Post-Pandemic Transformation of Healthcare Delivery in Provinces and Territories

As I write this, positive signs regarding the pandemic are beginning to affect our daily lives. We are now able to meet with our extended families, friends and neighbours. For many people, these changes signal the end of isolation, fear and loneliness and harken a return to normal life and behaviours.

Changes are now also appearing in the healthcare sector. Long-term care homes have been reopened to families and visitors. Homecare visits are returning to their pre-pandemic levels, and hospitals have restarted all elective surgeries.

We should celebrate the fact that the delivery of acute and emergency healthcare carried on throughout the pandemic. With some exceptions, cancer-related care continued throughout, trauma care was available and dialysis continued. This occurred even as the focus of governments, organizations and individual providers shifted to the pandemic's effects on physical and mental health.

Many new policies, procedures and physical spaces were used to deliver healthcare during the COVID-19 pandemic in order to provide critical care and lessen the risks of transmission within healthcare organizations and among providers, patients, their families and the community. As reopening unfolds, some of the significant challenges facing the federal government, provinces and territories are these: What new practices and behaviours should be retained in the post-pandemic era? How will the changes be paid for?

Competing Options for Healthcare Delivery

It is not yet clear how the pandemic has impacted current federal, provincial and territorial healthcare budgets. While healthcare is already a significant component of provinces' and territories' economies, the guess is that healthcare spending has jumped substantively.

For the healthcare sector, the short-term focus will be on provincial and territorial governments' actions and what they signal as their new-normal state for healthcare delivery.

I think that the policy-making window is open and many important decisions regarding healthcare delivery are going to be made in the near-term. In the interim, provincial and territorial governments, their ministers and deputy ministers of health will be the recipients of competing views on healthcare policy from the public, advocacy groups, government experts and health system researchers. For instance, one policy trade-off for which provincial governments could solicit input includes the following: Should long-term care be redesigned or should provinces and territories focus on reducing surgical backlogs caused by the COVID-19 pandemic? Both options are important, very expensive and compete for the same healthcare budget.

Emerging from a pandemic, the public voice will be particularly raw. This includes long-term care residents and families that have endured exceptionally difficult circumstances. The voices of patients and families should, and will, shape some governments' budgetary priorities for healthcare services.

Advocacy groups also provide provincial and territorial governments with input into potential changes in healthcare services and policy. Many advocacy groups play an important role in the health sector by representing oft-overlooked subgroups particularly disadvantaged by the pandemic. Their input ranges from minor policies – such as proposing new physician billing codes – to more major and expensive policies, such as staff's skill sets and scopes of practice in long-term care homes.

In some provinces, governments have nurtured in-house expertise in health system analyses. This pool of expertise will be critical in providing governments with spending and utilization models and projections. These outputs will constitute options for post-pandemic health policies. However, provinces or territories that have hollowed their internal expertise over the years will find themselves needing help and will need to either hire consultancy services or risk making expensive mistakes.

Lastly, health systems research is also used as one input into the government's healthcare policy options. However, careful research often requires years of data collection and interpretation – a lag that is too long to inform contemporaneous post-pandemic policy making and spending decisions. Complicating this perspective is that many health systems researchers have followed the money and pivoted to COVID-related research themes, thereby lessening the pool of available talent to generate non–COVID-related policy research.

Strengthening Long-Term Outcomes

New post-pandemic healthcare policies will have important consequences for healthcare delivery and spending. For each change in healthcare delivery models, the federal, provincial or territorial governments will have to pay for new treatment modalities and healthcare facilities or codify COVID-induced changes to practice. Good spending decisions by governments will maximize the value of new spending each policy generates. Poor investments may saddle provinces and territories with legacy programs and services that they cannot rid themselves of, thereby robbing value from future healthcare services.

To reduce the risk of poor investments, there are practical – and relatively inexpensive – steps that can be taken. Comparative data regarding the value of competing policies are needed: What is the health and quality of life that will be generated? Whom do the benefits go to? What are the costs and what other contextual information is needed to inform the government's decisions? This information may transcend traditional age- and sex-based analyses and encompass new budgetary analyses that include gains in employment status or situational vulnerability.

To generate these key insights to inform government policy makers, two key ingredients are needed: data and expertise. When it comes to the former, comprehensive health and social care data should be made more available as soon as possible with fewer encumbrances as currently exist. Regarding the latter, federal, provincial and territorial governments should target funding to policy-relevant health systems research as soon as possible.

The availability of comprehensive and timely data and the engagement of experts are needed to provide evidence-informed options for governments and complement other channels of input. As the window for policy change is at least partially open, this is the time for federal and provincial government action. Federal, provincial and territorial government investments are needed to support health systems research whose objectives are to provide policy options that avoid costly mistakes.

In This Issue

This issue of Healthcare Policy is led by a Discussion and Debate article addressing the COVID-19-induced challenges of engaging with patients. The article by Sayani et al. (2021) describes how the pandemic put a halt to the health system's engagement with patients, arguing that the health system's reopening provides an opportunity to focus on patient-identified priorities and a diversity of perspectives. For researchers and policy makers, the authors conclude by listing a number of attributes to use for engaging with socially marginalized groups and reducing health inequalities.

The Discussion and Debate article is followed by a rejoinder enhancing the discussion of the role of patients in engagement and partnership. Shaw et al. (2021) contend that the perspective of patients alone is not sufficient; the article posits that the perspectives of local communities are needed to provide input into the structure and processes of their health systems. The rejoinder concludes by advocating that “communities” should co-lead health system design in order to reduce inequities in health.

A second Discussion and Debate article focuses on the issue of medical malpractice insurance in provinces and territories. The article explains that the Canadian Medical Protective Association (CMPA) is a fund primarily dedicated to defending physicians against patients' and their families' lawsuits. Describing how the provinces and territories subsidize the CMPA premiums used to defend physicians, Lee et al. (2021) note that less than 0.3% of claimants have ever received compensation. The article concludes by advocating for significant reforms to the tort-based medical malpractice system.

Echoing the structural inefficiencies and expenses of the current system articulated by Lee et al. (2021), the rejoinder authored by Nelson (2021) adds to the topic of medical malpractice reform. This article argues that a no-fault system as a replacement would likely improve access to compensation, but would not address underlying issues of safety, appropriateness or accountability in healthcare, which are important to many patients. The article concludes that the current tort-based system needs reform, though further exploration of incentives including blended models may lead to a preferable balance between patient compensation and physician accountability.

In a Data Matters article, Aggarwal et al. (2021) describe the attributes of family physician data across provinces and territories. The authors detail that there is no national source of family physician data that includes the distribution of or comprehensively describes the practice characteristics of family physicians. The authors note that while there are over 20 sources of information on family physicians, none are sufficiently comprehensive or granular to support detailed workforce planning or detailed health systems research. The article concludes that strong federal leadership, support and funding are needed to develop a reliable data infrastructure for family physicians, complementary to other pan-Canadian data standards.

In Research Papers, Ogundeji et al. (2021) present the results of an Alberta-based, qualitative study of specialist physician incentives and payment models. As physician compensation models have remained static for decades, with some minor exceptions, this study reported on respondents' perspectives regarding alternative models. The results showed that blended fee-for-service and salary-based models may be more preferable to the health system in order to improve the value of physician services – when accompanied with suitable accountability mechanisms to measure value and quality. The study concludes that blended remuneration models are feasible for specialist physicians, and possibly preferred by specialists; however, legislative changes and new partnerships are required.

The next article in Research Papers presents the results and implications of the rapid adoption of telehealth in primary care clinics in Quebec during the COVID-19 pandemic. Based on an anonymous cross-sectional survey of teaching primary care clinics, Breton et al. (2021) reported that telephone-based consultations experienced the most significant increases in utilization, exceeding video consultations. The authors also reported that telephone-and video-based consultations limited the ability to collect relevant clinical information, potentially causing duplication of tests or services. The article concludes by identifying a number of important issues left to be addressed by policy makers, including telehealth training for physicians or allied healthcare providers and potential inequities in patients' access to technologies.

The focus of the third article in Research Papers is alternative level of care in Ontario. Alternative level of care is a perennial problem for all provinces' hospitals, with many hospitalized patients occupying beds that do not need the technologies or skilled care provided in acute care. Written by Nauenberg (2021), the article discusses the feasibility of Ontario following other jurisdictions in making use of empty residential spaces to temporarily house alternative level of care patients. Describing Ontario's regulatory, training and policy barriers to moving in this direction, the article concludes that novel health services and policy approaches are needed for the serious problem of alternative level of care.

The final article of this issue describes the implementation of the hub-and-spoke model for coordinated and integrated care for medically complex children in Ontario. Authored by Lin et al. (2021), this qualitative study of an implementation model reported strengthened communication between acute, specialty and community care, and improved family relationships. However, the study also reported challenges in overcoming fragmentation and resourcing dedicated social care workers, nursing support or mental health providers. The article concludes with a number of recommendations for other provinces to improve health and social care for medically complex children.