Empire Club Toronto, Ontario A Bridge Across Silos: Collaboration for Innovation and Better Value in Health Care Dr. Graham Sher Chief Executive Officer Canadian Blood Services 1
Introduction Thank you for the kind introduction and opportunity to speak. Before I begin, I am pleased to recognize some elected officials from the Ontario legislature in attendance today: a warm welcome to Minister Mitzie Hunter and MPP Han Dong. And sincere thanks to our sponsor, KPMG. You likely know Canadian Blood Services as the organization that manages the country s blood supply system. This is not a small task. We operate a national system spanning all provinces and territories except Quebec, which has its own blood system, and are responsible for meeting the needs of every patient and every hospital in the country in terms of blood and blood products. 2
We do this through our 4,300 strong employee base, operating out of 40 facilities coast to coast, and relying on a blood donor base of over 425,000 Canadians. Our revenue, derived from the provincial and territorial governments of Canada, excluding Quebec, is just over $1 billion annually. Given the legacy of the tainted blood scandal in Canada, from which our organization was created, our singular focus is to operate a system on which Canadians can rely, and which they can trust at all times. Recognizing that our name, Canadian Blood Services, emphasizes our responsibility for the blood program, it is less well known to many that we also bulk purchase a portfolio of plasma-derived drugs worth about 3
$500 million annually; that we manage the OneMatch Stem Cell and Marrow Network for Canadian patients needing a stem cell transplant; that we operate Canada s national public umbilical cord blood bank; and that we lead aspects of and collaborate in a national system in Canada for organ donation and transplantation. Our unique value proposition to the federated health systems that exist in Canada is precisely this: we are the only federally regulated, provincially and territorially funded pan-canadian health-care delivery organization. As we near the end of one of the longest and most contested federal election campaigns in many years, I am struck by how little health-care matters have been part of the election discourse. 4
While there is, finally, some discussion of health care within the election debate, the amount and depth of dialogue is still not, in my opinion, in line with how important these issues are to Canadians. In the recent report from the Advisory Panel on Health Innovation, led by Dr. David Naylor, several important themes were raised, such as greater collaboration for health-care innovation; better value in the procurement of drugs; refocusing health-care systems on the patient; and innovation to enhance the quality and sustainability of health systems. The pan-canadian platform from which our organization operates affords us a unique perspective on healthsystem issues in this country, and I want to explore some of these themes today, both because they 5
resonate strongly with our vision at Canadian Blood Services, and because we have experiences that can usefully inform these debates. I ll start to do that by sharing two patient stories that showcase improved health-system performance and patient outcomes, as well as equity and access to care. I ve chosen these stories among so many important ones because they stand as examples of what can be gained from greater collaboration for health-care innovation. Patient stories HSP patient: The first story is about Eileen. She needed a kidney transplant. 6
Unfortunately, Eileen relied on dialysis for 15 years because of the challenges brought to bear by her highly sensitized immune system. Sensitization happens when patients are exposed to other people s tissues through previous pregnancies, organ transplants, or blood transfusions. Like hundreds of other Canadians experiencing kidney failure, Eileen developed antibodies to these foreign antigens that prevented her from finding a potential match within the limited number of organs available for transplant in her region. This past April, however, her transplant finally happened. 7
A suitable kidney from a deceased donor was found through a program called the Highly Sensitized Patient program, or HSP for short. This is a new, pan-canadian organ-sharing program developed by Canadian Blood Services, in collaboration with provincial organ transplant programs and healthsystem partners across the country (including Quebec it is truly pan-canadian). In recent months, the HSP program has given real hope to highly sensitized patients like Eileen who typically wait the longest for kidney transplants. The program gives these patients priority access to a broader national pool of organs for transplant, as opposed to the smaller pool of organs available within their provincial or regional health systems. 8
Provincial organ programs support this prioritization, because the greater size of the national organ pool gives this disadvantaged group of patients a more equitable chance of finding a match. I m pleased to say that Eileen is one of almost 150 people who received a kidney transplant since this innovative, nationally cost-shared program began, less than 2 years ago. Without this pan-canadian approach, these 150 patients would likely continue to live decades of their lives on wait lists, tied heavily to their dialysis regimen. The HSP is the latest addition to the Canadian Transplant Registry, which is home to three programs for interprovincial organ listing and sharing: the Kidney Paired Donation program, the National Organ Waitlist 9
and most recently, the Highly Sensitized Patient program. The Canadian Transplant Registry is a perfect example of pan-canadian innovation. It is managed independently, and at a national level. It enables the work of provincial organ donation and transplantation programs, each of which is able to retain jurisdictional delivery and local decision-making, while working collaboratively toward and ensuring national performance standards. In managing the technical infrastructure for this webbased national approach to organ donation and transplantation, Canadian Blood Services is guided by interprovincial policy, as well as evidence-based leading 10
practices that have been developed collaboratively with health-system partners. The Canadian Transplant Registry is about building bridges across silos it is about sharing scarce resources across provincial jurisdictions and acting together as a nation to improve access. Within this context, innovation means thinking differently about our health systems and scaling up solutions at national as well as at provincial levels for the benefit of all patients. In bridging these silos of provincial health systems, innovative solutions such as the Canadian Transplant Registry neither undermine nor diminish constitutional and jurisdictional boundaries. Rather they refocus health 11
systems on the needs of patients, they promote sustainability and they add value. Simply put, they allow the Canadian health-care system, if one believes there is such a thing as a single system, to achieve levels of performance that no single provincial system can achieve on its own. For every kidney transplanted, studies have shown there is a cost avoidance of approximately $50,000 per patient per year. Given that to date, more than 360 people have received transplants through the Kidney Paired Donation program, which is the most mature patient matching program within the Canadian Transplant Registry, we can estimate that roughly $18 million annually is now able to be redirected to other health-system needs. 12
PPP patient: The second story is about Reg. He was born with common variable immune deficiency or CVID. Throughout his childhood, he suffered from many serious infections due to his condition. At age 14, he began monthly infusions of intravenous immunoglobulin, or IVIG to help protect him from infections. In his early 30s, Reg was diagnosed with sarcoidosis, an immune disorder involving the growth of tiny collections of inflammatory cells in different parts of the body. In Reg s case, his lungs were devastated and he began taking IVIG every two weeks instead of once a month, as well as oxygen. In his mid-40s, Reg s lungs and liver failed and after multiple life-threatening complications, he had a doublelung and liver transplant in March of 2014. 13
Reg has had a pretty rough ride. Without regular treatment with appropriate medicines, he may not have survived into his 40s, let alone managed the lung/liver transplant. Today, he continues to battle infections that have required multiple platelet infusions, as well as ongoing treatment with IVIG. IVIG is a lifesaving drug derived from human plasma. Since its inception in 1998, Canadian Blood Services has provided universal access to expensive plasmaderived drugs such as IVIG to all patients in need across Canada. There is no question of inability to access these lifesaving drugs, and no differential access across jurisdictions. This means that if Reg moves to another province, he ll still have access to the medicines he needs to live. 14
Reg s freedom to do this stands in stark contrast to the experience of other patients, who often face an unintended, but potentially debilitating postal code lottery when it comes to access to certain medicines. Canadian Blood Services provides this pan-canadian service through a bulk purchasing program that draws on our blood system expertise to achieve best prices for plasma-derived drugs on behalf of provinces and territories, while driving added value into the process. This approach doesn t stop at group buying to supply medicines to the 700-plus hospitals we serve in Canada. It also creates a pan-canadian platform from which we deliver multiple benefits to provincial health systems. 15
These include a comprehensive operating system for the acquisition, warehousing and delivery of plasmaderived drugs; a publicly tendered RFP process focused on cultivating diversity and sufficiency of supply; additional layers of safety, quality assurance and risk management; medical expertise and leadership in appropriate product utilization; enhanced patient and stakeholder involvement; and of course, proven negotiating power for ongoing cost-efficiency. These are all things Canadian Blood Services has been able to bring to the table on behalf of the stakeholders we serve. Equity of both access and quality on this pan-canadian scale seems unusual in today s broader health-care arena, doesn t it? 16
Likely so does Canadian Blood Service s integrated approach to national service delivery, which helped enable Reg s access to the IVIG, platelets, and organ transplants when he needed them most. Here too, innovation means thinking differently about health systems. Within the context of bulk purchasing, it means being more than a clearing house for best prices by building policy-driven, value-added services into the practice. Within the context of integrated national service delivery, it means leveraging pan-canadian platforms to help patients receive optimized care: a continuum of preventative and curative services, according to patients needs over time, and across the different levels of Canada s health systems. 17
Eileen and Reg s stories are real. Their experiences are windows into our organ donation and transplantation and bulk purchasing programs. But these are only two of our offerings. In fact all of the organization s programs and services have one common essential factor: an ongoing commitment to cross-jurisdictional collaboration in health service delivery. I d like to speak more broadly for a moment about how this commitment became, and today, remains a reality. And as I do that, I will continue to explore the other themes I raised at the beginning of my talk: innovation, equity and access to care, and ultimately, better value to both health-care systems and to patients who rely on these systems. 18
Canadian Blood Services as a model of what is possible In the case of plasma-derived drugs, equity of access is the norm in Canada because of a policy decision made by federal, provincial and territorial governments in 1997, when they were reforming the blood system at the height of the tainted blood crisis. At that time, governments chose to establish something unprecedented and unique to operate across Canada s provincial health system delivery silos: - a pan-canadian, cost-shared, patient-centred system where blood and blood products are collected, manufactured, procured and distributed nationally - a system where blood, blood products and stem cells for transplantation remain available to all patients at no direct cost. Whether they live in Edmonton, 19
Alberta, or Edmundston, New Brunswick, these biological products are accessible within the country s insured health system. This pan-canadian approach required political courage, leadership, and collaboration from both federal and provincial governments. It required a governance framework that challenged jurisdictional orthodoxies and which requires constant nurturing in order to remain relevant, viable and sustainable. Canadian Blood Services is regulated by Health Canada, through the federal Food and Drugs Act, and is funded in large part by 12 provinces and territories. The health ministers of the 12 jurisdictions, as corporate members, or shareholders, of Canadian Blood Services appoint our board of directors. 20
The organization is an independent not-for-profit corporation, and importantly is not an agent of any one government, while it remains accountable to the collective provinces and territories it serves. Within this governance framework, decisions can be made free of political and jurisdictional constraints, striving only to deliver the right service or right product to the right person at the right time rather than being rooted in individual jurisdictional boundaries. Delivering on our mandate this way leaves us free to maintain operations where they are needed to best serve our patients. Supported by this governance structure, the universal access to over 35 biological drugs enabled through Canadian Blood Services bulk purchasing program in 21
effect achieves many of the requirements of a national pharmacare program for some patients. Driving system performance improvement at the national, pan-canadian level is not easy and progress can sometimes be frustratingly slow. I described some successes in the area of organ donation and transplantation, such as the Highly Sensitized Patient program and the Canadian Transplant Registry improving access to organs for those patients hardest to match. While a national system is taking effect, organ donation and transplantation has not benefited from the wholesale reform the blood system saw starting in 1997. Levels of performance and regional disparities in access remain a problem today. The numbers make it clear that 22
more must be done. Nationally speaking, in terms of per-million population of deceased donors, Canada s performance is still half that of top-performing nations, and still trails countries with far fewer resources than our own, including Latvia and Uruguay. Canada is certainly not owning the podium when it comes to organ and tissue donation and transplantation. According to the Canadian Institute of Health Information, as of Dec. 31, 2013, approximately 4,400 patients in Canada were on waitlists to receive kidney, heart, lung, liver, pancreas or bowel transplants. In that same year, 245 Canadians died while waiting for a transplant. That s one about every 36 hours. As someone who is committed to improving system performance, and as we celebrate World Day of Organ 23
Donation and Transplantation later this week on October 17, I find those numbers awfully hard to accept. Adding urgency to this situation is the growth of dialysis in Canada. Dialysis use is exploding as the population ages and as the number of people with diabetes and end-stage kidney disease rises exponentially. For a variety of reasons, it is unlikely organ transplants will ever be as universally available as blood products. But we can do more to plan for what we know is coming. Although Canadian Blood Services is well-positioned to support and facilitate further interprovincial collaboration, both continued investments in front-line provincial delivery and governance are needed for the organ donation and transplantation system to gain more ground. 24
Appropriate action for challenging times The broader point I d like to make with these stories of patients and the programs that serve them, is that under the right circumstances, federal and provincial governments are able to do more together than either can do on their own. While health care necessarily falls under provincial jurisdiction, federal, provincial and territorial governments can and do collaborate for improved health-system performance. Canadian Blood Services experience is the proverbial proof in the pudding. Together, governments can think differently about health service delivery programs and empower innovation across jurisdictions for the benefit of patients. 25
It should not take crises or failures in health systems, such as was the case with the blood system in the 1990s, for governments to convene key stakeholders from across the country and collaborate in the spirit of leadership and consensus. Visionary policy decisions that lead to decades of great value for health systems and Canadian patients can and ought to be made using evidence as a basis, prior to imminent system collapse, and unconstrained by orthodoxies and traditions. As we face the dual realities of fiscal restraint and an aging population, we as health-system leaders and partners have a crucial role to play to promote innovation and improve system performance. 26
In addition to the examples I have spoken about in our biological program and the Canadian Transplant Registry, for Canadian Blood Services, leadership and innovation also mean mobilizing knowledge and experience to enhance value and to effect sustainable performance improvement across systems. As an example, our organization championed and led the development of an international Risk-Based Decision Making Framework, doing so through the Alliance of Blood Operators, a network of over 90 blood system operators from Europe, North America and Australia, of which Canadian Blood Services was a founding member. The result of this international collaboration and innovation is a pragmatic and principled, internationally applicable Framework that better guides major policy 27
and operational decisions regarding blood safety, and which takes into account evolving technologies, societal issues health economics and stakeholder expectations. Summary When I began my talk today, I referred to the recent report from the Advisory Panel on Healthcare Innovation. One of the main points of that report is that, within and across our provincial health-care systems, we have trouble scaling up innovative, successful solutions to the problems we face. Serious trouble. We have no shortage of innovative thinking or functional solutions, but often, we are unable to work together to achieve breakthrough performance. 28
I believe today s arm s-length management of our business and the experiences of patients like Eileen and Reg stand as an example of what s possible when we do scale up. Innovative leadership in Canadian health care is about doing things differently and setting up conditions for success. In Canadian Blood Services experience, this has taken place through pan-canadian collaboration making the whole more than the sum of the parts. This is not to say the approach is easy, or that there should be a national solution to every health-care problem we face. As many of you with experience in interprovincial relations will know, differing political realities and fiscal 29
constraints across the country make collaboration and decision-making highly challenging by nature. But collaboration, coordination and consensus are doable, and their dividends are what we all strive for: better health, better system performance and better value for Canadians. So, no matter who is in power federally after October 19th, I urge them to look at what s working within Canada s health systems and forge ahead. Together with its provincial and territorial counterparts, the federal government can play an essential role in enabling and replicating successes. And where there are gaps in value, equity and access, I hope that our next federal leaders will seriously consider 30
innovative calls for renewal and promote innovation to bridge the divide. Leadership and collaboration across jurisdictions can be game-changers in creating better, more equitably accessible health care in Canada. Let s have the courage to move beyond the current paradigms and build more bridges across silos. Together, we can deliver the kind of health care that Eileen and Reg are counting on. As a last word, I would be remiss if I didn t let you know how you can get involved further with Canadian Blood Services: - Be a blood donor, stem cell registrant or organ donor - Become a corporate/community partner 31
- Be a financial donor - Volunteer We are all counting on your help. Thank you. 32