Health — Issue No. 5 — Thursday, April 19, 2012 (HTML)

Present: Norm Letnick, MLA (Chair); Mike Farnworth, MLA (Deputy Chair); Ron Cantelon, MLA; Guy Gentner, MLA; Dave S. Hayer, MLA; Richard T. Lee, MLA; John Rustad, MLA; Dr. Moira Stilwell, MLA

2. The Committee received an update from KPMG regarding the work conducted to date.

3. The Committee received an update from the Chair regarding his meetings with health economists.

The following electronic version is for informational purposes only.
The printed version remains the official version.

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
HEALTH


CONTENTS
Page
Update on KPMG Phase 1 Work	25
G. Newman
P. Tambeau
Update from Committee Chair	28
Next Phase of Committee Work	28
P. Tambeau

N. Letnick (Chair): We're going to start, if no one has any objection to beginning. We don't have quorum yet, so we'll start off the record.

You have an agenda in front of you, so if I can get a motion to approve the agenda.

G. Newman: Ladies and gentlemen, we've got a very brief update for you, just to give you a feel for where we're at as a result of the issues that came out of the workshops, but also more importantly, I think, in terms of the report — the delivery of the report and the report structure — that I wanted to give you the opportunity to have sight of before we started to put pen to paper.

We have had a slight delay in the process between the workshops and last week, when we managed to get together finally with UBC and the Ministry of Health to talk about two areas in particular — the first, refining the aging and population growth projections, and the second, trying to more sensibly understand some of the issues and some of the figures behind health care inflation and utilization cost drivers.

We had a really productive meeting with them. In fact, both the ministry and UBC agreed that they would go away and perform some additional analysis that would support our work and have agreed to get back to us next week with some revised numbers for both aging and population growth and health care utilization and inflation. That will enable us to, I think, better position parts of our analysis.

We have built a model. We think that the model is reasonably robust. We're currently going through kind of internal Q-and-A processes in KPMG to make sure that we're happy with it.

Once we've got the additional information from the Ministry of Health and from UBC, we'll then complete that piece of work. But I think, as we suggested in the workshops, we need to get this right. For the sake of a couple of weeks, it might be that we just make sure that we do that.

We think that it will take us probably about a month to turn the report around once we've got this enhanced information. So we're thinking that we can get something to the committee probably mid-May to late May. We'll work with you to confirm the dates on that, once we've got the additional information.

Broadly, our aim is to get it to you as soon as possible. If we can get it by mid-May, then we're broadly on track with the preliminary timelines for consideration that I know we'll be discussing later. That's what we will try and do, but it might be a week either way.

N. Letnick (Chair): Anything else you want to report on before we go to questions?

G. Newman: Sorry. Then to say that we have a draft table of contents that we wanted to run you through, just to give you a feel as to how the report's going to shape up and look.

There'll obviously be an executive summary. There'll be an introduction. There'll be details of the methodology that we've undertaken. Then we'll be drawing out the key themes from the documents that we've got here and our own notes from the workshops and the stakeholder interviews so that you've got a record of that work that's been done and the feedback that we've had from the various stakeholders.

We'll then have a chapter on health care sustainability in the round, which will involve, as we discussed last time, a brief discussion on the broader definitions of sustainability. We'll also take the opportunity to provide some observations on the system, given the broader definitions that we've identified.

Then we'll have the core section, which is the health care costs and the cost analysis, before we conclude.

We're hoping that the report will be not overly long but will address all of the issues — a kind of manageable size for both the committee and also wider public consumption.

I'll start off. Part of phase 2 is to go to the public and ask them for options as to what we do, given the evidence that has been provided during part 1 through your report.

When you produce your report, are you going to be identifying, in five-year increments — like year 5, years 10, 15, 20 and 25 — the key challenges to a sustainable, publicly funded health care system so that we can focus our questions in part 2 on those key challenge areas?

G. Newman: Well, not in five-year increments. I think what we will be doing is saying that through our observations of the system, these are the things that we think are things that need to be discussed and addressed by the system as you are addressing long-term sustainability.

What we won't be doing is being definitive that you need to do that by year 5 or year 10. But we will be say-
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ing that these are the issues we see that we think need to be sorted out.

P. Tambeau: If I could add to that. The model and the graphs which will show the cost projections — there will be, in five-year increments, projections on percentage and total government spending, percentage of GDP and per-capita costs. So there will be some pieces on the five-, ten-, 15-, 25-year increments but not necessarily specific issues at those different increments.

N. Letnick (Chair): Okay. So if we look overall…. Let's say 25 years from now, so at the end of our scope here. If we look at 25 years from now, will you be able to say to us, "Here are the key cost drivers or the key impediments to sustainability, given the revenues that government has to work with and the expenses that you're going to get, given demographic changes and all the other cost drivers, that we really need to focus on," rather than just: "Well, here are a whole bunch. Here are seven things — inflation, utilization, aging, demographic change…. Now, good luck. Fill your boots"?

You know what I'm saying? It'd be nicer if you came back and said: "Here are the seven or eight categories. But really, at year 20 or 25 you really need to talk about end-of-life issues, or you really need to address utilization of lab services or of diagnostic imaging." Something specific, so that we can then go to the public with a specific case and say: "Look, here are the big challenges" — not just general challenges — "the specific areas that we need some advice on."

G. Newman: I think we'll have to take that away and think if we can deliver some of that. Certainly, we can provide you with some signposts just to the things that we'll need to get sorted out and addressed.

You see, the way the analysis will shape up is that there will be general factors that will…. The way the academic studies and our work is working is that we'll be providing what we've described at the moment — and I know that we probably need to find different language for this — as best, worst and the sort of likely scenarios.

The things that will fluctuate more than anything else are the issues around aging and demographics. Those are things that have been plotted out, and we can see how those impact on the cost drivers of health care over the 25 years.

The rest of it is more general in terms of what the impact of general inflation is. There are a certain number of models. We can see what the trends are, but essentially, we're almost sort of using what I would describe as generic uplifts for those sorts of cost drivers.

I think we will be able to draw some broad conclusions but nothing, necessarily, too definitive. I would be cautious at this particular moment in time to say that we'll be able to deliver for you a list of three factors that you need to have considered in the next five years and then another three that you need to have considered in the next ten, because I'm not sure the analysis will get us that sort of definition.

M. Farnworth (Deputy Chair): Just on that, one of the challenges…. I think you can make some reasonable assumptions around things such as inflation. You can make assumptions around demographics, because the number of people who are here are here, and each year that ticks by they get older.

Where the real challenge comes — and I get what you're saying — is in some of those areas where there is the potential for some significant changes, but we have no idea what they are. Like, we don't know what the advances in 25 years will be. We don't know what the advances will be in ten years, never mind 25 years, in things such as technology or advances in areas around genes and DNA and all those things and the impact they will have on health care and the health care system. I think that's a real problem.

To me, what you'd be looking for is accuracy as much as possible on those things where we actually know…. I guess the other is going to be much more sort of okay, here are some possible things, but it's going to be very difficult to predict the future in some areas of health care, despite our best efforts.

G. Newman: I would agree with that completely. I think that what we need to do is to make sure that we highlight, where we can, the sorts of things that you need to be thinking about. Technology is a very good example. To be honest, you almost don't know what's going to happen 12 to 24 months out, let alone 12 to 24 years out.

I also think that there is something that we need to consider, which is what I would describe as the way that the system should look to redesign and the impact of redesign strategies on sustainability.

There is a kind of balancing figure here, where you could say, "Well, we've got all these costs and everything that we know are going to drive inflation within health care," but then there are also, potentially, things that we can do and we should be looking to do to redesign the system. And can we take views on the amount that that will work in a deflationary capacity to offset the inflationary aspects of the other cost drivers?

We can see from learning around the world that it's very difficult to take substantial amounts of cost out of the system through modernization and through modernization strategies. But we can see that systems have changed, and there is a direct correlation between quality of care and the cost of care. If care is delivered in the right setting, then there is direct correlation, where we can see that costs are reduced across health systems.

It may be that part of the observations and part of the debate the committee needs to have is: well, what things can you be looking towards from the political, from the health system management perspective that can start to set things like that in motion over the shorter term? That, I think, is a worthwhile debate for the committee to kick off phase 2 with.

N. Letnick (Chair): By the way, now that we have quorum, I call the meeting to order.

Further to what Mike said, I thought we were saying that every five years they should update these reports, what the projections are. So if all of a sudden there's a huge change in endocrinology or something else — some miracle drug comes in that solves a lot of the health care problems and issues — then they could probably update it at least every five years — right?

G. Newman: Agreed, and that would be an appropriate thing to do. You are constantly updating this process so that you've got any flags that we can see from the trends from 2012. If we next do it in 2017, then the analysis will be different. We don't know how it will be different, but it certainly will be different.

D. Hayer: At least we'll have some road map. It might be going back and forth a different way but going the same direction.

N. Letnick (Chair): And some benchmark that maybe isn't currently happening — or if it is, it's not public — that we can use as a standing committee to guide us at those five-year increments.

G. Newman: Very much so. I'm sure that the academic community is looking at this analysis and seeing where they need to do additional research to inform the debate as well. I think it will be an iterative thing.

N. Letnick (Chair): Speaking of benchmarking and the academic community, could you repeat what you said regarding your meeting with the Ministry of Health and Dr. McGrail? Our colleagues weren't here for that.

G. Newman: Sure. It's just to confirm that, as you'll recall from the workshops, we agreed that we would have additional meetings with the Ministry of Health and UBC. That meeting took place. It was a really helpful meeting, helped clarify a number of things.

We discussed the need for short-term additional work to be done on some of the factors concerning aging and population growth. We also agreed that that was required with some of the factors around health care utilization and health care inflation.

The ministry agreed to perform some additional work on aging and population. UBC agreed to perform some additional work on health care inflation and utilization. Both are due to report back to us next week, and that analysis will refine and really help our work in terms of the final report. We're grateful to both the ministry and to UBC for providing that information and devoting the time to the process.

R. Lee: I think one issue that probably has not been touched too much is capital expense and maintenance for the health care facilities. Those questions probably will drive some of the questions towards that second stage, I believe. Do you have any ideas on what factors should be asked at this stage so that in the second stage there would be a better discussion on that?

G. Newman: Well, again, I think we can provide some insight into the sorts of issues that other jurisdictions are working through at the moment regarding capital expenditure. They will be general observations. There is, I think, probably some learning that you can take from other jurisdictions around how people have financed capital developments and the use of different financing models so that the government isn't necessarily footing the bill for everything itself. It's done more on a commercial basis.

Again, that would be something that I think would be a discussion that you would need to have in the wider realm, because the models that are used at the moment are very much based on public sector funding of developments.

N. Letnick (Chair): All right. Is there anything else you'd like to report on before we move on to the next item?

N. Letnick (Chair): Please participate with the rest of the items. We always appreciate your expertise and knowledge.

At this point I'd like to thank Tim Scolnick for all his work with the committee. How long has it been? We've been about a year.

N. Letnick (Chair): Eight months. Thank you, and good luck in the Ministry of Health.
[ Page 28 ]

S. Sourial (Committee Clerk): Morgan joined us, I think it was, at the end of July, August last year and has been working on the Special Committee on Pesticides up to now.

N. Letnick (Chair): So you go from Pesticides to the Standing Committee on Health, and Tim goes from the Committee on Health to the Health Ministry. It's an interesting family we have here — excellent.

Well, welcome to our group. You're gonna have a ball with us. We're pretty easygoing MLAs.

On to No. 2, an update by myself on some work that I've done since the workshop. Just before I go in there, I'd like to introduce John Rustad, MLA for Nechako Lakes, who is joining us as a new member of our committee.

John, it's a privilege and a pleasure to have you with us. Just remember. Everything we say is right. So just go "Yea."

It's a little bit of a steep learning curve, but I'm sure that you'll catch on really quickly. By all means, participate today. This is a new topic we're going to be talking about just in a minute or two, so look forward to having your input in the process as well.

N. Letnick (Chair): I met last week in Vancouver with four PhD profs from UBC to discuss phase 2 and a little bit of phase 3, just as far as the process goes. Three of the four were at our workshop, and I buttonholed them at the workshop and said: "I want to exchange some ideas with you."

I just thought I'd give you an update very quickly. When they looked at the proposed draft for phase 2, which, given the timeline that KPMG just told us, is now going to have to be adjusted…. That's good. Like you said, it's better to have it right than get it out too quickly and not have it right.

Their comment was one of deliberative democracies wherever possible — to include the general public in the process, more than just in a means of appearing in front of a committee but in the way of educating them, facilitating them and then getting them to come up with recommendations or ideas that we could take wherever we want to go with it.

Something larger than the standing committee members alone, but something not as large as a statistically valid survey of all the people of British Columbia. What they're talking about is processes that involve 20 to 30 people. You know, four or five days of intense education, deliberation and some conclusions through that.

I just wanted to bring that forward. I think a report went around to all the members as information, an e-mail, with some discussion on deliberative democracy and some of the different options. I'd just like you to keep that in the back of your mind. A primer on public involvement put out by the Health Council of Canada — just keep that in the back of your mind as we go through these discussions.

N. Letnick (Chair): So No. 3, a review of next phase of work for the committee. As we heard, the report from KPMG is likely to come to us by the end of May. Given that timeline, I would just like to refer to a discussion document that the Clerks and I have been working on to try to put something on the table for you to trash around, change, to get a sense as to whether or not you believe this is the right kind of format process for phase 2 of the committee's work.

As you may recall, phase 2 of the committee's work is to outline potential alternative strategies to mitigate the impact of the boomers on the provincial health care system. In the previous conversation that we've had at this table, we did say that we wanted to make sure that phase 2 and phase 3 were focused so that we can deliver something of value to the 85 members of the Legislature, as opposed to redoing the Conversation on Health and just going out to the public and saying: "What do you think?"

That's why the question that I posed to our colleagues from KPMG, which is, "Are you going to tell us what the key areas of concern are?" so that we can focus phase 2 discussions around those areas…. That's why I posed the question, and that's how this particular draft is written, which is: "Okay, here are the particular key areas of question. Now let's go to the public and find out what they think are some of the options available to us to address those areas."

Again, if your report does come out and say something to that effect, then that would help us in the work. If not, then I look to you for guidance as well — because I think part of the terms of reference was that you would provide us some input as to how to do phase 2 — on where we go with phase 2.

If I can just briefly outline what we have in front of us, just to give you a sense of what we're thinking of, and then get your comments, concerns, questions, changes. We won't adopt this today since we have another month and a half before we get the report anyways. It will just give us the time to think about it some more.

The first part was to receive the report from KPMG by the end of April — so that would be by the end of May — with some kind of matrix, looking at challenges. I'd have to get a clearer sense from Giles and Paul as to what exactly you think you can provide us. After you leave this
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meeting, sit down with your report with your colleagues and say: "Look, what can we really deliver that can facilitate the committee's work?"

So assuming we get something like that, then, in May — and of course that would now be later — the committee would deliberate on the report, consider challenges and identify themes to engage and involve stakeholders and the public.

We're thinking that maybe a consultant would be required for that — a health economist or some other professional that could help us understand the different themes.

Then we would call for written submissions focused on those themes. We would go to the general public and call for submissions, but the submissions would have a test to them, a filter. We would probably receive a number of submissions that don't qualify, and they would go in the parking lot as additional information that could fit itself into the report. But ideally, what we would be looking for to qualify as a proper, complete submission….

Submissions should be themes, robust, evidence-based, include pros and cons and — of course, now this probably won't apply anymore — where possible, targeted to five-year increments. Also, talk about how the particular options would address the sustainability challenges that the report has come up with, through KPMG.

What we would do then is sort the submissions into three streams: health care consumers, the general public; health care suppliers; and health care systems analysts — so the health economists and academics.

In (c), in the event that submissions are not received by the key groups, we would go out and ask them for submissions — the Ministry of Health, the health authorities, First Nations, key supplier groups. We can send invitations to them to appear.

Once we get these submissions — and we've budgeted roughly six weeks for that — the committee would look at the submissions and make requests to certain groups to present their submissions publicly. This is where we would go to each regional health authority base. Prince George, I think, is the northern.

N. Letnick (Chair): Okay. So Prince George — we'd go. Kelowna has IHA. Wherever VIHA is and wherever the rest of them — right? So we go into five or six regional health areas, and then get people to present to us, either in person or electronically, as we've done in the Finance Committee work.

We can then have a good discussion back and forth, not the usual ten-minute presentation and five-minute Q and A. I'm talking about a half-hour presentation and a half-hour Q and A back, because these would be robust submissions — right? These will be everything from one spectrum which is, maybe, blow up the system and bring in more private provision or bring in blended care or. You know, you name it. There will be different submissions from a range of areas.

It will take some good discussion with these folks to understand exactly what they're proposing and the implications of those. We would go out and ask those groups, plus any other groups we want to submit, and then have some time for all the health regions, as well, to speak. They, of course, have a lot of expertise that we'd probably want to listen to.

Then the last piece is that once we get all the submissions, we would come back here, look at the submissions, work through either a deliberative democracy kind of format or as a standing committee alone, with the help of some professional guidance, and then come up with the, maybe, three of four major options that we believe we should go to phase 3 with and to the public with to give us input to accommodate our mandate. It says that once we come up with the options, we have to measure the level of public support for those options.

That's roughly what the Clerks and I have come up with regarding the timing and the content. I'm open to questions, comments, changes. Again, I'm not looking for a motion here. It's just to get us starting to think of the process, and then we could bring it back at another meeting.

J. Rustad: I like the way that you're laying this out, although to add value when we do these public meetings, I think you should probably have a piece of time that's set aside for those more intensive submissions.

You might want to consider adding on an opportunity for the public and for a little bit of dialogue, because it always helps to try to get some of that public debate involved in it, especially if the press are going to be there — to understand a little bit of what's going on. Maybe five minutes shorter, and add it on to the end of it. It may add some value to what we're trying to do with this.

M. Stilwell: I just wanted to bring all the members of the committee's attention to the launch recently of our website, ThinkHealthBC. I think that it would be helpful…. First of all, it's an improved conversation about health. If you look at the videos that frame up the question, they relate to the questions we're asking. And for all of us, it also has other material on it that clearly indicates the innovation and change agenda for the ministry.

I think it's important that our conversations align with those conversations and to think about how to use the comments on that website as at least one of the methods of gathering public comments about what we're doing.
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Clearly, the additional video, I do think, frames up the question for the lay public and for us. To just make sure that we're feeding into that and encourage people to use it, I think, could be worthwhile.

P. Tambeau: Are you looking for original options, original work, as part of your submissions?

N. Letnick (Chair): Well, given the time frame, six weeks, what I anticipate will happen is that some groups that have already presented…. The BCMA, for example, in their submission to us for phase 1, gave us what they think we should do. I would expect that what people will do is dust off what they've already put together and maybe reshape it, given the specific questions that we ask.

Again, if we can focus the discussion on three or four or whatever major cost drivers that potentially have some solutions to them so that we can reduce the cost curve, then I think people like the BCMA, the Centre for Policy Alternatives, the Fraser Institute, and you name it, which already have a good idea, can tweak their submissions to answer the questions that we asked them, as opposed to just going out there and saying, "Okay. Well, KPMG has come back and said the system is as sustainable as we want it to be, but here are some overall challenges, like inflation," and then asking everybody: "Well, how do we address inflation?"

You know what I'm saying? It would be much better if it was focused on some specific areas.

The short answer to your question is: I expect some of them will just be dusted off, but I also expect people will collaborate. I firmly expect that the health economists from UBC, given my conversation with them last week, will put something together. It might be new; it might be old — if there's anything new in health care — but they'll put something together unique for our purposes. It all depends on how we frame the questions.

P. Tambeau: I only ask the question because, as we were going through the stakeholder reviews as part of informing this process and even in looking at the submissions that we got for this particular phase, we were really pushing people, if they had options or solutions, to say: "Okay. Well, that's phase 2."

I just want to advise the committee that, whatever the process, people feel that this is now their chance to speak, whether it is receiving comments through a website or something that may be beyond, say, formal submissions, formal papers, formal options that they come up with on their own — that that avenue be…. I think that expectation was set up in the work that we had done.

Okay. I see no other hands, comments, input. We'll go through the minutes, revise this, revise the timelines and come back to another meeting with a different version.

I'll also have a conversation with KPMG to see what exactly we're going to get, roughly, for the beginning of this, because that really frames the whole rest of the format.

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Chair:	* Norm Letnick (Kelowna–Lake Country BC Liberal)
Deputy Chair:	* Mike Farnworth (Port Coquitlam NDP)
Members:	* Ron Cantelon (Parksville-Qualicum BC Liberal)
	Katrine Conroy (Kootenay West NDP)
	* Guy Gentner (Delta North NDP)
	Sue Hammell (Surrey–Green Timbers NDP)
	Colin Hansen (Vancouver-Quilchena BC Liberal)
	* Dave S. Hayer (Surrey-Tynehead BC Liberal)
	* Richard T. Lee (Burnaby North BC Liberal)
	* John Rustad (Nechako Lakes BC Liberal)
	* Dr. Moira Stilwell (Vancouver-Langara BC Liberal)
	* denotes member present
Other MLAs:	Vicki Huntington (Delta South Ind.)
Clerks:	Kate Ryan-Lloyd
	Susan Sourial
Committee Staff:	Morgan Lay (Committee Researcher)
	Timothy Scolnick (Committee Researcher)

Witnesses:	Giles Newman (KPMG LLP, Canada)
	Paul Tambeau (KPMG LLP, Canada)

REPORT OF PROCEEDINGS (Hansard)

SELECT STANDING COMMITTEE ON HEALTH

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
HEALTH