Restricting drugs no cure for costs?
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- Created on Thursday, 13 June 2013 01:53
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On June 10th, Geraldine Vance, the chief executive officer of the British Columbia Pharmacy Assocation, wrote an Oped in the Vancouver Sun titled "Restricting drugs no cure for costs". The article below is a rebuttal.
On June 10th, Geraldine Vance, the chief executive officer of the British Columbia Pharmacy Assocation, wrote an Oped in the Vancouver Sun titled "Restricting drugs no cure for costs". The article below is a rebuttal.Vance paints a rather simplistic and one-sided story regarding the (rising) costs of health care and the cost of prescription medication in particular.
Her key point was that although New Zealand may have reduced spending on pharmaceuticals that may not be the way we should go. Vance cites as reasons that the New Zealand approach restricts choice, that it is a complex issue, and that there may be negative health and cost effects. The problem is that Vance does not substantiate any of her opinions and while I appreciate Vance for starting this important discussion I think a bit (actually a lot) of context is needed.
Those are the opinion pages (in the Vancouver Sun), however we cannot have a good discussion without facts and data.
Since Vance uses New Zealand as an example of how we maybe not should try to reduce spending costs, let’s have a look some key facts on Canada and New Zealand. How much do we spend on pharmaceuticals and Health Care?
The total expenditure on pharmaceuticals and other medical non-durables, per capita in US$ purchasing power parity in 2010, provided by the OECD , for Canada was $740.7. For New Zealand it was $285.4 and the average for all OECD covered countries was $494.5.
Looking at how much countries spend per capita on health care without looking at health outcomes is kind of useless. Since Vance mentions the aging populations let’s have a look at how Canada and New Zealand compare for “Life Expectancy at age 65”. In other words, for people who are currently 65, how many more years can they expect to life, on average of course. For Canada the numbers for 2010, are, 18.3, 21.5 and 19.9 respectively for males, females and the total population. For New Zealand the numbers are 18.8, 21.2 and 20.
And finally let’s have a look at the perceived quality of health. The last year for which data is available for both countries is 2007. The percentage of the population, aged 65 years old and over who report their health to be 'good' or 'better', was, in 2007, 74.5% and 83.2% for Canada and New Zealand respectively.
In other words while spending only just over a third of what Canada spends on medications life expectancy and perceived quality of health is higher in New Zealand. I am the first to admit that there are many factors that influence these factors but it makes one think when Vance says: “The way to control the total cost of drugs and deliver best health care results is with a comprehensive approach to patient care, not just one that counts the pennies of drug costs”. Maybe pinching pennies has given New Zealand the budgetary room to improve the health care system elsewhere. Who knows?
Since Vance tries to make the point that withholding choice of medications and non compliance of medication may have a negative cost effect on the health care system it is only fair to look at the total health care spending for both countries. On a per capita basis Canada spends $4445 and New Zealand $3022. The OECD average is $3265.
Secondly I will comment on a few statements Vance makes.
In the 5th paragraph states that the restrictions imposed on patients, physicians and pharmacists in New Zealand, most British Columbians would find unacceptable. She never explains why. Surely if you posit it as a limitation of freedom without looking at the benefits of the restrictions most people in BC would oppose it. If on the other hand you explain the why, the how and the what, including hard data the people in BC might not oppose it.
Next Vance states that the range of medications available to patients is severely restricted. However, she does not explain a) which medications and b) whether that is good or bad. By putting it this way Vance implies this is a bad thing. She never explains why.
Paragraph 8 is again a great example of this style of arguing, that is, without evidence and based on instilling negative images. I totally agree that if cost management gets in the way of patient focused care that would be a problem. The issue I have is the way in which Vance makes that statement. Vance implies this is what is currently happening in New Zealand. She does not provide one iota of evidence cost management gets in the way.
It may be true that one of the contributors to the rising PharmaCare budget is the growth in the volume of prescriptions as Vance sates in the following paragraph. However, Vance fails to mention that the prices we pay in Canada for medications are much higher than in New Zealand as one can see below.
Paragraphs 12 and 13 are troublesome as they contain a, what I would call, you can’t have it both ways fallacy. Vance argues that medication non-compliance comes at a great cost. She first names comprised health as a cost factor and then mentions the cost of the wasted medications as a factor of those cost. However, those medication costs are not incremental. They are so called sunk cost. The reason being that if there would be no non-compliance those medications would still cost the same!
The next two paragraphs (14,15) deal with the changing role of Pharmac. I argue that the information Vance provides is minimalist at best. In 1998 Pharmac already ran a campaign aimed at the inappropriate use of antibiotics. In 2010 the NZ government released a report suggesting indeed a wider role for Pharmac. This widening however is not only focused on giving Pharmac a bigger role in medication management but also to adopt the Pharmac model for medical devices! It is unfair to imply that the approach of New Zealand, as per the last sentence of paragraph 15, is solely based on penny counting.
In her concluding paragraph Vance once more uses the term 'simplistic' thus implying not 'thoroughly thought through'. The prescription in itself is indeed simple. Control cost by having a national/provincial procurement strategy. Implementation is of course far from simplistic. Finally Vance ties all this back to limiting choice again without explaining why that would not be a good idea. She certainly did not prove that not restricting choice is better.
Finally it is important to not only look at absolute numbers - since they will always rise given the growth in GDP and inflation - but to also look at cost as a percentage of GDP and all health costs. Again New Zealand outperforms Canada. Not only that, it appears spending on drugs in Canada seems to slow down. As a matter of fact, that is also something the Canadian Institute for Health Information (CIHI) reports. Lots to think and talk about.
In closing I want to address the inevitable retort I expect. Do I have a better solution for our increasing? No I do not have a silver bullet at my disposition. I have some ideas, such as the Pharmac approach, giving prescribers better access to medication costs, patient drug profiles and access to medication educational material to name a few.
I agree this is a complex issues that requires a comprehensive approach. With comprehensive we must also mean making sure all the available data is used and reviewed. No cherry picking please.
Erik Hamburger
Sources:
OECD for country statistics
Multinational Comparisons of Health Systems Data, 2010 by Common Wealth Fund.
Canadian Institute for Health Information (CIHI) for detailed information
Have you ever been listened to?
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- Created on Saturday, 09 March 2013 17:48
Dialogic Communication
While it’s clear that effective communication is essential to any business’ success, the traditional model is dated, and dare I say, up for dialogue (and yes, please note that I did not say debate).
Traditional business or project communication strategy depend on ‘efficient’ skills such as, speech and debate discourse strategies that are based on the ideals of polarization and hierarchy. These dated beliefs place importance on the individual voice, rather than the collective voice—but times are changing, and so to is communication discourse. From hierarchy to network; from transaction to interaction; from disabling to enabling; from debate to dialogue, what is ‘effective communication,’ is maturing. Communication language is becoming softer and more inclusive, illustrative of a dialogic model of communication.
Dialogue is a process of collective exploration. At the heart of this model, hierarchy is dethroned and collaboration is celebrated. It can be said that the goal of dialogic communication is to empower the participants to make their own informed decisions in the pursuit of mutual agreement. It is in fact the inclusive experience of dialogue that converts the communicator.
With a background in communication rhetorical theory, I was awestruck when I first came across the dialogic model utilized in an experiential learning program. Stranger still, this program was set within the greater University institution that prioritizes individualized learning. I thought, I don’t want to have to give my time for others to learn; instead, I want my hard work and efforts to be recognized as such.
I was yet to really learn the power of the collective.
I do my best everyday to live, work, and manage from my powerful experiences with the dialogic model of communication. From which I have built a toolkit based on three, (what I deem necessary) skills: active speaking and active listening, understanding verbal and physical communication, and learning the power in the pause/creating participatory groups.
Active Speaking and Active Listening
Active speaking is the engagement of the other(s) in discussion through the use of language; we choose open and inviting language to include, and closed and directive language to alienate. Be aware of the language that you choose, and the motive behind that conscious decision.
Active listening- Have you ever been listened to? I mean really listened to, where the person(s) you are speaking to not only hears you, but also internalizes what you have said, and could repeat it back to you? This is a much different experience than vacant listening, the other person(s) in conversation hears you, but instead of engaging with your words, that individual is preemptively creating his or her response or rebuttle to your comments. I acknowledge that the listener will form an opinion based on their personal biases, however when one actively listens, one is aware of those biases and recognizes them as such.
Verbal and Physical Communication - Are you open to communicate?
What does your body say? Remember that your body language and tone of voice tell others, yes, I’m ready to listen and engage in this conversation; or no, I know best, and I’m not willing to hear what you have to say. The slightest alterations in your demeanor, physical stance, or level and tone of voice can change how others perceive your willingness to communicate. Remember that these cues also translate your intent of communication, be it assertive, informative, and so on. Remember to consider these non-verbal cues from the other(s) in discussion, and do NOT make drastic assumptions; you know better than this!
Power in the pause/creating participatory groups.
What about silence in conversation makes us uncomfortable? Why do we jump to fill that space, instead of allowing ideas and conversation to ebb and flow naturally? Now if only we could allow the scary ‘pause’ to occur and did not speak to fill space, we would in turn, help to create a participatory space.
At the very heart of dialogic discussion is participatory space where all opinions are welcome, and opposing viewpoints are allowed to co-exist in the conversation. Participatory space requires you to learn the power of voice, understand the power of not using your voice- so someone else has space to use their voice, and do not forget the power of the pause.
So the next time you find yourself in a group discussion, try to remember these three simple skills:
- be aware of how you speak, and how you listen;
- consider non-verbal cues, both yours and those of the other(s);
- and, allow the very natural conversational pause to occur- you will be surprised by who speaks up!
To be continued… Understanding the power of rhetorical language.{jcomments on}
Written by Marissa Lawrence
Going undercover to uncover?
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- Created on Tuesday, 07 December 2010 04:10
We all know that an integral part of the strategic planning and realization process is having/getting a good understanding of what's going on in the organization.
As we also know there are multiple ways of doing that.
In 2009 a new TV-series called "undercover Boss" was introduced that gives a whole new meaning to the term fact finding. Basically it shows an executive going undercover as a worker for a week in her/his own company. Usually there are big eye opening moments and at the end of the week the executive sheds the disguise and shares her/his lessons-learned with his executive team and the employees she/he worked with during the week.
What do you think of going undercover to uncover? Please let us and the growing number of readers of this know what you think by casting your vote on the right.
{jcomments on}You can leave a comment below.
The Islands Trust Strategic Plan
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- Created on Wednesday, 10 October 2012 03:26
{jcomments on}As part of our Strategic Plan Sample&Review series we will have a look at the recently released 
Strategic Plan of the Island Trust in British Columbia, Canada.
Strategic Plan of the Island Trust in British Columbia, Canada.
The Islands Trust is a land use and planning agency - created by the province of British Columbia - to preserve and protect the trust area and its unique amenities and environment for the benefit of the residents of the trust area and of the province generally, in cooperation with municipalities, regional districts, improvement districts, other persons and organizations and the Government of British Columbia.
The Trust Council is responsible to provide strategic direction for the duration of it's elected term. The term of the current council is from November 2011 until November 2014. The strategic plan for the same period was released in September of 2012 after review and public consultation.
The plan is 12 pages long and divided into three distinct parts being:
We will briefly review each section and then end with a short summary of likes and dislikes.
Introduction and high-level objectives
This section of one page length. gives a short outline of the Trust area and the role the Trust Council plays in the governance of the Trust. These first two sections are the same as for the previous plan.
The third section of this part is a listing of the four main focus areas subdivided each with objectives and strategies. Each of the strategies is worded in an active way starting with a verb. We like that.
We miss the reason behind each of the four focus areas. In other words, why focus on those, what is the expected benefit for the trust?
Detailed overview of objectives, activities and success measures
The next 9 pages are used for a detailed breakdown of each of the focus areas. The form that is used is a landscape table with the following headings:
- OBJECTIVE
- STRATEGIES
- POTENTIAL ACTIVITIES AND PHASES
- WHO WOULD WORK ON IT?
- IS FUNDING REQUIRED OR IN PLACE?
- HOW WOULD WE MEASURE SUCCESS?
- STATUS (Italics indicate status change since last TC meeting)
The objective and strategies are the same as on page one.
In the activities and phases column the phases are identified by fiscal year. The activities are for the most part described in an active way with a verb and an expected output.
We don't like the title of the next column "Who would work on it" for the simple reason that the word would implies a certain level of uncertainty. We understand why they might has chosen would over will as a more polite way of saying it but we think in these kind of directional documents a more direct way of saying things is better.
We like the inclusion of a funding column as it clearly gives an indication, albeit small, of the likelihood of the activities actually being executed.
The success measure column is excellent as it provides focus for the activity owners. However, some of the measures are not very specific and may need shoring up. For example, one of the activities for strategy 1.6 is "Trustee workshop about protection of special areas". The associated measure is "By whether a trustee workshop has been held". This seems circular. Better is to outline the objectives of the workshop and include those as a measure in the success column.
The status column is great as it appears that the status of the strategic plan will be reviewed/presented during the quarterly council meetings.
Strategic Planning Process Diagram (2012-2013)
This diagram is a simple one page circular block diagram outlining the sequence of events in developing the plan and the related budgets. Although there is mention of the achievement of some objective and the quarterly measurement of success we mis a more robust approach of strategic plan control and alignment.There is no mention of the previous plan and its success (or lack thereof) and how the current plan relates to the previous plan. At least acknowledge what was and was not achieved and how the new plan builds on that or departs from that.
In conclusion
What we liked:
- Concise well written
- Use of active words
- Use a measures
What we did not like:
- Lack of benefit statement (the why)
- Use of non-specific measures
- No link with previous plan (only as reference document on web-page)
All in all an excellent plan with enough detail to make things happen.
Why have a strategy in the first place?
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- Created on Tuesday, 30 November 2010 08:00
Why indeed?
Because whether you like it or not, you have one. Some may argue that:
"In a world where change is the only constant having a strategy is a necessity"
I would rephrase that by:
"In a world where change is the only constant all organizations have a strategy"
The question is not whether you should have a strategy but rather whether you know your strategy and are in control of it.
And those are the two big strategy questions:
1 Do you know your strategy?
2 Are you in control of your strategy?
If you are able to say yes to both that's great. In that case you could stop reading here. Please don't though! We would really like to hear from you how you do that. Use the comment section below to share your approach with the other readers.
If you can't answer both questions or maybe only question 1 let's see if we can give you some insight in how to get to two yesses. By the way, saying yes to question 2 implies by definition saying yes to question 1 as well.
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Next time I will address the first question: Do you know your strategy?
I will tell you how to find out, even if you have never done any strategic planning at all, how to still determine what your current - yet implicit - strategy is.
I will give you some ideas how to establish a strategy.
Once that is done the real fun stuff begins (and it never ends!), getting and staying in control of your strategy.