Exploring the relation between Canadians’ values and health system costs

Anne W. Snowdon, PhD, Karin Schnarr, PhD, Abdul Hussein, PhD, Charles Alessi, MD


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There is a clear misalignment between what Canadians value and how the performance of Canada’s health care system is measured and funded. Survey data suggest that Canadians value greater autonomy and empowerment in managing their health care. They value more “personalized” care that engages every individual patient in a collaborative partnership with health care providers to make decisions that support health, wellness, and quality of life. Yet, health care systems focus on performance management in terms of costs; operational inputs, such as services delivered; or quality measures, such as medication errors, readmissions to hospital, and mortality rates. Their effectiveness is not evaluated in terms of delivering value to Canadians. Although Canadian values are primarily outcomes-based, funding of the health care system is focused on service delivery volumes and provider-focused outcomes.


KEY WORDS: patient values, performance management, health care, metrics, outcome measures, service delivery


Health care spending in Canada has been rising steadily for well over three decades.1 Canadians perceive health care as one of the most fundamentally important hallmark features of society,2 and their support for their much-loved health care system is as strong as ever.3,4 However, are Canadians’ values aligned with current expenditures in health care and measures of health system performance? Top


The concept of “value” in this study is defined as a quality based on a person’s principles or standards, one’s judgment about what is valuable and important in life. Given public representation on boards and governance structures, the mission, vision, and value statements of health sector organizations serve as a proxy to examine Canadians’ core health care values.


To examine what Canadians value, we first describe a synthesis of current studies, surveys, and reports on the views of Canadians toward the current success and outcomes of the health care system. Then, we examine specifically what Canadians and key stakeholders in the health care sector (e.g., hospitals, community organizations, health care professionals, and policymakers) describe as important and valued from a health perspective. Finally, we report the findings of a qualitative analysis of the mission, vision, and value statements of major health organizations, provider groups, and policy organizations to further determine the values inherent in health care organizations. Top


What are Canadians’ core health values?


Health care has a very important purpose and meaning in the lives of Canadians; however, Canadians are also aware of the challenges health care systems face. Canadians support increasing the quality of the health care system even in the face of increasing cost and, in particular, see value in the funding of services focused on promoting wellness and quality of life.5 Canadians believe that the job of the health care system is not only to treat disease, but also to improve the overall health of Canadians, and they believe that a fundamental change in the system is needed, in particular investment in long-term prevention to strengthen population health.6


Significant shifts in values over time have resulted in Canadians’ preference for greater autonomy and empowerment and the desire to make decisions, manage their own health information, and engage health providers as partners “on a level playing field” in managing their own health and wellness.7 Top


How values differ across the continuum of care


Values emerged from the analysis of the mission, vision, and value statements across each type of health organization: hospitals, community organizations, ministries of health, professional organizations (Table 1).



The most dominant theme in hospital mission, vision, and value statements focused on excellent care defined by collaborative partnerships between patients, their families, and the health care team whereby human dignity is honoured and respected to achieve the best possible quality-of-life outcomes for patients. Organizational reputation was a second key value, defined in terms of how hospital image and profile is a reflection of community identity, which reflects the values toward accountability of hospitals to the communities they serve. Quality work environments, new knowledge, and discovery emerged as necessary ingredients to support the delivery of quality health care services. For some hospitals, cultural and heritage values that respect diversity and community spirit were acknowledged as a key value in hospital mission, vision, and value statements. The responsible and accountable use of resources was also valued as a necessary component of health system sustainability by hospital organizations. Top


Community organizations

The values of community organizations were strikingly different in focus from those expressed in the hospital sector; empowerment and engagement to strengthen population health and the social determinants of health were their most central values. The concerns of community organizations focused heavily on the link between social determinants of health and overcoming barriers to health and wellness care. Somewhat similar to hospitals, community organizations valued partnerships between interprofessional teams and the community population they serve to deliver integrated and comprehensive care and strengthen population health and wellness. Top


Health professionals

Health professionals expressed values that reflect their unique role in providing care. They view the health system as a workplace that shapes and influences their professional practice. A dominant focus of the values of health professionals was leading and advocating health systems that support professional practice, which was viewed as a key ingredient for delivering quality health care. A common theme across all health professional organizations was the value of leadership, i.e., leading health service delivery or advancing health professional practice roles to achieve quality outcomes. Interprofessional approaches to care, integration of care, and collaborative partnerships with patients in communities were less clearly evident in this analysis. Top


Policymakers and funders

The values of policy organizations and system funders were, again, different from the other stakeholders. Here, the most dominant value focused on patient experience and the provision of compassionate, respectful, whole person care that meets individual patient needs. The values of funder organizations also focused on health teams, identifying key strengths that are highly valued, such as accountability, respect, integrity, courage, and trust. Health system stewardship was a third value, unique to funders, that focused on judicial and prudent use of resources. Finally, the only stakeholder that identified innovation and collaboration consistently across all organizations as a key value was funder organizations, such as ministries of health. Innovation and collaboration were evident in these values as a strategy for sharing knowledge and being a catalyst for change. Top


Values are deeply embedded in the perspective of Canadians. Community values that focus primarily on community empowerment and engagement, population health, and social determinants of health are not evident in hospital mission, vision, and value statements. Yet, hospitals and community organizations both serve the same communities where they are located, just from vastly different value-based perspectives. Integration and coordination of care was referenced by both hospital and community organizations; however there was no evidence that these two sectors envision each other as partners working together to achieve integrated, coordinated care. Rather, each holds values focused on their specific and distinct mandate, with no reference to their position or role in the larger health system context, in which patients and families are part of a community and a population, and each subsector plays an important role in achieving population health and wellness. Top


The relation between Canadians’ values and health system costs


Health care costs are related to what we can immediately see or experience as consumers (e.g., equipment, pharmaceutical costs, treatment costs, human resources). The major costs identified and measured by health systems include hospital costs, other institutions, physicians, other professionals, home care, drugs, and “other expenditures.”


It is clear from examining spending patterns that Canada funds health care organizations and health professionals, not the health services or quality of health outcomes that reflect Canadians’ values. This is because the Canadian health care system is input-focused; we measure the total costs of inputs (e.g., how many physician consultations, the cost of drugs prescribed, and the cost of hospital services) and equate this to total expenditures, often ignoring opportunity costs or benefit savings. In addition, the value or impact of resource use is not examined, despite the importance of values embedded in health systems. Top


Table 2 profiles the structure of health costs in Canada; there is no clear articulation of these costs with the values depicted in Table1. For example, the engagement and empowerment of communities in their agencies or in collaborative partnerships with health providers in hospitals to achieve quality-of-life outcomes are not captured in how health system costs are measured and evaluated. In other words, the cost of inputs is clear, but the degree to which these investments align with Canadian values is less clear. Costs are not associated with outcomes of health systems that may reflect or align with Canadian values.


In addition, there is little evidence that health system funding is linked directly to, or travels with, a patient within Canada’s health care system. Nor is there a link between funding models and population health outcomes. Indeed, across the spectrum of acute care and community agencies, values favour such health outcomes as quality of life — of either the individual patient or community — whereas priorities for health care funding are structured and focused on the services provided by organizations and professionals. Top


Despite public dialogue about moving funding toward supporting integration and coordination of care and providing incentives for collaboration among health care professionals to shift to a more patient-centric model, a significant shift must occur within system funding structures to align current values with costs. Such structures must focus on funding health and wellness outcomes, rather than services rendered, to drive system change toward patient-centric models of care focused on what Canadians truly value.

In addition, the narrow focus of current funding structures on health organizations, providers, and products precludes Canadians from understanding or identifying the value of health system costs. Thus, Canadians have few opportunities, if any, to be aware of, or judge whether their health care systems are delivering on the value proposition related to health care that the Canadian public strives to achieve. Top


How are Canadians’ values aligned with measures of health system performance?


Many jurisdictions across Canada are making great efforts to develop measures of health system performance, and much of this work is based on the premise that measures of performance can be used to support funding decisions. We examined health system performance indicators used by policymakers and system funders, considering how they relate to what Canadians value. Clearly there is a misalignment (Table 3).


Current measures of health system performance focus primarily on access to care and quality outcomes that identify, primarily, hospital-related adverse outcomes, such as hospital-acquired infections, mortality, and readmissions to hospital. In many instances, there are simply no metrics for Canadian values, such as innovation and collaboration, quality of life, organizational reputation, or community engagement.


Many performance measurement systems tend to measure and profile patient outcomes that are focused primarily on adverse events or factors related to mortality. Little attention is paid to measures important to patients, such as wellness, quality of life, and personal satisfaction. However, this may be shifting as there is an emergent trend in health system performance measures away from health-provider-centric transactions toward more patient-centric metrics focused on patient experience and more closely aligned with Canadian values. Top


In Canada, health system performance measures are clearly linked to funding and allocation of health resources in each jurisdiction. Thus, the challenges of moving from a traditional model of measuring performance in terms of services provided to a system that examines performance based on values, such as quality of life, are substantial, complex, and will continue to evolve over time. The intense competition for funding among organizations and providers may limit the ability of health systems to quickly and effectively move toward integrated and coordinated models of care that are highly valued by Canadians, as such a transition would require collaboration and cooperation among these organizations rather than a competitive dynamic. Thus, to effectively manage a health care system, leaders and decision-makers must find ways to measure system effectiveness and performance in terms of the degree to which they deliver value-based outcomes to the Canadian public. In particular, creating measures of performance in terms of collaboration and cooperative approaches to integrated health care services will be a considerable challenge for years to come. Top


Although performance measures are evolving, substantial progress is needed in the development of measures that capture the values Canadians expect. For example, despite the value of collaborative partnerships with health care providers and the importance of community engagement and empowerment, these factors are simply not reflected in health system measures of performance or cost effectiveness. Provincial and territorial health systems are striving to transition from a highly health-provider-centric (i.e., physician, organization) model of health care toward a more patient-centric (i.e., quality outcomes) model.


Much of this work is considered somewhat of a “moving target.” However, early trends in achieving the transition are evident in some Canadian provinces. For example, Alberta and Ontario are implementing patient-based payment strategies, which may offer greater opportunity to link health system costs to population health outcomes based on quality of health services provided to patients. Top


How do we achieve greater value for Canadians?


To achieve greater value for health system costs in Canada, health system values should be aligned with Canadians’ values — making a shift from a predominantly provider-focused, performance-based system to one that is focused on strengthening health and quality of life. Furthermore, health system performance metrics and funding models should be aligned more closely with Canadian values, which are more focused on health and wellness as a central mandate. Finally, we suggest a re-examination of health workforce values relative to the needs and values of Canadians, who strive for personalized and collaborative relationships with health care providers to achieve health and wellness. Top



1.National health expenditure trends, 1975 to 2013. Ottawa: Canadian Institute for Health Information; n.d. Available: http://tinyurl.com/jlxk6s9

2.Sinha M. Canadian identity, 2013. Publication 89-652-X. Ottawa: Statistics Canada; 2015. Available: http://tinyurl.com/hg35j92

3.Soroka SN. Canadian perceptions of the health care system: a report to the Health Council of Canada. Toronto: Health Council of Canada; 2007. Available: http://tinyurl.com/ks4mqdf

4.Canadian Health Coalition. Support for public health care soars: 94% of Canadians — including Conservatives — choose public over for-profit solutions. Ottawa: Canadian News Wire; 2011. Available: http://tinyurl.com/hfxbslb

5.Mendelsohn M. Canadians’ thoughts on their health care system: preserving the Canadian model through innovation. Ottawa: Commission on the Future of Health Care in Canada; 2002. Available: http://tinyurl.com/zo59fkx

6.Maxwell J, Jackson K, Legowski B, Rosell S, Yankelovich D. Report on citizens’ dialogue on the future of health care in Canada. Ottawa: Commission on the Future of Health Care in Canada; 2002.

7.Farm M, Purdy L. Treating patients as consumers: 2009 Canadian health care consumer survey report. New York: Deloitte; 2009. Available: http://tinyurl.com/hv746as



Anne W. Snowdon, PhD, is a professor of strategy and entrepreneurship and chair of the World Health Innovation Network, Odette School of Business, University of Windsor, Windsor Ontario, Canada.

Karin Schnarr, PhD, is an assistant professor of strategic management at the Lazaridis School of Business and Economics, Wilfrid Laurier University, Waterloo, Ontario, Canada.

Abdul Hussein is an associate professor of mathematics and statistics, faculty of science, University of Windsor, Windsor, Ontario, Canada.

Charles Alessi, MD, is a senior advisor, public health, in London, UK.


Correspondence to: anne.snowdon@uwindsor.ca.


This article has been reviewed by a panel of physician leaders.



How values differ across the continuum of care

Table 2 profiles the structure of health costs in Canada; there is no clear articulation of these costs with the values depicted in Table1. For example, the engagement and empowerment of communities in their agencies or in collaborative partnerships with health providers in hospitals to achieve quality-of-life outcomes are not captured in how health system costs are measured and evaluated. In other words, the cost of inputs is clear, but the degree to which these investments align with Canadian values is less clear. Costs are not associated with outcomes of health systems that may reflect or align with Canadian values.

How are Canadians’ values aligned with measures of health system performance?