Should Health Reform in New Brunswick embrace any of the elements of U.S. healthcare?
It is Friday, 4 p.m., the chest infection that you have nursed for a week is not getting better and has you weak and sick. You call your family doctor’s office; a recorded message says “call telecare, go to an afterhour’s clinic, or go to the Emergency Department.”
None of those is a good option that will lead to optimum care. A common outcome from a call to Telecare is that at the end of the call there is encouragement to go to the Emergency Department. When that advice has been heeded, what could take 10 minutes of professional time has always taken many, many hours. Sitting in a waiting room when I should be home in bed with prescribed medical therapy is not an attractive option.
Presentation at an After Hours clinic will possibly get you medical care, but each operates differently, some with a “wait and take your chances”, others where you call to make an appointment, while still others require you to go to the clinic in person to get your name on the list after which you may be seen a few hours later. And in no case does the after-hours clinic have access to any of your records, particularly of medications you may be on or to which you may be allergic, or, better still, what antibiotic worked for you the last time!
In writing this column, I am working from an office in Augusta, Georgia where I see Prompt Care, Primary Care, and Urgent Care usually within a 5 minute drive of my office! And when you go to Urgent Care with flu-like symptoms or other symptoms, the receptionist calls up our records from the hospital on the computer and can tell right away what hospital and emergency visits you have had, what clinical interventions you have had, results of diagnostic tests. You can get routine lab testing on the spot along with some imaging scans. You can be out and back home with any essential medications within an hour!
Each of these facilities, including Emergency Departments, advertises time to wait and Time to Care, the latter being the measure of efficiency. Each facility seems to take great pride in the lowest possible “Time to Care”. Why is that?
Unlike the New Brunswick urban system, the method of payment to physicians and clinics is dependent on customer (patient) satisfaction; as with buying cars or fast food, there is a doctor and patient financial relationship that recognizes that while the service provider has time pressures, so do I as the patient. I need to get home to heal; I need to get back to work as quickly as possible.
This is a sharp contrast with the semi-socialized system that seems to direct primary care in New Brunswick. In our system, we have the blessing of not having to worry about whether there is a co-pay charge or whether our insurance has somehow lapsed or whether the treatment is covered. Most of what we need for life sustaining care is available with the presentation of the Medicare care.
In our system, we are patients but there is no buyer-seller relationship; strictly doctor-patient, professional, mysterious, wonderful in many ways. But the waiting times, the delays, the inability to see our records, the inability to check diagnostic test results. This is 2020 and New Brunswick is supposed to be an IT leader……but not in health.
My friends in Augusta have access to a portal at which they can obtain on the internet their full hospital medical record, results of diagnostic tests including lab results. And a new resident in the area can find a family doctor pretty much the same day. And the discovery of a bad gall bladder can be fixed on the same day as its discovery!
That all costs money, my critics will say. That undoubtedly is true but more importantly it requires understanding that service providers have their first duty to their customer, the patient. Jim Sinegal, founder of Costco, makes the point that organizational success in dealing with customers is all about culture. That is why employees happily remain with Costco for years when other retailers experience turnover.
Then it requires vision of a system that places the interests of the patient at the centre and builds services and systems that ensure efficient and effective care. It also requires a commitment to putting the people with the best training, experience and skill in charge of essential programs.
We could build these patient-centred systems in New Brunswick. It will never happen as long as we keep violating the key principles that make the system patient-centric. When all is said and done, what makes this system so much more efficient is customer focus whereas in New Brunswick, until now, our system has largely been driven by the convenience of service providers. This relates to office hours, access to care, weekend care both in the community and in the hospital. Every service provider needs to start their work day by asking one simple question: if I were treating my parents today, how would my service be different?
In using the American health system analogy, we get immediately to the issue of cost and certainly when we hear tales of six figure invoices for what we deem to be routine surgery that is sobering. And when we hear about the large number of “charity cases” and persons without coverage that too is sobering. Just adopt the principles and apply them to New Brunswick.
For instance, the first thing that I learned many years ago studying some excellent centres is that the physician community plays a huge role in governance! By having physician and nursing leaders embedded in the governance structure, or even leading it, there is a better than average chance that policies and strategic directions of the organization will go down better with the professional community.
Another key element is reliance on efficient information systems, driven in the US by the critical billing system. Being able to get access to records and test results on line is huge.
The focus on getting patients processed efficiently with a minimum of delay is another feature that requires physicians and administrators to work very closely together. Both benefit because of the way the system is financed whereas in Canada the compensation and reimbursement models tend to present a wedge between physician practice and hospitals.
Another stunning feature is that staff functions at full scope of practice: LPNs, RNs, Nurse Practitioners, Nurse Anaesthetists, Family Practice Nurses and more. This stands as a serious contrast with New Brunswick where rivalries, inter-professional angst still is strong. This feature alone is a great roadblock to patient-centred care.
In examining other health systems, the Organization for Economic Cooperation and Development ranks the US and Canadian systems as the lowest amongst 10 western world countries. So we would not want to blindly parachute elements of one system over another. We should, however, have the courage to acknowledge that for all of our excellence in New Brunswick we can be so much better for our patients by doing some things that other systems have already shown to be effective. That starts with putting the patient at the centre and building programs around them, not around the convenience of service providers.
Ken McGeorge,BS,DHA,CHE is a retired veteran health care CEO, part time consultant and columnist with Brunswick News.
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Ken McGeorge, BS,DHA,CHE is a career health care executive based in Fredericton, NB, Canada.