Abstract
that the definition of insanity is when we continue to do the same thing over and over and yet we expect a different result.
Albert Einstein
With the Trump administration discussing how to repeal the Affordable Care Act (i.e. Obama care), we thought it was a good time to provide an alternative approach. For the past 150 years, Western healthcare has been physician-centric and yet healthcare costs continue to escalate and the quality of health has either remained unchanged or in some cases has decreased. This commentary is not to diminish the importance of physicians in delivering quality and affordable healthcare, but to provide an alternative, where a team of health professionals such as pharmacists, dietitians, nurses and nurse practitioners among others are utilised to their full potential and capabilities by working in a complimentary fashion with physicians, to deliver high-quality healthcare at affordable and potentially lower costs. The success of such an approach is predicated on defining overlapping professional scopes of practice, and developing interprofessional practice standards and collaborative practice models with the patient and family at the centre. 1
In 2010, the Ontario Provincial government under the leadership of Premier Dalton McGinity commissioned economists from the Toronto Dominion Bank to analyse the Ontario healthcare system. This group of economists, from a purely economic perspective, concluded that the Ontario government could save hundreds of millions of dollars in healthcare costs without diminishing, and in some cases enhancing, the quality of healthcare delivered by utilising all health professionals to their full potential.
This report addresses the utilisation of all health professionals to their full scope of practice in effective collaborative team-based models could decrease unnecessary hospitalisations and prevent inappropriate emergency room visits by practising preventative proactive healthcare interventions before they escalated out of control, thus decreasing the burden on healthcare institutions and freeing up physicians to deal with the more serious and acute healthcare problems.
The Canadian and international experience (i.e. Australia and the United Kingdom) suggests that re-allocating functions from physicians to non-physician health professionals, and notably pharmacists and nurse practitioners, can accomplish the dual aim of improving access to healthcare and increasing patient satisfaction. Since the introduction of nurse practitioners has typically occurred within established physician practices or in remote under-serviced areas, it has not led to lower overall system costs.2,3 However, if these changes were made in conjunction with the move to new modes of organising and remunerating physician practices, there could be greater scope to capture potential savings. A recent Irish study concluded that creation of positions for autonomous advanced practice nurses (including nurse practitioners and clinical nurse specialists) was associated with improved case management, stronger collaborative decision-making, reduced readmission rates, reduced waitlist times, positive relationships with physicians, smoother transitions for patients and families within the healthcare system, improved continuity, a strengthened patient and family focus and improved patient satisfaction. 4
There is strong evidence internationally regarding the cost-reducing potential of giving pharmacists a stronger role in prescribing, especially within the context of healthcare teams.5,6 What’s more, there also appears be to significant potential for technologists with special competencies to carve out parts of physicians’ roles and responsibilities.
The potential for Ontario’s healthcare system to take advantage of so-called ‘care-shifting’ or ‘care sharing’ over the next several years is likely to be constrained by the supply of healthcare practitioners. Accelerating recent efforts to lift remaining barriers to immigration and foreign credential recognition as well as supporting programs targeted at immigrant talent could help to increase the healthcare workforce fairly quickly. The Province has made headway in addressing the physician side of the equation in recent years by funding increased enrolment at existing medical schools and establishing a new facility in Sudbury.
The passage of Bill 179 (the Regulated Health Professions Act) in Ontario in 2009 and Bill 51 in Saskatchewan in 2015 marked a significant step towards expanding the scope of certain regulated non-physician healthcare professions in treating patients. In particular, nurse practitioners are now able to perform ultrasound and other energy diagnostic tests, communicate a diagnosis to a patient and prescribe drugs that are designated in the regulations. Pharmacists are now permitted to prescribe certain medications, with the definition of ‘pharmacy’ widened to include remote dispensing locations. Still, since the regulations are pending, there remains a question mark as to how far the government will go in re-allocating functions.
This strategy would actually benefit physicians, freeing them up to utilise the full potential of their training and expertise to treat the serious/acute life-threatening conditions while other members of the healthcare team dealt with non-life-threatening conditions and manage chronic illness, preventing such situations from escalating to more serious conditions. Higher quality healthcare at an affordable price is a right all should have.