I recently attended a briefing of Ontario health system stakeholders by representatives of the famed Kaiser Permanente Health System, often called America’s leading nonprofit integrated health plan. Kaiser Permanente representatives are regularly invited to Ontario to provide advice (and maybe hope) to the rest of us that health system reforms could produce the same sort of high quality, lower cost (at least by US standards) integrated health system that Kaiser has become known for.
I listened with a mixture of envy and suspicion. Envy at things like a sophisticated IT platform which gives Kaiser providers 24/7 access anywhere in the country to the same comprehensive electronic health record.
And suspicion, wondering about how different Kaiser’s insurance paying and/or employed population of patients is from the Ontario population (they must be better off? better educated? younger?). But according to Kaiser, the demographics of their insured clients are pretty similar to those of the general American population.
Yet as I listened to one of the Kaiser doctors describe the benefits of working within a strong integrated system of care – the emphasis on teamwork, the feedback on practice performance, peer comparisons and accountability for the work they do – it struck me that he did not sound much like a prototypical American doctor (or Canadian one, for that matter). And, in response to a question about that, he admitted that Kaiser’s doctors probably aren’t typical of the average US physician.
Many doctors (American and Canadian) are reluctant, fearful or downright hostile to working in a system that limits doctors’ freedom to practice as they see fit, that regulates things like work hours and vacation time, and that makes them accountable for the quality of the care they provide to their patients. So, Kaiser does the sensible thing: it attracts and hires doctors who are aligned with their vision and way of doing things, and, if (or when) the fit turns out to be poor, a parting of ways between doctor and Kaiser is always an option.
However, in Ontario things are different. If the Ministry of Health, or a LHIN, or a hospital implements a particular policy, they have to work with a diverse population of doctors who will welcome the new agenda with variable degrees of enthusiasm ranging from rapt support to denunciations of socialist medicine, and a medical association (Ontario Medical Association) that will defend individual physician autonomy even while sometimes supporting innovative policy initiatives. And in Ontario, when the fit is poor, a parting of ways between physician and Ministry of Health isn’t an easy option.
Kaiser Permanente has been around for 69 years, longer than even Medicare in Saskatchewan. Today it insures about 9.5 million Americans, in 37 hospitals across 8 states primarily on the west coast and the District of Columbia. Independent rankings rate them as providing excellent quality health care at lower cost. So why is it that after so many years such a successful system covers only about 3% of the US population, while Canada’s Medicare covers close to 100%? Kaiser has carefully expanded over the years, though in a few states it failed and pulled out. Why this happened I don’t know, but the mere fact that Kaiser can pull out of a region where it can’t operate successfully illustrates another difference: our universal health system can’t slowly expand or pull out of geographic regions where care cannot be delivered cost-effectively, it must cover the entire jurisdiction, all the time, regardless of the challenges and costs that entails.
We should look to systems like Kaiser for inspiration, and there is no doubt we have much to learn from integrated health systems in the US and elsewhere. But understanding key differences between our systems and the key enablers will make it easier to identify which lessons hold the most promise for Canada.