Problem: Option 2: Coordinate (at the provincial level) continuing professional development for healthcare providers that enables

lack of team-based, process-oriented, just-in-time learning coordinated and proactive chronic disease management (CDM) in Ontario

Institutions Government Structure: Federalism- Canada Health Act has led to shared powers, with regards to federalism, for issues that impact the core bargain of public finance, private delivery. The federal governments role in healthcare is as overseer and partial source of finance, while the provincial government is responsible for all other aspects. The proposed changes do not infringe on Canada Health Act, therefore is an issue of reserved powers, where only the province is involved in decision-making. Since only one level within the federation is involved, the proposal is more likely to be introduced. Veto points- The proposal in question involves the Ontario provincial government. In Ontario, the Liberal party holds the majority of seats in parliament. Members of parliament practice strict party discipline, therefore the majority party can pass any proposal they like. In practice, there is no opportunity for an executive decision in government. Therefore, no veto point exists. Since no veto point exists, the proposal is more likely to be introduced. Policy Legacies: Resource and incentive effects- government elites (administrative capacities): Due to past policies, provincial civil servants have built up specific administrative capacities within the healthcare system. Civil servants have had years of experience to develop expertise in specific areas of administration. In Ontario, civil servants are experts at administering the health insurance program. However, they are inexperienced at coordinating continuing professional development for healthcare providers.

Historically, there is an absence of coordination in continuing professional development. Furthermore, its administration has been the role of specific interest and industry groups. If the policy were to pass, it would involve new roles for civil servants, which they are have no experience with. The policy, if passed, would involve a significant and unfamiliar role for civil servants, reducing the likelihood of the proposal being introduced. MAYBE NOT?? - interest groups (spoils, organizing niches, financing, access to authority): Past policies, namely Canada Health Act, have led to the development of Ontarios healthcare system, notable for its core bargain of public payment and private delivery, for physicians and hospital-based care. The agreement has allowed physicians to become a very privileged group in the healthcare system, working in private practice with first-dollar, fee-for-service payment. Unlike other healthcare providers, such as nurses and psychologists, physicians have the spoil of guaranteed public payment. Organizing niches are a result of the Canada Health Act and failed proposals in the 1940s. Physicians have come together to negotiate collectively with the government, as the professional organization, the Ontario Medical Association (OMA). The OMA represents Ontarios physicians political, clinical, and economic interests and is recognized by the Ministry of Health and Long Term Care (MOHLTC) as the exclusive bargaining agent for physicians in Ontario. Physicians are required to submit annual dues to the OMA, as a condition of their right to practice in the province, according to the Ontario Medical Association Dues Act of 1991. Because the OMA is financed by compulsory dues, resources are available to mobilize expensive advocacy campaigns when the organization is for or against a proposal, and to support their bargaining rights. The OMA is very privileged with respect to access to authority. The collective bargaining relationship that exists between the OMA and the MOHLTC was re-established, after some turmoil, with the Physicians Services Agreement in 1997. Strictly for economic issues, including the fee schedule and fee increases, the OMA is directly involved in the decision-making process. The Physician Services Committee was established as the hub of OMA-MOHLTC bargaining processes, consisting of 5 members from the OMA and 5 from the MOHLTC. The proposal to coordinate continuing professional development does not provide significant benefits to the OMA, but instead may be rather costly. Since there are no benefits for the OMA, they would be unlikely to use their power to support the proposal, thereby reducing the likelihood of the proposal being introduced. - mass public (lock-in effects): Lock-in effects occur when the public becomes accustomed to certain expectations being met by the healthcare system. Past policies will shape lock-in effects with the mass public, which can place limitations on healthcare reform. For example, the public is accustomed to physician care having first dollar coverage and would likely oppose a change that would impact their expectations. With regards to the policy of coordinating CPD, the public would not be directly impacted and therefore lock-in effects do not create any barriers to the proposal being introduced. Interpretive effects-

- government elites (policy learning): Government elites, such as provincial civil servants, learn from success and failures of past policies what they can and cannot do in the future. Historically, proposals that attempt to change the core bargain have never been introduced. Government elites have since learned that for new policies to be introduced, they are more likely to be successful if they leave the core bargain largely untouched. The approach of coordinating CPD at the provincial level, to strengthen chronic disease management in Ontario, is an example of policy learning. While there is a clear problem defined in the way chronic disease is managed in Ontarios healthcare system, government elites are more comfortable considering solutions that tweak the system, without touching the core bargain, such as coordinating CPD, than policies that require more drastic changes, such as changing the approach to primary care. - interest groups (policy learning): Interest groups, like government elites, also learn from the success and failure of policies historically. Groups learn how to organize themselves around certain issues and mobilize efficiently. The OMA has learned how to spark fear in the mass public when policies of primary healthcare reform infringe on their freedom to practice, as they like. If the government were to take on the role of coordinator for CPD, as suggested in the proposal, the OMA may react to oppose the proposal. Physicians in Ontario are self-regulated, through the College of Physicians and Surgeons of Ontario (CPSO). The proposal suggests an increase in government regulation, impacting physicians directly. This could be perceived as a threat to physicians autonomy, given their reactions and the implications of past policies. The OMA would then be able to use its experience and expertise, which its developed from policy learning, to mobilize an advocacy campaign against the proposal, making it less likely to be introduced. - mass public (visibility and traceability): Visibility refers to how easy it is for the public to identify a change in policy. Visible changes often try to change the core bargain, which the mass public is familiar with and therefore would notice a difference. The proposal of continuing CPD is not highly visible, as it directly impacts healthcare providers rather than the public and its interaction with the system. Traceability refers to how easily one can identify and hold accountable the individual responsible for the policy decision. Because the proposal is strictly a provincial issue, for it to be introduced, the majority Liberal party and the Minister of Health and Long Term Care would have to approve it. The mass public would be able to hold the Premier of the Liberal party, Dalton McGuinty, and the Minister, Deb Matthews, accountable. Therefore the change would be easily traceable, if the public were to oppose the proposal. However, its unlikely that the mass public would not be in line with the policy, so high traceability may not be an important factor in whether the proposal is introduced. Because the change is not highly visible, its more likely to be introduced. The high traceability would likely be less important because the change is in line with mass opinion. Policy Network:

Clientele pluralist network- In clientele pluralism, the state relinquishes some of its authority to private-sector actors, who, in turn, pursue objectives with which officials are in broad agreement. Through the Physician Services Committee, the OMA has the potential to be a part of the clientele pluralist network. However, the policy does not impact fee scheduling or fee increases, so the OMA would not have a seat at the decision-making table. In Ontario, there are no other organizations that could be involved in clientele pluralism. There are no organizations in the network, therefore clientele pluralism cannot impact the likelihood of the proposal being introduced. Pressure pluralist network- Since the OMA is not in the clientele pluralist network for the proposal to coordinate CPD, the organization would be considered a powerful actor in the pressure pluralist network. Pressure pluralist groups do not have access to the decision-making table, so they assume primarily an advocacy role, and the government remains an autonomous agency. Other groups of organized interests also contribute to the pressure pluralist network, such as citizen and patient groups, including Cancer Care Ontario, and the Ontario chapter of the Canadian Diabetes Association.

Interests

Societal Interest Groups: Citizen groups and patient groups- There is no group or organization for chronic care, specifically. As a result, there is a no accepted framework for how to support individuals living with chronic diseases, nor incentives and accountabilities for practices and organizations. There are many disease-based groups, such as Cancer Care Ontario and the Ontario chapter of the Canadian Diabetes Association, that fall under the chronic care umbrella, which leads to arguments between groups. Each group has unique objectives causing problems of collective action and lack of cohesion. As such, the citizen and patient groups are weak and carry little influence. Disease-based groups aim to improve the quality of care for their patients, therefore would likely be supportive of healthcare reforms targeted at such care. Professional groups- The Ontario Medical Association (OMA) is professional organization for physicians in Ontario. The policy proposal, if introduced, will directly impact their current practices, as continuing professional development is aimed towards physicians. Guidelines to care for chronic diseases are more time consuming and do not address teambased care. Professional development usually occurs within ones discipline, however the proposal would require physicians to learn partake in interdisciplinary training. Funding for the new protocol is largely unknown. Therefore, the OMA would likely resist the suggested changes. The OMA is very powerful and influential. Its sources of power include money for media campaigns and the ability to sway public opinion in their favor. The OMA also has the capacity to affect implementation, as physicians must be on board for CPD to be successful. They can also provoke an anticipatory

reaction, as a result of their strength. Industry groups- Pharmacy companies, device manufacturers, and for-profit firms often finance continuing professional development. This can introduce bias, by focusing on training that would benefit the companies and increase sales, rather than focusing on patient needs. Expanding CPD would increase opportunities for industries to promote their products. For this reason, the government would need to regulate and limit their contributions. The industry groups would not be in favor of increased regulation, which could place limitations on their profits, therefore would oppose the suggested change. Who wins? Citizen and patient groups benefit with improved care for their members. Who loses? Professional groups, such as the OMA, and industry groups, stand to lose their autonomy and freedom to self-regulate due to imposed regulations and directives. By how much? Citizen and patient groups face diffuse benefits. Policy implementation would ideally improve care, but is not directly aimed towards any specific disease. Because the groups are disease-based, the benefits are not concentrate for any one group. Therefore, citizen and patient groups may mobilize to pursue their interests, but the likelihood is less so than if they faced concentrated benefits. Professional groups face concentrated costs, because the policy directly impacts physicians responsibilities. Therefore, professional groups would be more likely to mobilize resources in opposition to the proposal. Industry groups face concentrated costs because the regulation would have a direct impact on their involvement in CPD. However, compared to professional groups, the costs are of smaller magnitude, as CPD is only one aspect of their business. Therefore, industry groups would be likely to mobilize against the proposal, but less likely than professional groups. With respect to societal interest groups, changes that provide concentrated benefits or diffuse costs to groups with influence or power are more likely to be introduced. The most influential interest group, the OMA, faces concentrated costs and will likely mobilize to pursue their interests, making it less likely for the change to be introduced. Elected Officials: Minister of Health and Long Term Care Civil Servants: Ministry of Health and Long Term Care Researchers: Policy analyst, physicians specializing in chronic disease management

Policy Entrepreneurs: Not yet apparent. Knowledge or beliefs about what is,: Research evidence- Support for improvements in appropriateness of care include: Educational meetings are generally effective; audit and feedback may be effective alone, or in combination with other interventions; mixed effects observed in comparing clinical decision support systems with no such system; educational outreach visits were found to be generally effective; opinion leaders generally effective; patient-mediated interventions have mixed effects or are generally effective; and interprofessional approaches to education meetings were generally shown to be effective. No key findings were identifies with respect to potential harms of coordinated continuing profession development. Therefore, the overwhelming majority of evidence is in favor of the proposed change. Other types of information- The United Kingdom provides diabetes monitoring to 85% of patients, while Ontario only examines 51%. The National Health Strategy suggests physicians in the UK aim to examine feet and eyes of 100% of diabetes patients (OHQC, 2010). The Ontario Chronic Disease Prevention and Management framework is based on models that were successful in countries such as the US, UK, Australia, New Zealand, and parts of Europe, as well as provinces such as B.C., Alberta, Saskatchewan, and Manitoba (MOHLTC CDP&M website). Tacit knowledge- The Ontario Chronic Disease Prevention and Management framework makes suggestions for a system to manage chronic care, but does not have an implementation plan or resources to support it. Thousands of guidelines, from the Canadian Medical Associations Infobase and the Ontario Guidelines Advisory Committees database, are available to healthcare providers to address CDM, but again there is no prioritization, clear plan, or resources to support implementation. Values/Mass opinion about what ought to be: Mass opinion- Healthcare consumers tend to favor immediate gratification with respect to healthcare and disease management, over preventative services. While there is no evidence to support that Ontarians are in favor of coordinating CPD specifically, several opinion polls indicate that they are thinking about healthcare reform, and want healthcare to be a priority on the governments agenda (http://www.ipsos-na.com/news-polls/pressrelease.aspx?id=5111 and http://www.longwoods.com/content/16723). Therefore, mass opinion would likely support efforts to improve chronic care.

Ideas

Informed mass opinion following deliberation- Stakeholder dialogues indicate that the public may be more interested if the policy issue is reframed to focus on supporting people to live well with chronic conditions, rather than chronic disease management. Elite opinion- OHQC believes chronic care should include regular monitoring of condition and risk factors and that patients should be on the correct medication and have knowledge about how to manage their condition (2010). Cancer Care Ontario, a disease-based organization, wants to improve performance of the cancer system by driving quality, accountability, and innovation in all cancer-related services (cancercare.on.ca). Meanwhile, the Canadian Diabetes Association, another disease-based group, hopes to ease the burden of access and cost, ensure access to the optimal care, respect individual rights and privileges, and encourage government accountability. The proposed change is supported by both research evidence and mass opinion, therefore is more likely to be introduced.

External Factors

Post-recession environment with emphasis on cost cutting and deficit reduction initiatives. Canadians feel the system is sufficiently funded, but reprioritization of existing funds is necessary. (Health Canada Performance Survey 2009). Three major reports have been released within the past two years that address inadequacies of Ontarios current system for chronic care. The reports include two annual reports from OHQC (2009 and 2010) and the OMA Policy on Chronic Disease Management (2009).