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June 16, 2020

From: Rosalie Wyonch

To: Healthcare policymakers and managers

Date: June 16, 2020

Re: Low-Value Care: Re-opening the healthcare system and living with COVID-19

Canadian provinces are in the midst of re-opening their economies and healthcare systems following the restrictions imposed to fight the COVID-19 pandemic.

The shutdown came fast, but the recovery is slow. This gives the healthcare system an opportunity to avoid re-introducing unnecessary services that add no clinical value to patients and divert resources from better uses.

The first meeting of the Policy Forum on COVID-19 and Low-Value Care discussed some of these critical issues. The Forum, hosted weekly by Choosing Wisely Canada, brings together dozens of policymakers and subject matter experts.

So far, the suspension or delay of most health services has not resulted in a spike of negative health outcomes for the majority of patients.

This suggests that a significant number of missed tests and treatments might be of the low-value variety, and that there is significant opportunity to constrain low-value care as the systems re-open.

In particular, Forum members urged implementation of the more than 400 Choosing Wisely recommendations put forward by 80 clinician groups on separate low-value health services.

COVID-19 necessitated drastic changes in physician-patient interactions and resulted in unprecedented progress on previously intractable issues, notably virtual care. There has been a significant increase in virtual delivery of healthcare services due to the physical distancing measures and the activation of new billing codes for virtual care.

The natural experiment is ongoing, and the effects of expanded virtual care for patients, clinicians and healthcare spending should be closely monitored. The increase of virtual care has ambiguous potential effects on low-value care. For example, it could contribute to declines in low-value laboratory testing, but increases in inappropriate antibiotic prescriptions because of added diagnostic uncertainty from the inability to physically examine patients.

The pandemic experience across Canadian provinces has differed, and these differences are reflected in various approaches to prioritization and re-opening of healthcare services.

In Alberta, for example, urgent surgeries continued throughout, and some elective surgeries have resumed, but only for patients not requiring post-operative care in order to reserve hospital bed space for COVID-19 patients.

In Ontario, health services are being progressively re-opened on a regional basis, and guided by provincial parameters. In Saskatchewan, a major priority of the re-opening is primary care services to prevent illnesses from progressing to the point of requiring acute care: a policy focus on prevention to ensure the acute care capacity necessary to manage a COVID-19 second surge. A temporary Pandemic Physician Services Agreement has been established to facilitate redeployment of physicians to high-need services, and to achieve some measure of income stabilization.

Provincialized systems such as those managed by Alberta Health Services and Saskatchewan Health Authority are able to quickly implement a unified approach to prioritizing services. For example, Saskatchewan was able to restrict its laboratory services menu in order to free up resources to support more urgent COVID-19 related testing.

Similarly, there were discussions about the employment of a single queue / single entry model for certain services, a more consistent and efficient method of matching highest-need patients with soonest available resources. A number of tensions would have to be resolved, including how to balance efficiency objectives with the importance of maintaining patient-provider relationships.

Strategies to limit the growth of low-value services would need to also consider public education and expectation-setting. For example, increasing the percentage of Canadians who have advanced care directives will help reduce the need for end-of-life care.

Regardless of the current pandemic situation in a particular province, ensuring that people can access necessary healthcare services is critical to re-opening. With the unprecedented shut down and restriction of many healthcare services, governments and healthcare managers should prioritize the highest value services and look for opportunities to reduce low-value or unnecessary healthcare. From particular services or supplies to total system efficiency, the COVID-19 pandemic presents a unique opportunity for systemic change as healthcare in Canada transitions to a new normal.

Rosalie Wyonch is a Policy Analyst at the C.D. Howe Institute.

To send a comment or leave feedback, email us at blog@cdhowe.org.

The views expressed here are those of the author. The C.D. Howe Institute does not take corporate positions on policy matters.