• Article
  • August 31, 2017

Both Sides of the Border: Perspectives from an American Pediatric Specialist and Hospital Executive in Canada

This CEO with experience working in Canadian and American children's hospitals shares his perspectives on health care.

Michael Apkon, M.D., MBA, Ph.D., has been president and CEO of The Hospital for Sick Kids (SickKids) in Toronto, Ontario, since January 2014. Before that, he spent years as a pediatric physician and senior executive in leading U.S. children's hospitals, including Children's Hospital of Philadelphia and Yale New Haven Children's Hospital in Connecticut.

Children's Hospitals Today spoke with Apkon, who shares his opinions on pediatric health care on both sides of the northern border, and how a new partnership he helped form with two other leading pediatric centers in Ontario has made a difference for patients, families, and even the electronic health record (EHR).

Kids Health Alliance

  • SickKids launched Kids Health Alliance with Holland Bloorview Kids Rehabilitation Hospital and the Children’s Hospital of Eastern Ontario – Ottawa Children's Treatment Centre (CHEO – OCTC)
  • The goals: to coordinate and improve care for Ontario's children with complex medical needs who require care from multiple providers and to simplify care coordination for families
  • Kids Health Alliance will include other pediatric health care providers: community hospitals, pediatricians, rehabilitation services, home health agencies, mental health services and other service providers
  • Ontario's Ministry of Health and Long-Term Care is supporting Kids Health Alliance with $1.3 million, and the Alliance has attracted philanthropic support

What do you think the U.S. health care system can learn from SickKids and from the health care system in Canada?

First, through my experience in the States and now in Canada—and working in a number of countries through my prior roles and through the work we're doing internationally at SickKids—I'd say all health systems are dealing with the same universal truths of not having enough revenue to keep up with the increasing expenses driven by innovation, inflation and population growth.

We also face much greater demands on the part of patients and providers for better systems, better outcomes and better experiences. In addition, children's hospitals and health systems are trying to address the very high concentration of pediatric expertise in a small number of centers, which is creating an increased need for kids to get their care further and further from home.

I have come to appreciate significant differences between the U.S. and Canadian systems…at the most basic level, the main differences are in the structure of the health care system and the fact that, in Canada, there is universal coverage—and within each province, a single-payer system.

We have fantastic health care systems in the U.S., but if you don't have the right insurance, you can't use them. Any child in Canada whose parents can find their way to Toronto can get their services at SickKids, and there will never be a bill for them. In Canada, there is no cost to individuals for physician or hospital services.

From a social justice standpoint and the way we think about equitable distribution of pediatric care across socioeconomic zones, geography or other considerations, there's a lot to learn from Canada and other countries that have addressed things this way.

One of the other things that flows out of a single-payer, publicly funded system is that government can make it easier for children's hospitals to support care across a broader health care system. The funding of the Kids Health Alliance is a great example of that.

As one example, we provide thousands of telepsychiatry visits a year to remote parts of the province that otherwise would not have a children's mental health specialist. You still have to convince the payer to fund programs like that in a way that's similar to what I experienced in the U.S., but there's only one payer you have to convince. And the payer also carries great sway with the other provider organizations that you might need to have to work with—making it easier to establish partnerships.

Talk about how Kids Health Alliance came about and, even though the partnership is in the early stages, what kind of effect you are seeing.

We came up with the idea of building on the programmatic partnerships that we had for some time and deepening the relationships by creating a corporate alliance among the three children's hospitals so we could do business with each other in a more efficient way.

Through the launch of Kids Health Alliance, we created a brand signaling excellence and expertise that we could extend to affiliates along a broader care continuum and work with them in a consistent way.

The bottom line is kids who face illness, injury or disability rely on a complex network of providers that involves hospitals, home and school environments and a wide spectrum of publicly funded and unfunded community services. Kids Health Alliance will help facilitate a coordinated approach to care and support a holistic view of each patient's needs and experiences.

It's still in the early days, but our first community hospital affiliates have already signed on, and we're working with them quite closely around emergency department care, neonatology and inpatient care.

We also are using Kids Health Alliance to integrate our IT strategies between Children's Hospital of Eastern Ontario and SickKids. We're implementing a single instance of Epic as the EHR that will serve our organizations. As far as Epic knows, we're the only organization in the world they're working with right now that has two autonomously governed entities coming together to build a single instance of the EHR.

I look at the EHR implementations in the U.S. children's hospital market, with every hospital essentially running their own IT shops and building their own installations. The kind of structure we're using actually has a lot of applicability in the States.

This kind of corporate alliance would bring scale, geographic reach and new research opportunities—and probably a way to interact differently with the payer market and the government.

The Kids Health Alliance seems to bring tremendous benefit to parents and families.

In many ways, the parents drove us to think this way. Soon after I arrived in Ontario, I met a number of families. I visited them in our clinics and on the patient wards as well as a number of community venues. I recall one conversation I had with a mom of a child with complex medical problems. She lived about an hour away from Toronto.

I was asking her what kind of work she and her husband did—and she said she couldn't work outside the home because her full-time job was being her child's health care general contractor, putting together all the different pieces of her child's health care spanning many different organizations. That was the kind of conversation that really made me, and others, recognize there's an opportunity to help families bridge the dynamics between different organizations.

What are your thoughts on the health care debate in Washington?

The current system leaves people out and creates a considerable economic burden for some. It creates a situation where people can simply not afford to be covered and receive services.

If I contrast that with my experience in Canada, there is a much greater tolerance for not necessarily having everything you want, but being proud of the fact that a billionaire and somebody who is not working and living on the lower-income end of the spectrum are getting exactly the same care from the exact same organizations with the same good outcomes. Health care is very much viewed as a right.

What troubles me about the U.S. system, beyond the fact that some people lack coverage, is that I do think it impacts the quality of the overall health of the population. For example, if you look at the management of patients with cystic fibrosis—a condition all children's hospitals are familiar with—you will live 10 years longer in Canada than if you're born with the condition in the U.S.

We don't have any different medications. We don't have any different treatments. I don't think the doctors, nurses and health care administrators are any smarter in Canada than they are in the U.S. It's primarily an access issue. It's that people here get what they need. Canadians work hard to ensure that people aren't disenfranchised by geography, social economic status, gender or other factors.

Rather than talking about improving health care delivery and managing costs, the current dialogue in the States centers on how many people are we going to be able to leave uncovered at one end of the earning spectrum in order to save money that will go into tax cuts at the high-end of the earning spectrum….that, I find deeply troubling.

Send questions or comments to magazine@childrenshospitals.org.