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Canada could find itself in the same position if it does not flex its collective muscle.

Instead of developing a real national strategy, most provinces (except Quebec and Newfoundland and Labrador) decided to concentrate only on standalone agreements for very expensive brand-name prescription drugs, through what are called product listing agreements (PLAs).

By choosing to stand alone in the way that they have purchased prescription drugs in the past, provinces collected some crumbs in terms of savings, but they consolidated a system that remains inefficient and inequitable for Canadian workers and patients. It also puts the smaller provinces at a disadvantage because, alone, they will never be able to obtain the same savings from PLAs as their larger cousins.

Every new drug in Canada should be purchased through a national bulk-purchasing agency to maximize savings for the benefit of all Canadians.In fact, the smartest path would be to establish a national drug plan with no deductible or co-insurance payment, which will ensure equity of funding and access to essential medicines for all Canadians.

The provinces will look to expand a collective drug-purchasing plan, set new guidelines to cut the number of unnecessary medical procedures and improve home care for senior citizens. These strategies were on the table Friday as provincial health ministers hunkered down in Toronto for two meetings on overhauling the nation's universal health-care system and wrestling down its cost.

The greatest cost pressure on the system, however, may be the demographic shift and the steady rise in the number of senior citizens requiring chronic care.

The second, chaired by Ontario Health Minister Deb Matthews, focused on dealing with the nation's aging population.

The provinces are also looking at ways to cut back on pricey diagnostic tests and surgeries such as MRIs, knee replacements and cataract removals. After consulting with health-care professionals, they hope to draw up a series of voluntary guidelines, to be presented this summer, on when such procedures are necessary and when they can be skipped.

The provinces will look to expand a collective drug-purchasing plan, set new guidelines to cut the number of unnecessary medical procedures and improve home care for senior citizens. These strategies were on the table Friday as provincial health ministers hunkered down in Toronto for two meetings on overhauling the nation's universal health-care system and wrestling down its cost.

The first session was part of the Health Care Innovation Working Group

The first session was part of the Health Care Innovation Working Group

The second, chaired by Ontario Health Minister Deb Matthews, focused on dealing with the nation's aging population.

Last year, the working group produced a deal that saw the provinces and territories, with the exception of Quebec, team up to purchase six generic drugs in bulk, which resulted in savings of $100-million annually.They want to take a similar approach to buying name-brand medicines. Mr. Ghiz estimated such a plan could save $25-million to $100-million more.

Last year, the working group produced a deal that saw the provinces and territories, with the exception of Quebec, team up to purchase six generic drugs in bulk

They want to take a similar approach to buying name-brand medicines. Mr. Ghiz estimated such a plan could save $25-million to $100-million more.

The provinces are also looking at ways to cut back on pricey diagnostic tests and surgeries such as MRIs, knee replacements and cataract removals. After consulting with health-care professionals, they hope to draw up a series of voluntary guidelines, to be presented this summer, on when such procedures are necessary and when they can be skipped.

The greatest cost pressure on the system, however, may be the demographic shift and the steady rise in the number of senior citizens requiring chronic care.

finding ways to keep seniors out of hospital.

For all the provinces' innovations, however, Mr. Ghiz said they could use more help from Ottawa.

“Hopefully, some day, the federal government will be at the table with dollars and with ideas – we're open

The report concluded, “What the Canterbury experience demonstrates is that it is possible to provide better care for patients, reduce demand on the hospital, and flatten or reduce elements of the demand curve across health and social care by improved integration—particularly around the interface between the hospital, primary care and community services.”

On the contracting side, the report said that the abolition of the purchaser-provider split in the health system was important as it gave boards the autonomy to decide how to fund their hospitals.

BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f5503 (Published 12 September 2013) Cite this as: BMJ 2013;347:f5503

Gareth Iacobucci

There aren’t enough nursing home beds to accommodate the surge of seniors needing care, so home care may be the solution, said Saskatchewan Premier Brad Wall.

The working group, which Ghiz and Wall both lead, is also making progress on lowering the cost of prescription drugs, they said.

Several provinces and territories reached a deal in January to team up when purchasing six widely used generic drugs, which will collectively save them about $100 million a year, Wall said.

They’re also looking at brand-name drugs and will have more to say about it in July at the Council of the Federation meeting in Niagara-on-the-Lake

The provinces have agreements for seven brand-name drugs and they’re negotiating prices for 13 others, said Ontario Health Minister Deb Matthews.

The working group also talked about “appropriateness of care” — ways to make the health-care system more efficient and cut down on soaring costs. “The radiologists in this country have said 10 to 20 per cent of diagnostic imaging is probably not required,” Wall said.

There might be other suggestions from providers, in terms of cataracts

only some of the savings will be reinvested in health care

In other jurisdictions, generic drug purchases are put out to tender, which can lower prices further.

Jim Keon, the president of the Canadian Generic Pharmaceutical Association, said his organization was pleased that the provinces took the bulk-purchasing route instead.

The Canadian Medical Association said Friday's agreement is a good first step, but more needs to be done. "It doesn't really replace an overall pharmacare strategy for the country that would cover a very broad range of prescription drugs," said the CMA's chair, Dr. Anna Reid.

Their trust would be further hit. Within two weeks, the Star reported that health-care companies are allowed to mix drugs for hospitals without federal or provincial oversight, prompting top health officials — Ontario health minister Deb Matthews and federal health minister Leona Aglukkaq — to scramble to close that regulatory grey area.

Since the crisis, all the hospitals involved have stopped outsourcing gemcitabine and cyclophosphamide mixtures and brought it in-house, mixing their own medications.

The federal government has new rules defining who can be a drug producer, adding that any facility supervised by a licensed pharmacist can do the job. The province has said that hospitals can only purchase drugs from accredited suppliers.

The Ontario College of Pharmacists has passed legislation that allows it to inspect any premises where a pharmacist works — not just licensed pharmacies.

All of the changes taken together would have seen Marchese Hospital Solutions still able to supply drugs as it did but subject to inspection by the college.

This week Jake Thiessen, the founding director of the University of Waterloo school of pharmacy, submitted a final report of his investigation into the issue. There has been no formal indication when it will be made public. Hospital administrators say they have been told it will be two to three weeks before they or the public see this report.

There is very little clinical evidence to indicate what might happen to a cancer patient who receives an underdose of chemotherapy.

At the same time, many of the more recent advances in chemotherapy have been in drugs that alleviate side effects like nausea.

In an oncology pharmacy, strange is not good. And on March 20, one week before Marley’s last cyclophosphamide treatment, Craig Woudsma, a 28-year-old pharmacy assistant, and a colleague at the Peterborough Regional Health Centre, had a bad feeling.

In this case, it was a shipment of new gemcitabine chemotherapy bags that required refrigeration, according to the label. Previous batches, from a different supplier, had not.

When preparing the solution, staff at Marchese Hospital Solutions, in Mississauga, Ont., dissolved the medication into a pre-filled 100 mL bag of saline. These bags typically contain between 3 to 20 per cent more solution than 100 mL,

The new bag’s label did not contain enough information for him to accurately mix the patient’s dose. He needed to know the specific concentration.

Woudsma noticed more differences. The bags from Marchese only had a total volume and concentration on the label — 4 grams of gemcitabine in 100 mL of saline — instead of the specific concentration, the amount of drug per single mL of saline, as the old bags indicated.

“I told the pharmacist in the area. And then it kind of went above me at that point ... They came to me saying, this is kind of a big deal; teleconferencing with the minister of health, that kind of stuff,” said recently, sitting on the front steps of his red-brick, semi-detached home in the village of Millbrook, Ont. “It’s kind of a foreign concept, to think that what we do, in our corner of the hospital, is going to get that kind of exposure.”

referred to in the industry as overfill, included to account for possible evaporation.

People have asked Woudsma why he was able to catch a problem that went undetected at other hospitals for more than a year. Simple, he says. He had something to compare it to.

The company’s pharmacy workers did not remove the known overfill when mixing the medication because they thought each bag was going to a single patient

This means that the bag Woudsma was holding contained 4 grams of gemcitabine in more than 100 mL of solution. The concentration of the medication wasn’t what the label would have made him think. It was weaker than advertised.

The hospital had switched that very day to a new supplier — Marchese Hospital Solutions. A bag of the old supply from Baxter CIVA was still on site.

Medbuy, a group purchasing company for hospitals, starting in 2008, had a contract with Baxter Central Intravenous Admixtures to provide drug-mixing services. The two drugs in question, cyclophosphamide and gemcitabine, were outsourced because they come in powder form and are tricky to mix. It takes about four hours to reconstitute them in liquid, and in that time they must be shaken every 20 minutes.

As that contract was about to expire, Medbuy issued a request for proposals for drug-mixing services: Baxter CIVA, which wanted its contract renewed, Quebec-based Gentes & Bolduc and Marchese all stepped forward.

Marita Zaffiro, president of Marchese, testified at Queen’s Park that the Medbuy contract did not indicate the hospitals wanted the labels on these drugs to cite a specific concentration. The reason she included it that way in the RFP was simply to show what could be done.

The details of the new arrangement remain known only to Medbuy. It was founded in 1989 to get better deals for hospitals buying products like scalpels, bed pans and even some medications in bulk. The company’s 28 member hospital organizations in Ontario, New Brunswick and Prince Edward Island spent a combined $626-million on contract purchases in 2012.

Sobel ran the calculations in his office. For a single patient to require a 4,000 mg dose of cyclophosphamide, on a common breast cancer treatment regime, that patient would need to be about 7 feet tall and weigh 2,200 lbs.

“The chance of 1,200 patients getting 4,000 mg exactly — it’s just impossible.”

Four Marchese pharmacists who played a role in the new contract work revealed to the Queen's Park committee in June that they had either limited or no background in oncology.

Marchese Hospital Solutions began as Marchese Pharmacy, a Hamilton-area community drugstore that expanded beginning in 1998 when Zaffiro became president. In 1999 the company obtained a contract to supply the Hamilton Niagara Haldimand Brant Community Care Access Centres, business they did until the contract expired in 2011, shortly before it was awarded the Medbuy contract.

It lost the CCAC contract in 2011, shortly before the Medbuy deal, and shed employees. Fifty-seven were either laid off or left the company during this troubled time, according to internal newsletters. But then things started looking up.

Zaffiro attempted to get accreditation for the site, according to her Queen’s Park testimony, approaching both the Ontario College of Pharmacists and Health Canada, neither of which took steps to regulate the fledgling business because each thought the other had jurisdiction.

Medbuy, Marchese and Jake Thiessen have maintained that cost was not a factor in the error. Marchese’s bid on the request for proposal came in at about a quarter of the cost of previous supplier Baxter Corporation. Bags from Marchese cost from $5.60 to $6.60; Baxter charged $21 to $34.

CEO David Musyj thinks about what went wrong. The problems, he says, go far beyond Marchese and Medbuy. “All of us are culpable,” he says. “We could have done some things internally that could have prevented this. We could have weighed the bags when they came in.”

That's also a key word when looking at the history - and potential future - of the Hamilton Realty Capital Corporation (HRCC). As The Spectator's Steve Buist has reported, HRCC has completed only one transaction in the past nine years - the purchase of the Cannon Knitting Mills property at the corner of Cannon and Mary streets in downtown Hamilton. And that project seems to be going ... nowhere. On the face of it, HRCC seems like a good idea. The city refers to it as a "joint venture" with Forum Equity Partners, an investment and development company based in Toronto. The goal of the partnership was to spur untold millions of dollars in downtown redevelopment, bring neglected properties back to life and, as a result, create new tax revenues to fill the city coffers.

The result? The city has spent or promised millions of dollars since HRCC was formed in 2006. The company is a privately owned subsidiary of Forum. And while the city paid half the $200,000 purchase price for the Cannon Knitting Mills, the property is 100 per cent owned by Forum. The property was purchased by HRCC in 2011. Redevelopment of the contaminated property is stalled; no purpose for the building that would suit a tenant or tenants has been established. The city is collecting fewer tax dollars on the property. Under the 50-50 funding arrangement, the city is also paying half the property taxes - to itself. It is extremely difficult to categorize this venture as a success of any kind, even if one takes the most optimistic of views. The project is costing city taxpayers every year with virtually no return on the investment. The "joint venture" seems tilted strongly in favour of the private partner, yet the city seems to be left holding much of the risk. If there is an upside for the city in this arrangement, it defies discovery. In 2006, the city and Forum Equity Partners struck a 10-year agreement. Next year might be the right time for the city to cut its losses on this venture. Lee Prokaska

The proposed changes were prompted by the recent discovery of under-dosing of chemotherapy drugs supplied by an independent company to four hospitals in Ontario and one hospital in New Brunswick.

Just now in Ontario this arrangement would appear to have hit a wall. Having negotiated a four-year deal offering average annual fee increases of 2.5 per cent, the Ontario Medical Association executive was dismayed to find it rejected by nearly two-thirds of its members, who complain it does not make up for cuts in fees imposed last year. How things should have broken down to this extent need not detain us here. But it does perhaps point to the need to find another way.

Because doctors' fees, as such, are not the issue. To be sure, they are part of the puzzle: at $11.5 billion annually, they are roughly one-fifth of Ontario's health-care budget. But all the hard bargaining in the world isn't going to rescue Canada's health-care system from the fiscal cliff to which it is headed. Much more important than doctors' fees are doctors' decisions, as the gatekeepers dictating how resources are allocated within the system: how many tests are ordered, what procedures are done, and so on.

The problem is that decisions about treatment are too often divorced from decisions about budgets. Governments set a budget constraint at the macro level, which filters down through the various regional health authorities and local health networks the provinces have seen fit to establish. But doctors typically do not: they make whatever they can bill. And the incentives of feefor-service are to perform as many surgeries and other treatments as they can. Absent changes in those incentives, simply capping fees isn't going to change much.

You can see why doctors felt the need to organize. Governments had set themselves up as sole purchasers of medical services. The idea was supposed to be that they could exploit that monopoly power to drive down costs. But it didn't quite work out that way: politicians in need of re-election, it seems, do not make terribly tough negotiators (who knew?). It was always easier to pass the problem on to the next government, or the next generation - or, as federal governments got in on the act, Ottawa. In consequence, health-care spending skyrocketed through much of the 1970s and 1980s.

Traditionally, doctors have been paid per service, while hospitals have been funded on a block grant basis. The key to reform is to turn this around: giving groups of doctors a fixed amount per patient, with which to purchase services from hospitals, clinics and other providers, that is on a per-treatment basis. Paying doctors a lump sum localizes the budget constraint, forcing doctors to take account of costs in decisions on treatment; paying hospitals per service makes it possible for lower-cost competitors to undercut them.

Even in the more recent wave of cuts following the last recession, these have been largely untouched. As documented in a new study by the C. D. Howe Institute

("Hold the Applause: Why Provincial Restraint on Healthcare Spending Might Not Last"), governments have largely resorted to the familiar public-sector strategy of starving the capital account to feed the operating account: while capital spending has been sharply curtailed, physicians' fees have not.

This is not sustainable in the long run - as new doctors enter the profession, and most of all, as the population ages. As it is, provinces are now spending more than 40 per cent of their budgets on health care; by 2030, a recent Fraser Institute paper projects the number will have risen to nearly 50 per cent. Yet wait times continue to mount: at more than 18 weeks, on average, from GP referral to treatment, they are nearly twice what they were 20 years ago.

Clearly the answer does not lie in more money, least of all more federal money: for every additional dollar in federal transfers the Howe study's authors find that provincial health spending increases by 36 cents. But neither is the answer ever stricter doses of austerity - any more than one would improve a car's mileage by putting less gas in the tank. Rather, what's needed is systemic reform, altering the way that public funds flow through the system, and how the different players within it are remunerated.

Only with the onset of the early 1990s recession, and particularly the sharp cut in federal transfers as Ottawa tried to stabilize its finances, was there the first serious effort at retrenchment. But as the fiscal crisis eased, and particularly after the 2004 health-care accord, with its massive 10-year increase in federal transfers, whatever impetus for reform there might have been dissipated. Rather than "buying change," most of the new money went to increases in provider compensation.

In sum, rather than doctors and governments negotiating with each other at one gigantic bargaining table, what we need are lots of little bargaining tables, at which providers can haggle with each other.

Many within the system believe allowing private, for-profit options is a potential solution. Government has always relied on private facilities such as walk-in clinics, X-ray clinics and laboratories to provide insured services within the public system. Perhaps it’s time to allow Canadians to purchase medical services on the open market.

Although a province may have an oversupply of surgeons, it has a shortage of the other disciplines. The hours nurses and anesthesiologists work in the private system would come at the expense of the hours they can devote to the public system.This is a key caveat on the argument in favour of allowing more private, for-profit health care options: it is difficult to create a private tier that does not ultimately weaken the public tier. In fact, it is tough to find examples where increased private options relieve pressure on the public system and reduce wait times.

There is some evidence of this in Saskatchewan, where the government has been allowing private, for-profit MRIs for about 10 months. To date, Saskatchewan claims it has taken 2,200 patients off public wait lists for MRIs. And yet, its wait times in the public system have not gone down.

In fact, during the first six months Saskatchewan allowed residents to purchase their own MRI tests, the government’s own website shows wait times went up.

study published in the journal PLoS One

health care expenditures in Canada are on a steep upward climb

hospitals and governments should look at ways to break down the silos around prescription drug purchasing and dispensing

Substituting the least expensive version of each drug could have saved $1.6 million, or 47 per cent, for PPIs

Medications represent an increasing share of those costs, currently around 16 per cent.

Monthly premiums would have ranged from $235 to $391, even as high as $3,000 under some scenarios, the administration said. At those prices, healthy people were unlikely to sign up. Suggested changes aimed at discouraging enrollment by people in poor health could have opened the program to court challenges, officials said.

“If healthy purchasers are not attracted ... then premiums will increase, which will make it even more unattractive to purchasers who could also obtain policies in the private market,”

Sebelius said the administration wants to work with Congress and supporters of the program to find a solution. But in a polarized political climate, it appears unlikely that CLASS can be salvaged. Congressional Republicans remain committed to its repeal.

While the access agenda has been the central focal point of the 2004 health accord, it is time to have the 2014 health accord focus on quality, of which access is one important dimension, with the others being effectiveness, safety, efficiency, appropriateness, provider competence and acceptability.

we also propose three specific funds that are strategically focused in areas that can contribute to improved access and wait time

Can the 2014 health accord act as a catalyst to ensure appropriate post-hospital supportive and preventive care strategies, facilitate integration of primary health care with the rest of the health care system and enable innovative approaches to health care delivery? Is there an opportunity to move forward with new models of primary health care that focus on personal accountability for health, encouraging citizens to work in partnership with their primary care providers and thereby alleviating some of the stress on emergency departments?

one in five hospital beds are being occupied by those who do not require hospital care — these are known as alternative level of care patients, or ALC patients

the creation of an issue-specific strategically targeted fund designed to move beyond pilot projects and accelerate the creation of primary health care teams — for example, team-based primary health care funds could be established — and the creation of an infrastructure fund, which we call a community-based health infrastructure fund to assist in the development of post-hospital care capacity, coupled with tax policies designed to defray expenses associated with home care

consider establishing a national health innovation fund, of which one of its stated objectives would be to promote the sharing of applied health system innovations across the country with the goal of improving the delivery of quality health services. This concept would be closely aligned with the work of the Canadian Institutes of Health Research in developing a strategy on patient oriented research.

focus the discussion on what is needed to ensure that Canada is a high performing system with an unshakable focus on quality

of the Wait Time Alliance

Dr. Simpson

the commitment of governments to improve timely access to care is far from being fulfilled. Canadians are still waiting too long to access necessary medical care.

Table 1 of our 2011 report card shows how provinces have performed in addressing wait times in the 10-year plan's five priority areas. Of note is the fact that we found no overall change in letter grades this year over last.

The WTA has developed benchmarks and targets for an additional seven specialties and uses them to grade progress.

the lack of attention given to timely access to care beyond the initial five priority areas

all indications are that wait times for most specialty areas beyond the five priority areas are well beyond the WTA benchmarks

we are somewhat encouraged by the progress towards standardized measuring and public reporting on wait times

how the wait times agenda could be supported by a new health accord

governments must improve timely access to care beyond the initial five priority areas, as a start, by adopting benchmarks for all areas of specialty care

look at the total wait time experience

The measurements we use now do not include the time it takes to see a family physician

a patient charter with access commitments

Efficiency strategies, such as the use of referral guidelines and computerized clinical support systems, can contribute significantly to improving access

In Ontario, for example, ALC patients occupy one in six hospital beds

Our biggest fear is government complacency in the mistaken belief that wait times in Canada largely have been addressed. It is time for our country to catch up to the other OECD countries with universal, publicly funded health care systems that have much timelier access to medical care than we do.

The progress that has been made varies by province and by region within provinces.

Dr. Michael Schull, Senior Scientist, Institute for Clinical Evaluative Sciences

Many provinces in Canada, and Ontario in particular, have made progress since the 2004 health accord following large investments in health system performance that targeted the following: linking more people with family doctors; organizational changes in primary care, such as the creation of inter-professional teams and important changes to remuneration models for physicians, for example, having a roster of patients; access to select key procedures like total hip replacement and better access to diagnostic tests like computer tomography. As well, we have seen progress in reducing waiting times in emergency departments in some jurisdictions in Canada and improving access to community-based alternatives like home care for seniors in place of long-term care. These have been achieved through new investments such as pay for performance incentives and policy change. They have had some important successes, but the work is incomplete.

Examples of the ongoing challenges that we face include substantial proportions of the population who do not have easy access to a family doctor when needed, even if they have a family doctor; little progress on improving rates of eligible patients receiving important preventive care measures such as pap smears and mammograms; continued high utilization of emergency departments and walk-in clinics compared to other countries; long waits, which remain a problem for many types of care. For example, in emergency departments, long waits have been shown to result in poor patient experience and increased risk of adverse outcomes, including deaths.

Another example is unclear accountability and antiquated mechanisms to ensure smooth transitions in care between providers and provider organizations. An example of a care transition problem is the frequent lack of adequate follow-up with a family doctor or a specialist after an emergency department visit because of exacerbation of a chronic disease.

A similar problem exists following discharge from hospital.

Poorly integrated and coordinated care leads to readmission to hospital

This happens despite having tools to predict which patients are at higher risk and could benefit from more intensive follow-up.

Perverse incentives and disincentives exist, such as no adjustment in primary care remuneration to care for the sickest patients, thereby disincenting doctors to roster patients with chronic illnesses.

Critical reforms needed to achieve health system integration include governance, information enablers and incentives.

we need an engaged federal government investing in the development and implementation of a national health system integration agenda

complete absence of any mention of Canada as a place where innovative health system reform was happening

Dr. Brian Postl, Dean of Medicine, University of Manitoba, as an individual

the five key areas of interest were hips and knees, radiology, cancer care, cataracts and cardiac

no one is quite sure where those five areas came from

There was no scientific base or evidence to support any of the benchmarks that were put in place.

I think there is much less than meets the eye when we talk about what appropriate benchmarks are.

The one issue that was added was hip fractures in the process, not just hip and knee replacement.

in some areas, when wait-lists were centralized and grasped systematically, the list was reduced by 30 per cent by the act of going through it with any rigour

When we started, wait-lists were used by most physicians as evidence that they were best of breed

That continues, not in all areas, but in many areas, to be a key issue.

The capacity of physicians to give up waiting lists into more of a pool was difficult because they saw it very much, understandably, as their future income.

There were almost no efforts in the country at the time to use basic queuing theory

We made a series of recommendations, including much more work on the research about benchmarks. Can we actually define a legitimate benchmark where, if missed, the evidence would be that morbidity or mortality is increasing? There remains very little work done in that area, and that becomes a major problem in moving forward into other benchmarks.

the whole process needed to be much more multidisciplinary in its focus and nature, much more team-based

the issue of appropriateness

Some research suggests the number of cataracts being performed in some jurisdictions is way beyond what would be expected to be needed

the accord did a very good job with what we do, but a much poorer job around how we do it

the accord has bought a large amount of volume and a little bit of change. I think any future accords need to lever any purchase of volume or anything else with some capacity to purchase change.

We have seen volumes increase substantially across all provinces, without major detriment to other surgical or health care areas. I think it is a mediocre performance. Volume has increased, but we have not changed how we do business very much. I think that has to be the focus of any future change.

It is at these transition points, between the emergency room and being admitted to hospital or back to the family physician, where the efficiencies are lost and where the expectations are not met. That is where medical errors are generated. The target for improvement is at these transitions of care.

I am not saying to turn off the tap.

the government has announced, for example, a 6 per cent increase over the next two or three years. Is that a sufficient financial framework to deal with?

Canada currently spends about the same amount as OECD countries

Many of our physicians are saying these five are not the most important anymore.

they are not our top five priority areas anymore and frankly never were

this group of surgeons became wealthy in a short period of time because of the $5.5 billion being spent, and the envy that caused in every other surgical group escalated the costs of paying physicians because they all went back to the market saying, "You have left us out," and that became the focus of negotiation and the next fee settlements across the country. It was an unintended consequence but a very real one.

if the focus were to shift more towards system integration and accountability, I believe we are not going to lose the focus on wait times. We have seen in some jurisdictions, like Ontario, that the attention to wait times has gone beyond those top five.

people in hospital beds who do not need to be there, because a hospital bed is so expensive compared to the alternatives

There has been a huge infusion of funds and nursing home beds in Ontario, Nova Scotia and many places.

Ontario is leading the way here with their home first program

There is a need for some nursing home beds, but I think our attention needs to switch to the community resources

they wind up coming to the emergency room for lack of anywhere else to go. We then admit them to hospital to get the test faster. The weekend goes by, and they are in bed. No one is getting them up because the physiotherapists are not working on the weekend. Before you know it, this person who is just functioning on the edge is now institutionalized. We have done this to them. Then they get C. difficile and, before you know, it is a one-way trip and they become ALC.

I was on the Kirby committee when we studied the health care system, and Canadians were not nearly as open to changes at that time as I think they are in 2011.

One thing I heard on the Aging Committee was that we should really have in place something like the Veterans Independence Program

some people just need someone to make a meal or, as someone mentioned earlier, shovel the driveway or mow the lawn, housekeeping types of things

I think the risks of trying to tie every change into innovation, if we know the change needs to happen — and there is lots of evidence to support it — it stops being an innovation at that point and it really is a change. The more we pretend everything is an innovation, the more we start pilot projects we test in one or two places and they stay as pilot projects.

the PATH program. It is meant to be palliative and therapeutic harmonization

has been wildly successful and has cut down incredibly on lengths of stay and inappropriate care

Where you see patient safety issues come to bear is often in transition points

When you are not patient focused, you are moving patients as entities, not as patients, between units, between activities or between functions. If we focus on the patient in that movement, in that journey they have through the health system, patient safety starts improving very dramatically.

If you require a lot of home care that is where the gap is

in terms of emergency room wait times, Quebec is certainly among the worst

Ontario has been quite successful over the past few years in terms of emergency wait times. Ontario’s target is that, on average, 90 per cent of patients with serious problems spend a maximum of eight hours in the emergency room.

One of the real opportunities, building up to the accord, are for governments to define the six or ten or twelve questions they want answered, and then ensure that research is done so that when we head into an accord, there is evidence to support potential change, that we actually have some ideas of what will work in moving forward future changes.

We are all trained in silos and then expected to work together after we are done training. We are now starting to train them together too.

The physician does not work for you. The physician does not work for the health system. The physician is a private practitioner who bills directly to the health care system. He does not work for the CEO of the hospital or for the local health region. Therefore, your control and the levers you have with that individual are limited.

the customer is always right, the person who is getting the health care

It is refreshing to hear something other than the usual "we need more money, we absolutely need more money for that". Without denying the fact that, since the population and the demographics are going to require it, we have to continue making significant investments in health, I think we have to be realistic and come up with new ways of doing things.

How do you help patients navigate a system that is so complex? How do you coordinate appointments, ensure the appointments are necessary and make sure that the consultants are communicating with each other so one is not taking care of the renal problem and the other the cardiac problem, but they are not communicating about the patient? That is frankly a frequent issue in the health system.

There may be a patient who requires Test Y, X, and Z, and most patients require that package. It is possible to create a one-stop shop kind of model for patient convenience and to shorten overall wait times for a lot of patients that we do not see. There are some who are very complicated and who have to be navigated through the system. This is where patient navigators can perhaps assist.

There have been some good studies that have looked at CT and MRI utilization in Ontario and have found there are substantial portions where at least the decision to initiate the test was questionable, if not inappropriate, by virtue of the fact that the results are normal, it was a repeat of prior tests that have already been done or the clinical indication was not there.

Designing a system to implement gates, so to speak, so that you only perform tests when appropriate, is a challenge. We know that in some instances those sorts of systems, where you are dealing with limited access to, say, CT, and so someone has to review the requisition and decide on its appropriateness, actually acts as a further obstacle and can delay what are important tests.

food that accounted for nearly half (43 per cent) of its $194 million spending in 2011/2012

A year after it was created, the Lower Mainland BISS contracted out patient food services and house cleaning operations, both to Sodexo

10-year, $330-million agreement

Sodexo is responsible for conducting audits and surveys

a 2008 independent survey of patient experiences in acute care across all VCH facilities reported a dismal 52 per cent for "overall quality of food"

The glowing audits had been done by Sodexo's own kitchen staff

getting awarded these contracts is very competitive. Providing recipes opens the door to determining food costs and therefore profits.

Nor does Sodexo reveal its suppliers for specific clients.

there's zero accountability,"

"There's no traceability

"There's a reason why hospital food feels like it's sort of a last frontier in the good food movement. And I think it is in part due to the fact that it is the place where some of the stickiest, deepest, dirtiest corporate contracts exist."

in 2011, Sodexo paid $20 million to settle an accusation of fraud levied against it by the state of New York.

former Sodexo managers turned whistle-blowers, claimed that the company had pressured its suppliers for huge "off-invoice" rebates that were never shared with its clients.

The New York State Attorney General's office investigated, and found that Sodexo had in fact failed to disclose supplier rebates it received, and to pass the savings on to state facilities, including a treatment centre for at-risk youth and a service organization for developmentally disabled children, as its contract required.

Sodexo has "vendor discount agreements;" discounts on based on large-volume orders. "But there is nothing in our contracts to say that clients are entitled to that,"

Vancouver Coastal Health has actually reduced the reporting it requires from Sodexo. A Freedom of Information request showed that VCHA does not collect food purchase records from Sodexo, an item of information the original contract required.

Neither are there any records available for patient tray audits.

"While this documentation is indeed a requirement in our agreement with Sodexo, it is one that we ourselves have waived."

"patient food user committee." VCHA's 2004 contract with Sodexo stipulated that each of its facilities would set up such a body to provide ongoing patient input and feedback.

UBC Hospital never created the envisioned committee to seek patients’ views

It is not wrong for cities to care for their employees. But leaving these costs to the cities makes about as much sense as requiring every homeowner to maintain the roads and infrastructure surrounding their properties. Just as would happen if infrastructure were left to individual homeowners, the system that leaves drug coverage to individual patients and employers - including cities - creates an unco-ordinated patchwork. Most cities provide coverage, but some can't afford to. Some workers qualify for coverage, but some don't.

The same pattern plays out in cities, hospitals, schools and businesses across the country. As a result, millions of Canadians are without drug coverage and one in 10 Canadians cannot afford to fill their prescriptions. This patchwork is inequitable and profoundly inefficient because it fails to place responsibility for drug coverage and costs with the right level of government.

Provinces and the federal government are responsible for Canada's health-care system. They are best suited to manage access to medicines as an integral part of health care for all Canadians. They are also best positioned to reduce waste and overspending on pharmaceuticals. Having multiple drug plans operating in every province - including multiple private plans for public-sector employees - needlessly duplicates administrative costs. This fragmentation also diminishes Canadians' purchasing power on the global market for pharmaceuticals. Provincial governments wield about $10 billion in purchasing power when negotiating rebates for prescription drugs. This reduces public drug-plan costs by millions of dollars, but it does not lower costs for cities and other organizations that insure their workers through private drug plans that are minuscule in comparison. No matter how hard they try, cities would have about as much chance of negotiating competitive drug prices as homeowners would have of securing the best prices for infrastructure planning, engineering and construction.

Some things are best done through well-planned, population-level procurement processes. A recent study in the Canadian Medical Association Journal shows how a universal public drug plan run by the provinces could provide all Canadians coverage for prescription drugs while saving taxpayers $7 billion per year. Such a program would end the downloading of prescription drug costs to local governments and thereby allow cities to better address problems like traffic, housing and crime.

The federal and provincial governments should take responsibility for our prescription drug problem by implementing universal pharmacare for all Canadians. Doing so would support the health and wellbeing of public-and private-sector workers alike at far lower cost than Canadians are paying for our disorganized, patchwork system today. Steve Morgan is a health policy professor at the school of population and public health at the University of B.C.