April 2017

I’ve been working in Canadian primary health care now for almost 40 years, and it seems to me that while in many ways we’re making progress, in others we keep making the same mistakes.

At the moment our homecare of the frail elderly program is threatened because of administrators’ perception that it is not delivering return on investment, a legitimate business term being used in a completely un-businesslike setting. I should be clear the I say this speculatively because it’s impossible to find out how much of a threat we are under, what kind of changes are proposed or being considered, whether tuning up the cost or the productivity side of the equation would improve things, and how accurate or reasonable the numbers administrators base their decisions on are.

A friend and colleague in the Midwest USA has recently sold a company he started based on principles similar to our homecare of the frail elderly program to a huge US health insurer for dozens of millions of dollars. US dollars. The idea that being available for frail patients 24 hours a day, seeing them at home, forming a relationship of trust with them, having a care plan conversation, and showing up when they are in crisis saves money seems to me founded in common sense. To say nothing of its being better care. Famously venal and hardhearted American business interests get the message, whereas our supposedly kindly and open-handed Canadian managers don’t.

So let me generalize about healthcare management from my experience.

The rare really capable healthcare managers I’ve worked with have an instinct for good clinical work. They form personal trusting relationships with the best clinical people, and include them in brainstorming and planning. When they encounter lazy or incompetent clinical people, they get rid of them. There arises out of this programs that work for everybody.

Sadly more often I see healthcare managers who default to an adversarial attitude with clinical people, presuming like industrial revolution overseers that we are lazy and will minimize work unless kept under threat of sanctions and always being made to feel we aren’t quite doing enough. Out of this kind of thing arises programs fraught with labour-management conflict, dissatisfied clinical people, and blunted outcomes.

These less effective managers substitute numbers for accurate instinct about what works for clinical people but more importantly for patients. Statistics. These are famous for being crystalline and unarguable, but are well known among anyone who has spent any time with them for being plastic and for serving any interest through sophisticated selection.

So it is at the moment with our homecare of the elderly program. An administrator recently emailed me about a related program in the emergency room that the physicians were only 50% effective at identifying and paying attention to proposed family practice admissions. And this, she told me, represented an “opportunity”. My physicians in that program are absolutely 100% effective at identifying those patients and discharging them back to the community if at all possible. The administrator involved has never spent a day shadowing the doctors she is evaluating, and teeters between listening to capable clinical people and making decisions based on numbers that don’t make any sense.

Decisions here, it seems, are based on whichever ill-defined buzzword is turning heads in administrative circles. At the moment it’s called “medical home”. To the extent that there is a definition of that, I can say with confidence that the only program meeting that definition in this city is our homecare of frailty program. But that doesn’t matter. It will be months before I become aware of whatever latest buzz now interests local administration, by which time our program could be gutted and scattered.

It’s enough to make a Canadian long for the economic realities of healthcare south of the border. For all its abuses and expense, at least decision-making eyes are reliably fixed on the bottom line, and where, as we have in home care of frailty, a program can improve care and at the same time save money, American business as they did in my Midwest friends’ case jumps onboard and buys it.

Here we strangle resources, constrained only by yearly budgets and preferring appearance to both economic and clinical reality.

Canadian administrators! Wake up!