November 5, 2014

The First Challenge for the New Quebec Government

by Ghislain Gauthier, Director

Phillippe Couillard, the new Quebec Premier, made wise choices and smart decisions during the election campaign. It was not about making bold promises or adopting a flashy style. Using his doctor’s demeanor, the austerity treatment proposed to the Québec population contributed to his winning the election.

Among the wise decisions he made, having a strong team of new Liberal candidates responsible for health care the economy and health care weighed in the balance. Without much suspense, Premier Couillard selected Gaetan Barrette as the new Health Minister. M. Barrette, a radiologist by profession, was, until the election, the President of the Québec Association of Specialists.

The first challenge of the new Health Minister will be to find ways to cut health care expenses. The Québec budget has reached a $3.1 billion deficit and is projected to be $3.7 billion in 2014. The ask, in terms of the target budget reduction from the Ministry of Health, is $900 million. There are ongoing discussions with key players in the health care system to explore solutions. One solution is to ask Québec specialists and family practitioners to stretch the agreed upon salary adjustment over a longer period of time than the period negotiated. Ironically, as head of the Québec Specialists Association, Mr. Barrette negotiated the last salary adjustment with the previous Health Minister, Philippe Couillard.

The Health Ministry will also be looking at different funding reforms for hospitals. The Government of Quebec asked a group of experts to propose a plan for the implementation of an activity-based funding (ABF) system for the hospitals and a system for the management of chronic diseases. Following a two-year-long consulting process with various stakeholders in the province and abroad, the expert committee presented their recommendations to the Health Minister last February. Due to the election, this document was put aside, but it is expected to be considered by the new government. Here are the highlights:

1. Access to Surgical Services

This program was set in 2004 and has shown progress since implementation, but there are still significant differences between regions. There are no quality metrics in place, and the pro- gram is not well understood by clinicians or by those managing the program regionally. Recommendations include: *Tracking quality metrics, including readmission rates and infection rates *Monitoring wait times *Expanding the ABF program to cover 150 additional surgeries *Increasing hospital targets to an average of 1,000 surgeries, yearly

2. Funding Based on Quality of Care Using Best Practice Guidelines

In 2008, the Québec institute of public health noted that there were significant quality discrepancies in colorectal cancer screening. In 2010, the College of Physicians drafted best practice guidelines and quality metrics that were implemented as a pilot project at eight sites. There were also financial incentives to decrease wait times. Overall, the pilot project allowed the hospitals to generate savings by means of greater efficiency. The next stage is to extend this program to all hospitals running an endoscopy program. Based on the learning and outcomes of the pilot project, the program will select four to six procedures every year and the same process will be implemented with them. Funding will be based on each hospital’s quality of care and volume metrics.

3. Funding the Management of Chronic Care Diseases

Based on a UK program “year- of-care” and the Ontario Action Plan for Health Care, a new Québec plan is proposing funding that follows patients treated for multiple chronic diseases. The concept is to engage greater interdisciplinary collaboration between all health care professionals involved in care. Funding will be based on patient conditions and desired outcomes. Unlike the two other initiatives, this project is starting from scratch and the journey to a wide provincial implementation is a long-term goal.

Changing the way acute care medicine is delivered will require a great deal of engagement from everyone involved. This means imposing best practices, treatment, and guidelines on all health care professionals involved. Such increased controls will not be well received by highly- skilled professionals. Good change management programs will be crucial.

The five year plan is very ambitious in some respects. In the context of budgetary constraints, this funding reform is meant to provide greater efficiency while minimizing the impact on the Québec health care budget. At best, cost neutrality would be a great achievement. The experience of other countries has shown that, despite all good intentions behind these types of reforms, there are failures (and possibly some disasters). The premise is that funding should follow the patient. This will require a significant shift in the mindset of health care professionals and all those who will administer the reform. Bureaucrats, technocrats, and health care professionals don’t always dance well together. It is all about accountability. This funding reform will be challenging the traditional ways of delivering health care.

This article was originally published in Canadian Pharmaceutical Marketing June/ July 2014.