Wednesday, December 16, 2015

Pincher Creek Initiative - Localized healthcare pilot project announced

Pincher Creek Health Centre (C.Davis file photo)
Christian Davis

On December 10, 2015 a public meeting was held to unveil and discuss the "Pincher Creek Community Initiative".  According to the invitation, "Pincher Creek has been selected to demonstrate a community based high-performing health system that can be spread to other communities across Alberta. A local partnership based governance committee will be accountable to improve the linkages of healthcare and social services to improve quality of care and better support population health."

Approximately 90 people attended, including several members of the councils for the Town of Pincher Creek and the MD of Pincher Creek, healthcare professionals, members of Pincher Creek Emergency Services, and private citizens. Pincher Creek Associate Clinic Executive Director Jeff Brockmann acted as facilitator for the event.


Eileen Patterson

Eileen Patterson was called the Director of Health Innovation Group (no web presence found by this reporter) at the meeting and in an email inviting people to the meeting. She is also elsewhere credited as the Operational Lead of Choosing Wisely Alberta, and on her LinkedIn page she lists Choosing Wisely Alberta and EMP Consulting (a Louisiana U.S.A. "full service engineering consulting and design firm") as her current employers. According to their website, Choosing Wisely Alberta "is an initiative with the goal of reducing tests, treatments and procedures identified as being of low or no value for patient care. CWA is part of a larger Canadian movement (Choosing Wisely Canada) to help physicians and patients engage in conversations about unnecessary tests, treatments and procedures."

Patterson previously worked for Health Quality Ontario, which describes itself as an arms-length agency of the Ontario government, "a partner and leader in transforming Ontario’s health care system so that it can deliver a better experience of care and better outcomes for Ontarians and better value for money". She was also previously the lead for the Taber Integrated Primary Care Project.  According to her CV she studied at Queen’s University, earning a B.A. Life Sciences, and completed her Master in Continuing Education (MCE) Specializing in Workplace Change at the University of Calgary.

Dr. Tobias Gelber (speaker)

According to The Associate Clinic (Pincher Creek) website, Dr. Tobias Gelber specializes  in obstetrics and anesthesia. He earned a medical degree from the University of Calgary in 1999, and also received education from the Family Medicine/Canadian College of Family Physicians in 2001, and earned an Anesthetics-fellowship from the University of Calgary in 2002. He's been with The Associate Clinic since 2002. "Dr. Gelber was named, in September, 2007, a University of Calgary, Faculty of Medicine, award finalist in recognition of his outstanding contributions to continuing medical education and family medicine."

The presentation and feedback:

"Why we're here is because Alberta, like every province has been trying to figure out how to improve the delivery of health services for patients," explained  Eileen Patterson at the beginning of the presentation. "The Health Quality Council of Alberta (HQCA) continuously is monitoring what's the status of the health system, and what are the best things that are happening in the health system. In part of doing that they said 'We see an opportunity and we are looking for a community to work with us around that opportunity.' That is the opportunity that we will be describing, which is about partnership-based population care."

"Patients in Alberta tell us we have to do better. Right now people are working as hard as they can in the systems they are working in. A lot of us experience excellent health care, excellent service, and in Pincher Creek in particular, you would likely have that experience."

"However, that's not the story everywhere. There are limitations put on how care can be delivered the way it's set up right now in the system."

According to Patterson, HQCA says 58% of Albertans say there needs to be a fundamental change to the delivery of health care. "Two thirds of Albertans who are seeking care are saying 'It's not working for me'. Something needs to happen here. When you look at our healthcare system as compared to other healthcare systems, although we have a lot to be proud of, there are others who have invested more in making the changes that are making it easier to deliver care for patients."

The Commonwealth Fund is a private U.S. based foundation that according to their website "aims to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults". Patterson cited a Commonwealth Fund survey of the health system performance of 11 industrialized countries. "Canada comes tenth. The States come after us," she said, apparently referring to a 2014 survey of adults aged 65 and over. She said it was also found that Canada spends more per capita than any of the other countries except for the United States, adding that examples of other countries with more positive ratings include England and Denmark.

"We do poorly when it comes to quality, we do poorly when it comes to efficiency, we do poorly when it comes to equity, and when it comes to access to care we come dead last," said Patterson. She explained how these statistics were accumulated. "When people are sick in Canada they report only one third of them can see their doctor in two days, when people have chronic diseases which they need to manage day by day in order to stay well, only half of them have a management plan in partnership with their providers. So statistically we know we are not reaching the targets. Not because people are not doing their best. They are. It's the systems that we have in place."

Patterson said HQCA wants to improve the system. "There is a population based decision-making model that actually brings decisions closer to a smaller population, to say 'Lets actually make the decisions that will actually work for our population'." According to Patterson Pincher Creek was chosen as a possible test community with a proven record of strong partnership relations. " This is about integrating health and social care in a way that's going to work best for people. "

"They put more decision-making into the people who do the work. So anybody who is delivering service also knows if they see a better way of delivering service to that patient, that they have a way to talk about that, a process where they can share that. We know that the people do the work are the ones that need to be closely engaged in development."

"At this point there is the opportunity to write a proposal, there is no proposal. I know typically you're accustomed to coming in announcing 'there's a proposal, and here is how it's going to work,' we don't have those answers for you. This is true community engagement. There's an opportunity, and we can define for you that opportunity is, but then we have to plan the next step out together to answer the questions that you would probably have."

Patterson listed some of the strengths she said were already identified in the Pincher Creek community. "When I have traveled around, Pincher Creek is one of the models that I point to in terms of strengths of people actually working together to deliver the kind of care I would want my family to get."

"There's a history of community engagement and partnership and because people have invested in this work over the last 10 to 15 years, could be longer than that, there is a skill set built around doing this improvement, working together. That's a skill set that exists in this community."

Dr. Tobias Gelber also spoke of the Commonwealth Fund survey mentioned above, which ranked Canada 10th out of 11 countries in terms of healthcare outcomes for those over the age of 65. "When we break that down across the provinces Alberta is ranked number one for expenses, and is middle of the pack at best for outcomes across the provinces. What that to me says is there is a significant opportunity for improvement for system design. Again, not a lot of resources, we are number one for spending resources, but I think we can do better with the resources we currently have."

Dr. Gelber also touched on some of the changes that are happening in the Ontario Health Care System. "The provinces, more than any other time in history, have been working together and learning from each other in terms of how they interact with their citizens and deliver programs, so there is concern that (a) risk of change that is not very pleasant could happen here. This is an opportunity for us to be able to define what that change looks like rather than sitting back and saying 'Let's wait for the government to make a decision'."

Gelber and Patterson worked together to present some of the principles of how they see the project moving forward. Dr. Gelber said, "Those who do the work will redesign the work. Anyone who's familiar with any kind of change in management literature is aware that if you have a top-down approach there is often a lot more resistance from those involved, as opposed to involving everybody from the beginning, including those who receive the services. So to the population of Pincher Creek... (we're asking) 'What matters to you as a community when it comes to your health care?' and integrating that into a proposal before it's developed." Gelber said local health care providers have already seen the presentation to get them started thinking about this project. "Now we're reaching out to the community as a whole." Both Patterson and Gelber said there will be more opportunities for the public to be heard.

Patterson said "This is the beginning of a long conversation so there is no risk to anybody to not being here."

One of the stated desired outcomes is to have a system designed around this community's needs. Dr. Gelber said "It's pretty hard to design a system based on community needs without asking the community 'What are your needs?', so this is the first step in being able to do that."

Gelber said the Health Quality Council of Alberta is responsible for and has legislated access to all sorts of databases across the healthcare system. "They identified Pincher Creek as a potentially strong opportunity that already delivers relatively high quality healthcare and is supported by a team both locally and in the Chinook Health Region, or what used to be the Chinook Health Region, and are a primary care network (seen) as a likely successful environment to be able to trial a new model."

Gelber said members of the HQCA approached Pincher Creek health practitioners and asked 'What if we were able to provide you as a community all of the healthcare dollars to deliver healthcare to the population?' Essentially if we look at the last budget healthcare was about a 20 billion dollar line item, almost. With the population of Alberta being four million that translates into about $5,000 being spent on health care, all Health Care needs for one year."

"What they are suggesting is what it is we gave you that money and you locally were able to determine how that's spent on your population?" Essentially, that in a nutshell is what we're talking about here. A local governance group, and the makeup of that has not been suggested, not been formed or anything like that." He recalled a time when there was a local hospital board. "It is almost like going back to that sort of a model." He suggested that along with local oversight the project would be watched carefully at a higher level with a high level of accountability to the government for expected outcomes.

"What could this look like for our community in terms of health care needs? What this would mean is that with this pot of money we would be able to manage all of the healthcare that would be permanently delivered."

Question period:

A public input/question and answer session followed the formal presentation.

Philippe Francois said that although he was satisfied with local care, "It's the access to the advanced diagnosis" that concerned him, specifically waiting times for MRI equipment and specialists. Dr. Gelber replied "Currently all advanced imaging is done outside of the community. Anything we are unable to deliver within the community we would actually be purchasing through our fund of money. So currently our only option is to wait in line for the MRI machine in Lethbridge or Calgary. We might have the opportunity now to be able to now be able to make an arrangement with a private facility." Gelber said the services have an associated cost that would still have to be administrated and paid for, however they may have more flexibility under the new project. "We are paying for it anyway, it is coming out of the publicly funded money that we are getting, but how we spend that money is now up to us."

"It's very important to know that there are certain things in the system that we will have much more control over and there are other things that we will not have any control over. There are still going to be some system things that still will be beyond our sphere of influence."

Town Councillor Doug Thornton asked what happens if we spend all the money allotted. Gelber replied "My first answer will be a quick one saying that we haven't determined that yet, that would be part of the proposal development. My initial thoughts as one of the people contributing would be that, first off, when I look at what is being spent in healthcare now, there are office towers that are filled with non clinical people, administrators, who deal with the administration of the healthcare system. That is all part of the dollars that are spent, that we would get out of the per capita basis, but we would not be paying for that anymore. Because we have our local administration that is going to be managing this. A yet undefined model, but certainly not the same concentration of administrators that we currently have. My initial feelings without having done any number crunching is that the amount of money coming to us on a per capita basis would be far more than we are currently spending, as a hypothesis."

Gelber said some of the stakeholders in the project include Alberta Health Services, the Alberta Medical Association, and the Health Quality Council of Alberta. " They are going into this wanting to see some system change. They are not going into this to set us up to fail."

Patterson said there are models which are being looked at about how to proceed. "Typically, there is a conversation about risk/reward. If you want to protect yourself from risk, then maybe instead of all the money being reinvested here you only have most of the money reinvested here. There are other high performing communities who have shifted the health system and have gone through this before." She mentioned that there are publications which could be referenced. "We do have some of those references for you, but this is not all unknown territory."

Dr. Gelber said "One of the high level principles that we are looking at is this idea of having some sort of built in insurance. That kind of goes along with what Eileen is saying. Maybe not completely all of the money comes here. For example if we ended up with a child who had an unusual metabolic syndrome, whose drugs cost $700,000 a year, and we have all heard about that in the news, that could bankrupt us. So some sort of insurance policy to say 'This is an extreme case not actually representative of the population based costs', maybe that is outside of the funding."

Councillor Thornton commented that the Pincher Creek Health Centre is becoming a regional hospital serving more than the local population. "How is this going to work?" Dr. Gelber replied "The funding that we get is based on the rostered population that we have here. Anybody who seeks and receives services from this project and that is not part of that, we bill the rest of the system and recoup the costs. That's for any costs they incur."

Marg Cox of Pincher Creek Emergency Services (PCES) asked about the use of the CT equipment when people travel here to use the service. "They would probably not pay for it themselves, as we are not a private delivery," replied Gelber. "What would happen is Alberta Health Services would purchase it from the Pincher Creek project, at the rate that it costs us."

MD Councillor Garry Marchuk asked about operational funds and capital for the project. Dr. Gelber said the equipment costs will come out of the healthcare budget for sure, but new buildings would come out of infrastructure, not health. "So we would still be at the whims of government in terms of getting in line for a new facility." He said similar concerns were raised at other forums. "Are we buying a lemon here?'. Ours was one of the first hospitals built in this style, and everybody else who has the triangular based hospitals that we currently have learned from our hospital in terms of what worked and what didn't. They decided it was a model that was successful so they spread it out across the province. Yes, we would have to talk about making sure that we're not getting a lemon, and there is plans to be able to maintain it."

Another citizen spoke about the history of regionalization to centralization to decentralization in Alberta. He said he believed decentralization could offer better healthcare and cost savings, and suggested the possibility of buying equipment to 'sublet that out to other jurisdictions'. "I am a firm believer that we're ready, because 20 billion a year is not sustainable." Patterson answered "A community like Pincher Creek is a great community to start with because of all the strengths and all the pieces that you would want to see for success are here. That doesn't mean that if it's successful in Pincher Creek and that every population of 7500 is going to do something similar." She talked about how as this may become latest model there were a lot of learning opportunities. "It's not that we're going to lose all of the efficiencies of scale and move to a bunch of small microsystems, but you start by seeing what is the opportunity."

Two tier system health care was mentioned as a concern by another attendee. Dr. Gelber answered by saying "Many people are concerned that we may be might be pursuing the idea of privately delivered healthcare, and I would like to debunk that myth right now. We're talking about having publicly funded dollars out of the 20 billion that is our portion coming in, and that's the only funding to the system. In terms of the delivery we would have this local governance group that is populated by folks from this room, other healthcare providers, that are kind of like a board in charge of managing us, but there is no private delivery of care. The idea that all care is publicly funded right now is is actually a little bit... It's true, but in terms of the delivery, if you think about what our current clinic situation is, that's actually a private clinic. It's owned by the physicians as small business owners. Publicly funded dollars coming in based on the work that we do, but it is still privately owned. So we're actually thinking of taking that and putting that under this new governance structure to be managed, just like the hospital would be, just like community care would be, and any other health care organization. So there would be the same accountabilities now the privately operated clinic would be taking on. So this is by no means private healthcare delivery."

"We have the opportunity now of taking the good from the central system..."

Another attendee asked about social programming involvement in the new project, as many of the existing social programs do not get funding from AHS currently. "Is there going to be a separate budget that comes from other aspects that will be added to that allotment? What kind of priority will social programs take in terms of the development of this project as a whole?" Dr. Gelber replied "I don't have an answer for that, off of the top, we have recognized that social programming makes a huge difference in the overall health costs and outcomes of patients. So it's certainly something that would be, I think, integrally involved in the project. Would we look for funding from those provincial agencies that currently fund them now? Absolutely, we will take any funding we can get, but if we're just talking just healthcacare dollars then what we may be able to look at is if we have some funding left over... We could potentially look at contributing to some of those programs or maybe joining with the community to ask joint funding of certain things. That all has yet to be determined."

Marg Cox asked "Do you see PCES under the umbrella?" Dr. Gelber said "Absolutely 100%, I do anyway... it makes sense to me." Patterson queried Cox for more information. Cox said she could see people staying in their home for longer than they currently do if they get more assistance. She talked about being proactive rather than reactive within the community.

"Will the board be paid?" asked another attendee. "How sustainable is it with fluctuations in the population?" Dr. Gelber replied "The model hasn't been developed yet. Just off the top of my head it's pretty hard to get the type of folk you want to run a healthcare system for free. So probably, yes. The model is a population-based funding model, so it is dependent on the number of people you are serving. I guess one would assume that if the population goes down probably demand would go down for the services as well. Having said that, I think there is a base level of funding that is required and just to maintain certain things." He mentioned expenses like utilities, rent, and base staffing. "Those are all costs independent of population. I suppose if our population was to drop enough, that might be at risk." He said that the local population has been stable for more than 10 years.

"It might be initially you have to answer all these questions," said Patterson. "Here we want to identify all those things and make sure they are being addressed at the right level by the people who have the information for informed decision-making care."

Another attendee asked how the project might affect the indigenous population in the area. In response Dr. Gelber explained how the system currently works. "The reserve is funded through the federal government. Any of the services they require through this project is billed through AHS, or Alberta health, and they then invoice the Federal government. Off the top of my head and we haven't explored this, if the population is being funded at $5000 per patient, then it stands to reason that maybe the Feds are billed $5000 per patient on reserve that seeks care here and that's part of the funding that we use. That's just one possibility."

Another attendee asked if $5000 was the limit for healthcare, and should one not go to the doctor, because they may use up their individual fund? Dr. Gelber explained that wasn't how it works. "It's certainly not meant to ration care. When we look at the needs of a population there is a triangle of folks that need care. About 80% of the population falls in this very low cost population. They may see a doctor once or twice a year." He then explained that there are certain people who require intensive healthcare for a short duration, and lastly those with chronic conditions who use the service is quite intensively. "We all currently will subsidize that 1% based on the taxes that we pay and the same sort of thing would happen here. This is by no means a strategy to encourage people not to seek healthcare. You will be cared for in the exact same, if not better manner, with the funding that we have." The woman asking the question queried further, asking if she personally ran past the $5000 which had been mentioned during the presentation would she would then owe the difference. "Absolutely not," said Gelber. "You don't have your own personal budget." Patterson clarified further. "The communication is that there is however many millions for the population. That's the budget. There is no budget by person, there's a population budget. And we wouldn't necessarily have heard that, if it wasn't for these meetings, so thank you."

Another attendee asked if this means that services are charged the same from one facility to the next, as a number of requirements are not being met locally. "Not necessarily," replied Dr. Gelber. Say for example we put you in line and I can tell you right now that a routine MRI is being booked for August or September next year, that's the current status quo." He said they can look at the cost and wait time of the MRI and search for other alternatives. "We might then say 'Well we're going have this person who might potentially be disabled or delayed in their care, but we could pay $800 in a private facility and get it tomorrow'. There may be the opportunity to do that, and expedite care or be able to get you on your recovery journey that much faster, even though it costs a little bit more, we may have that ability to do that." He said this may actually decrease costs in the long run by expediting the individual's recovery journey. "Those are some of the bigger system thinkings that we now have the flexibility to be able to offer." Patterson said this will be invisible to the patient going through services. "This is the Alberta system saying 'Pincher Creek, help us figure this out'. It's not in anyone's interest to gouge Pincher Creek. Everyone wants Pincher Creek to be successful in moving this forward."

Insurance and base level care was another concern raised. Dr. Gelber said patients could expect "the current level of healthcare services that you have come to expect as an Albertan... the baseline remains the same, regardless. Some people have added benefits through third party plans, and those third party plans are outside of this." Patterson pointed out that that is how the system currently works.

Mayor Don Anderberg said recent statistics show that the town of Pincher Creek currently has a relatively young population by Alberta standards. He asked about the current partners and the cost of developing the formal proposal. "Are they willing to put money into the situation to help fund the formal proposal or are you looking for funding from the local jurisdictions to developed this?" Dr. Gelber replied "No one in the local improvement groups so far has the time or ability to create a proposal of this magnitude." He said the HQCA has already suggested a model and are developing a panel of health quality experts from across the country and the province. "They're underwriting the cost of that, that faculty will then take some of the information from here and our other sessions and use that to inform a proposal development." he assured those in attendance "There's no cost to the community for doing that."

Patterson said "I thinking you are getting the sense that we don't have answers, we are here to gather the right questions."

Philippe Francois said he was concerned about inefficiencies, which he said meant waiting for months to have an MRI under the public system, compared to often being seen within days at a private facility. "We are limited by the Canada Health Act in terms of the way healthcare is funded and delivered, we still have to work within those limitations," said Dr. Gelber.

I asked what the timeline for the project was. Dr. Gelber said "We had a meeting with the folks from the Health Quality Council on Friday. To develop a proposal of this scale and magnitude, they're saying it could be as long as a year. That's just for the proposal."

"We see this is coming at the right time when governments are faced with escalating healthcare costs and we have the opportunity to inform that, and informed decisions being made," said Gelber. "This is an opportunity to possibly been part of the solution as opposed to just saying we'll figure it out and having it imposed upon us."

Cliff Elle said there are already a variety of unions and associations that are involved in Alberta healthcare. "Will those associations allow the local group to vary in terms of working conditions etcetera?" Another person asked if Pincher Creek would lose collective buying power by not being a part of Alberta Health Services in the same way. Answers were not immediately available for those questions.

Deputy Fire Chief Pat Neumann asked if funding will be capped at the top $5000 per capita level and if so for how long. Dr. Gelber replied, "This government has declared that the last budget was a 5.8% increase in Health Care. The next year they are committing to a 5% increase, and then 4%, then 3%, and they want to sustain it at 2%... All of those are actually growth budgets not cuts. I imagine funding levels will follow that same sort of thing."

Dr. Gerber at one point explained that a communications strategy will be developed regarding the initiative, possibly involving a website and said that currently questions can be emailed to .

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