Remarks by
Deborah Marshall, PhD
Canada Research Chair, Health Systems and Services Research
Arthur J.E. Child Chair Rheumatology Outcomes Research
Associate Professor of Community Health Sciences, University of Calgary
Director, Health Technology Assessment, Alberta Bone and Joint Health Institute
To the
Economic Club of Canada/Arthritis Alliance of Canada
Canadian Healthcare Reform Expert Panel
November 22, 2013
The Westin Hotel
Ottawa, Ontario
(As Delivered)
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Economic Club of Canada / Arthritis Alliance of Canada
November 22, 2013
Deborah Marshall
Good afternoon. I am delighted and thank you for the invitation to be here with
Economic Club of Canada at the Arthritis Alliance of Canada Inaugural Conference
and Research Symposium and to have the opportunity to discuss improved
performance and better outcomes for chronic disease management in Canada.
And I applaud the Alliance for their commitment to advancing innovation and
patient care for Canadians with arthritis. I am pleased to be part of the team.
First, let me take you back to the ’80s to a lab in Seattle. A triumph occurred. A
biochemist discovers a cloned receptor. The first successful biologic treatment. A
treatment that provides relief for rheumatoid arthritis sufferers.1 It’s a
blockbuster. Sales of the drug – which we know as Enbrel – hit $13 million dollars
in the first weeks.2
Once facing a virtual death sentence, crippled and robbed of years of life,
rheumatoid arthritis sufferers can now walk instead of crawl. They can open their
hands. They can pick up a fork. They can work. They can play. In what some refer
to as the Lazareth effect, they are, “risen from the dead”.
Something else of great consequence has happened. These rheumatoid arthritis
sufferers have become chronic disease patients.
But as chronic disease patients in Canada, they are going to enter a public health
care system that is ill-equipped to care for them in the most effective way
possible.
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Economic Club of Canada / Arthritis Alliance of Canada
November 22, 2013
Deborah Marshall
Canada remains in the shadows of medicine’s Industrial Age3 – an age
characterized by mass production, passive patients, and an enormous
infrastructure oriented to acute care.
Meanwhile, chronic disease has overtaken acute illness as Canada’s number one
health challenge.
One reason for this is that we are, thankfully, victims of our own success in
medicine. Conditions that used to kill can now be managed through long-term
intervention.4
Another reason is demographics with the aging population . . . baby boomers
entering a stage of life when joints creak, bones become brittle and blood sugars
rise.
And it’s not going to get any better. Conditions like obesity, diabetes and
hypertension, which used to be the exclusive domain of adults, are showing up in
our children.
The point is – industrial age institutions and one-size-fits-all treatment are not
the optimal way to deal with our approaching chronic disease epidemic.
And make no mistake. It is an epidemic. Take arthritis as the example - by 2040, 1
in 4 Canadians will have arthritis.5 And over 50% of them will be under the age of
65 years.6
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Economic Club of Canada / Arthritis Alliance of Canada
November 22, 2013
Deborah Marshall
Chronic disease requires ongoing management in the community, tailored to the
individual – what is called ‘personalized’ or ‘precision medicine’.7 So. . . we
scrutinize the patient’s complete medical history. Past medical problems.
Treatments that worked. Treatments that didn’t work. We examine
environmental factors. We peer into an individual’s genetic code to select the
best treatment approach. We find out what the patient’s treatment preferences
are.
And we use all of this information – genetics, medical history, environment and
preferences – to develop a custom-tailored plan for managing chronic illness. The
plan is holistic and multifaceted, involving lifestyle changes, medication, a
multidisciplinary care team, family support, and self-help networks. Patients are
educated and given the tools to manage their condition.
Health professionals take on different roles at different times, depending on
circumstances. They may be facilitators at one point, partners at another, or
authorities when needed.
And patients receive care whenever they need it and in many forms, not just faceto-face office visits.8 This implies that the health care system must be responsive
at all times, and have the capability to respond to individual patient choices and
preferences.
What I have just described is medicine in the Information Age.4 An age of
connectivity. An age where the patient is a digital warrior.7
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Economic Club of Canada / Arthritis Alliance of Canada
November 22, 2013
Deborah Marshall
Tools like wristbands that monitor and transmit your blood pressure and heart
rhythm. Smart phones that take a cardiogram and send it to your doctor.
By 2015, all citizens with chronic disease in the United Kingdom will have a digital
customized care plan. The U.K. will launch a process for entrepreneurs to easily
offer online tools and services that support customization for chronic disease
patients.9
But things are happening at a slower pace in Canada.
The good news is we can make the change to the Information Age. The recipe is
straightforward.7,8
 First, we need good, rapid knowledge translation.10 It means turning great
evidence-based ideas and products into practice and policy quickly. We can do
much better than the typical decade and a half it takes now to get an
innovative health care product to market.
 Next, we need to make patient preferences – the things patients need and
value – a central part of the care they receive.11
 Third, we need to engage with patients – to be an active and integral part of
their own care team, and to influence medical practice, research and policy.
 We need incentives linked to achieving health outcomes. Incentives not just
for practitioners; but for managers and patients, too.
 And finally, we need systems thinking to understand the interactions among
the many pieces that make up a health system and consider the intended and
unintended consequences of changes.12
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Economic Club of Canada / Arthritis Alliance of Canada
November 22, 2013
Deborah Marshall
For example, the wait to see a rheumatologist could be 1 year. But, if a patient
with rheumatoid arthritis is not seen within a few months, the chance of
achieving remission is cut in half.13 And at 1 year, the opportunity to treat early
with conventional disease modifying drugs that cost about $1,000, is lost. With
the disease advanced, biologics are now needed - at a cost of more like $30,000.
These unintended consequences of a 1 year wait are bad news for both the
patient, in terms of outcomes, and to the health system in terms of cost and
chronic disease management.14
This recipe will get us better health care at lower costs with higher patient
satisfaction.
I trust this recipe resonates with you as business people. You know the market
value of knowledge translation – getting great products from concept to shelf.
The value of knowing your customers’ preferences – of engaging with your clients
to win market share - of incenting performance - of using systems thinking to
understand service and production efficiencies.
Further, as employers, I’m sure you are concerned about the relationship
between health and wealth. Good chronic disease care leads to a more
productive workforce, reduced absenteeism and higher numbers of Canadians
able to work. The costs of poor health to the economy can be staggering - the
SARS outbreak took $3.7 billion out of Canada’s GDP and 1% off its economic
growth.15
Clearly, we need transformative change to get to the Information Age.
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Economic Club of Canada / Arthritis Alliance of Canada
November 22, 2013
Deborah Marshall
I would propose that we need more business principles applied in health care.
I’m not suggesting privatization. I am suggesting we adopt private enterprise
concepts. A key concept is benchmarking and measuring performance. In health
care, this includes measuring across all dimensions of care quality – safety, access,
efficiency, effectiveness, acceptability and appropriateness. This is the way to get
accountability into our health system. And accountability, leads to transformative
change.
We don’t need more money. We do need to redirect our money to right places.
One of Canada’s greatest needs in addressing chronic care, is for leadership that is
prepared to pull our health system out of the Industrial Age and leap into an
enlightened Information Age. We all have a vested interest in this change and the
influence to help make it happen. Like the Nike slogan, ‘Let’s do it’.
Thank you!
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Economic Club of Canada / Arthritis Alliance of Canada
November 22, 2013
Deborah Marshall
References:
1. Smith C, Goodwin R. The story of Enbrel. Innovation.org. Available from:
http://www.innovation.org/index.cfm/StoriesofInnovation/InnovatorStories/The_Story_of_Enbr
el?popwindow. [Accessed November 22, 2013].
2. Funding Universe. Immunex Corporation History. Available from:
http://www.fundinguniverse.com/company-histories/immunex-corporation-history/. [Accessed
November 22, 2013].
3. Ferguson T. Consumer health informatics. Healthcare Forum Journal 1995; 38:28-33.
4. Barnes K, Levy D. Lutz S. Customizing healthcare: How a new approach to diagnosis, care, and
cure could transform employer benefits in a post reform world. PwC Health Research Institute.
Available from: http://www.pwc.com/us/en/view/issue-13/customizing-healthcare.jhtml.
[Accessed November 22, 2013].
5. Arthritis Alliance of Canada. Joint action on arthritis: A framework to improve arthritis
prevention and care in Canada (2012). Available from:
http://www.arthritisalliance.ca/docs/media/201209171000_framework_EN_588.pdf. [Accessed
November 22, 2013].
6. Arthritis Society Alberta and Northwest Territories Division. Arthritis in Alberta Study, 2013.
Available from:
http://www.industrymailout.com/Industry/View.aspx?id=485008&q=631331270&qz=3454df.
[Accessed September 9, 2013]
7. Marshall DA. Health care, meet Xbox: The Mass Customization of Medicine. International
Society for Pharmacoeconomics and Outcomes Research (ISPOR) Connections, May-June 2013;
19(3):3-4.
8. Committee on Quality of Health Care in America. Institute of Medicine. Crossing the Quality
Chasm: A New Health System for the 21st Century.
http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-QualityChasm/Quality%20Chasm%202001%20%20report%20brief.pdf. [Accessed May 23, 2013.]
9. Medcity News. NHS: Everyone in U.K. with chronic condition to have a digital, personalized plan
of care by 2015. Available from: http://medcitynews.com/2013/09/nhs-everyone-uk-chroniccondition-digital-personalized-plan-care-2015/. [Accessed November 22, 2013].
10. Marshall DA. We Have the Means, Motive and Opportunity: Bridging the Gulf between Health
Care Knowledge and Practice. International Society for Pharmacoeconomics and Outcomes
Research (ISPOR) Connections, September-October 2012; 18(5):3-4.
11. Bridges J, Brett Hauber, Deborah Marshall, et al. Conjoint analysis applications in health – a
checklist: A report of the ISPOR good research practices for conjoint analysis task force. Value
Health 2011;14:403-13.
12. Marshall DA. Getting Connected: Systems Solutions for Generating Maximal Value from Health
Care Resources. International Society for Pharmacoeconomics and Outcomes Research (ISPOR)
Connections, November-December 2012;18(6):3-4.
13. Schipper LG, Vermeer M, Kuper HH, et al. A tight control treatment strategy aiming for remission
in early rheumatoid arthritis is more effective than usual care treatment in daily clinical practice:
a study of two cohorts in the Dutch Rheumatoid Arthritis Monitoring registry. Ann Rheum Dis
2012;71:845-50.
14. Barnabe C, Thanh N, Ohinmeaa A, Homik J, Barr S, Martin L and Maksymowych W. Healthcare
service utilisation costs are reduced when rheumatoid arthritis patients achieve sustained
remission. Ann Rheum Dis 2013;72(10):1664-8.
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Economic Club of Canada / Arthritis Alliance of Canada
November 22, 2013
Deborah Marshall
15. Frank C. EvidenceNetwork.ca. It’s time to view public health care as an economic asset.
http://umanitoba.ca/outreach/evidencenetwork/archives/9487. [Accessed November 22,
2013].
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