has caused, many would qualify as a desperate measure.

Before diving in, some quick context:

• Many Ontario hospitals are at or over-capacity when it comes to bed occupancy

• Some of this capacity (~17%) is being taken up by patients who no longer require hospital-level resources and could be better (and more cost-effectively) cared for in the community; these individuals are known as alternate level of care (ALC) patients

• ALC patients exist because: (1) there isn’t sufficient home and community care capacity to place them locally so they have nowhere else to go; and (2) a small proportion of ALC patients would rather stay in the hospital than be transferred to long-term care (LTC) even when a spot becomes available

The problem of ALC patients existed well before the pandemic and Doug Ford’s premiership, but has been exacerbated by the pandemic.

The main ALC problem today is that our hospital EDs are filling up with sicker folks who actually need these beds, but instead of getting admitted, they are left waiting in hallways and other ‘unconventional’ locations until space becomes available.

With another flu season around the corner and COVID as prevalent as ever, the province is worried that our already-broken hospital system is going to get absolutely crushed without pre-emptively freeing up some capacity for the people who truly require (or will require) hospital-level resources and care this winter.

Enter Bill 7.

Subscribe now

What is Bill 7?

Currently, ALC patients and their caregivers choose their top 5 list of LTC homes they would prefer to live in. Bill 7 gives hospitals/the province the power to transfer ALC patients to a LTC home that isn’t on their top 5 list (although the province has said every effort will be made to accommodate patient/family preference whenever possible).

Put simply, Bill 7 could lead to patients being forcefully discharged from hospital and temporarily transferred to LTC homes that are geographically far away UNLESS they are willing to pay a fee to remain in their current hospital bed.

The Bill includes a lot of vague language, but the government has said the ambiguity will be clarified in the soon-to-come regulations (i.e., how far away could a patient be moved, what will happen if someone refuses to leave the hospital, how much will the daily rate be for those that refuse).

Why the uproar?

I mean…

Regardless of how heartless or naive you may be, it is pretty easy to appreciate how a proposal like this could be negatively received.

I’ve seen it called unethical, ageist, illegal, inhumane, and even just straight up evil.

I don’t disagree that Bill 7 is operating in a moral grey area, and I fully acknowledge it is a far-from-perfect solution, but when facing a problem that is both massive and time-sensitive in nature, you can’t let great get in the way of potentially good.

So why support Bill 7?

I want to start by saying in an ideal world, we wouldn’t have to be in a situation where something like Bill 7 had to even be a consideration. We should have sufficient hospital and post-acute capacity to support better transitions of care, but alas, after years of poor investment and policy, we don’t.

I also realize this take might get me #cancelled on Canadian healthcare Twitter, but I believe Bill 7 has the potential to be a net positive for a number of key reasons (assuming there aren’t any truly unethical regulations once those are finalized and released):

1. It is the lesser of two evils (in my opinion)

To kick things off, I want you to think about which one of the following options is the more unethical situation:

1. Forcing a person who no longer requires hospital care to move to a LTC facility that is potentially far away from family and friends; or

2. Forcing a person who absolutely requires hospital care to wait days or weeks for a bed that is currently being occupied by a person that can and should be effectively treated outside the hospital?

To me, that is the fundamental question we all need to be asking ourselves, and to me, it isn’t even close.

All the critics of Bill 7 have a myopic focus on the ALC patients that will be effected by this bill, but what about the very sick people waiting for a bed? Given their condition, these are the folks that are at a higher risk of deteriorating and have the most to benefit from having a hospital bed and the care that comes with it.

And sure, the actual best solution would be to make thoughtful investments in primary care to reduce avoidable hospital admissions and attack the ALC issue from upstream, but that isn’t a solution for a problem that is only weeks away.

2. Nothing changes if nothing changes

As I mentioned towards the top of this article, the concept of an ALC patient is a long-standing problem in our health system. In fact, it was in 2009 that Ontario hospitals began using the standardized definition to designate patients as ALC.

When you look at the number of ALC patients, there is a clear trend and it isn’t a good one. Worth noting that everything on this chart is pre-COVID so in the years leading up to the pandemic, there was nothing to blame other than our lack of inventiveness and/or commitment to solving the problem.

Although I couldn’t find a pretty chart to highlight what the trend has been since the start of the pandemic, the Ontario Hospital Association (OHA) said that as of August 17th, the number of ALC cases in Ontario hospitals is at 5,930 (AKA 10% higher than it was at the end of 2019).

Taken together, this highlights that whatever our approach has been — both before and during the pandemic — it hasn’t been working and this proverbial boat is still sinking.

Even if you are a staunch critic of Bill 7 and its potential implications, you can’t deny that it is a new and unique approach to tackling the problem.

Healthcare is often criticized for being too risk-averse. Well, Bill 7 is about as bold as it gets, and at least it has the potential to make progress on the government’s current primary objective of optimizing hospital capacity leading up to and during flu season.

3. The Canada Health Act better aligns to Bill 7 than the status quo

Although it only impacts a fraction of how healthcare is funded across the provinces and territories, the Canada Health Act (CHA) has been — and still is — the most important piece of healthcare legislation in this country.

The CHA is built on 5 foundational principles/criteria: public administration, comprehensiveness, universality, portability, and accessibility.

These 5 principles together are meant to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to medically necessary health services without financial or other barriers.

In the status quo, is the person waiting in the ED hallway receiving comprehensive and/or accessible care?

Why should a person who has been medically cleared for discharge to a different care setting be allowed to take up a resource that is as limited and critical as a hospital bed for as long as they want AND not pay for it?

When you get designated as an ALC patient, the attending physician is saying that it is no longer medically necessary for you to receive round-the-clock care in a hospital setting. And at that very moment, you no longer have the right to receive “free” care, because it is no longer an insured service. So technically, if you are ALC and reject a transfer to LTC when an opening becomes available, you should’ve already been getting charged every day.

In my opinion, if you want to live in a single-payer, publicly-funded system, then you need to also accept the fact that the system will sometimes need to take a calculated yet utilitarian approach to care delivery — which by definition means it needs to bring the most benefit to the most people possible, even if that means stepping on a few toes in the process. And I think that describes Bill 7 to a T.

Albeit aggressive, Bill 7 is just another attempt to deliver the right care, in the right place, at the right time — to move ALC patients to the most appropriate care setting in the fastest time possible, whilst getting hospital beds for those that are desperately in need of acute care services.

You might not agree with it, and it is most definitely nothing more than band-aid solution, but desperate times call for desperate measures.

And winter is coming.

Subscribe now

In Canada, our primary care system lacks direction. It is effectively a bunch of clinics and well-meaning practitioners that want to do right by their patients, but have limited (and dwindling) means to do so — financial or otherwise.

Resources for primary care have been historically limited for a few reasons:

1. Primary care isn’t “sexy” 

Building a new hospital? Sexy.

Buying a shiny new MRI machine to go into said hospital? Sexy.

Going into a beige building with old, sterile furniture to chat a couple times per year about your random pains, chronic disease, and/or other general worries? Not sexy.

In that sense, the whole sex sells mantra doesn’t just apply to the media industry, it also applies to government investment into healthcare. It is easier (and arguably more persuasive to the average citizen) for Doug Ford to say the province will build 30,000 new long-term care spaces by 2028, than it is for him to say we are going to modernize and improve access to primary care for all Ontarians.

2. Primary care investments take years, if not generations to realize

Coordinated efforts to promote health, catch disease earlier, or even prevent disease altogether are all critically important to population health — they just don’t happen overnight. And investments that take a long time to realize carry little weight when it comes to winning elections. Unfortunately, that’s really the main goal of any government — to get elected, and then re-elected, and then set the stage for the party’s successor to get elected (and so on and so forth).

The research supporting primary care investment is robust and well-documented, but it likely isn’t something that a sitting administration will be able to realize in their term, and that makes it a hard thing to prioritize and campaign on to the public.

3. Primary care is often nebulous and diverse, making it difficult to know what exactly to invest in

Primary care focuses on health promotion, illness and injury prevention, and the diagnosis and treatment of illness and injury — and although it is largely quarterbacked by a family doctor, there are so many other provider types that fall under the primary care umbrella. Investing in primary care could mean a million different things, including:

• Moving physician remuneration to value-based from volume-based;

• Improving access to mental health therapy and supports;

• Training/recruiting more family doctors, both domestically and internationally; and/or

• Moving more services under “one roof” to enable better and more team-based care models to surface across the system.

Either way, it is such a wicked problem that it is hard to know where to start, making it politically easier to do just enough to prop up the increasingly fragile status quo and focus on more tangible investments like new hospital wings or long-term care facilities.

With barriers like these, there comes stagnation; and where there is stagnation, there comes opportunity.

Enter the private sector.

In Canada, organizations like Telus, Shoppers Drug Mart, and Rexall are showing that if the public system can’t/won’t step up, the private sector happily will. Although it is still early days, it is clear that these businesses see opportunity to fill an unmet patient need (and probably ideally make some money in the process).

Naturally, as is the response to anything that can be skewed as “two-tier healthcare” in Canada, these moves are getting their fair share of backlash from a broad set of stakeholders. Perhaps reignited by Amazon’s OneMedical acquisition announcement from the US and the corporatization that a move like that represents, I’m seeing an overwhelming anti-private rhetoric across Twitter, as if increased private sector participation by default equals American/two-tier/evil healthcare.

It seems there is this grand fear that primary care will slowly become this monster of an industry where corporations rule all, profit trumps everything, and patient care suffers. I can appreciate this sentiment, but I think that this will ultimately bring more good than bad.

Firstly, I trust Shoppers/Telus and the physicians they recruit to create a more integrated primary care experience than a hodgepodge of independent clinics that receive little-to-no government guidance and have minimal capacity for effectively collaborating across the system, scaling innovative ideas in a sustainable way, and/or building strong digital assets.

Most family physicians don’t get into medicine to run a business, but the unfortunate reality is that managing overhead and administration takes up almost as much time as patient care for many of these physicians. Why not “outsource” all of the non-clinical components (i.e., overhead, administration, technology, marketing/engagement, support staff) to a private sector party that can likely do it way better?

When the loud minority preaches about private healthcare, they assume it means patients paying exorbitant out-of-pocket fees to skip lines, or procedures suddenly costing 10-20x more than they do now. Although I would never say never to anything, that is almost certainly not the case.

They also seem to forget that there are dozens of other countries that perform way better than us from a healthcare perspective that have hybrid public/private health systems.

Either way, there’s nothing like a threat — whether perceived or actual — to spark change and innovation. And if the shadow of privatization is what it takes to get public sector stakeholders to think (and more importantly, act) differently, then so be it.

This is probably a good time to further reiterate that I don’t think profits should drive decisions in primary care, but that doesn’t mean new ideas from — or partnerships with — the private sector are automatically bad for the system.

Although there may be some valid concerns around the “corporatization of primary care” as some call it, effective primary care ultimately comes down to relationships, and the quality of those relationships. If Shoppers, Rexall, Telus, or whomever else can create an environment that enhances the patient-provider relationship, whether that is through bringing some much-needed scale and urgency to primary care reform, better digital tools for patients and providers alike, or even just an ability to make the overall care experience more modern, simple, and convenient for everyone involved, then all the power to them. The fact that groups like these have large existing physical footprints and strong digital teams to support virtual initiatives, means they are also more well-suited than most to offer the omni-channel experience that we need our primary care system to evolve into.  

Regardless of how you feel about the current discourse around public/private healthcare financing in this country, it is important to remember that neither public nor private are inherently good or bad. But what our country has generally shown is that the people and structures running our public system from a macro perspective are not doing a good enough job. And for the people in Ontario specifically that are blaming all of this on Doug Ford, our healthcare and primary care problems go far beyond this current administration (reminder: Doug Ford initially campaigned, and arguably won, on ending Hallway Healthcare, meaning we had big problems before the Cons came into power, and before the pandemic).

I’m afraid the anti-private mob is defending something that no longer exists. They preach about access and equity, but if everyone has the same shitty access, is that really the equity we want to strive for?

We need all hands on deck, whether they are of the public or private variety.

Current CMA president Dr. Katharine Smart, said it best in a spirited Twitter conversation:

“We need to be absolutely clear what we are talking about and what principles we want to underlie change. What is clear is the status quo is not the way forward. We shouldn’t be afraid of change — we need it desperately.”

Subscribe now

As in most media, positivity doesn’t sell (or in this case, engage) nearly as well as negativity. That is why I use lists to curate what I see on my Twitter feed, because the last thing I want when all I’m looking for is a funny meme or the latest in NBA gossip (KD to the Raps???), is a dark thread on how our political systems are broken beyond repair or how we are past the point of no return when it comes to global warming.

Prior to the pandemic, my feed focussed on Canadian healthcare had its share of negativity, but there were always rays of sunlight breaking through the clouds; beacons of hope that there were pockets of promise that could act as models to slowly turn this Titanic around and avoid its own iceberg moment. However, it appears as though we are in our iceberg moment, and as of late, all I’m seeing is doom and gloom. We are entering what feels like the endemic COVID phase, but what our health system is currently going through is anything but regular, and we need to do whatever it takes to make sure this doesn’t become our new normal.

A workforce in transition (and crisis)

The unsustainably heroic effort put forth by our healthcare workforce over the last couple years is starting to catch up with us, and we are now seeing unprecedented levels of burnout, career transitions, early retirements, and thus, staffing shortages at a time when we really, really can’t be having shortages.

As we enter what is commonly referred to as cottage season, one thing that I’ve seen more than ever is hospitals announcing temporary closures of emergency departments (EDs) due to nursing and/or physician shortages. This was definitely a problem pre-pandemic, but it is now a problem on steroids.

I’ve spoken to several hospitals that are expecting multiple closures over the summer due to these shortages, and saw at least 5 organizations in Ontario alone announce this past week that they reduced hours over the Canada Day long weekend (and there were definitely many more than that).

When EDs close down, it creates an insidious ripple effect. It isn’t only the community in question that suffers, because that extra demand gets diverted to the next closest hospital that is likely already at their own breaking point (and as a kicker, may also be hundreds of kilometres away). And it is a problem that compounds each time it gets punted down the road.

There is no simple solution to this. Staffing shortages are not a new thing, especially in “cottage country” over the summer, and it will take new ways of thinking and a different investment paradigm to get us to an even remotely viable position.

In smaller communities where there isn’t reliable primary care infrastructure, the ED ends up dealing with a lot of minor ailments (CTAS 4/5) that could’ve (and should’ve) been handled elsewhere.

Here’s a recent quote from Dr. Vikram Ralhan, the chief of staff at Georgian Bay General Hospital (GBGH):

Regardless of the summer season, GBGH’s ED sees approximately 60 per cent of patients who have a minor illness or injury which could potentially have been addressed in another setting, leaving the Emerg for patients with more serious conditions.

There is definitely variation and this is not always the case, but GBGH’s experience is fairly similar to other small-to-medium-sized community hospitals I’ve spoken to across the country.

If ~60% of the patients presenting to a rural hospital have minor illnesses or injuries, that speaks to bigger upstream problems in the system. However, if there is a hospital that needs to temporarily (or permanently) shut down because they have a shortage of physicians, the more thoughtful utilization of virtual physician networks to create more adaptive “virtual EDs” could help service this 60% until we get our shit together as a cohesive system.

The current role of virtual ED programs

Before I describe how different virtual ED models can help, I want to make one thing abundantly clear: virtual EDs do not cure the underlying problems in our system. Regardless of if a virtual ED is using an organization’s own internal providers or leveraging a distributed network, there is only so much in the realm of emergency medicine that a virtual physician can treat.

As such, offering a different access channel, like a virtual ED, does not change the fact that the people dealing with high-acuity emergencies will still be deeply impacted by these ongoing ED closures. It also does not change the fact that we have — amongst many other terrible, horrible, no good, really bad things — inequitable primary care access and a disproportionate health human resource allocation that leads to these healthcare deserts in the first place.

BUT, that doesn’t mean we should ignore the role these programs can play in still helping a pretty large subset of the patient population.

There are two overarching virtual ED access models that can each be used in isolation or in tandem:

Community-based model: Patients accessing a hospital’s emergency services without having to physically present to the ED (i.e., accessing care from home via the hospital’s website).

Facility-based model: Patients physically presenting to the ED with a qualifying condition who can opt to seek care via the “virtual pathway” to virtually connect with an off-site physician instead of waiting in the traditional in-person queue.

There are examples of both of these models in practice across Canada:

• Community-based: Toronto’s Virtual ED, Grey Bruce Health Service’s Virtual Urgent Care program

• Facility-based: Nova Scotia Health’s VirtualEmergencyNS program, Newfoundland and Labrador’s Virtual ER

All of these programs have impressive data to highlight the impact they are making in improving access and filling gaps in the system, but as the title of this post implies, I’m more interested in how we can optimize the physician staffing model for these programs versus the access model.

Levelling up virtual EDs with virtual physician networks

If you are a hospital offering a virtual ED program that only uses your own internal providers, you may be creating more convenient access channels and unlocking some more efficient workflows, but you aren’t adding any previously-dormant provider capacity to the system — and if you are a hospital dealing with a physician shortage, no amount of technology or workflow redesign will help you avoid your next closure.

To get the most out of our existing virtual EDs, but more importantly to level up new ones that can limit ED closures caused by physician shortages in the future, we should be leveraging centrally-managed, geographically-distributed physician networks to complement the staffing for these programs.

A community that is experiencing physician recruitment/retention issues in their ED shouldn’t have to repeatedly face these tough shutdown decisions. Instead, they should be able to seamlessly leverage virtual physicians to lighten the load on the few local physicians they do have, and improve local access to low-to-medium-acuity services in the process.

The proof is in the lobster

A successful example of a virtual ED model leveraging this type of provider network can be found in PEI.

In 2019, Western Hospital in Alberton, PEI had to close its ED 19 times(!) due to physician shortages. Instead of rolling the dice that they’d get lucky in their recruitment efforts in 2020, they decided to implement a then first-in-Canada virtual ED program (that also won the 2020 Patient Care Innovation Award from Digital Health Canada).

In partnership with Maple, and following the facility-based model described above, Western Hospital launched a virtual ED program that gave patients the option to immediately connect for a virtual consultation with an off-site physician, instead of waiting for an in-person consultation. With an on-site nurse to assist with vitals, physical examination, and testing, this program was ultimately able to treat a broad array of conditions, sometimes representing up to 33% of the daily volume in the ED.

Although the wait time improvements are the most eye-popping (wait times for low-acuity patients dropped from up to 8 hours to 5 minutes), maybe the most transcendent impact of this program was proving the power of leveraging a geographically-distributed physician workforce in a Canadian ED.

Our health system seems to be in a perpetual mismatch of supply and demand, with this imbalance intensifying over COVID (especially in communities like Alberton). And yet, despite the rapid adoption of virtual care throughout the pandemic, our health systems generally still carry a very narrow view on what it can and should do.

If there are willing emergency physicians in other parts of the province (or country) with available capacity, why not harness modern technology to dispatch this capacity where it is most needed? As Western Hospital was able to show, this is a proven way to add hours of previously untapped provider capacity to the emergency care system, at a time when we need every minute we can get.

Although not quite there, Newfoundland and Labrador’s Virtual ER program is a great example of a large-scale program that is in the early days of moving towards a province-wide physician staffing structure to minimize the impact of gaps at the local level. This is also the vision for VirtualEmergencyNS in Nova Scotia — to build a centralized network of interested Nova Scotian physicians to power this program across all the sites where it is operational. AKA the East Coast is killing it.

There are always going to be unavoidable closures (unfortunately virtual care doesn’t have the same ability to assist with nursing shortages), but for ones that are based on a lack of local physician availability, we need to see this progressive thinking from Atlantic Canada expand to the rest of the country in a meaningful way.

It isn’t the cure, but sometimes a Band-Aid can go a long way.

(No, the answer is not '“Justin Bieber and Drake” — anyone who criticizes either doesn’t appreciate the art of making absolute bangers)

If you guessed healthcare and real estate, you are correct (at least according to me).

You would be hard-pressed to find two industries that are talked about more, with an overwhelming majority of the discussion being negative in nature. There are valid reasons for the criticism that I won’t spend much time on because we know them all too well.

However, as someone who bought a place in Toronto at the previous real estate peak back in 2017 (RIP) and as someone who currently spends way too much time on HouseSigma (don’t lie, you do too), I can see that our health system has much to learn from our equally-flawed friends in real estate land.

Here are some things that happen in real estate that if applied correctly, could play a role in making healthcare more value-driven, transparent, and innovative in Canada:

1. Applying bidding war principles to public sector RFPs

Although real estate prices have cooled in recent months, with the lengthy bull market we’ve been in, chances are if you’ve put an offer on a condo or house in a major Canadian city over the last decade, you’ve been in a bidding war.

As a buyer, they absolutely suck. As a seller, they are generally pretty awesome. This is because a bidding war has a single purpose: to drive up price so that the seller can get the most out of their asset as possible. Although frustrating (or downright depressing) for buyers, this makes a lot of sense.

In healthcare, the power dynamic is flipped. Governments and healthcare organizations are the buyers, and they are the ones who hold all of the power.

But with the way public sector procurement in our country works, our healthcare organizations can’t run bidding wars to drive down price and find the optimal balance between best price and best solution.

To illustrate how and why this is an issue, here is a tale of a recent digital health RFP process I was a part of:

We had a good relationship with the buyer organization and we also had a good idea of what they were looking for in this specific solution, so we felt we were well-positioned to win when the RFP came out. Some ballpark budget numbers for the program had been thrown out in conversations months prior to the RFP being released, so we thought we generally knew how we could/couldn’t price our proposal.

Over 30 organizations ended up bidding on this work, and we made it to the top 3 for final presentations — good start.

We did our shortlist, which was seemingly well-received so things were continuing to trend in the right direction.

Then pricing was evaluated.

A couple months went by and we didn’t hear anything (never a good sign), and then finally we got word that we did not win the work. With the prolonged silence after the shortlist, the loss ultimately wasn’t a surprise, but it still hurt because everything had been going so well up to that point, and we knew that we could’ve done an amazing job had we been chosen.

We had our official debrief with the buyer and they told us that going into the pricing evaluation, we had the highest score (written submission + shortlist), but we only scored 15/45 on pricing — which based on the scoring formula, effectively meant we were 3x as expensive as the winning vendor.

When responding to any RFP, there is always a risk that someone can come in and “buy the work” by pitching an absurdly low price. This is a strategy some vendors are notorious for, but my issue with the process is that we were never even asked if we’d be willing to adjust our price.

There is no way we would’ve been able to totally match the low-ball pricing from the winning bid, but I’m sure we would’ve been open to dropping our prices enough so that our total score (written submission + shortlist + pricing) would’ve been more competitive. However, since that was never an option, the buyer is now left with a suboptimal solution from a technical perspective, and from what I hear, the cost of implementing said solution is slowly creeping up and they have already pushed back go-live due to difficulties. You hate to see it.

Public sector RFPs should be designed in a way to allow for real estate-esque bidding wars, but with the purpose of driving prices down instead of up. This is the only way a healthcare buyer can be certain that they are getting the best solution at the best price available in the market at that exact moment in time. Sure, it might add a little bit of headache and administration to the evaluation phase, but if I were a buyer, I’d rather have a one-time headache than a multi-year migraine.

2. Better access to historical purchase prices

Aside from overall local/regional pricing indices, until relatively recently, the only way to know what a house previously sold for was to go through a real estate agent. The (bullshit) argument was that, as a consumer, having access to this information without a trained professional to explain the nuance was dangerous (insert eye-roll).

Now there is a clear parallel here between the real estate example above and the perpetual debate around patients having access to their own health information, but I’m going to leave that one alone for now and choose the more boring, business-oriented parallel: there should be accessible, public-facing tools to see what our healthcare organizations are spending their money on.

I’m not saying the public should have access to the detailed loonie and toonie-level budget of a hospital, but for purchases over a certain dollar threshold, this should be something that I can easily access in a self-service format (after all, we are the ones paying for it). Think of a less-flawed Sunshine List, but instead of salaries, you can see how much your local hospital just spent on that “transformational” Epic implementation (hint: it ain’t pretty).

Beyond giving us all more gossip ammo, I think would be beneficial for a few reasons:

Transparency and trust

For a publicly-funded system, it is pretty hard to get access to downloadable raw data on how all that taxpayer money is spent. Sure, we have rolled-up hospital financial statements and those pretty reports that CIHI puts out, but there are very few avenues for publicly accessing more detailed financial information at the regional or organizational level, and in specific areas like technology and digital health.

There was a great 2017 KPMG report that evaluated healthcare transparency across 32 countries. One of the domains of transparency they evaluated was financial transparency (i.e., public reporting on how much x procedure/treatment costs to deliver, gifts/donations, audited financial statements). In this domain, Canada tied for 28th (reminder: that is out of 32 countries). Considering how much we spend on healthcare, and the fact that it is largely our tax dollars funding these expenditures, that is unacceptable.

One of the key ways to build trust is through transparency, so being less cagey/vague about financial information and trusting us to view, judge, and use the data accordingly could go a long way towards rebuilding trust in our healthcare institutions.

Linking spending with value

Based on my earlier Epic comment, it might seem that I am a bit salty when it comes to the absurd amount of money we spend on hospital information systems. I am self-aware enough to admit that there is some truth to that, but my bigger issue with these purchases is that they are largely made before developing a robust framework on how this money will actually translate into quality improvements, cost savings, or other system gains.

This is starting to shift a little bit (or at least I hope it is), but having been part of a planning and implementation team for one of these large HIS deployments in the past, I can say that the order of operations is often RFP —> negotiate with top-scoring vendor —> kickoff implementation —> develop benefits framework. This implies that how the solution should tangibly benefit the system, provider, and patient, is being determined after committing to that $100MM+ spend.

By making these eye-opening contract values more accessible, we can put more data-driven pressure on our healthcare leaders to highlight what quantitative and qualitative value we are getting (or can expect to get) from these massive investments.

Citizen-driven innovation

At the beginning of the pandemic, it was rightfully decided that the government needed to be as open and transparent about the latest COVID data as possible, and made much of it available to the public. The government stood up publicly available data sheets and dashboards, and within days, we had citizen-created services and tools to give us evidence-based, digestible information on how the pandemic was evolving.

When it came to vaccine rollout (remember that shitshow?), a group of citizens consolidated a bunch of disparate, but quasi-publicly-available data to stand up Vaccine Hunters, a user-friendly way to identify when and where you could get vaccinated across the country. Although this wasn’t an example of historical pricing information driving innovation, it is an example of what being more transparent with health system data can lead to: citizen-led ideas that ultimately result in system improvements.

Overall, I can’t think of one time in history when making qualified, accurate information more accessible to the public caused more bad than good, and this is no exception. If done correctly, making this type of financial information more publicly available (as it is in residential real estate) could create:

• more trust amongst the public;

• more fiscal accountability across the health system; and

• more grassroots, evidence-based conversations around ways to get better value for money.

3. Creating a level playing field (in theory)

Bear with me on this one, but in real estate, any given property that goes up for sale could, in theory, be purchased by any given person. Obviously, the wealthiest people have the advantage of being able to offer the most, but savvy investors are always looking for a specific return which becomes impossible to achieve above a certain purchase price. As such, residential sellers often don’t favour one type of buyer versus another — they craft their listing and stage their house to appeal to as many people as possible in hopes of getting the most interest, and ultimately the best price. That could result in a multi-millionaire buying the house as an investment property or a young, middle-class family purchasing it as their first home.

In Canadian healthcare, RFPs are not written to favour the young, middle-class family of our world: startups. In fact, I’d argue they are explicitly written to hurt them. Between RFPs that I’ve assisted in writing, read, and responded to, I can confidently say that they are (mostly) all built from the same template. And this template heavily values things like where have you done this, how long have you been doing this, what are your results, and who/what are your references.

These are definitely elements that should factor into a buying decision, but when they are disproportionately weighted, we are effectively incentivizing the status quo and disincentivizing innovation. Most startups can’t score well on these questions because they haven’t been around long enough and/or they haven’t gotten their chance to prove themselves in practice (because they are dependent on winning these antiquated RFPs). As long as RFPs are written this way, it will be the same 2-3 companies winning all the work, which further reinforces the problem and drives our homegrown companies to pivot their growth efforts to other markets (AKA entrepreneurial brain drain).

Say what you want about real estate and real estate listings, at least they don’t discriminate like healthcare RFPs do.

By no means am I suggesting Canadian real estate is a healthy, thriving industry (in fact it is almost the exact opposite), but I’m a firm believer that some of the best ideas can come from unrelated fields. And I also believe that just because something doesn’t work in one context, doesn’t mean it won’t work elsewhere.

A bidding war may suck when you are looking to buy a home in a bull market, but it could be greatly beneficial to a health system that is trying to purchase a high-quality solution under fiscal constraints. Access to historical price information may make you jealous when you see how much your friend bought their condo for back in 2012, but it could force your local hospital to become more proactively results-oriented when making large capital investments. Losing out on an investment property because another buyer wrote a tear-jerking letter to sway the seller may not make sense to you, but giving everyone a fair shot in healthcare procurement could accelerate the adoption of innovative solutions and promote local economic growth.

When the situation is as dire as it is in Canadian healthcare, we need all the help we can get, even if that means looking to the dark world of real estate for inspiration.

I’d like to start by stating the obvious: primary care is incredibly important.

It is universally regarded as the foundation of a high-performing health system, but it is also a part of the health system that has never wavered from its underlying premise: everyone needs a family doctor.

This 1:1 connection is and has always been the gold standard in primary care. And if we want to measure against this standard, we are falling way short, as almost 5 million Canadians do not have a regular primary care provider (including yours truly — more on that later).

The thinking is that if you are attached to a family doctor, this is someone you can build a relationship with over time and as a result, they’ll be able to manage your health in a more holistic manner. Think of that old friend who can take one look at you and know that something is wrong even when you are saying everything is ok; that is the idealistic picture of what having a family doctor is like.

I have no doubt that there are many examples of amazing patient-doctor relationships that are like this, but I don’t think this structure is necessarily a mandatory feature of good primary care. And more importantly, it is becoming increasingly difficult/impossible to match every Canadian with a family doctor, especially in the more rural parts of the country.

Things are not trending in the right direction

In Canada, we have a growing divide between what our health system looks like in big cities versus small towns. This generally coincides with the consistent urbanization and urban spread of our country. From 2016-2021, 18 of the top 25 largest municipalities in Canada grew at a faster pace than Canada as a whole. Even during the Great Relocation during the pandemic, most people that moved “out of the city” stayed within 1-2 hours of a major urban centre.

Despite an assortment of carrots and policies to combat this, the distribution of our physician population is no different. In 2019, only 8% of physicians practiced in rural areas whereas about 19% of Canadians lived in rural areas. When you look at family doctors specifically, the number is a bit more balanced — 14% of family doctors practice in rural areas versus 19% of the population — but this is still a significant gap.

Money fixes everything (except in healthcare)

Although there is a massive (and growing) delta in the physician per capita rates between urban and rural settings, our governments — bless their hearts — have been trying to solve this, albeit in the most government way: by throwing more money at it.

Most provinces across Canada have long-standing programs to incentivize the recruitment and retention of physicians in rural areas, but the verdict on these programs is mixed at best (as evidenced by the fact that this is still a major issue plaguing our system). There are probably plenty of reasons as to why these programs aren’t meaningfully moving the needle (i.e., difficult to understand, not effectively communicated to the medical community, short-term in nature, the amount of money isn’t tantalizing enough); however, as a casual observer, I think it unfortunately boils down to one simple fact that aligns with trends we are seeing across the globe: an increasing majority of people want to live in or around cities.

To make matters worse, the urban migration of society happens to coincide with the subtle deterioration of family medicine as a whole.

The family doctor is under attack

The good news: the growth of the physician population in Canada has been outpacing population growth as a whole, to the point that we currently have a record number of physicians practicing across the country.

The bad news: a shrinking number of medical graduates are choosing to pursue a career in family medicine, and a growing number of existing family doctors are retiring early from clinical practice.

From 2015 to 2021, the percentage of medical graduates choosing family medicine fell from 38.5% to 31.8%. That is a 17.4% drop in less than a decade.

It would be one thing if the demand for family medicine wasn’t there, but in December 2021, there were 2,400 family physician positions advertised on government recruitment sites across the country. In 2020, only 1,400 family physicians exited the postgraduate system to enter practice. That difference can maybe be partially made up by career transitions, international medical graduates, and nurse practitioners (more on that later), but still, not great, Bob!

I’ve spoken with several rural hospitals, primary care organizations, and municipalities who are trying to get creative to fill this gap, but the funding that is available for rural retention programs generally can’t be repurposed, even if the alternative being explored is attempting to achieve the same goal of better access to primary care.

One avenue for improving primary care access has been to rely more heavily on nurse practitioners. Province by province, we have seen the scope of practice for a nurse practitioner expand, to the point that in some parts of the country, they can basically do everything a family doctor can do. Many people see this as a great thing (myself included), but no one talks about the impact this has on the attractiveness of family medicine as a career path.

To bring this to life, let’s do a little thought exercise.

I want you to put yourself in the shoes of an aspiring healthcare professional that is passionate about primary care. You Google nurse practitioner versus family doctor as I did and come across this table from Alberta (that I added two rows to).

Yes, you can make more money annually as a family physician over the long-term, but the gap isn’t as big as you’d think when you factor in all the expenses and added administrative work many family doctors need to do, especially when they don’t practice in family health team/interdisciplinary settings.

As such, I think our messaging is ignorant and damaging when we continue to preach how important family doctors are, while pushing the narrative that NPs can basically do their entire job for less money and with half the education. Add on the limited number of alternative funding-based family physician roles (i.e., capitation) that are currently out there — which then forces a lot of family docs into problematic fee-for-service-driven positions — and the argument for pursuing the family physician pathway isn’t nearly as compelling as it was ~15 years ago.

Ignoring the sibling fight happening between family doctors and NPs, are we sure that NPs can actually solve the problem? There is no question that nurse practitioners have a vital role to play in the present and future of primary care, but I’ve seen too many thought pieces/articles simply stating that nurse practitioners can fill the primary care gap in rural/remote Canada. And this doesn’t make any sense.

If we have decades of evidence suggesting that recruiting and retaining family doctors in rural Canada is a systemic challenge, why would recruiting and retaining NPs be any different?

Is the nurse practitioner profession just loaded with people that hate big cities and love the outdoors? Are NPs more likely than a family doctor to take an extra $20k per year to live and work in a remote community? I think we all know the answer to these questions.

So that leaves us in the same predicament: an uneven distribution of primary care providers (MDs and NPs) resulting in many of our rural and remote communities being especially underserved.

Good primary care ≠ being attached to a single family doctor

It should be clear by now that throwing more money or more doctors or more nurse practitioners at the problem is nothing more than a band-aid solution. This is what we’ve been doing for a generation, and we still have a growing urban-rural divide and 5 million Canadians that don’t have access to proper primary care (and probably millions more that have family doctors, but can’t access them in a timely fashion).

Now to connect this back to my original point about the 1:1 patient-provider relationship being the gold standard, I think it is time we get rid of the idea that good primary care automatically equals being attached to a single family doctor.

Story time…

To give a real-life example of this, I’m going to use my own experiences. A caveat to start: I am a healthy young person that has very rarely had to use primary care services over the last 15 years, but that doesn’t change the reality of the situation.

I had a family doctor that worked out of a top academic health centre as part of a highly-regarded family health team. Over the course of the ~15 years that she was my family doctor, I probably went 4-5 times. Every time I saw her, the visit itself went smoothly and we had a good relationship, but by no means was she or the remainder of her FHT accessible/responsive leading up to these encounters; for example, for each of those visits, I was never able to get an appointment in the same week, let alone the same day.

Fast forward to January of this year when I wanted to speak to my family doctor to get a dermatology referral for a rather suspicious mole that I have on my shoulder (notice the word have — if you are a derm, hit me up to help a brother out). I called the FHT to get an appointment (no online booking), only to be told that I wasn’t on her active patient panel. I thought this was odd so I asked the admin to see if there was an archive or something she could search in, and low and behold, I had been “removed from the doctor’s panel for inactivity” because I hadn’t been in the last 5 years.

I appreciate that a family physician’s roster only has so many spots and they would likely want to prioritize patients who use services to have a spot on that roster, but to remove someone without any warning or notice? They have my phone number and email on file, would it have been so hard to send a note saying something like:

We’ve noticed you haven’t been to the doctor in a while. If you’d like to keep Dr. X as your family physician, please book a wellness checkup within the next 6 months to maintain your spot as one of her patients.

Unfortunately, I received no such call/text/email. I was effectively kicked to the curb for being healthy.

So now I am one of the 5 million Canadians without a family doctor, but given my relative youth and health, plus the experiences I’ve had with what is regarded as a good primary care practice, I’m in no rush to find another spot.

But what if there was another way?

We’ve been so set on finding every person a family doctor that we’ve lost sight of the fact that this isn’t actually the goal. Every person doesn’t need a family doctor — what every person needs is timely access to effective, coordinated primary care.

And in my opinion, that is something that can be done without singularly pursuing this sacred 1:1 relationship.

Some provinces have started to realize this and have launched (or are launching) innovative programs to support their unattached patient populations.

In Nova Scotia, VirtualCareNS (VCNS) is a provincial program that gives every person on their unattached registry virtual access to same-day primary care, by using a team-based approach that is supported by modern technology. The program is open during standard business hours, is staffed by 40+ family physicians located across the province that each contribute a few hours per week, and allows patients to request and access primary care from the comfort of their home.

But this is more than just a virtual walk-in clinic. Patients can digitally receive prescriptions, specialist referrals, lab/imaging requisitions, and other notes/forms, and all the participating providers contribute and have access to the same electronic chart to support continuity and coordination. There is also a centralized clinical team that manages all lab and imaging work from end-to-end — from reviewing and triaging results, to following up with labs for missing tests, to coordinating with patients and providers for follow-up as appropriate.

On top of this, if during a virtual encounter the provider thinks that the patient needs to be seen in person, there is a referral pathway integrated into the technology platform that allows providers to send patients to a number of conveniently located NP-led clinics across the province where the patient can receive a physical examination and/or additional testing (with all the documentation from this in-person visit still making its way back into the same electronic chart).

Although there are unquestionably many improvements still to be made, based on program data and patient surveys, VCNS has been a huge success after one year:

• 15,000+ visits completed;

• 94% patient satisfaction rate;

• 32% of visits resulted in an avoided ED visit;

• 38% of patients saved at least one hour of travel time as a result of the program; and maybe most incredibly

• It survived its initial pilot phase (!!!), has scaled province-wide, and also survived a provincial election!

As an unattached Ontarian, I would love to have access to a government-sponsored program like this. And I know my primary care experience isn’t necessarily the norm, but even when I was attached to a family doctor, what VCNS offers patients is a far superior experience to what I had.

VCNS is meant to be a temporary solution while eligible patients wait to get matched to a permanent family doctor in their area, but I think a model like this should be considered as a permanent tenet of how we deliver primary care to unattached patients and/or folks living in more remote regions across the country. We have enough data to show that dangling more carrots in front of doctors isn’t enough to close the urban/rural gap, and dangling those same carrots in front of NPs likely won’t do much either, so we need to think different like Nova Scotia Health has — a multimodal, team-based approach that harnesses the best of what the virtual and physical worlds have to offer in a primary care setting. It is also living proof that you can deliver high-quality, comprehensive, and sustainable primary care without a traditional 1:1 patient-provider relationship.

Primary care that is built on this type of model gives patients timely, convenient access to virtual AND in-person primary care, while eliminating the long-held belief that our ability to deliver primary care in rural communities is fully predicated on our ability to recruit and retain providers to live there year-round.

What do you think? Am I completely off the mark? Should we still be prioritizing the 1:1 patient-to-family doctor relationship for every Canadian above all else, or have we gone down this path long enough to start exploring other solutions?

And I know there are lots of great healthcare newsletters out there; unfortunately I have yet to come across any good ones focused primarily on the Great White North.

So with that, I’d like to introduce you to CDN Healthcare.

On the surface, Canada might not seem as exciting as our neighbours to the south from a healthcare perspective, but what we lack in digital health unicorns and medical bankruptcies, we make up for in failed faxes, long wait times, and a bureaucratic clusterf*ck of a system that makes it next to impossible to get anything done.

However, within this flawed system we find ourselves in, there are cool ideas being piloted every day that if properly supported, could eventually flip the script on this slowly sinking ship (but that’s a big if).

Anyway, my hope with this newsletter is to semi-regularly analyze the good, the bad, and the ugly in Canadian healthcare. This could be anything from deep-dive thought pieces, to interviews, to completely biased, half-baked takes supported by nothing but gut instinct and memes. But no matter the topic, you have my guarantee that I’ll do my best to keep it informative, digestible, and entertaining.

If you are interested in following along with another one of my hobbies that will inevitably fizzle out (I’m setting the O/U at 4.5 months), feel free to subscribe — I promise not to flood your inbox in the slightest.

And if you are interested in partnering on a piece/topic or just want to connect on something, feel free to message me on Twitter (@_peterforte).