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Getting the Diagnosis Right… Toward a Sustainable Future for Canadian Health Care Policy (Part One of a two-part brief to the Royal Commission on the Future of Health Care in Canada)

https://policybase.cma.ca/en/permalink/policy1970
Last Reviewed
2020-02-29
Date
2001-10-31
Topics
Health systems, system funding and performance
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2001-10-31
Topics
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) welcomes this opportunity to provide a perspective to the Royal Commission on the Future of Health Care in Canada on behalf of our 50,000 physician members, provincial/territorial divisions and affiliated medical organizations. Canada’s doctors are literally at the coal face of the health care system. Collectively each year our physicians, including licensed physicians, post graduate trainees and medical students have at least one, and often several face-to-face interactions with at least 80% of Canadians. Moreover, on a daily basis we interact with a wide range of other health professionals and agencies. The striking of the Commission has come at a cross-roads in the evolution of our national health care program. We face a faltering health care system, characterized by no long-term vision or systematic plan. There is a lack of common purpose among the stakeholders, waning public confidence and extremely low provider morale. If we do not act immediately to address these key areas, we will very soon lose the underpinnings of social support for the publicly funded health care system. This brief is the first of two parts. In medicine it has long been accepted that the key to a successful treatment is to first get the diagnosis right. In Part One we will focus on the “signs and symptoms” leading to a diagnosis and also outline some of the broad pathways to stabilizing our traumatized health care system. In Part Two, which will be completed in the spring of 2002, we will put forward recommended treatments. The overall theme is that we cannot manage our way out via increased efficiency gains alone. SIGNS AND SYMPTOMS OF A “TRAUMATIZED PATIENT” As a result of the relentless cost-cutting of the 1990s, we are now in the midst of a crisis of sustainability that has at least five dimensions: Crisis of Access – For those of us who spend increasing amounts of time each day trying to secure diagnostic and treatment resources for our patients, it is clear that we are in a deepening crisis of access to people, to technology, and to the surrounding infrastructure. What were once routine and timely referrals and treatments are now unacceptably long waits for all but the most urgent care. Crisis of Provider Morale – The morale of physicians, nurses and other providers in the system is at an all-time low. Physicians are working harder than ever, with fatigue and burnout becoming more commonplace. We are increasingly frustrated by the growing effort and time required to secure resources for our patients. Moreover, physicians have been largely marginalized in decision making at a system level as a result of the reforms of the 1990s. Crisis of Public Confidence – While Canadians continue to report high satisfaction with the health care they receive, they have lost confidence that the system will be there for them in the future. At the same time, they are being barraged through multiple media about the promise of revolutionary technology that is fueling their expectations about what we as physicians and the health care system are able to provide for them. Crisis of Health System Financing – While the federal government had been paring back its contributions to Medicare since the late 1970s, this was greatly intensified in the mid-1990s and only recently has begun to reverse itself. Health care spending is projected to exceed 40% of provincial/territorial government revenues in the not too distant future. Demographics and technology will continue to put upward pressure on costs. We believe that the top-down supply side management approach to cost containment has been a resounding failure. Crisis of Accountability – There is a growing problem of accountability at several levels. There continues to be bickering between the federal and provincial/territorial governments – is the federal share of Medicare 11% or 34%? At the provincial/territorial level, accountability has been pushed down to regional health authorities while authority continues to be held by the central health ministry. Proposals for reform have targeted providers for increased accountability but have ignored consumers as patients. We believe that the health care system and those of us who work in it have been seriously traumatized. We believe that these five signs and symptoms will only grow worse in the years ahead unless there is concentrated and timely action. PATHWAYS TO STABILIZING THE TRAUMATIZED PATIENT While we are not ready to put forward specific recommended treatments at this time, we would suggest that there are five “pathways” that will help guide the Commission’s work on the stabilization and recovery of this trauma. Focus on the “Hows”, not just the “Whats” – The health reform discussions of the 1990s in Canada have been dominated by the “whats” rather than the “hows”. When the “how” was considered at all, governments generally approached reform with a “big bang” approach. International experts have recognized that this is very unlikely to be successful when there are many stakeholders in a plurality of settings—which is certainly an apt depiction of the Canadian health care landscape. There is a clear need for a collaborative approach to “change management” that is based on early, ongoing and meaningful involvement of all key stakeholders. Adopt a Values-Based Approach to Change – We believe that Canadian Medicare has been largely well-served by its values-based approach, as expressed in the five program criteria of the Canada Health Act. We believe that a modernized Medicare program must continue to be underpinned by basic values such as universality and expressed through national principles. In particular, as physicians, we believe it is fundamental that we must continue to be agents of our patients and moreover that we must continue to uphold the principles of choice between patients and physicians. Striking a Better Balance Between Everything and Everyone – As we contemplate what a vision of Medicare for tomorrow might include we must be mindful that no country in the world has been able to pay for first dollar coverage for timely access to all health services. In light of the rapidly transforming delivery system with a shift from institutional to community-based care, a re-examination of the Medicare “basket” is overdue. Generate New Thinking – The new millennium requires new thinking. We have become complacent about Medicare. We are unlikely to find durable answers as long as discussions are bound by the current scope of application and interpretation of the five principles of the Canada Health Act. We need to reflect on the discussions among provincial/territorial premiers over the past few years and on international experience in order to gain an appreciation of the new consensus that may be emerging. Canada can and must learn from the experience of other countries that have already been forced to deal with, for example, the demographic shifts that Canada is about to encounter. We also need new thinking about the evolving context of the delivery of care in the age of the Internet and the new generation of both consumers and providers. Recognize That Better Management (while necessary) Will Not Be Sufficient – We do not believe that we can simply manage our way out of this crisis. Physicians have supported, indeed led, many innovations such as the implementation of clinical practice guidelines and have participated in primary care reform demonstration projects. Improved efficiency alone, however, cannot meet the demands we expect to see in the future. The system must be properly resourced on a predictable basis. NEXT STEPS… There is no “magic bullet” or quick fix that will put our national health program on a sustainable footing and restore Canadians’ confidence in it. Working harder to make the current system work better will not be sufficient. While there are still gains to be made from efficiencies and integration, we cannot simply manage our way out of this problem. It is time for fundamental change. We should not be discouraged from pressing on with this daunting challenge; it is imperative that we begin to act immediately. This brief sets out the variety of pressures that render the current health system unsustainable. It also sets out a value-based policy framework that can help guide future deliberations and point us to policies that can help address the rising concerns among both providers and Canadian health consumers. The brief is not intended to be all-encompassing. Various other medical organizations will be making representations to the Commission. The CMA encourages the Commission to seriously consider the complementary briefs submitted by our sister organizations. The CMA intends to submit its final recommendations, building on this framework, in the spring of 2002. This second brief will again be the product of our extensive set of discussions with the profession. INTRODUCTION The Canadian Medical Association (CMA) welcomes this opportunity to provide a perspective to the Royal Commission on the Future of Health Care in Canada on behalf of our 50,000 physician members, provincial/territorial divisions and affiliated medical organizations. Canada’s doctors are literally at the coal face of the health care system. Collectively each year our physicians, including licensed physicians, post graduate trainees and medical students have at least one, and often several face-to-face interactions with at least 80% of Canadians. Moreover, on a daily basis we interact with a wide range of other health professionals and agencies. The striking of the Commission has come at a cross-roads in the evolution of our national health care program. We face a faltering health care system, characterized by no long-term vision or systematic plan. There is a lack of common purpose among the stakeholders, waning public confidence and extremely low provider morale. If we do not act immediately to address these key areas, we will very soon lose the underpinnings of social support for the publicly funded health care system. This brief is the first of two parts. In medicine it has long been accepted that the key to a successful treatment is to first get the diagnosis right. In Part One we will focus on the “signs and symptoms” leading to a diagnosis and also outline some of the broad pathways to stabilizing our traumatized health care system. In Part Two, which will be completed in the Spring of 2002, we will put forward recommended treatments. The development of this brief has been guided by the policy debates within the CMA over the past few years , including those at General Council in 1994 to 1998 and 2001, and by current deliberations with our Divisions and Affiliates. It has also been informed by the results of a series of Public Dialogue Sessions that were held across Canada in May/June 2001 and a National Report Card Survey that was conducted in late June 2001. The overall message of this initial submission is that working harder to make the current system work better, while necessary, is not sufficient. While there are still gains to be made from efficiencies and integration, we cannot simply manage our way out of this problem. It is time for fundamental change. Changes must focus, first and foremost, on restoring public confidence and provider morale. They should focus on care and speak to individuals and their needs, rather than being dispassionate at a systems level analysis. As a society, Canadians need a new consensus on the fundamentals of our health and health care system. SIGNS AND SYMPTOMS OF A “TRAUMATIZED PATIENT” 1. CRISIS OF ACCESS—ACCESSIBILITY MEANS NOTHING WITHOUT AVAILABILITY Access is a critical dimension of quality care. We are facing a growing crisis of access to timely health care with human, technological and physical infrastructure dimensions. As a result, the ability to provide quality care is suffering. The Health Workforce While we believe that the health workforce in general is facing a major sustainability challenge, we will focus our discussion on the physician workforce, with which we are most familiar. For most of the past decade, governments have acted on advice that Canada has too many physicians. Ministers of Health met in Banff in January 1992 to discuss the 1991 Barer-Stoddart report Toward Integrated Medical Resource Policies for Canada. 1 Out of the comprehensive set of 53 recommendations in this report, the Ministers clearly “cherry-picked” the one recommendation with a number attached to it – namely the 10% cut in enrolment that was implemented in the Fall of 1993. A year later governments began proposing/introducing a range of punitive measures to promote distribution objectives. Probably the most extreme of these was a proposal by the Ontario government in April of 1993 to discount by 75% the fees of what would have been the majority of new family physicians, paediatricians and psychiatrists. 2 Undergraduate medical school enrolment was already on the decline when the 10% cut was implemented, so the overall reduction translated into 16% fewer positions by 1997/98 than in 1983/84. Opportunities for young Canadians to enter medical school (relative to the population) decreased at an even greater rate. First year enrolment peaked in 1980 with 1 student per 13,000 citizens but by 1998 this had fallen to 1 per 20,000 (compared to 1 per 12,000 in the UK for example). While there was no decrease in the number of postgraduate new entry positions, re-entry opportunities were less plentiful and fell from 663 positions in 1992 to 152 by 1998. 3 Against this backdrop one should scarcely wonder why the number of physicians leaving Canada doubled between 1989 and 1994 (384 to 777). Since 1994, the outflow has abated somewhat to just over 400 in 1999. During 1998 and 1999 the number of physicians returning from abroad increased, thus the net loss was reduced to just under 250 physicians in each of those 2 years. In 2000, owing to a significant drop in the number of physicians leaving, the net loss dropped to 164. Nonetheless this is still equivalent to more than 1.5 graduating medical classes. 4 Over the 12 year period from 1989 – 2000, the net loss of physicians to emigration was almost 4,000. While long term planning is a key element of other large public enterprises in Canada, the same cannot be said for the health workforce. One of the ten core principles of the United Kingdom National Health Services reads “the NHS will support and value its staff”. An application of this principle may be seen in a recent UK strategy document for the scientists, engineers and technologists working in healthcare science. This 3-point strategy covers pay and career opportunities, working conditions and recruitment. 5 We would suggest that such a consideration has been largely absent from Canadian health policy over the past decade, certainly at a national level and most probably at the provincial/territorial level. The health workforce received scant attention by the National Forum on Health. The Provincial/Territorial Health Ministers’ 1997 Renewed Vision for Canada’s Health System makes only incidental mention of the health workforce. 6 These examples suggest that the health workforce has largely been taken for granted. By comparison, during the past decade, no fewer than three task forces have been struck to address the renewal of the federal public service. (Public Service 2000, La Relève and the 2001 Task Force on Modernizing Human Resources Management in the Public Service ). 7 We are now paying the price for this neglect. If we are to continue to maintain health care as a public enterprise in Canada, we believe that there needs to be a high level policy acknowledgement of the value of and commitment to the enhancement and renewal of the health workforce. A recent national consultation on research priorities for health services and policy issues reported that “health human resources was seen as the dominant issue for the next two to five years by policy makers, managers, and clinical organizations. The concerns of policy makers included regulatory frameworks, mechanisms for avoiding cycles of surplus/shortage, and the leadership vacuum within management and policy-making organizations.” 8 There are some signs that governments have belatedly begun to acknowledge that we are in a shortage situation. In November 1999, the Canadian Medical Forum presented the report of its Task Force on Physician Supply (Task Force One) at a meeting hosted by the co-chairs of the Confererence of Federal/Provincial/Territorial Ministers of Health. One of the key recommendations of the report called for an increase to 2000 first year medical school places for 2000.3 Since that time several provinces have announced increases in undergraduate enrolment and postgraduate training. As of July 2001, these increases numbered 353 undergraduate, 153 postgraduate and 37 re-entry (specialty) training positions. 9 However, these increases will not begin to have an appreciable impact for a minimum of five to six years. Another key recommendation, calling for efforts to repatriate Canadian physicians practising abroad and which would have a more immediate payoff has received no attention that we can discern. While these enrolment increases are most welcome, they highlight another problem, namely the steep increases in medical tuition and the prospect of tuition deregulation. Already there are reports of cumulative debt loads from undergraduate and medical education that may exceed $100,000. If this upward trend continues, we fear that this might not only re-ignite an exodus of physicians to the U.S. (where loans may be repaid more quickly), but that access to medical education may be restricted to only the most advantaged Canadians. Indeed a 1999 study 10 at one Ontario medical school found that the median family income of the 1st year intake class following a large tuition increase was significantly higher than the 2nd and higher year classes. A further challenge that is posed by the enrolment increases is in the capacity of the 16 Academic Health Sciences Centres (AHSCs) to provide undergraduate medical education and post-graduate training. There is a tendency to overlook the fact that AHSCs have a threefold mission; to provide teaching, to conduct original research, and to provide all levels of care for the surrounding population and highly specialized care for outlying regions. As the site of training moves increasingly out to the community, it will become necessary to recruit even more teachers from a pool of physicians who are only barely able to cope with their existing workloads. With few exceptions the resources required to fund the expansion of medical education to the community have not been forthcoming. Another development is that Human Resources Development Canada (HRDC) is in the process of initiating several sectoral studies in health including home care, natural products, nursing, oral health care, pharmacists and physicians. 11 The Canadian Medical Forum, made up of the major national Canadian medical organizations, together with others will be working with HRDC and Health Canada to implement the physician sector study over the next few years. Again, these studies will not produce any short term payoffs toward alleviating the immediate and growing shortages of physicians and other health providers. Looking to the decades ahead we know that the demographic composition of the profession is going to change markedly. Women now represent more than 50% of our graduating medical classes, and while at present they represent 29% of the practising physician population, by 2021 this is expected to reach 44%. The medical profession is also aging. As of 2001 some 27% of physicians are aged 55 and over; by 2021 this proportion will be 37%. Given the historical (and continued) gap of some eight hours per week between the average work week of male and female physicians, there will be a major challenge in sustaining the volume of service required to meet the needs of our aging population. Information Technology in Service of Health The health care system operates within an information intensive environment. However, to date, a substantial portion of the data being collected is gleaned as a derivative of administrative or billing/financial systems. Although this provides useful information for arriving at a “high level” view of the operation of the health care system, it is generally of limited value to health care providers at the interface with their patients. A detailed costing study prepared by PriceWaterhouse Coopers for the CMA in 2000 estimated the cost of connecting all delivery points in the Canadian health care system at $4.1 billion. The $500 million announced in the September 2000 Health Accord is only a modest start. Health care providers require access to a secure and portable electronic health record (EHR) that provides details of all health services provided to their patient as well as the appropriate decision support tools. An EHR that meets the clinical needs of health care providers when interacting with their patients will serve to benefit not only the health of Canadians, but the overall efficiency and effectiveness of the health care system. 12 A critical aspect of the EHR that remains to be addressed is that of privacy. While the Personal Information Privacy and Electronic Document Act is due to come into force for health information in 2002, the privacy protection afforded to patient and provider interactions is not at all clearly defined. The CMA has ongoing serious concerns about the lack of clarity in the Act. These concerns have recently been exacerbated by a decision of the federal Privacy Commissioner to deem physician information as “professional” rather than personal, thereby making confidential information more accessible. This will not make it any easier for Canadian physicians to embrace information technology in service of health. Capital Infrastructure Much of our current infrastructure dates back to the early days of Medicare—forty years ago. In order to provide necessary health services, the health care system must be supported by adequate infrastructure. However, public investment in this area has declined substantially since the late 1980s with the first wave of health care reform initiatives. For example, from 1986-87 to 1993-94, the number of approved public hospital beds decreased by 2.8% annually, and in 1994-95 the decline increased to 7.2% annually after the introduction of the CHST. In total, over this period the number of approved public hospital beds decreased by 36.1%. 13 While the trend in shorter inpatient days, and therefore an increase in outpatient care, has mitigated the problem of a bed shortage somewhat, there is a need to monitor readmission rates on an ongoing basis. Furthermore, the question of whether Canada has an adequate supply of acute care beds for those who require inpatient care must be addressed. We would also add that this has resulted in considerable offloading to the community in the area of primary care, community based services and informal caregivers without any transfer or infusion of resources to support the community’s efforts. Further evidence of the disinvestment in health care infrastructure can be seen in the areas of building construction, machinery and equipment. The following considers expenditures in terms of constant 1992 dollars so that levels are adjusted for inflation. Real per capita capital health expenditures by provincial governments have declined by 16.5% from its 1989 peak at over $63. In terms of new building construction by hospitals, between 1982 and 1998 real per capita expenditures decreased by 5.3% annually. Finally, real investment in new machinery and equipment in the hospital sector has declined annually by 1.8% since 1989. 13 2. CRISIS OF PROVIDER MORALE We are concerned that this telling comment, written by a physician respondent in the CMA’s 2001 Physician Resource Questionnaire (PRQ), reflects the mood of many physicians in Canada today. [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] Canada’s physicians are working harder than ever. According to the 2001 PRQ survey the average work week of a physician is 53.4 hours (not including call). The bulk of this is taken up with direct patient care (35 hours). The remainder is occupied by activities such as indirect patient care, teaching, research, and education. The physician’s work week does not end there. Again according to the PRQ, three out of four physicians (74%) report taking shared call for their patients out of hours and those who do report an average of 144 hours (six 24-hour days) per month, during which their activities are constrained to a significant degree. It is no surprise that more than one out of two (54%) respondents to the 2001 PRQ reported that their workload had increased over the past 12 months, while fewer than one out of ten (9%) reported a decrease. In every age group, physicians were likely to report that their workloads are heavier than they would like – in terms of potentially compromising their ability to provide high quality care to their patients – rising from 53% among those less than 35 years of age to roughly 70% of those in the 35-54 age group, and then declining to 64% among those aged 55-64 and 37% among those 65 and over. 14 There are at least three main contributing factors to the crisis of physician morale. The first has been the aforementioned blunt and coercive measures made by governments in the early 1990s to curtail physician numbers and manage distribution. Planning requires taking a longer term view and resisting the temptation to “cherry pick” for short term relief. A second facet of practice life that has become increasingly burdensome for patients and providers is the increasing amount of time that it takes to arrange for referrals, tests and treatments for our patients. In urgent or life-threatening situations, care is being provided. However, about two thirds or 64% of respondents to the 2001 PRQ reported difficulty in obtaining appropriate resources on behalf of their patients. The difficulty that Canadian physicians experience in accessing resources on behalf of their patients is further illustrated by the results of a survey conducted by the firm of Harris Interactive, in which physicians were surveyed in 2000 in Australia, Canada, New Zealand, the U.K. and the U.S. Data from this study show that high proportions of Canadian physicians report problems with access to care in their practices, particularly when compared to their U.S. colleagues. While Canadian and U.K. physicians report similar levels of problems, there are dramatic differences between Canada and the U.S. For example, Canadian physicians are almost eight times more likely to report problems with access to the latest medical and diagnostic equipment than their U.S. colleagues (63% vs. 8%). Similarly, 61% of Canadian physicians reported problems of availability of medical specialists and consultants, compared with 13% of U.S. physicians, while 66% of Canadian physicians reported major problems with long waiting times for surgical or hospital care compared with just 7% of U.S. physicians 15. This is an avoidable cause of stress on the physician-patient relationship. Third, when regionalization was implemented during the 1990s, physicians and other providers were generally marginalized in the process. Indeed, in several provinces, health providers were expressly prohibited from serving on regional boards. An early indication of this was gained in the CMA’s 1995 Physician Resource Questionnaire. Only 10% of respondents agreed that physicians had been involved or consulted in the implementation of regionalization in their region, and just 21% agreed that the medical profession had any ongoing input. While we have not surveyed our members recently on this, we have little reason to believe that there has been significant change. The crisis of morale is by no means confined to physicians. The authors of a recent policy synthesis on the benefits of a healthy workplace for nurses, their patients and the system declared that “the Canadian healthcare system is facing a nursing shortage that threatens patient care. Many nurses, physically and mentally exhausted, quit; employers cannot fill those vacancies, while paradoxically other nurses cannot find secure jobs with hours that suit them. Meanwhile, nursing schools cannot keep up with the demand for new recruits.” 16 3. CRISIS OF PUBLIC CONFIDENCE The observation quoted here was made by one of the physician moderators at the CMA’s 2001 Public Dialogue Sessions. 17 We believe that, if anything it understates the perilous state of Canadians’ confidence in our health care system. [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] The precipitous decline in Canadians’ assessment of our health care system has been tracked by the Ipsos-Reid polling firm over the 1990s. While in May 1991, 61% of Canadians rated our health care system as excellent or good, by January 2000 this has declined to just 26%. 18 We found further evidence of the dimensions of this concern in the first CMA National Report Card on Health Care Survey, which was carried out on our behalf by Ipsos-Reid in the summer of 2001. In terms of an overall rating, just 21% of Canadians gave the system an “A” grade, 44% “B”, 26% “C”, and 9% “D”. While the report card confirms previous findings that those who have used the system are generally satisfied (30% “A”, 38% “B”) the ratings of access to most health care services are distressing (Figure 1). While access to family physicians receives an “A” rating, the ratings of most specialized services are dismal. Just 15% of Canadians rate access to medical specialists as “A”, while 22% assign it a failing “F” grade. 19 [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [TABLE END] Similarly, our Public Dialogue Sessions from the summer made it clear that Canadians believe that the quality of health services has declined in Canada and many fear that it will get worse before it gets better. Six out of ten Canadians (64%) reported that the overall quality of health care services in their community had deteriorated over the past 10-15 years. Looking ahead, 37% of Canadians expect health services to be worse in five years, outnumbering the 30% who think they will get better. As one of our Public Dialogue participants put it this summer, “It will get worse—nursing homes have long waiting lists. Hospital beds are plugged up with people waiting to get into nursing homes. With our aging population—it’s only going to get worse.” 17 Although we do not have much quantitative evidence yet, we believe that patient expectations will continue to increase, as Canadians are bombarded by news of promising new developments through multiple channels. The growth of health information on the Internet has been a chief contributor to this. In the CMA’s 2000 PRQ survey, 84% of physicians reported that patients had at least occasionally presented medical information to them that they had found on the Internet. 20 Also worrisome is the vast array of sources of medical information that can be found on the world wide web – information that is not always from credible sources nor based on scientific evidence. In summary, we are deeply concerned that Canadians’ confidence in our system is hovering at a level that threatens the sustainability of the social consensus that underlies our current Medicare program. Clearly this must be addressed before we attempt to strike a new one. 4. CRISIS OF HEALTH SYSTEM FINANCING When Tommy Douglas’ government implemented Medicare in Saskatchewan in 1962, he said at the time, “all we want to do is pay the bills”. It was not too long after Medicare was implemented nationally in 1971, however, that governments started thinking about ways of controlling costs, and before the decade was out, under the Established Programs Financing (EPF) arrangements, 50:50 cost sharing had been replaced by a combination of tax points and cash contributions linked to economic growth. Clearly, policy thinking has been dominated by top-down supply side management for the past two decades. In a commentary on Justice Emmett Hall’s second (1980) report, noted Canadian health economist Roderick Fraser warned, “the size of the Canadian health care sector in relation to the current health status of Canadians and in particular to the current lifestyle of Canadians, hazardous as it is to health status, leads one to wonder if we have been over-sold on cost-containment.” 21 When EPF was merged with the Canada Assistance Plan (CAP) in the 1995 federal budget, creating the Canada Health and Social Transfer (CHST), total federal contributions to health care became impossible to distinguish from contributions to social assistance and services and post-secondary education. Latterly, this has resulted in ongoing feuding between the federal and provincial/territorial governments over the respective shares of health financing. Not only is the portion of the CHST allocated to health care variable and indistinguishable from other social programs, the amount of the CHST itself has been unstable since its introduction. In the two fiscal years beginning April 1996, government cut CHST cash by 33%. It will not be until 2002-03 that the CHST cash floor will equal its 1994-95 level, with no adjustment for the increasing health care needs of Canadians, inflation or economic growth. 12 A five year $11.5 billion cumulative reinvestment in health care announced in 1999 and an additional one-time unearmarked investment of $2.5 billion in 2000 are a combination of increases to the CHST cash floor and one-time supplements. These CHST supplements, totalling $3.5 billion over three years starting in 1999 and $2.5 billion over four years starting in 2000 are not included in the CHST cash floor, nor are they intended to grow over time through an escalator. These multi-year supplements are charged to the preceding year’s budget. Once allocated and spent, the money is gone. These supplements are merely “tentative half-measures” and by no means a substitute for fostering short-, medium- and/or long-term planning. 12 The effect of the squeeze on public health care finance in Canada is clearly evident in international comparative perspective. During the 1980s and early 1990s, governments were fond of calling Canada the “silver medalist” in health expenditures as we were second only to the U.S. in terms of total per capita expenditures. As of 1998, however, Canada ranks fourth among OECD countries and much lower when we consider just the public component. In 1998, Canada ranked 8th with respect to public per capita spending (the “private system” U.S. ranked third and indeed recorded per capita public spending that was 13% higher than Canada). When public expenditure is considered as a percentage of total health expenditure, Canada was much closer to the bottom, ranking 23rd out of 30. 22 These rankings are not generally well-known and governments are generally not interested in getting this information out to Canadians. Demographics The issue of demography has been widely discussed in recent years and a variety of scenarios regarding the impact of the aging Canadian population has been presented. It was featured in the CMA (1982) report as one of two major pressures on the system, along with technology (see below). According to a 1998 Report of the Auditor General of Canada, the number of people 65 years of age and over is expected to more than double from 3.6 million in 1996 to almost 9 million by 2031. 23 The implication for health care is substantial. On average, per capita public spending on health for those aged 65 and over is almost five times greater than per capita spending on the rest of the population. 23 In our 2000 research, we identified four schools of thought: * The first, and the one that has probably received the greatest attention, posits that as a result of population aging, total health costs will increase significantly and will require an increased relative share of GDP. * The second argues that total health costs will increase, but only gradually, and this increase will be absorbed by GDP growth and reallocations from other sectors. * The third school believes that population aging will result in an increase in the demand for health care, but that we will be able to contain costs by delivering health care more efficiently. * The fourth school holds that the demand for health care will decrease because the future population, and in particular the future elderly population, will enjoy better health status. From the 2000 discussion paper it was evident that there is no clear consensus on the prospects for sustainability. 24 In July 2000, Ipsos-Reid polled the Canadian public on behalf of the CMA, with respect to their agreement on the likelihood that each school will play out over the next 20 years. The results are shown in Table 1 (with exact wording). 25 Clearly, Canadians are skeptical about our ability to sustain an affordable health care system. We share their concern. [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 1: Poll of Canadians’ Views School of thought % reporting agreement 1. Healthcare costs will rise sharply, thereby increasing demands for public funds for health care 45 2. Healthcare costs will rise gradually, the increase will be manageable due to growth in the economy 19 3. The demand for healthcare will increase but we will be able to contain costs by operating the healthcare system more efficiently 29 4. The demand for healthcare will decrease because the population will enjoy better health status 11 [TABLE END] A September 2001 OECD study has compiled the most recent projections of aging related to public expenditures over the 2000-2050 period, and in general, significant health care cost increases associated with population aging are expected. “The average increase over the 2000-2050 period for the 14 countries where this information is available is 3 to 3.5 percentage points of GDP. But for five countries (Australia, Canada, the Netherlands, New Zealand and the United States), increases of 4 percentage points or more are projected.” 26 For Canada specifically, the study estimates that the 2000 level of 6.5% of GDP allocated for public health expenditures will increase to roughly 10.5% over the 2000-2050 period—more than the current GDP share of total health expenditures (9.3% in 2000). Similarly, according to a recent study by the Conference Board of Canada, “public health expenditures are projected to rise from 31% in 2000 to 42% by 2020 as a share of total provincial and territorial government revenues.” 27 This would clearly squeeze other categories of social spending and public expenditure. While to a certain degree these projection studies are intended to be “self-defeating prophecies”, in our judgement, when these are factored in to the overall context of what the demographic shift will mean for the aging workforce and social security generally, there is reason for profound concern. Health Technology Over the past few decades, technology has made a great contribution toward pushing back the frontiers of Medicare. Based on a 2001 survey of U.S. general internists of their assessment of 30 of the most significant innovations over the past 25 years, Fuchs and Sox reported that the most important innovation by a considerable margin is magnetic resonance imaging (MRI) and computed tomography (CT) scanning. 28 The potential of CT and MRI technology for screening, diagnosis and the image-guided treatment of cardiovascular and cerebrovascular diseases and cancer has been documented by Industry Canada’s Medical Imaging Technology Roadmap Steering Committee. 29 In terms of keeping pace with developments in technology, Canada is woefully behind other OECD countries for selected diagnostic and treatment technology, except for radiation therapy equipment (Table 2). 30 The CMA has estimated that, for the technologies listed in Table 2 (plus positron emission tomography, for which data are not available from the OECD), it would require an overall capital cost of $1 billion plus an operating cost of $0.74 billion (for a three-year period) to bring Canada up to the standard of access to medical technology of developed countries with a similar level of per capital income. [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 2: Canada’s relative position among OECD countries with respect to selected medical technology, 1997 Canada OECD countries reporting Selected Technology Level; units per million pop. Rank No. of countries Avg. level; units per million pop. First rank; units per million pop. Computed tomography 8.1 12 15 12.7 24.9 Magnetic Resonance Imaging 1.7 11 13 3.7 8.4 Lithotripter 0.5 10 11 1.9 3.7 Radiation therapy 7 5 13 6.1 14.8 [TABLE END] The Canadian Coordinating Office for Health Technology (CCOHTA) has just completed a national inventory of several types of imaging equipment, which will form a useful basis for further discussion. If we relate the numbers of units to the July 2001 population 31, the only significant shift since 1997 has been in MRI scanners, where the rate has more than doubled to 3.6 units per million population – still below the 1997 OECD average of 3.7. The 2001 level of CT scanners of 9.7 per million is still significantly below the 1997 OECD average of 12.7, and there has been no change in the relative availability of lithotripters. 32 The September 10, 2000 10-point health accord that was concluded by First Ministers 33 did include a $1 billion fund to modernize technology, however, no accountability measures were attached to it and so a year later we really do not know how much of it has actually been spent on the purchase of new equipment that has been put into the service of patients. More generally, the Canadian Association of Radiologists (CAR) has expressed concerns about aging equipment that may be providing unreliable diagnostic information. 34 In summary, the CMA supports the efforts of CCOHTA to date, while suggesting that the introduction, diffusion and replacement of medical technology is still occurring across Canada in too haphazard a fashion. The need for better planning has been well put by the Industry Canada Committee, which stated that “The health-care system needs to develop budgetary tools and financial systems which permit and facilitate cost-effective technological innovation. Health-care funding, including capital cost amortization, needs to be stable and predictable, and independent of political uncertainties.” 29 5. CRISIS OF ACCOUNTABILITY . . . COOPERATIVE MECHANISMS Why is it that those who know the most about health and health care – practitioners – have the least opportunity to participate in the key decisions about health and health care? This is the key to re-establishing accountability in the system. We believe that the crisis of accountability is due in large measure to a profound problem in the governance of Canada’s health system. If we may define governance as the process of effective coordination when knowledge and power are distributed, there are at least three axes in Canada along which power and knowledge are distributed: a. between federal/provincial/territorial and regional authority/municipal levels of government/administration; b. along the east-west array of provinces and territories; and c. among a range of stakeholders, including government, non-governmental agencies (NGOs) and citizens. There has been a substantial and growing imbalance among these axes over the past decade; it seems that at any given time it is difficult to achieve concerted direction on more than one of them. For much of the past decade, the tension between the federal/provincial/territorial governments in relation to healthcare has been very pronounced. For example, the provinces and territories did not generally participate in the National Forum on Health. Conversely, when the provincial/territorial Health Ministers produced their 1997 Renewed Vision for Canada’s Health System (Conference of Provincial/Territorial Ministers of Health 1997), the report received very little attention at the federal level. 6 In both cases, the admonitions of the health care community went largely unheeded. While there has been progress along this front, as evidenced by the February 1999 Social Union Framework Agreement (Canadian Intergovernmental Conference Secretariat 1999) and the September 2000 health accord, this highlights a second problem. In general, governments have discounted the role that NGOs and citizens might play in policy-making and in promoting policy among its members. The recent federal/provincial/territorial agreements have been negotiated by government officials behind closed doors (executive federalism), and yet it is the providers and patients who are expected to implement and live with the results. This is in keeping with the lack of openness and transparency of the entire federal/provincial/territorial policy process. To highlight one problem that this has caused, the acute shortage of physicians in many places across Canada is due, in part, to the unilateral decision by Health Ministers in 1992 to reduce undergraduate medical enrolment by 10%. These problems are exacerbated by the rapid turnover of both Health Ministers and Deputy Ministers. Again, the admonitions of the health community went largely unheeded. Clearly, Canadians are unimpressed with the back and forth squabbling between levels of government. We believe this is partly reflected in the findings of our 2001 Report Card Survey. When asked to rate the federal government’s performance in dealing with health care in Canada, Canadians were six times as likely to give it a failing “F” grade (30%) than they were to give an excellent “A” grade (5%). Similarly, 35% of Canadians gave their provincial government an “F” grade while just 6% gave it an “A” grade. 19 If we are to achieve a vision for a sustainable Medicare program in the challenging decades ahead, it will be critical to resolve the imbalances along these axes. Governments must begin to work collaboratively with other stakeholders, including citizens. Prior to the Health Ministers meeting in September 2000, the Canadian Health Care Association, Canadian Nurses Association and the CMA put forward a proposal to them for a Council on Health System Renewal based on the principles of consultation and collaboration. 35 A year later we have yet to hear a response. Perhaps there may be lessons to learn from the Council of Ministers of Education, which has been meeting since 1967. While this Council does not include formal NGO representation, it does sponsor events such as a symposium that involve key stakeholders.36 PATHWAYS TO STABILIZING THE TRAUMATIZED PATIENT The traumatized patient of “Medicare” needs to be stabilized. The Health Accord (September 2000) goes part of the way. What remains is to set out some of the parameters of change that can ensure that we keep the best of what we have but also progress the system to address the challenges set out in the previous section. Five such parameters of change are set out below. 1. FOCUS ON THE “HOWS”(not just the “whats”) The health reform discussions of the 1990s in Canada have been dominated by questions of what we need to do, e.g. expand benefits to include pharmacare and home care. Discussions did not deal with the “hows”. When the “how” was considered at all, governments generally approached reform with a “big bang” approach. International experts have recognized that this is very unlikely to be successful when there are many stakeholders in a plurality of settings—which is certainly an apt depiction of the Canadian health care landscape. There is a clear need for a collaborative approach to “change management” that is based on early, ongoing and meaningful involvement of all key stakeholders. In approaching change management there are two important principles to keep in mind. The first is the need for evidenced-based decision-making. This is adapted from the concept of evidenced-based medicine, which stresses the examination of evidence from clinical research based on a range of quantitative and qualitative approaches. 37 The second would be to reaffirm the Canadian way of approaching change, namely: evolution not revolution. By this we mean that we should build on the best of what we have in the current Canadian system 2. ADOPT A VALUES-BASED APPROACH TO CHANGE After much discussion, the CMA is of the view that any proposed changes should be assessed in relation to a limited number of first principles. For the purposes of this paper, Medicare as we know it today consists of those services that are covered by the five program criteria of the Canada Health Act; essentially medically necessary services provided in hospitals and doctors’ offices. As we reflect on where we have come in Medicare and where Canada might go, as physicians we believe that the following first principles underpin any new and sustainable policy direction. * Patient-centered focus – reforms must focus on meeting the needs of the patient rather than the system * Inclusivity – to truly achieve buy-in to change all key stakeholders; payors, providers and patients; must be engaged in early, ongoing and meaningful consultation * Accountability – all stakeholders must assume some level of accountability for the health care system * Universality – we believe that health care must be available and accessible to all Canadians and that health resources should be allocated on the basis of relative medical need. We would underscore that Medicare is the last remaining universal program in Canada and needs to be preserved and protected. * Choice – one of the hallmarks of Medicare is that patients have the freedom to choose their physician, to switch with another physician and/or to seek a second opinion. We believe it is essential that the principle of choice between physicians and patients must be sustained. * Physician as Agent of the Patient – we believe that Medicare has promoted the concept of the physician as agent of the patient and that this must continue. * Quality – we believe that the Canadian health care system must continuously strive to provide quality care. By quality care we mean services that are evidenced-based, appropriate for patient needs and delivered in a manner that is timely, safe and effective. In summary, we believe that these principles can serve to guide the “modernization” of our health care system for the future, while at the same time building on the best of our current system. 3. STRIKING A BETTER BALANCE BETWEEN EVERYTHING AND EVERYONE As we contemplate the future of Medicare it is useful to begin by establishing a frame of reference for the Canadian system. Historically, Canada has distinguished itself in terms of health system design by essentially subsuming the demand side of the market (i.e. public financing) while leaving the supply side alone (e.g. fee-for-service payment methods). Canada has also chosen to provide everyone with first dollar coverage for a somewhat limited range of benefits (unlike our European counterparts). Accordingly, there are two broad dimensions that may be used to describe publicly financed or regulated health care systems in the developed or industrialized world: * Universality Dimension…Coverage of Everybody – the extent to which the public program covers the entire population over all health services; and * Comprehensiveness Dimension…Coverage of Everything – the range of services that are included in the public program and the extent of that coverage. An overall proxy measure of comprehensiveness is the share of total health expenditures that come from the public purse. From a national perspective, physician and hospital services are essentially both universal and comprehensive programs. The universality and comprehensiveness of other health services varies between the provinces and territories. With respect to comprehensiveness as it relates to the total health care system, the Canadian system comes in at 70% public coverage – an amount not dissimilar from most industrialized nations.22 Where Canada differs from other countries is in the distribution of that coverage. Canada has provided extensive public coverage in physician and hospital services (over 90% public payment), with less attention to other services such as home care and prescription drugs (e.g. less than 60% of prescription drug expenditures were public in 1998 38). Other countries tend to spread the extent of public coverage more evenly across the broad spectrum of health services. As we think of the future of Medicare, a key challenge will be to determine whether the uneven distribution of public coverage is a significant issue. It is the view of the CMA that this issue does require serious consideration for a number of reasons: * Canadians can point to the fact that the allocation of physician and hospital resources is predominantly based on patient need. This same principle, however, does not extend to patients whose condition requires access to other kinds of services – out-patient prescription drugs, community mental health care and home care being three examples where economic factors may play a greater role in access decisions. We must consider the equity issues of this dichotomy, acknowledging that there are practical constraints. * Where there are treatment alternatives, the lack of comprehensive coverage may lead to biases that increase costs. Physicians faced with decisions about separation from acute care facilities must factor in the availability of home care programs which are often less than adequate. Some drug treatments are simply outside the reach of many Canadian families, though this may be the most efficacious and cost-efficient route. * The problems cited above have been intensifying due to the changing nature of health service delivery, such as the movement of care to the community and the growth in drug therapies. * Canadian provinces do not all have the same ability to expand beyond physician and hospital services and there are no generally accepted principles to govern that expansion. As a result, there is a patchwork quilt of coverage across the country with widely varying services. If the Commission determines that a more comprehensive range of services is required, then the question will become how this can be achieved. There are several alternatives that can be considered, and there will be a need for new thinking. 4. GENERATE NEW THINKING In Canada, Medicare has been defined by five principles that, taken together, embody the collective value or sense that we are all in the same health lifeboat. Over the years the five program criteria or principles of the Canada Health Act (CHA) have been effective in preserving the publicly funded character of hospital and physician services, although there has been a growing crisis of access. The delivery of health care has been markedly transformed. Treatment methods provided today are often quite different from those provided in the past for the same conditions. This affects the extent to which their care is publicly insured, which is dependent upon how they are treated, who treats them, and where they are treated. During the past few years a number of questions have been raised about the values that underlie health care systems both in Canada and internationally. In the Canadian context we can think of the following three critical questions. First, what range of services should be covered by national principles? Second, are the five principles that currently apply to Medicare sufficient? Third, having defined a range of services whose provision is assured by a set of principles, how do we pay for them? One example of an attempt at new thinking may be seen in the 1995 report of the provincial/ territorial Ministerial Council on Social Policy Reform and Renewal which sets out 15 principles along four themes, namely that social programs must be accessible and serve the basic needs of all Canadians; reflect individual and collective responsibility; be affordable, effective and accountable; and be flexible, responsive and reasonably comparable across Canada. 39 In our view, this language promotes a flexibility of interpretation that reflects our modern diversity and allows for a realignment of priorities as they may change over time. To summarize, in our view the language and content of the principles put out over the past few years are a reflection of the following points: * the principles that have defined Medicare to date cover a declining share of the delivery of health care * the existing CHA principles are increasingly inadequate in respect of assuring Canadians a reasonable (i.e. timely) access to medically necessary services * internationally, it appears that there is a move to adopt guiding principles that cover a broader range of the continuum of care and which rebalance individual and collective responsibility in some measure. We have grown complacent while the rest of the world has experimented. Indeed, to some extent our national health insurance system has forced out innovation. On the other hand, because provinces are reasonably autonomous regarding health, we have had the benefit of interprovincial comparisons. We are also on the leading edge of both a health information and a bio-technological revolution that is going to fundamentally change the practice of medicine and the nature of the patient-physician relationship. We will need to promote flexibility and adaptability in an era of diversity and rapid change. 5. RECOGNIZE THAT BETTER MANAGEMENT (WHILE NECESSARY) WILL NOT BE SUFFICIENT Up to the present, the reports of the federal and provincial/territorial task forces and commissions since the 1980s have concluded that we can manage our way out of the sustainability crisis by introducing a series of supply side measures to control costs. In Canada, these initiatives have included the wave of regionalization (and rationalization), physician controls and numerous proposals for primary care reform. The multi-faceted crisis that we are now experiencing is clear evidence of the inadequacy of these strategies. We suspect that many in the health policy community continue to believe that major efficiency gains remain to be squeezed out of the system. After four consecutive years of negative real growth in public sector health spending (1992 to 1996 inclusive) 38, the CMA cannot accept the premise that working harder or smarter is going to solve the problems of the system. Strategic reinvestments in health are clearly required. We do not believe that we can simply manage our way out of this crisis. Physicians have supported many innovations such as the implementation of clinical practice guidelines and have participated in primary care reform demonstration projects. Improved efficiency alone, however, cannot meet the demands we expect to see in the future. The system must be properly resourced on a predictable basis. NEXT STEPS … There is no “magic bullet” or quick fix that will put our national health program on a sustainable footing and restore Canadians’ confidence in it. Working harder to make the current system work better will not be sufficient. While there are still gains to be made from efficiencies and integration, we cannot simply manage our way out of this problem. It is time for fundamental change. We should not be discouraged from pressing on with this daunting challenge; it is imperative that we begin to act immediately. This brief sets out the variety of pressures that render the current health system unsustainable. It also sets out a value-based policy framework that can help guide future deliberations and point us to policies that can help address the rising concerns among both providers and Canadian health consumers. The brief is not intended to be all-encompassing. Various other medical organizations will be making representations to the Commission. The CMA encourages the Commission to seriously consider the complementary briefs submitted by our sister organizations. The CMA intends to submit its final recommendations, building on this framework, in the spring of 2002. This second brief will again be the product of our extensive set of discussions with the profession. REFERENCES 1 Barer M, Stoddart G. Toward Integrated Medical Resource Policies for Canada. Winnipeg: Manitoba Health; 1991. 2 Shortt S. The doctor dilemma: public policy and the changing role of physicians under Ontario Medicare (Chapter 3). Montreal & Kingston: McGill-Queen’s University Press; 1999. 3 Tyrrell L, Dauphinee D. Task force on physician supply in Canada. Ottawa: Canadian Medical Forum; 1999. 4 Slight rise in Canada’s physician supply, more specialists and fewer family physicians, reports Canadian Institute for Health Information. Ottawa: Canadian Institute for Health Information; Aug. 9, 2001. [Media release] [http://www.cihi.ca/medrls/09aug2001.shtml] 5 National Health Service. Making the change: a strategy for the professions in healthcare science. London: Department of Health; 2001. [http://www.doh.gov.uk/makingthechange/index.htm] 6 A renewed vision for Canada’s health system. Provincial/Territorial Ministers of Health; Jan. 1997. 7 Prime Minister announces formation of Task Force on Modernizing Human Resources Management in the Public Service [press release]. Ottawa: Prime Minister of Canada; Apr. 3, 2001. [http://pm.gc.ca/default.asp?Language=E&Page=newsroom&Sub=newsreleases&Doc=managementtaskforce. 20010403_e.htm] 8 Listening for direction: a national consultation on health services and policy issues. Ottawa: Canadian Health Services Research Foundation; 2001. 9 Buske L. Additional undergraduate, postgraduate and reentry positions announced since summer 1999. Ottawa: CMA Research Directorate; July 16, 2001. 10 Sim P. Report of the 1999 survey of medical students. London: University of Western Ontario; 1999. 11 Human Resources Development Canada Studies in Progress. http://www.hrdc-drhc.gc.ca//hrib/hrib/hrp-prh/ssd-des/english/projects/projects.shtml. Accessed May 1, 2001. 12 On the road to recovery…an action plan for the Federal Government to revitalize Canada’s health care system. Ottawa: Canadian Medical Association; Sept. 2000. 13 Specialty care in Canada: issue identification and policy challenges. Ottawa: Canadian Medical Association; 2001. 14 2001 Physician resource questionnaire. Ottawa: Canadian Medical Association; 2001. 15 Blendon R, Schoen C, Donelan K, Osborn R, DesRoches CM, Scoles K, et al. Physicians’ views on quality of care: a five-country comparison. Health Aff 2001;20(3):233-243. 16 Commitment and care: the benefits of a healthy workforce for nurses, their patients and the system. Canadian Health Services Foundation, The Change Foundation; 2001. 17 Public dialogue sessions 2001: Planning a full recovery—voices, values & vision. Ottawa: Canadian Medical Association; 2001 18 Wright J. The public domain: current public opinion attitudes and expectations on Canada’s healthcare system. (presentation). Vancouver: Ipsos Reid Group; May 15, 2000. 19 National report card on health care 2001. Ottawa: Canadian Medical Association; 2001. 20 2000 Physician resource questionnaire. Ottawa: Canadian Medical Association; 2000. 21 Bird R, Fraser R. Commentaries on the Hall Report. Toronto: Ontario Economic Council; 1981. 22 Health data 2001. Paris: Organisation for Economic Co-operation and Development; 2001. 23 Population aging and information for parliament: understanding the choices (chapter 6). In Report of the Auditor General of Canada. Ottawa: Office of the Auditor General of Canada; April 1998. 24 In search of sustainability: prospects for Canada’s health care system. Ottawa: CMA; 2001. 25 Canadians call for funding and multi-stakeholder involvement to cure health care ills. Ottawa: CMA; Aug. 13, 2000. [http://www.cma.ca/advocacy/news/2000/08-13.htm]. 26 Dang T, Antolin P, Oxley H. Fiscal implications of ageing: projections of age-related spending. Paris: OECD; Sep. 5, 2001. 27 The future cost of health care in Canada: balancing affordability and sustainability. Ottawa: The Conference Board of Canada; 2001. 28 Fuchs V, Sox H. Physicians’ views of the relative importance of thirty medical innovations. Health Aff 2001; 20(5):30-42. 29 Medical Imaging Technology Roadmap Steering Committee. Future needs for medical imaging in health care. Ottawa: Industry Canada; 2000. 30 Health data 1999. Paris: Organisation for Economic Co-operation and Development; 1999. 31 Statistics Canada. Latest Indicators; Oct. 24, 2001. [http://www.statcan.ca/start.html]. 32National Inventory of Selected Imaging Equipment. Ottawa: Canadian Coordinating Office for Health Technology; 2001. [http://www.ccohta.ca/newweb/imaging_equip/imaging_equip.htm]. 33 First Ministers’ meeting: communiqué on health. Ottawa: Canadian Intergovernmental Conference Secretariat; Sep. 11, 2000. [http://www.scics.ca/cinfo00/800038004_e.html]. 34 Radiology in crisis: majority of equipment dangerously outdated. Montreal: Canadian Association of Radiologists; Sep. 28, 2000. [http://www.car.ca/press/equipment.htm]. 35 Barrett P. Letter to Hon. Allan Rock and Hon. David Chomiak. Ottawa: CMA; Sept. 25, 2000. 36 About the Council of Ministers of Education, Canada. Toronto: CMEC; 2000 [http://www.cmec.ca] 37 Evidence-Based Working Group. Evidence-based medicine: a new approach to teaching the practice of medicine. JAMA 1992; 268(4): 2420-2425. 38 National health expenditure trends 1975-2000. Ottawa: Canadian Institute for Health Information; 2000. 39 Report to Premiers. Ottawa: Ministerial Council on Social Policy Reform and Renewal; 1995.
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Disability Tax Credit Program : CMA Submission to the Sub-Committee on the Status of Persons with Disabilities (House of Commons)

https://policybase.cma.ca/en/permalink/policy1972
Last Reviewed
2020-02-29
Date
2002-01-29
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2002-01-29
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) welcomes the opportunity to appear before the Sub-Committee on the Status of Persons with Disabilities to discuss issues related to the Disability Tax Credit (DTC). This tax measure, which is recognition by the federal government that persons with a severe disability may be affected by having reduced incomes, increased expenses or both, compared to those who are not disabled i, helps to account for the intangible costs associated with a severe and prolonged impairment. It also takes into account disability-related expenses that are not listed in the medical expense deduction or which are excluded by the 3% threshold in the Medical Expense Tax Credit. Physicians are a key point of contact for applicants of the DTC and, given the way the program is structured, a vital participant in its administration. It is for these reasons that we come before you today to address specific concerns related to the program’s performance. In addition, we would like to discuss the broader issue of developing a coherent set of tax policies in support of health and social policy. The Integration of Tax Policy with Health Policy and Social Policy The federal government, through a variety of policy levers such as taxation, spending, regulation and information, has played a key role in the development of our health care and social systems. To date however, discussion about the federal role in these areas has centered largely on federal transfers to the provinces and territories and the Canada Health Act. However, in looking at how to renew Canada’s health and social programs, we should not limit ourselves to these traditional instruments. Today we have a health system that is facing a number of pressures that will challenge its sustainability. These pressures range from an aging and more demanding population in terms of the specialty care services and technology they will seek; the cry for expanding the scope of medicare coverage to include homecare and pharmacare; and a shortage of health personnel. These are only some of the more immediate reasons alternative avenues of funding health care, and thus ensuring the health and well-being of our citizens, must be explored. In our pre-budget consultation document to the Standing Committee on Finance ii, the CMA recommended that the federal government establish a blue ribbon National Task Force to study the development of innovative tax-based mechanisms to synchronize tax policy with health policy. Such a review has not been undertaken in over 25 years since the Royal Commission on Taxation in 1966 (Carter Commission). The CMA is echoing its call for a National Task Force to develop new and innovative ways to synchronize tax policy with health policy and social policy. A study of this nature would look at all aspects of the taxation system, including the personal income tax system, in which the DTC is a component. The remainder of our brief addresses issues specific to the DTC. Physician Involvement in the DTC Program The CMA has in the past provided input with respect to the DTC program. Our working relationship on the DTC program with the Canada Customs and Revenue Agency (CCRA) has been issue-specific, time-limited and constructive. Our first substantive contact in regard to the DTC program was in 1993 when the CMA provided Revenue Canada with a brief review of the program and the T2201form. It is interesting to note what our observations were in 1993 with regard to this program because many of them still hold true today. Here are just some of the issues raised by the CMA in 1993 during our initial review of the program: * The tax credit program may not address the needs of the disabled, it is too hit and miss. The DTC program should be evaluated in a comprehensive way to measure its overall effectiveness in meeting the needs of persons with disabilities. * The program should be called the “Severe Disability Tax Credit Program” – or something equivalent to indicate that not everyone with a disability is eligible. * The program puts physicians in a potential conflict with patients—the responsibility of the physician to advocate for the patient vs. gate-keeper need for Revenue Canada. The physician role should be to attest to legitimate claims on the patients’ behalf. * Revenue Canada should clarify the multiplicity of programs. There are numerous different federal programs and all appear to have varying processes and forms. These overlapping efforts are difficult for patients and professionals. * A major education effort for potential claimants, tax advisers and physicians should be introduced. * A suitable evaluation of claimant and medical components of the process should be undertaken. The CMA does not have a standardized consultative relationship with the CCRA in regard to this program. An example of this spotty relationship is the recent letter sent by the CCRA Minister asking current DTC recipients to re-qualify for the credit. The CMA was not advised or consulted about this letter. If we had been advised we would have highlighted the financial and time implications of sending 75 to 100 thousand individuals to their family physician for re-certification. We also would have worked with the CCRA on alternative options for updating DTC records. Unfortunately, we cannot change what has happened, but we can learn from it. This clearly speaks to the need to establish open and ongoing dialogue between our two organizations. Policy Measure: The CMA would like established a senior level advisory group to continually monitor and appraise the performance of the DTC program to ensure it is meeting its stated purpose and objectives. Representation on this advisory group would include, at a minimum, senior program officials preferably at the ADM level; those professional groups qualified to complete the T2201 Certificate; various disability organizations; and patients’ advocacy groups. We would now like to draw the Sub-committee’s attention to three areas that, at present, negatively impact on the medical profession participation in the program, namely program integrity, program standardization (e.g., consistency in terminology and out-of-pocket costs faced by persons with disabilities) and tax advisor referrals to health care providers. Program Integrity A primary concern and irritation for physicians working with this program is that it puts an undue strain on the patient-physician relationship. This strain may also have another possible side effect, a failure in the integrity of the DTC program process. Under the current structure of the DTC program, physicians evaluate the patient, provide this evaluation back to the patient and then ask the patient for remuneration. This process is problematic for two reasons. First, since the patient will receive the form back immediately following the evaluation, physicians might receive the blame for denying their patient the tax credit—not the DTC program adjudicators. Second, physicians do not feel comfortable asking for payment when he or she knows the applicant will not qualify for the tax credit. For the integrity of the DTC program, physicians need to be free to reach independent assessment of the patient’s condition. However, due to the pressure placed by this program on the patient-physician relationship, the physician’s moral and legal obligation to provide an objective assessment may conflict with the physician’s ethical duty to “Consider first the well-being of the patient. There is a solution to this problem it’s a model already in use by government, the Canadian Pension Plan (CPP) Disability Program. Under the CPP Disability Program, the evaluation from the physician is not given to the patient but, it is sent to the government and the cost to have the eligibility form completed by a physician is subsumed under the program itself. Under this system, the integrity of patient-physician relationship is maintained and the integrity of the program is not compromised. Policy Measure: The CMA recommends that the CCRA take the necessary steps to separate the evaluation process from the determination process. The CMA recommends the CPP Disability Program model to achieve this result. Fairness and Equity The federal government has several programs for people with disabilities. Some deal with income security (e.g., Canada Pension Plan Disability Benefits), some with employment issues (e.g., Employability Assistance for People with Disabilities), and some through tax measures (e.g., Disability Tax Credit). These government transfers and tax benefits help to provide the means for persons with disabilities to become active members in Canadian society. However, these programs are not consistent in terms of their terminology, eligibility criteria, reimbursement protocols, benefits, etc. CMA recommends that standards of fairness and equity be applied across federal disability benefit programs, particularly in two areas: the definition of the concept of “disability”, and standards for remuneration to the physician. These are discussed in greater detail below. 1) Defining “disability” One of the problems with assessing disability is that the concept itself is difficult to define. In most standard definitions the word “disability” is defined in very general and subjective terms. One widely used definition comes from the World Health Organization’s International Classification of Impairments, Disabilities and Handicaps (ICIDH) which defines disability as “any restriction or inability (resulting from an impairment) to perform an activity in the manner or within the range considered normal for a human being.” The DTC and other disability program application forms do not use a standard definition of “disability”. In addition to the inconsistency in terminology, the criteria for qualification for these programs differ because they are targeted to meet the different needs of those persons with disabilities. To qualify for DTC, a disability must be “prolonged” (over a period of at least 12 months) and “severe” i.e. “markedly (restrict) any of the basic activities of daily living” which are defined. Though CPP criteria use the same words “severe” and “prolonged” they are defined differently (i.e., “severe” means “prevents applicant from working regularly at any job” and “prolonged” means “long term or may result in death”). Other programs, such as the Veterans Affairs Canada, have entirely different criteria. This is confusing for physicians, patients and others (e.g., tax preparers/advisors) involved in the application process. This can lead to physicians spending more time than is necessary completing the form because of the need to verify terms. As a result if the terms, criteria and the information about the programs are not as clear as possible this could result in errors on the part of physicians when completing the forms. This could then inadvertently disadvantage those who, in fact, qualify for benefits. Policy Measures: The CMA would like to see some consistency in definitions across the various government programs. This does not mean that eligibility criteria must become uniform. In addition, the CMA would like to see the development of a comprehensive information package for health care providers that provides a description of each program, its eligibility criteria, the full range of benefits available, copies of sample forms, physical assessment and form completion payment information, etc. 2) Remuneration The remuneration for assessment and form completion is another area where standardization among the various government programs would eliminate the difficulties that some individuals with disabilities currently face. For example, applicants who present the DTC Certificate Form T2201 to their physicians must bear any costs associated with its completion out of their own pockets. On the other hand, if an individual is applying to the CPP Disability Program, the cost to have the eligibility form completed by a physician is subsumed under the program itself. Assessing a patient’s disabilities is a complex and time-consuming endeavour on the part of any health professional. Our members tell us that the DTC Certificate Form T2201 can take as much time and effort to complete as the information requested for CPP Disability Program forms depending, of course, on the patient and the nature of the disability. In spite of this fact, some programs acknowledge the time and expertise needed to conduct a proper assessment while other programs do not. Although physicians have the option of approaching the applicant for remuneration for the completion of the DTC form, they are reluctant to do so because these individuals are usually of limited means and in very complex cases, the cost for a physician’s time for completing the DTC Form T2201 can reach as much as $150. In addition, physicians do not feel comfortable asking for payment when he/she knows the applicant will not qualify for the tax credit. Synchronizing funding between all programs would be of substantial benefit to all persons with disabilities, those professionals completing the forms and the programs’ administrators. Policy Measure: We strongly urge the federal government to place disability tax credit programs on the same footing when it comes to reimbursement of the examining health care provider. Tax Advisor Referrals With the complexity of the income tax system today, many individuals seek out the assistance of professional tax advisors to ensure the forms are properly completed and they have received all the benefits they are entitled to. Tax advisors will very often refer individuals to health professionals so that they can be assessed for potential eligibility for the DTC. The intention of the tax advisors may be laudable, but often, inappropriate referrals are made to health professionals. This not only wastes the valuable time of health care professionals, already in short supply, but may create unrealistic expectations on the part of the patient seeking the tax credit. The first principle of the CMA’s Code of Ethics is “consider first the well-being of the patient.” One of the key roles of the physician is to act as a patient’s advocate and support within the health care system. The DTC application form makes the physician a mediator between the patient and a third party with whom the patient is applying for financial support. This “policing” role can place a strain on the physician-patient relationship – particularly if the patient is denied a disability tax credit as a result a third-party adjudicator’s interpretation of the physician’s recommendations contained within the medical report. Physicians and other health professionals are not only left with having to tell the patient that they are not eligible but in addition advising the patient that there may be a personal financial cost for the physician providing this assessment. Policy Measure: Better preparation of tax advisors would be a benefit to both patients and their health care providers. The CMA would like CCRA to develop, in co-operation with the community of health care providers, a detailed guide for tax preparers and their clients outlining program eligibility criteria and preliminary steps towards undertaking a personal assessment of disability. This would provide some guidance as to whether it is worth the time, effort and expense to see a health professional for a professional assessment. As raised in a previous meeting with CCRA, the CMA is once again making available a physician representative to accompany DTC representatives when they meet the various tax preparation agencies, prior to each tax season, to review the detailed guide on program eligibility criteria and initial assessment, and to highlight the implications of inappropriate referral. Conclusion The DTC is a deserving benefit to those Canadians living with a disability. However, there needs to be some standardization among the various programs to ensure that they are effective and meet their stated purpose. Namely, the CMA would like to make the following suggestions: 1. The CMA would like established a senior level advisory group to continually monitor and appraise the performance of the DTC program to ensure it is meeting its stated purpose and objectives. Representation on this advisory group would include, at a minimum, senior program officials preferably at the ADM level; those professional groups qualified to complete the T2201 Certificate; various disability organizations; and patient advocacy groups. 2. The CMA recommends that the CCRA take the necessary steps to separate the evaluation process from the determination process. The CMA recommends the CPP Disability Program model to achieve this result. 3. That there be some consistency in definitions across the various government programs. This does not circumvent differences in eligibility criteria. 4. That a comprehensive information package be developed, for health care providers, that provides a description of each program, its eligibility criteria, the full range of benefits available, copies of sample forms, physical assessment and form completion payment information, etc. 5. That the federal government applies these social programs on the same footing when it comes to their funding and administration. 6. That CCRA develop, in co-operation with the community of health care providers, a detailed guide for tax advisors and their clients outlining program eligibility criteria and preliminary steps towards undertaking a personal assessment of disability. 7. That CCRA employ health care providers to accompany CCRA representatives when they meet the various tax preparation agencies to review the detailed guide on program eligibility criteria and personal assessment of disability, and to highlight the implications of inappropriate referral. These recommendations would certainly be helpful to all involved - the patient, health care providers and the programs’ administrators, in the short term. However what would be truly beneficial in the longer term would be an overall review of the taxation system from a health care perspective. This could provide tangible benefits not only for persons with disabilities but for all Canadians as well as demonstrating the federal government’s leadership towards ensuring the health and well being of our population. i Health Canada, The Role for the Tax System in Advancing the Health Agenda, Applied Research and Analysis Directorate, Analysis and Connectivity Branch, September 21, 2001 ii Canadian Medical Association, Securing Our Future… Balancing Urgent Health Care Needs of Today With The Important Challenges of Tomorrow”, Presentation to the Standing Committee on Finance Pre-Budget Consultations, November 1, 2001.
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Presentation to the Standing Committee on Finance Pre-Budget Consultations : Securing Our Future . . . Balancing Urgent Health Care Needs of Today With The Important Challenges of Tomorrow

https://policybase.cma.ca/en/permalink/policy2013
Last Reviewed
2020-02-29
Date
2001-11-01
Topics
Health systems, system funding and performance
Health human resources
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2001-11-01
Topics
Health systems, system funding and performance
Health human resources
Text
The Canadian Medical Association (CMA) values the open, constructive and ongoing dialogue afforded by the Standing Committee on Finance’s Pre-Budget Consultations process. As a society, it is essential that we make every effort to work together to find lasting solutions to what are a series of complex and interdependent policy issues, especially during these turbulent times. Last August, the Committee set out objectives for this year’s consultations. You asked for advice on how to ensure that Canada remains a major player in the New Economy while providing Canadians with equal opportunities to succeed and create a socio-economic environment where they can enjoy the best quality of life and standard of living. However, world events have intervened and the urgent has crowded out the important. The CMA has suspended, for the most part, what we consider important longer term issues in an effort to do our part in helping guide the government’s deliberations in this time of national need. We support the government’s commitments, to date, in response to the events of September 11 and their aftermath. We are cognizant of the economic forecasts that show a slowing economy as a result and the need to re-focus our national attention on security issues. The overriding challenge for this Committee therefore, will be to develop recommendations for the next budget that address the current and future situation with respect to national security without losing sight of internal needs such as pursuing the innovations necessary to ensure the long-term sustainability of our health care system. Indeed, we see the latter as supporting the former. The CMA is committed to working closely with the federal government to ensure that Canada’s health care system can respond to immediate health security challenges. Our members are committed to continuing to ensure that Canadians’ confidence is restored by developing and implementing policy initiatives that serve to strengthen Canadians’ access to quality health care when they need it. To this end and building on our efforts since September 11, the CMA has put together a to meet these objectives. Specifically, the CMA has examined and developed recommendations that address national preparedness in terms of security, health and capacity; the capacity of our health human workforce in addressing current and future demands; and a look beyond the urgent to the necessary, in the form of a proposed process to review tax policy in support of health policy. II. PREPAREDNESS Health and Security The events of September 11, 2001 have had a profound impact on the lives of Canadians. Anxiety over the openness of our borders, the safety of our airlines and our vulnerability to attacks filled the media and our conversations in the days following the tragedies in the United States. A Canadian Ipsos Reid Express survey taken for the Canadian Medical Association October 23-25, 2001 indicated that 31% of respondents report ongoing sadness, anger, disturbed sleep, or are overprotective of their children. 1 This confirms what our members are telling us, based on everyday practice. A GPC International survey indicates that three-quarters of Canadians have a moderate to strong fear that the US-led anti-terrorist campaign will lead to Canada being a possible terrorist target. 2 An earlier Canadian Ipsos Reid Express survey taken October 1, 2001 shows that the attacks have risen to the top of the list of issues (73%) that should receive the greatest attention among our leaders. 3 Social issues, including health, are the second rated (49%) concern among Canadians. The Canadian Medical Association’s response following the terrorist attack was immediate and is ongoing. Working through and with our provincial/territorial Divisions and Affiliates, the Association began collecting names of those physicians willing to offer assistance to US agencies dealing with the tragedy should it have been requested. As well, we spearheaded the development of the Canadian Mental Health Support Network (www.cma.ca/cmhsn), which includes Health Canada and twelve other national health associations, to help Canadians and Canada’s health professionals cope with the mental health aftermath of the attack. The work of this network continues in terms of a series of public security announcements to be released very soon and in terms of ensuring that the information available through health professionals is clear, concise and consistent. We also provided continuous updated advice to Canadian doctors about bioterrorist threats. In the early days of the anthrax scare, before Health Canada had materials available for the public, hundreds of calls for information to 1-800-OCanada were referred daily by Health Canada to the CMA. However, there is an aspect of this issue requiring urgent attention given the current environment. It is the ability of our health system to respond to a disaster, be it a terrorist attack, a natural disaster or a large scale accident. As the Canadian Medical Association and others have documented, the people and the infrastructure of our system is already stretched in its capacity to deal with everyday demands. We have seen that emergency rooms across this country can barely cope with the increased demands brought on by the annual flu season. The system is already operating at or beyond capacity. Devastation approaching the scale of September 11 has not been seen in Canada since December 6, 1917 with the Halifax explosion. While no health system can ever be fully prepared to meet such a staggering level of destruction, it must have the confidence, the resources and, the disaster planning and referral systems to rise to the challenge if Canadians are to be reassured that help will be there if and when they need it. Public Health and Safety The challenge – if and when it comes – will require a local response that is supported nationally. To appreciate the scope of the work necessary to prepare the health system for the threats brought by terrorism it will be useful to understand the challenges currently facing public health in Canada. We have long enjoyed the benefits of a solid public health system through the various health protections, health promotion, and disease prevention and control programs created to maintain and improve the health of the population. The essential role of the medical officer of health in the public health system must be acknowledged, supported, and respected. Their credibility provides the community and health care professionals, particularly physicians, with balance and specialized medical expertise on public health matters. When the board of health is performing its mandated duties successfully, few are even aware that it is at work. Yet when a public health crisis strikes, the community expects rapid, knowledgeable, expert and quality attention to matters. But it can only do that if there is a strong infrastructure in place to meet the challenge. A clear and present danger is the emergence of new diseases or the re-appearance of old ones. An editorial in the April 27, 2000 issue of the New England Journal of Medicine expresses concern about the ability of public health infrastructures to cope with this problem without the resources needed to respond. 4 Increased trade, rising migration rates, and changes in the environment have led to worries over the revival of diseases thought to be under control or near extinction (e.g., human plague, tuberculosis and malaria) and even the recognition of some new “bugs”. The need to be vigilant about the re-emergence of infectious diseases was brought home to governments with a large outbreak of human plague in India in 1994. 5 Out of 876 cases reported, characterized as presumptive plague, 56 were fatal. A large outbreak of Ebola in Zaire in 1995 led to as many as 233 people dying from the disease and further strengthened the case for devoting resources to this problem. 6 West Nile Virus The New York City area got a first-hand look at this problem in 1999 with the appearance of the West Nile virus in North America. As the New York Times reported, it may have come in the blood of a traveler returning from Africa or Europe. 7 It may have arrived in an infected bird smuggled in baggage or even in a mosquito that got onto a jet. In spite of efforts to contain the disease, it has now begun to spread through the eastern portion of the continent, as far north as southern Ontario and as deep as Florida. Tuberculosis Tuberculosis remains one of the world’s two deadliest infections and it is feared to be on the verge of a major comeback. The disease kills 1.5 million to 2 million people a year, almost as many as AIDS. Experts say that toll could increase in the coming years because TB bacteria are evolving dangerous new strains that are increasingly drug-resistant. 8 Health Canada reports that there have been some cases (and deaths) in Canada of multiple drug-resistant TB (MDR-TB) strains. 9 Only Newfoundland, PEI and the territories have not had cases of drug-resistant TB. Latvia and Russia are considered “hot spots” in the world for MDR-TB. However, one in three reported isolates in New York City in recent years was MDR-TB. As well, highly resistant strains spread from New York to Florida, Nevada, Georgia and Colorado in less than two years. Malaria The World Health Organization estimates that one million die from malaria a year and 90% of those deaths are Africans (2500 African children under five die from malaria each day). 10 The disease seems to be dying back in other continents but growing stronger across Africa. The WHO report on infectious diseases describes malaria as having the power to “overwhelm a young child causing high fever, convulsions and breathing difficulties. With the onset of cerebral malaria the child lapses into a coma and may die within 24 hours.” 11 AIDS According to the WHO, there are over 33 million people worldwide living with HIV/AIDS. 12 The hardest hit area is sub-Saharan Africa where one in four of the adult population has HIV/AIDS. In South Africa, 10% of the population is now infected with HIV. 13 The problem among pregnant women is worse, with 22% infected with HIV. In May, 2000, the US National Security Council declared that the spread of AIDS across the world is a threat to national security. 14 The concern, like many of the infectious diseases, is that eventually it will overwhelm the ability of governments to cope with the disease. The US government has sought to double to $254 million to combat AIDS overseas. Readiness Post-September 11 The tragic events of September 11 provided a grim reminder of the necessity of having a strong public health infrastructure in place at all times. As was demonstrated quite vividly that day, we do not have the luxury of time to prepare for these events. While it is not possible to plan for every contingency, certain scenarios can be sketched out and prepared for. To succeed, all communities must maintain a certain consistent level of public health infrastructure to ensure that all Canadian residents are protected from threats to their health. These are only some of the external threats. The Canadian public health system must also cope with domestic issues such as diseases created by environmental problems (e.g., asthma), sexually transmitted diseases, and influenza, among many others. Even before the spectre of bioterrorism this country’s public health experts were concerned about the infrastructure’s ability to deal with multiple crises. There are many vacancies among the public health physician and nursing staffs, particularly in rural and northern Canada as well as the First Nations units. This workforce is also aging and efforts to attract and retain staff have been lagging. The announcement of October 18, 2001 by the federal government of a $11.59 million investment was welcome news to Canadians in the aftermath of September 11. It provided for the “basics” in terms of stockpiling of necessary antibiotics, the purchase of sensor and detection equipment to help respond to radio-nuclear incidents, enhancing a laboratory network to better equip them to detect biological agents, and provide training to front-line health care professionals to help them recognize, diagnose and treat suspicious illnesses. However, far more needs to be done to improve our ability to respond to health and security contingencies of all kinds. The Walkerton water crisis is an example of the difficulties often faced by public health officials. Without the full resources (legislative, physical, financial, human) to do the job properly, the health of Canadians is potentially jeopardized. The Ontario Medical Association emphasized this point in its brief to the Walkerton Inquiry: “Unstable and insufficient resources hamper the Ontario public health system. Steps must be taken by the provincial government to enhance the ability of boards of health to deliver public health programs and services that promote and protect health and prevent disease and injury. Sufficient and reliable public health funding is critical.” 15 The CMA reinforced that message in a resolution passed at its 2001 Annual General Meeting: “That CMA recommend all levels of government across Canada urgently review legislation governing all aspects of drinking water from source to consumption to ensure that comprehensive programs are in place and being properly implemented, with effective linkages to local, provincial and territorial public health officials and Ministries of Health.” In a recent broadcast in the United States, Dr. Jeffrey Koplan, Director of the US Centers for Disease Control and Prevention laid out seven priority areas for building capacity and preparedness within a public health system: 16 * A well trained, well staffed public health workforce * Laboratory capacity to produce timely and accurate results for diagnosis and investigation * Epidemiology and surveillance to rapidly detect health threats * Secure, accessible information systems to help analyze and interpret health data * Solid communication to ensure a secure two-way flow of information * Effective policy evaluation capability * A preparedness and response capability which includes a response plan and testing and maintaining a high state of preparedness These points apply whether the threat is a natural disaster or a terrorist attack. Public health must be ready for all such threats. And, at present, we are told, that responding to a crisis like Walkerton or North Battleford, not to mention the possibility of co-ordinated bioterrorism, effectively results in public health units shutting down many core programs that are the building blocks of the health care system. As the long shadow of bioterrorism rises over Canada and menaces our health and wellbeing, these issues take on even more significance to Canadians. This Committee must do its part to provide for an “act locally by thinking nationally” with regard to public health support systems. The Current Context As noted above, prior planning and preparation is one of the keys to ameliorating the effects of such sudden and calamitous occurrences. It must be remembered that a catastrophic event of the nature that occurred on September 11 is a local event in that it happens within the jurisdiction of a specific municipality. The quality and level of the response depends on how well prepared the local authorities are for such actions. The local capacity to respond varies across Canada with some area health services (e.g., the larger urban centres) better prepared and equipped than others (there may be jurisdictions that do not have plans). Regardless of how well prepared any municipality is there is always the very strong possibility that public health officials will be overwhelmed and need to turn to the province or territory for help. It is also possible that the event is so massive that even the provincial or territorial resources are besieged and it must call on the federal government with their stockpiles of medical supplies and access to epidemiologists and laboratory services. That assumes good planning before hand between the federal and provincial/territorial governments and that is not necessarily the case. There is an important role for the federal government to urgently improve the coordination among authorities and reduce the variability among the various response plans in cooperation with provincial authorities (and assist those in preparing plans where none exist). Health Canada must help facilitate efforts to rationalize preparations and make it easier for jurisdictions to assist one another in a time of disaster. This could include measures such as transferring patients quickly to facilities outside the affected area when the immediate hospitals are full or even to transferring them to other provinces or territories if necessary. Disease surveillance is another component of these measures. To be effective there must be, at the provincial and territorial level, linked electronic surveillance mechanisms that are standardized and the staff available to analyze and report the data. At the federal level, the government must be ready to provide data in a timely fashion, especially in an emergency. However, very few of Canada’s doctors will have seen the disease entities that threaten Canadians at the moment (e.g., anthrax, smallpox). The CMA has expressed its willingness to assist Health Canada in bringing together stakeholders to develop quickly a curriculum that would train health care professionals to recognize, diagnose and treat the new threats we face as a society. The government must also aid in the development of volunteer teams of health professionals and other experts that can be mobilized rapidly in response to disasters wherever and whenever they occur. The concept would be similar to the military's Disaster Assistance Response Team (DART). 17 DART consists of medical, engineering, logistics, communications and security personnel ready to deploy at short notice to anywhere in the world from their support base at Canadian Forces Base Trenton. It is crucial, that the federal government build and maintain its supplies for emergency use, its public health laboratories for early detection, its capacity to rapidly train and inform frontline health workers of emerging threats, its ability to assist the provinces and territories, and co-ordinate provincial responses in the event of overwhelming or multiple simultaneous threats. In this area, the CMA recommends that: 1. The federal government immediately provide a minimum of $15 million for an assistance fund to municipal and provincial authorities to improve the co-ordination of their emergency responses among public health officials, police, fire and ambulance services, hospitals and other services. This fund should be over and above a similar sized investment to ensure that Health Canada’s Centre for Emergency Preparedness can function even only at a minimal level of effectiveness. The announcement of October 18 by the Minister of Health that $11.59 million would be spent to enhance our response to a potential attack is an important step toward reassuring Canadians that help will be there when they need it. However, far more must be done to further expand the federal government’s ability to assist municipalities, provinces and territories in dealing with disasters. The vital role played by disease surveillance cannot be stressed enough. In the event of an unusual or particularly feared illness, or an outbreak of a preventable disease, the public’s attention can quickly focus on the public health unit’s response. The medical officer of health communicates with physicians (specialists and, general and family practices physicians) in the community. Physicians, especially general and family practice physicians, depend upon their medical officers of health and the health units as an important resource. This includes information on contact tracing, interpretation of unusual clinical symptomatology, vaccination, communicable disease control, outbreak control, environmental health, cluster investigation, epidemiology, travel medicine etc. An effective and efficient surveillance system must be in place in order to provide this data quickly to stop the spread of a disease as fast as possible. Unfortunately, a weak link in the existing surveillance system is communications. This has had an impact on health professionals’ ability to receive timely information regarding changes in disease incidence in their community. Regional, provincial/territorial and federal authorities must work to improve the coordination of communications at all levels to protect the health and wellbeing of Canadians in times of crisis. The CMA recommends that: 2. The federal government continue to invest, at a minimum, $25 million in the coming year in the resources and infrastructure (i.e., medical supplies, equipment, laboratory facilities, and training for health care professionals), needed to anticipate and respond to disasters. The sale of Connaught Laboratories meant that Canada lost much its residual capacity to manufacture vaccines. If this were a “normal” war, Canadians would be looking to divert our manufacturing capacity toward meeting the threat. Given the biological threat, the Government of Canada should be negotiating with the pharmaceutical industry to increase our capacity to produce a secure supply of vaccine on Canadian soil. This would include the need for more than one supplier and the capacity to increase quickly the production of the vaccine. The CMA recommends that: 3. That the federal government undertake an immediate review of Canada’s self-sufficiency in terms of critical medical supplies (e.g., vaccines) required in the event of disasters with a view to short term self sufficiency. Surge Capacity Among the first points of contact with the health system for Canadians in the event of a significant attack on our population it will be the doctors offices and the emergency rooms of our hospitals. As noted earlier, we have witnessed in recent years the enormous strain these facilities can be placed under when even something quite routine like influenza strikes a community hard. The media abounded with stories of patients waiting hours to be examined, of stretchers lining corridors and of ambulances being redirected from hospital to hospital. Canadians themselves experienced first-hand how the resources of the hospitals, particularly the human resources, were stretched to the breaking point. The acute care occupancy rates of Ontario public hospitals across the Ontario Hospital Association regions in 1999-00 illustrate this point. In three of the five regions (Eastern Ontario, Central and South West) the occupancy rate ranged from 94% to 97% 18. The highest rate was found in the very heavily populated Central region. A British Medical Journal study suggests that an occupancy rate over 90% indicates that the hospital system is in a regular bed crisis 19. This problem is not unique to Ontario: “the decrease in the number of acute care beds across Canada over the past decade, coupled with an aging population and our extraordinary success in extending the survival of patients with significant chronic illness, has eliminated any cushion in bed occupancy in the hospital system.” 20 With this in mind, picture a catastrophe similar in scale to the destruction seen in New York or Washington D.C. occurring in downtown Toronto, Vancouver or Montréal; or perhaps the release of smallpox or botulism over Fredericton or Winnipeg. As noted earlier, the public health system and medical diagnostic and treatment systems in the community and hospitals could become overwhelmed very quickly without the ability to absorb the extra caseload. Like our hydro system, that is why surge capacity must be built into the system nationally to enable hospitals to open beds, purchase more supplies, and bring in the health care professionals it requires to meet the need. An element of surge capacity that is seriously lacking is the federal government’s contribution to emergency bed space. With the closure of most of the Canadian Force’s hospitals and the severe loss of experienced health professionals in the military, the government’s ability to assist local and provincial/territorial civilian authorities should their systems become overwhelmed is limited. Currently the National Emergency Stockpile System can supply up to 40,000 cots, as well as medical supplies and relatively rudimentary hospital equipment. Reports indicate, however, that much of the equipment is decades old, and that protocols for logistical management (e.g., transport and rapid deployment) are outdated. There is an urgent need to reassess and reaffirm capacity in this context. The CMA is in close contact with the American Medical Association as they advise their government on coordinating the use of civilian and federal facilities in an emergency. Most hospitals work on a just-in-time inventory basis for the purchase of drugs. Without some sort of plan to quickly re-supply their pharmacies and expand their capacity, patient care will suffer. The federal government must assure Canadians that municipal and provincial plans are in place with an overarching national plan to support these jurisdictions if their service capacities are overwhelmed. As mentioned earlier, the announcement by the federal government of the $11.59 million investment to enhance our response to a potential attack is a good step. But the government must help further by making available an emergency fund that would enable hospitals to plan and organize their surge capacity. The CMA recommends: 4. The federal government provide, in the coming year, $25 million in specific earmarked funding to the provinces and territories to enable health care facilities to plan, build and maintain surge capacity (e.g., open more beds, purchase emergency supplies) into their systems. The purpose of having such elaborate response plans and stockpiles of supplies and equipment is to be ready for the possibility that, in spite of all efforts to prevent a catastrophe from occurring, it nevertheless happens. That is when responsibility for dealing with the aftermath of the event falls largely to the public health system where a strong and viable infrastructure must already be in place to meet the challenge. Without the resources and the preparations, the crisis might well deteriorate and spread beyond “ground-zero.” That notion is often very difficult for non-health sector agencies and organizations to appreciate and can be an impediment to improving our capacity to help Canadians in times of disaster. No one can be completely prepared but you can prepare for certain scenarios. That is where the federal government can facilitate the health system’s readiness and reassure Canadians that help will be there when they need it. The federal government has taken several steps to reassure Canadians that their physical safety is enhanced. This includes the introduction of the Anti-Terrorism Act and the development of an Anti-Terrorism Plan. As well, there is increased funding to the Canadian Security and Intelligence Service and the Communications Security Establishment to help those agencies do their jobs more effectively. The health system must be considered an integral component of any plan to combat terrorism. It too requires assistance, especially the public health infrastructure, in strengthening its ability to counter the effects of an attack, whomever or whatever is responsible. III. THE CAPACITY OF OUR HEALTH HUMAN WORKFORCE Although the right mix of physical infrastructure and sustainable, long-term funding is necessary, in and of itself, it is not sufficient to ensure that all Canadians have timely access to quality medical services. We must also have an adequate supply of physicians and other health personnel or the system will not have the flexibility or adaptability to respond to basic societal needs or a crisis in times of disaster. We believe that the health workforce in general is facing a major sustainability challenge, and as such, this section of the brief proposes initiatives that are not solely focused on physicians but the entire health human workforce. Reports produced by several health professional organizations show that although overall numbers may be increasing, it is not sufficient to meet future demands. In 2000, there was a moderate 1.7% increase in the nurse population 21; however, a 1997 Canadian Nurses Association report projected that the supply of nurses must grow by 2.1% per year to meet future demand. 22 Similarly, the number of physicians per 100,000 population appears to be increasing slightly each year (187 in 2000), but it remains below the 1993 level of 191 per 100,000 population. The physician to population ratio can be misleading in that it does not necessarily represent full time physicians. CMA figures show that a larger proportion of physicians fall into the older age groups and may not be working full time or indeed may not be providing patient care at all. Also, one needs to factor in the demographics of the current physician workforce. Female physicians, who tend to work fewer hours per week than their male colleagues, now represent 30% of the practising pool. This means that more physicians will be needed to provide the same number of services. But this may not be possible, as approximately two-thirds of all family physicians are no longer routinely accepting new patients. 23 This is placing considerable pressure on those currently working within the health care system with little hope for relief. For example, data gathered through the CMA’s annual Physician Resource Questionnaire (PRQ) substantiates anecdotal evidence that physicians are working harder. Over half the respondents to the 2001 PRQ (53.7%) indicated that their workload had increased over the past year. Looking at specific areas that have caused physicians the greatest degree of stress, 63.7% indicated that their workload is heavier than they would like (up from 62% in 1998), while 58.1% felt that their family and personal life had suffered from choosing medicine as a profession (up from 55% in 1998). There are a number of short-term and longer term initiatives that can be implemented to reverse the shortage in our health care personnel and alleviate the stress they are feeling from trying to keep the system operating as best it can. What follows is a description of the short-term initiative the CMA is proposing for consideration by the Standing Committee. For a detailed description of the longer term initiatives and recommendations, please refer to Appendix A. What Can be Done Today? Given the immediate need for more physicians and other health professionals in Canada and the time lag involved in training, especially for physicians, the CMA proposes that a variation on the strategy adopted by the Canadian Forces (CF) 24 be used to repatriate physicians and other professionals. The CF announced the implementation of a Medical and Dental Direct Entry Officer Recruitment Allowance effective April 1, 1999 to recruit licensed family physicians, general practitioners and dentists. Recruitment incentives involve a lump-sum signing bonus/recruitment allowance of $80,000 per direct entry medical officer and $25,000 per direct entry dental officer after a successful completion of 3 months of basic officer training. The commitment is for a duration of 4 years and retention incentives involve an adjustment to medical and dental rates of pay that are competitive with private sector net earnings. The CMA concurs with the concept of an incentive program as proposed by the CF and suggests that a similar approach be implemented for recruiting and retaining Canadian physicians and other health care professionals currently practising outside of Canada. Presently there are some 10,500 Canadian physicians practicing in the US as well as tens of thousands of Canadian nurses. Of these physicians, close to 1,000 are considered active physicians both in Canada and the US. 25 Some of these physicians are no doubt practising in border towns where dual licensure is common, but many may be expatriates who have maintained their licensure in Canada hopefully with plans to either return or at least leave their future options open. Rather than proposing a lump sum approach as an incentive the CMA proposes that the incentive come through graduated federal income tax relief by reducing federal income tax payable by 50% for 3 years for Canadian physicians and health care professionals who return to practice in Canada. Such an approach provides direct relief and over a period of 3 years would provide incentives similar in size to those proposed by the CF in their recruitment and retention program. It is estimated that such a program would cost approximately $45 million over 3 years to repatriate an estimated 5% or 500 physicians back to Canada. If repatriation of other health care providers were included then it is estimated that the total cost of such an initiative could increase to $85 million over 3 years. The CMA therefore recommends: 5. That the federal government seriously consider implementing a 3-year graduated tax relief and re-allocation policy to encourage expatriate physicians and other health professionals to return to Canada. IV. TAX POLICY IN SUPPORT OF HEALTH POLICY The federal government has played a key role in the development of our health care system, primarily through a variety of measures or policy levers such as: spending; taxation; regulation; and information. Up until now, Canada’s health care system has made extensive use of only two federal policy levers, namely spending, in the form of cost-sharing arrangements between the federal and provincial/territorial governments; and by regulation, through the Canada Health Act. However, the degree to which the government can continue to rely on these levers must be examined. In the not-too-distant future, our health care system will face a number of pressures that will challenge its sustainability. Namely, an aging and more demanding population in terms of the specialty care services and technology they will seek; the cry for expanding the scope of medicare coverage to include homecare and pharmacare; and a shortage of health personnel. Several national health care studies, namely the Prime Minister’s Forum on Health and more recently, the Senate Standing Committee on Social Affairs, Science and Technology’s Study of the Health Care System have raised the need to look at alternative health care funding sources. We can not and should not wait any longer to explore and act upon the options available to us. Looking at Alternatives One of the lesser-explored options has been the strategic use of Canada’s taxation system. A public discussion of tax policy has not been seen in Canada since at least 1966. 26 Nor have we seen a major assessment of tax policy in relation to social policy since the 1980’s Macdonald Commission. In fact, the last major overall tax policy review was that of Benson in 1971. There is an urgent need to more fully consider the role that the tax system can play in supporting the health care system. Several proposals have been put forward over time in this areas, such as earmarked taxes for health; health-related excise taxes; input tax credits for health care services; medical savings accounts; saving for long-term care; social insurance; and refundable tax credits. This list is not exhaustive. In fact, the CMA has done some preliminary work in this area by commissioning a discussion paper on taxation and health policy. 27 In the paper, the author puts forth 10 “real world” proposals where the tax system can be used to support health policy. The CMA has initiated detailed discussion with Health Canada, Statistics Canada and others to model some of the possible scenarios. Of course, some of these are more promising than others. It is for this reason that the CMA is recommending the federal government to establish a National Task Force to review the tax system with the purpose of developing innovative tax-based mechanisms that better synchronize tax policy with health policy. In this area, the CMA recommends: 6. That the Federal Government establish a blue ribbon National Task Force to study the development of innovative tax-based mechanisms to better synchronize tax policy and health policy. First and foremost this Task Force would study: a) increasing the reach of the medical expense deduction (i.e., increasing the threshold from the current 3% of taxable expenditures) b) extending the medical expense deduction from a non-refundable tax credit to a refundable tax credit so that those not having income tax payable are afforded easier access to those services not covered under universal health “programs” c) dealing with the untoward inequities arising out of the application of the GST. The CMA envisions the mandate of the Task Force as being – to conduct a thorough policy and costing analysis of all potential tax-based mechanisms (not limited to those outlined in the above recommendations) that can be developed to assist in the financing and management of the health care system. The Task Force would be comprised of representatives from government, the health care system, private sector, and the public and it would issue its findings and recommendations within 2 years of its conception. V. SUMMARY OF RECOMMENDATIONS In closing, the CMA has offered a powerful and strategic combination of policy initiatives designed to re-vitalize Canada’s health care system as well as to restore Canadians’ confidence that they will be taken care of in times of disaster. The proposals are realistic and practical. They give the provinces and territories full flexibility in terms of policy implementation while ensuring full recognition to the federal government for its essential investments. These proposals emphasize the need for the federal government to continue its leadership to ensure that our health care system, Canada’s most cherished social program, is available to meet the health care needs of all Canadians. No one group can address all of the issues and challenges facing the health care system. The CMA reiterates its commitment to work with the federal government and others to ensure that our health care system will be there for all Canadians in the future and in times of crisis. The Summary of Recommendations is as follows: 1. The federal government immediately provide a minimum of $15 million for an assistance fund to municipal and provincial authorities to improve the co-ordination of their emergency responses among public health officials, police, fire and ambulance services, hospitals and other services. 2. The federal government continue to invest, at a minimum, $25 million in the coming year in the resources and infrastructure (i.e., medical supplies, equipment, laboratory facilities, and training for health care professionals), needed to anticipate and respond to disasters. 3. That the federal government undertake an immediate review of Canada’s self-sufficiency in terms of critical medical supplies (e.g., vaccines) required in the event of disasters with a view to short term self sufficiency. 4. The federal government provide, in the coming year, $25 million in specific earmarked funding to the provinces and territories to enable health care facilities to plan, build and maintain surge capacity (e.g., open more beds, purchase emergency supplies) into their systems. 5. That the federal government seriously consider implementing a 3-year graduated tax relief and re-allocation policy to encourage expatriate physicians and other health professionals to return to Canada. 6. That the Federal Government establish a blue ribbon National Task Force to study the development of innovative tax-based mechanisms to better synchronize tax policy and health policy. First and foremost this Task Force would study: a) increasing the reach of the medical expense deduction (i.e., increasing the threshold from the current 3% of taxable expenditures) b) extending the medical expense deduction from a non-refundable tax credit to a refundable tax credit so that those not having income tax payable are afforded easier access to those services not covered under universal health “programs” c) dealing with the untoward inequities arising out of the application of the GST. APPENDIX A The Capacity of Our Health Human Workforce Looking to the Future There are some signs that governments have begun to acknowledge that we are in a sustained shortage situation. In November 1999, several health ministers met with members of the Canadian Medical Forum Task Force on Physician Supply in Canada which recommended 2000 first year medical school places for 2000. Since then, governments have been very active in committing to increases in both undergraduate and postgraduate medical training. Enrolment of new medical students in 2000/2001 reached 1763 for an increase of 12% since 1997/98. This closely matches the promised increases to undergraduate enrolment made by governments. Approximately 140 more positions have been promised for the school years beginning 2001 and 2002. In this area, the CMA recommends that: 7. That the federal government immediately establish a Health Human Resources Education and Training Fund in the amount of $500 million per year for 5 years to fund: (1) increased enrolment in undergraduate and postgraduate education; and (2) the expanded infrastructure (both human and physical resources) required at Canada’s 16 health science centres as a result of increased enrolment. While the outlook for the future supply of physicians in Canada seems brighter, it will be quite a few years before we can benefit from the current increases in undergraduate enrolment. These initiatives must not only continue, but be enhanced to ensure that our health care system is sustainable into the future. However, there is one factor that may keep us from attaining the optimal level of medical school enrolment – high and rising medical school tuition fees. In August 2000, at the Conference of Premiers, Prime Minister Chretien said, “It is indeed important in the new knowledge-based economy that Canadians … have access to high quality post-secondary education without excessive debt loads, and that every child get the best possible start in life. This is all part of the Canadian competitive advantage.” 28 This sounds well and good, but the facts tell us otherwise. Since 1980, medical school tuition costs have increased by almost 880%, or more than twice as fast as the general cost of living. 29 The average tuition for students entering first year medical school in September 2001 was $12,840, a 158% increase over the 1997 average fee of $4,977. This means that over the course of four years, an undergraduate medical student is likely to spend approximately $110,000 in tuition, academic and living expenses. 30 Many students have had to resort to bank loans to cover the shortfall from their government-sponsored student loan, but the growing amount of debt accumulating for medical students is starting to worry the banks. The CIBC says that rising medical education costs have resulted in debt loads growing much faster than medical students’ potential income and so, it will no longer grant medical students preferred lending rates. The CIBC sets limits on the amount of debt that they feel students can repay in the years following their training. Unfortunately, medical students are now reaching these limits – which are in the $100,000 - $130,000 range. 31 Unlike the government-sponsored loans, interest on bank loans begin accruing immediately, up to a decade before a medical student starts earning a full income. This trend raises serious concerns that access to medical education will be restricted solely on the basis of personal financial resources. High debt loads will discourage capable and qualified students – particularly those from modest financial backgrounds – from applying to medical school. Canada’s health care system needs individuals from different socio-economic, cultural, rural and urban backgrounds to serve an equally diverse population of patients. First and foremost, the government must address the situation concerning the high and rising tuition fees and the insufficient financial support systems available to medical students. It must also consider purchasing additional training positions in Canada’s medical schools specifically targeted for groups, such as Aboriginal, Indian and Inuit populations. These measures will foster the education and training of a diverse population of health care givers, and will support the culturally and socially sensitive health care needs of all Canadians. The CMA sees a strong role for the federal government in ensuring that medicine remains a rewarding and affordable career accessible to students based on their passion and academic performance, not their financial status. The CMA therefore recommends: 8. That, in order to alleviate some of the pressures driving tuition fee increases, the federal government increase transfer payments to the provinces/territories with targeted amounts for post-secondary education. 9. That the federal government create and fund a national health services student bursary program to encourage students who have limited financial resources to apply for an education in health care services. 10. That the federal government develop financial support systems for health services students that are: (a) non-coercive; (b) developed concomitantly or in advance of any tuition increase; (c) in direct proportion to any tuition fee increase; and (d) provided at levels that meet the needs of the students. 11. That the federal government purchase additional training slots in Canadian medical schools for particular segments of our population, such as aboriginals. REFERENCES 1 Canadian Ipsos Reid Express. Terrorist Effect. October 23-25, 2001. 2 GPC International. Canadians split on the best response to the terrorist attacks and fear reprisals at home. Media Release October 18, 2001. www.gpcinternational.com/media/releases/20011018.html 3 Canadian Ipsos Reid Express. The Public Agenda Post September 11, 2001. October 1, 2001 4 Osterholm M. Emerging infections – another warning. NEJM 2000; 342(17) http://www.nejm.org/content/2000/0342/0017/1280.asp. 5 World Health Organization. Plague Manual – Epidemiology, Distribution, Surveillance and Control. The Organization: 1999. http://www.who.int/emc-documents/plague/docs/whocdscsredc992a.pdf 6 Sanchez A. et al. Reemergence of Ebola virus in Africa. Emerging Infectious Diseases Vol. 1(3); July-September 1995. http://www.cdc.gov/ncidod/eid/vol1no3/sanchez.htm. 7 Revkin A. Mosquito virus exposes the hole in the safety net. New York Times Oct. 4, 1999. http://www.nytimes.com/library/national/regional/100499ny-pest.html 8Okie S. Tuberculosis is threatening to make a comeback. International Herald Tribune Aug. 11, 1999. http://www.iht.com/IHT/TODAY/WED/IN/tb.2.htm 9 Health Canada. When anti-tuberculosis drugs don’t work. Tuberculosis Epi Update January 2000. http://www.hc-sc.gc.ca/hpb/lcdc/bah/epi/tbdrug_e.html. 10 BBC News Online. Africa confronts malaria. Apr. 25, 2000. http://www.bbc.co.uk/hi/english/world/africa/newsid_724000/724445.stm 11World Health Organization. World Health Organization Report on Infectious Diseases – Removing Obstacles to Healthy Development. Geneva: The Organization, 1999. http://www.who.int/infectious-disease-report/pages/textonly.html 12 Ibid. 13 BBC News Online. South Africa AIDS crisis worsens. Apr. 19, 2000. http://www.bbc.co.uk/hi/english/health/newsid_719000/719183.stm 14 Richwine L. US declares AIDS a threat to security. National Post May 1, 2000 A1. 15 Ontario Medical Association. Ontario Medical Association Input to Walkerton Inquiry Part II: Protecting the Public’s Health. Toronto. April 2001 16 Koplan JP. Building Infrastructure to Protect the Public’s Health. Public Health Training Network Broadcast September 21, 2001 (Downloaded from Web: October 19, 2001 www.phppo.cdc.gov/documents/KoplanASTHO.pdf ) 17 Dept. of National Defence. Canadian Forces Disaster Assistance Relief Team. BG-99-051 (Amended) October 10, 2001. (Downloaded from Web: October 25, 2001 [www.dnd.ca/eng/archive/2001/oct01/28DART_b_e.htm] 18 Ontario Hospital Reporting System, 2001. Acute Care Occupancy Rates, Ontario Public Hospitals by OHA region, 1999/00. Ontario Ministry of Health and Long Term Care. 19 Bagust A, Place M, Posnett J. Dynamics of bed use in accommodating emergency admissions: stochastic simulation model. BMJ; 319: 155-158 July 17, 1999. 20 Nicolle L. Viruses without borders. Can J Infect Dis Vol. 11, Issue 3, May/June 2000 (Downloaded from Web: October 23, 2001: www.pulsus.com/Infdis/11_03/nico_ed.htm) 21 CIHI. Canadian Institute for Health Information Reports Moderate Rise in Register Nurses Workforce, Fewer RNs Working on Casual Basis, More Working Full-time, Media Release, May 23, 2001. 22 Canadian Medical Association. Specialty Care In Canada: Issue Identification and Policy Challenges, October 2001. 23 Canadian NewsWire. Not enough family-physicians to meet patient needs, October 25, 2001 [www.cnw.ca/releases/October2001/25/c0304.html] 24 Incentive Programs for the Recruitment and Retention of Medical and Dental Officers, http://www.dnd.ca/eng/archive/1999/jul99/05DocIncen_b_e.htm 25 Based on a linkage done by Canadian Institute for Health Information of data from Southam Medical Data Base and the America Medical Association’s Masterfile. 26 Carter K. Royal Commission on Taxation, Canada, 1966. 27 Thompson A. Taxation and Health Policy: A Discussion Paper, August 2001. 28 Letter from Prime Minister Jean Chretien to the Honorable Gary Doer, Premier of Manitoba, Chair, Conference of Premiers, August 4, 2000. 29 Ontario Medical Association. Medical Education Fact Sheet, 2001. 30 Admissions/Student and Equity Affairs, Faculty of Medicine, University of Western Ontario. Budgeting Guide for Medical Students: 1999-2000. 31 Banks no longer banking on earning potential of medical students, Canadian Medical Association Journal, June 12, 2001; 164(12) 1735
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Canadians’ Access to Quality Health Care: A System in Crisis : Submitted to the House of Commons Standing Committee on Finance 1999 Pre-budget consultations

https://policybase.cma.ca/en/permalink/policy1987
Last Reviewed
2019-03-03
Date
1998-08-31
Topics
Health human resources
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
1998-08-31
Topics
Health human resources
Health systems, system funding and performance
Text
I. INTRODUCTION The Canadian Medical Association (CMA) commends the federal government, in its second mandate, for continuing the public pre-budget consultation process. This visible and accountable process encourages public dialogue in the development of finance and economic policies of the country. As part of the 1999 pre-budget consultation process, the CMA welcomes the opportunity to submit its views to the House of Commons Standing Committee on Finance, and looks forward to meeting with the Committee at a later date to discuss our recommendations and their rationale in greater detail. II. POLICY CONTEXT While the current and future status of our health care system is a top priority for all Canadians, it is evident that their faith in the system’s ability to ensure access to quality care is eroding. In May 1991, 61% of Canadians rated the system as excellent/very good. By February 1998 that rating had slipped to 29% - a dramatic decrease in the confidence level of Canadians in the health care system. 1 Unfortunately, their outlook on the future of the health care system is not much better. Some 51% of Canadians believe that their health care will be in worse condition in 10 years than it is today. 2 It is not surprising that Canadians are losing confidence in the future sustainability of the health care system. They have experienced firsthand the decline in access to a range of health care services (see Table 1): * 73% reported that waiting times hospital emergency departments had worsened, up from 65% in 1997, and 54% in 1996 * 72% reported that waiting times for surgery had lengthened, up from 63% in 1997, and 53% in 1996 * 70% reported that availability of nurses in hospitals had worsened, up from 64% in 1997, and 58% in 1996 * 61% reported that waiting times for tests had increased, up from 50% in 1997, and 43% in 1996 * 60% reported that access to specialist physicians has worsened, up from 49% in 1997, and 40% in 1996 [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 1 (a) [TABLE END] [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 1 (b) [TABLE END] Clearly, these findings are significant, and demonstrate the public’s increasing concerns regarding current access to quality health care, as well as the future sustainability of our health care system. Canadians have made it clear that it is not, nor can it be, “business as usual” in attempting to meet their health care needs as we move into the next millennium. Medicare, Canada’s crowning social policy achievement, is in crisis. It is time for the federal government to re-establish its leadership role in this strategic priority area. The CMA has repeatedly placed its concerns about access to quality health care on the public record. Physicians, as patient advocates, have consistently expressed their frustration with the difficulties faced in accessing medically necessary services - only to fall on the deaf ears of the federal government. In surveying Canadian physicians on the front lines, they know the degree of difficulty in accessing services that their patients need: 3 * only 27% of physicians surveyed rated as excellent/very good/good their access to advanced diagnostic services (e.g., MRI) * only 30% of physicians surveyed rated as excellent/very good/good their access to long-term institutional care * only 45% of physicians surveyed rated as excellent/very good/good their access to psychosocial support services * only 46% of physicians surveyed rated as excellent/very good/good their access to acute institutional care for elective procedures These findings are cause for concern. Particularly troublesome is that only 63% of physicians surveyed rated as excellent/very good/good their access to acute institutional on an urgent basis. The cause for this crisis of confidence is clear - the federal government's unilateral and repeated decreases in the rate of increase in transfer payments beginning with Established Financing Programs (EPF), established in 1977, and continuing for the next decade-and-a-half. It culminated, in April, 1996, with the severe and successive cuts in cash transfers for health, post-secondary education (PSE) and social assistance via the Canada Health and Social Transfer (CHST). The CMA is not alone in its view. In addition to the public, other health groups and the Provincial and Territorial Premiers have expressed serious concern about the sustainability of the health care system and the urgent need for Federal leadership and reinvestment. Following their meeting in August, 1998, the Premiers "re-affirmed their commitment to maintaining and enhancing a high quality universal health care system for all Canadians and observed that every government in Canada but one - the federal government - has increased its funding to health care - the people's priority". 4 Underscoring the Premiers' view was a detailed proposal submitted to the federal government calling for an immediate increase in CHST cash transfers. From Federal Government Acknowledgement to Action At the 1997 Annual General Meeting of the CMA in Victoria, the federal minister of health, Allan Rock, stood before delegates and acknowledged "the very real anxiety that's being felt by Canadians" over the future of the health care system. 5 The minister also conceded that cuts to transfer payments have not been insignificant and have had an impact on the system, a point on which the CMA wholeheartedly agrees. The CMA recognizes that the federal government has made a series of difficult decisions when it comes to its funding priorities in order to restore our country’s fiscal health. However, the time has come to consider the fundamental issue of reinvesting in the health of Canadians. The federal government must move beyond the rhetoric in terms of acknowledging the pain and suffering that the cuts have caused, and move to an agenda of action by showing leadership and making the necessary and overdue re-investments in our health care. At a time when the federal government is beginning to reap the benefits of a fiscal dividend, it must recognize that health care is not simply a consumption good that, once spent, provides no additional benefits. Investments in the health care system provide a substantial and lasting social rate of return in terms of restoring, maintaining and enhancing Canadians health. Furthermore, in an increasingly interdependent and global marketplace, a sustainable health care system must be viewed as a necessary precondition for Canadians to excel, thus strengthening the link between good economic policy and good health care policy in Canada. They should not be viewed as competing against each other or that one must be sacrificed at the expense of the other. The 1998 federal budget ignored Canadians' number one concern and did nothing to bolster their confidence that the system will be there when they or their family need it. In responding to the massive reductions in cash transfers to the provinces and territories, in his February 24, 1998, budget speech, federal finance minister Paul Martin announced that he had increased the floor under cash transfers to the provinces in support of health and other programs from the $11.0 billion to $12.5 billion annually and further that it "will provide provinces with nearly $7 billion more in cash over the 1997/98 to 2002/03 period”. 6 While this was announced as an "increase" these statements are misleading. It must be remembered that this is not “new” money; the $12.5 billion represents nothing more than a partial restoration, which falls $6.0 billion (or 32%) short of the cash floor of $18.5 billion prior to the introduction of the CHST in 1996/97. To date, the cumulative impact of cuts to the Canada Health and Social Transfer (CHST) in 1996 and 1997 amounts to a $15.5 billion withdrawal in federal cash from health and social transfers. Their impact is still working its way through the system and being felt in patients' pain and suffering and unfortunately, even death. The CMA has consistently stated publicly that the integrity of the health care system is being jeopardized by reductions to federal cash transfer payments for health. The federal government, however, has failed to respond to these concerns. Unless the federal government reinvests in health care, it will only deepen the crisis of confidence Canadians share about the future sustainability of the health care system. III. HEALTH CARE FUNDING AND THE FEDERAL ROLE The Federal Role When it comes to the health care system, the federal government’s role is aimed at ensuring that Canadians have access to health care services under “uniform terms and conditions”. This derives from the government’s right to exercise its spending power and has been manifested over the past 40 years through a number of cash-transfer mechanisms to the provinces and territories, framed more precisely by the principles of the Canada Health Act (i.e., public administration, comprehensiveness, universality, portability and accessibility). Since the inception of national health insurance in Canada, the federal government has played a central role in the funding of health care. Until 1977, the government reimbursed each province 50 cents on each dollar spent in the areas of hospital and medical care insurance. Following a renegotiated formula, government moved from a “cost-sharing” to a “block funding” formula from 1977/78 to 1995/96. Federal-provincial transfers were distributed through a funding mechanism known as Established Programs Financing (EPF). Under EPF, a combination of (basic) cash and tax points were transferred to the provinces for health care and post-secondary education (PSE). While both the tax points and cash components are important in funding health care, there are those who argue that the level of federal cash should be viewed as a true reflection of the government’s commitment to health care. This is significant for two reasons. First, it demonstrates the priority the government places on our health care system, and secondly, the cash component (which can be withheld under the Canada Health Act) can play an important role in preserving and enhancing national standards. 7 The Origins of Federal Cash Withdrawal The genesis for the crisis in confidence about the future of Canada’s health care system can be traced to 1982, when the federal government introduced a series of unilateral decisions which reduced its cash contributions to the provinces and territories for health and other social programs. Figure 1 highlights the changes made to the EPF formula used to fund health and post-secondary education between 1977 and 1995. These unilateral changes, resulted in the withholding of approximately $30 billion in federal cash that would have otherwise been transferred to provincial and territorial health insurance plans (and an additional $12.1 billion for post-secondary education - for a total of $42.1 billion). 8 This dollar amount is of no small consequence when it comes to ensuring that all Canadians have access to quality health care. [FIGURE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Figure 1 [FIGURE END] Into the Mist... Prior to April 1, 1996 the federal government's commitment to insured health services, post-secondary education and social assistance programs could be readily determined since the federal government made separate notional cash contributions to the provinces and territories in each of these areas. 9 Announced in the 1995 federal budget, the creation of the Canada Health and Social Transfer (CHST), on April 1, 1996, saw EPF merge with the Canada Assistance Plan (CAP). In effect, health, post-secondary education, and social assistance were collapsed into one large cash transfer. At the time, the government claimed that the CHST was “a new approach to federal-provincial fiscal relations marked by greater flexibility and accountability for provincial governments, and more sustainable financing arrangements for the federal government.” 10 In reality, the increased “flexibility and accountability” was accompanied by a $7.0 billion reduction in the cash portion of the new transfer, and introduced a lower level of transparency with respect to where and what proportion the federal government notionally allocated its dollars for health, PSE and the social programs previously funded under CAP. In its 1998 budget, the federal government moved to partially restore CHST funding by establishing a new cash floor of $12.5 billion (see Table 2) - however, this is still $6.0 billion short of the pre-CHST cash floor. To date, the cumulative impact of previous CHST cash reductions in 1996 and 1997 amounts to a $15.5 billion withdrawal of cash from health and social transfers to 1998/99. By 2002/03, it is estimated that $39.5 billion will have been removed from the CHST. This is in addition to the $30 billion withheld from fiscal transfers that would otherwise have gone to the provinces and territories for health between 1982 and 1995. 11 [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [TABLE END] Furthermore, in addition to the current cash floor, the cash entitlement will stagnate at $12.5 billion, as adequate provision has not been made to maintain the value of the cash portion of the transfer. 12 This means the spending power of the cash entitlement will continue to erode as the health care system is forced to meet the changing needs of Canadians based on population growth, aging, epidemiology, new technologies and inflation. With the introduction of the CHST, the disappearance of health, post-secondary education and social assistance into the shadowy mist makes it impossible to hold the federal government accountable with respect to its relative commitment to each of these important policy areas. Using the pre-CHST percentage distribution, the federal government’s current cash allocation to health care stands at roughly $5.0 billion, or 7% of total health care expenditures. This is not surprising considering that the “H” in CHST was added later, only after health organizations protested its absence. Based on the reduced federal cash contribution to health care, it would appear that the government has made a conscious decision to abdicate its responsibility and leadership role in funding health care. While claiming to uphold the integrity of our national health care system, the reality of reduced cash transfers has forced all provinces and territories to make do with significantly fewer federal dollars for health. Federal “offloading” at its best has allowed the federal government to meet (and exceed) its own financial projections; at its worst it has forced the provinces and territories to consider a series of unattractive options: re-allocate program spending from within current budgets; deficit-financed program spending; or reduced program spending. To be clear, from a national perspective, the CMA believes that the single most important reason for the deterioration of the health care system is the significant decline in federal financial support for health care. It is critical that the federal government immediately signal its commitment to Canadians that the health care system is a high priority, and to immediately reinvest in a program that will restore the confidence of Canadians' that the system will be there for them when they need it. Now is the time for the federal government to demonstrate leadership and address the number one concern of Canadians by turning the "vicious cycle" of deficit reduction into a "virtuous cycle" of reinvesting in the health care system. This is not business as usual, and the status quo is not sustainable. IV. A TIME TO RE-ESTABLISH FEDERAL LEADERSHIP IN HEALTH CARE Stabilize the System Canadians, who strongly support a publicly-funded health care system - a conviction shared by the CMA - need to see some leadership from their federal government about how it perceives the future of the health care system unfolding. The failure to re-invest in health care in the last federal budget leaves them confused by the contradiction of seeing the government withdraw funding while at the same time talking about introducing new programs such as home care and pharmacare. Before the federal government can even contemplate future program expansion, it must move quickly to stabilize our current health care system. Canadians have made it very clear where they believe the federal government's spending priorities lie. Seventy-one percent (Angus Reid, November, 1997) want federal cash transfer restored and 81% (Ottawa Sun/Roper, June 1998) of Canadians want the federal government to dedicate more resources to Medicare. The CMA believes strongly that there is an immediate need for a measured, deliberate and responsible approach to re-invest in our health care system. Canadians need to be reassured that the system will be there for them and their families when they need it. To restore access to quality health care for all Canadians, the CMA respectfully recommends: 1. That in order to ensure greater public accountability and visibility, the federal government introduce a health-specific portion of the cash transfers to the provinces and territories. 2. That in addition to the current level of federal cash transferred to the provinces and territories for health care, the federal government restore at a minimum $2.5 billion in cash on an annual basis to be earmarked for health care, effective April 1, 1999. 3. That beginning April 1, 2000, the federal government fully index the total cash entitlement allocated to health care through the use of a combination of factors that would take into account the changing needs of Canadians based on population growth, aging, epidemiology, current knowledge and new technologies, and economic growth. The principles outlined in the above recommendations are fundamental and underscore the importance of establishing an accountable (i.e., linking sources with their intended uses) and visible transfer for federal cash that is targeted for reinvestment into health care. While there is ongoing discussion about the mechanism(s) to reinvest in health care, the minimum federal cash restoration of $2.5 billion on an annual basis into the health care system recognizes the high priority of placing health care on a more sustainable financial footing for the future. This figure is separate from the $5 billion notionally allocated to health care via the current CHST, and is calculated on the basis of the recent historical federal cash allocation (approximately 41%) under EPF and CAP (now the CHST) to health care as a proportion of the $6.0 billion dollars required to restore the CHST cash floor to $18.5 billion (1995/96 level). The recommendations also speak to the necessity of having in place a fully indexed escalator to ensure that the federal cash contribution will continue to grow to meet the future health care needs of Canadians, and with the economy. The escalator formula recognizes that health care needs are not always synchronized with economic growth. In fact, it could be argued that in times of economic hardship (i.e., unemployment, stress, anxiety), a greater burden is placed on the health care system. Taken together, the above recommendations are a targeted approach to reinvesting in health care, and serve to re-establish the federal government's leadership role when it comes to the current and future sustainability of our health care system. It also signals that the federal government is prepared to address, in a focused and strategic approach, Canadians' number one concern - access to quality health care. Finally, it is important to note that in principle the above recommendations are consistent with those of other groups such as the provincial and territorial ministers of finance, the Canadian public and other national health organizations, who are not asking for new resources but an immediate restoration of monies that have been taken out of the federal/provincial/territorial transfer envelope over the past three years. Looking to the Future At the same time that the federal government reinvests to stabilize the health care system, it must also consider the broader spectrum of health care services that must be in place to ensure that Canadians do not fall through the cracks. In addition to the re-investment required to stabilize our Medicare system, there is also an urgent need for investments into other components of the health system. In many ways, this suggests that new transitional funding is required to ensure that as the system evolves, it remains accessible, and can do so with minimal interruption of service to Canadians. Proposed by the CMA, the Health System Renewal Fund, is time limited, sector-specific, and strategically targeted to areas that are in transition. Funding is intended to meet defined need and give the federal government sufficient flexibility in how the funds will be allocated, with full recognition for the investment. The CMA respectfully recommends: 4. That the federal government establish a one-time Health System Renewal Fund in the amount of $3 billion to be disbursed over the three-year period beginning April 1, 1999, for the following areas of need: a. Acute care infrastructure support: assist health institutions to enhance the delivery of a continuum of quality patient care by improving their access to necessary services including new technologies, and modernizing health facilities and upgrading infrastructure. b. Community care infrastructure support: to enable communities to develop services to support the delivery of home and community-based care in the wake of the rapid downsizing of the institutional sector. c. Support Canadians at risk: to provide access to pharmacotherapy and medical devices to those in need, who are not adequately covered by public or private insurance (pending the development of a long-term solution). d. Health information technology: to allow the provinces and territories to put in place the transparent, clinically driven health information infrastructure necessary to support the adequate and appropriate management of access and delivery of health care. In implementing the health information infrastructure scrupulous attention must be paid to privacy and confidentiality issues. The Acute Care Infrastructure Support program is designed to ensure that targeted reinvestments are made in the institutional sector such that it has the necessary physical capacity and infrastructure to deliver quality health care. In a world where downsizing has become the accepted wisdom, health care facilities need to be modernized in terms of new technology and equipment to ensure the full continuum of patient care is available. The Community Care Infrastructure Support program speaks to the important need to develop adequate community-based systems before any reforms are introduced in the acute care sector. It also recognizes that community-based programs should not be implemented at the expense of the acute care sector, but rather, should be designed such that both sectors complement one another and add value to the health care system. The Support Canadians at Risk program focuses on those who with inadequate coverage and have compromised access to needed pharmacotherapy and medical devices. Currently, drug coverage is not universal nor is it comprehensive. In many cases, the working poor, those that are self-employed or employed by small businesses do not have drug coverage (nor are they eligible for government sponsored plans). In other cases, co-payments/deductibles of some public plans are so high that individuals must pay out-of-pocket (e.g., $850 deductible, semi-annually, in Saskatchewan, then 35% co-payment) for all necessary prescription drugs. As a result, this patchwork coverage may inhibit Canadians access to quality care and may place additional demands on the acute care sector. Similarly, Canadians may not have access to medical devices covered by the public and/or private plans. The Health Information Technology program speaks to the critical need to develop and implement a transparent and clinically driven information systems that will support better management, measurement and monitoring of the health care system. At the same time, scrupulous attention must be paid to privacy and confidentiality issues. To this end, the CMA has taken a proactive approach in addressing these issues by developing a health information privacy code. Taken together, our recommendations are a powerful and strategic package. They speak to the need to immediately stabilize the health care system - which is in crisis, and the need to look at the broader spectrum of health care services to ensure that Canadians in need do not fall through the cracks. V. REINFORCING GOOD ECONOMIC POLICY WITH GOOD HEALTH CARE POLICY IN CANADA While the system-wide issues related to the federal role in funding health care is clearly of importance to Canada's physicians, there are also other important issues that the CMA would like to bring to the attention of the Standing Committee on Finance. As mentioned earlier in the brief, good economic policy and good health care policy should go hand-in-hand. They should serve to reinforce, not neutralize, one another. They should not be viewed as one gaining at the expense of the other. Viewed in their proper context, they can be balanced such that policy decisions produce outcomes that are fair to all parties. Tobacco Taxation Policy Smoking is the leading preventable cause of premature mortality in Canada. The most recent estimates suggest that more than 45,000 Canadians die each year due to tobacco use. The estimated economic cost to society from tobacco use in Canada has been estimated between $11 billion to $15 billion 13. Tobacco use directly costs the Canadian health care system $3 billion to $3.5 billion 14 annually. These estimates do not take into account intangible costs such as pain and suffering. CMA is concerned that the 1994 reduction in the federal cigarette tax has had a significant effect in slowing the decline in cigarette smoking in the Canadian population, particularly in the youngest age groups - where the number of young smokers (15-19) is in the 22% to 30% range and 14% for those age 10-14 15. The CMA congratulates the federal government’s February 13, 1998 initiative which selectively increased federal excise taxes on cigarettes and tobacco sticks. This is a first step towards an integrated tobacco tax strategy, and speaks to the importance of strengthening the relationship between good tax policy and good health policy in Canada. The CMA understands that tobacco tax strategies are extremely complex. Strategies need to consider the effects of tax increases on reduced consumption of tobacco products with increases in interprovincial/territorial and international smuggling. In order to tackle this issue, the government could consider a selective tax strategy. This strategy requires continuous stepwise increases to tobacco taxes in those areas with lower tobacco tax (i.e., Ontario, Quebec and Atlantic Canada). The goal of selective increases in tobacco tax is to increase the price to the tobacco consumer over time (65-70% of tobacco products are sold in Ontario and Quebec). The selective stepwise tax increases will approach but may not achieve parity amongst all provinces; however, the tobacco tax will attain a level such that inter-provincial/territorial smuggling would be unprofitable. The selective stepwise increases would need to be monitored so that the new tax level and US/Canadian exchange rates do not make international smuggling profitable. The selective stepwise increase in tobacco taxes can be combined with other tax strategies. The federal government should apply the export tax and remove the exemption available on shipments in accordance with each manufacturers historic levels. The objective of implementing the export tax would be to make cross-border smuggling unprofitable. The federal government should establish a dialogue with the US federal government regarding harmonizing US tobacco taxes with Canadian levels at the factory gate. Alternatively, US tobacco taxes could be raised to a level that when offset with the US/Canada exchange rate differential renders international smuggling unprofitable. The objective of harmonizing US/Canadian tobacco tax levels (at or near the Canadian levels) would be to increase the price of internationally smuggled tobacco products to the Canadian and American consumers. The CMA's comprehensive tobacco taxation strategy is designed to achieve the following objectives: (1) to reduce tobacco consumption; (2) to minimize interprovincial/territorial smuggling of tobacco products; (3) to minimize international smuggling of tobacco products from both the Canadian and American perspective; (4) to reduce and/or minimize Canadian/American consumption of internationally smuggled tobacco products. The CMA recommends: 5. That the federal government follow a comprehensive integrated tobacco tax policy: a. To implement selective stepwise tobacco tax increases to achieve the following objectives: (1) reduce tobacco consumption, (2) minimize interprovincial/territorial smuggling of tobacco products, and (3) minimize international smuggling of tobacco products; b. To apply the export tax on tobacco products and remove the exemption available on tobacco shipments in accordance with each manufacturers historic levels; and c. To enter into discussions with the US federal government to explore options regarding tobacco tax policy, bringing US tobacco tax levels in line with or near Canadian levels, in order to minimize international smuggling. The Excise Act Review, A Proposal for a Revised Framework for the Taxation of Alcohol and Tobacco Products (1996), proposes that tobacco excise duties and taxes (Excise Act and Excise Tax Act) for domestically produced tobacco products be combined into a new excise duty and come under the jurisdiction of the Excise Act. The new excise duty is levied at the point of packaging where the products are produced. The Excise Act Review also proposes that the tobacco customs duty equivalent and the excise tax (Customs Tariff and Excise Tax Act) for imported tobacco products be combined into the new excise duty [equivalent tax to domestically produced tobacco products] and come under the jurisdiction of the Excise Act. The new excise duty will be levied at the time of importation. The CMA supports the proposal of the Excise Act Review. It is consistent with previous CMA recommendations calling for tobacco taxes at the point of production. Support for Tobacco Control Programs Taxation should be used in conjunction with other strategies for promoting healthy public policy, such as public education programs to reduce tobacco use. The Liberal party, recognising the importance of this type of strategy , promised: "...to double the funding for the tobacco control programs from $50 million to $100 million over five years, investing the additional funds in smoking prevention and cessation programs for young people, to be delivered by community organizations that promote the health and well-being of Canadian children and youth." 16 The CMA applauds the federal government's efforts in the area of tobacco use prevention and cessation - particularly its intent to commit $50 million to public education through the proposed Tobacco Control Initiative. However, a time limited investment is not enough. Substantial and sustainable funding is required for programs in prevention and cessation of tobacco use. 17 A possible source for this type of program investment could be tobacco tax revenues or the tobacco surtax. The CMA therefore recommends: 6. That the federal government commit stable funding for a comprehensive tobacco control strategy; this strategy should include programs aimed at prevention and cessation of tobacco use and protection of the public from tobacco's harmful effects. 7. That the federal government clarify its plans for the distribution of the Tobacco Control Initiative funds, and ensure that the funds are invested in evidence-based tobacco control projects and programs. 8. That the federal government support the use of tobacco tax revenues for the purpose of developing and implementing tobacco control programs. Fair and Equitable Tax Policy? - The Goods and Services Tax (GST) and Harmonized Sales Tax (HST) When it comes to tax policy and the tax system in Canada, the CMA is strongly of the view that both should be administered in a fair and equitable manner. This principle-based statement has been made to the Standing Committee on a number of different occasions. While these principles are rarely in dispute, the CMA has expressed its strong concerns regarding their application - particularly in the case of the goods and services tax (GST) and the recently introduced harmonized sales tax (HST) in Atlantic Canada. By designating medical services as "tax exempt" under the Excise Tax Act, physicians are in the unenviable position of being denied the ability to claim a GST refund (i.e., input tax credits - ITCs) on the medical supplies necessary to deliver quality health care, and on the other, cannot pass the tax onto those who purchase such services. This is a critical point when one considers the raison-d'etre of introducing the GST: to be an end-stage consumer-based tax, and having not a producer of a good or a service bear the full burden of the tax. Yet this tax anomaly does precisely that. As a result, physicians are "hermetically sealed" - they have no ability to claim ITCs due to the Excise Tax Act, or pass the costs to consumers due to the Canada Health Act. To be clear, the CMA has never, nor is currently asking for, special treatment for physicians under the Excise Tax Act. However, if physicians, as self-employed individuals are considered as small businesses for tax purposes, then it only seems reasonable that they should have the same tax rules extended to them that apply to other small businesses. This is a fundamental issue of tax fairness. While other self-employed professionals and small businesses claim ITCs, an independent (KPMG) study has estimated that physicians have "overcontributed" in terms of unclaimed ITCs by $57.2 million per year. By the end of this calendar year, physicians will have been unfairly taxed in excess of $480 million. Furthermore, with the introduction of the HST in Atlantic Canada, KPMG has estimated that it will costs physicians an additional $4.686 million per year. As it currently applies to medical services, the GST is bad tax policy and the HST will make a bad situation worse for physicians. Last year, the Standing Committee, in its report to the House of Commons stated: "According to the CMA, the GST is fundamentally unfair to physicians and is a deterrent in recruiting and retaining physicians in Canada. This issue merits consideration and further study". 18 The CMA believes that it has rigorously documented its case and further study is not required - the time has come for concerted action from the federal government to alleviate this tax impediment. There are other health care providers (e.g., dentists, physiotherapists, psychologists, chiropractors, nurses) whose services are categorized as tax exempt. However, there is an important distinction between whether the services are publicly insured or not. Health care providers who deliver services privately have the opportunity to pass along the GST costs through their fee structures. It must be remembered that physicians are in a fundamentally different position given that 99% of their professional earnings come from the government health insurance plans: under the GST and HST, "not all health care services are created equal". There are those who argue that the medical profession should negotiate the GST at the provincial/ territorial level, yet there is no province that is prepared to cover the additional costs that are being downloaded onto physicians as a result of changes to federal tax policy. Nor do these governments feel they should be expected to do so. The current tax anomaly, as it affects the medical profession, was created with the introduction of the GST - and must be resolved at the federal level. As it currently stands for medical services, the GST and HST is not a tax policy that reinforces good health care policy in Canada. The CMA view is not unique. The late Honourable Chief Justice Emmett Hall recognized the principles that underpin the fundamental issue of tax fairness by stating: "That the federal sales tax on medical supplies purchased by self-employed physicians in the course of their practices be eliminated". 19 Even though Mr. Hall's recommendation was made prior to the introduction of the GST and HST, the principles outlined above are unassailable and should be reflected in federal tax policy. Canadian physicians work hard to provide quality health care to their patients within what is a publicly funded health care system. Physicians are no different from Canadians in that they, too, are consumers (purchasers). Why then, they ask, has the medical profession been singled out for such unfair treatment under the GST regime? The CMA respectfully recommends: 9. That health care services funded by the provinces and territories be zero-rated. The above recommendation could be accomplished by amending the Excise Tax Act as follows: (1). Section 5 part II of Schedule V to the Excise Tax Act is replaced by the following: 5. "A supply (other than a zero-rated supply) made by a medical practitioner of a consultative, diagnostic, treatment or other health care service rendered to an individual (other than a surgical or dental service that is performed for cosmetic purposes and not for medical or reconstructive purposes)." (2). Section 9 Part II of Schedule V to the Excise Tax Act is repealed. (3). Part II of Schedule VI to the Excise Tax Act is amended by adding the following after section 40: 41. A supply of any property or service but only if, and to the extent that, the consideration for the supply is payable or reimbursed by the government under a plan established under an Act of the legislature of the province to provide for health care services for all insured persons of the province. Our recommendation fulfils at least two over-arching policy objectives: (1) strengthening the relationship between good economic policy and good health policy in Canada; and (2) applying the fundamental principles that underpin our taxation system (fairness, efficiency, effectiveness), in all cases. Registered Retirement Savings Plans (RRSPs) There are (at least) two fundamental goals of retirement savings: (1) to guarantee a basic level of retirement income for all Canadians; and (2) to assist Canadians in avoiding serious disruption of their pre-retirement living standards upon retirement. Reviewing the demographic picture in Canada, we see that an increasing portion of society is not only aging, but is living longer. Assuming that current demographic trends will continue and peak in the first quarter of the next century, it is important to recognize the role that private RRSPs savings will play in ensuring that Canadians may continue to live dignified lives well past their retirement from the labour force. This becomes even more critical when one considers that Canadians are not setting aside sufficient resources for their retirement. Specifically, according to Statistics Canada, it is estimated that 53% of men and 82% of women starting their career at age 25 will require financial aid at retirement age - only 8% of men and 2% women will be financially secure. In its 1996 Budget Statement, the federal government announced that it froze the dollar limit of RRSPs at $13,500 through to 2002/03, with increases to $14,500 and $15,500 in 2003/04 and 2004/05, respectively. As well, the maximum pension limit for defined benefit registered pension plans will be frozen at its current level of $1,722 per year of service through 2004/05. This is a de facto increase in tax payable. This change in policy with respect to RRSP contribution limits run counter to the White Paper released in 1983 (The Tax Treatment of Retirement Savings), where the House of Commons Special Committee on Pension Reform recommended that the limits on contributions to tax-assisted retirement savings plans be amended so that the same comprehensive limit would apply regardless of the retirement savings vehicle or combination of vehicles used. In short, the principle of "pension parity" was endorsed. Furthermore, in three separate papers released by the federal government, the principle of pension parity would have been achieved between money-purchase (MP) plans and defined benefit (DB) plans had RRSP contribution limits risen to $15,500 in 1988. In effect, the federal government postponed the scheduling of the $15,500 limit for seven years - that is, achieving the goal of pension parity was delayed until 1995. The CMA has been frustrated that ten years of careful and deliberate planning by the federal government around pension reform has not come to fruition, in fact, if the current policy remains in place it will have taken more than 17 years to implement (from 1988 to 2005). As a consequence, the current policy of freezing RRSP contribution limits and RPP limits without making adjustments to RRSP limits to achieve pension parity serves to maintain inequities between the two plans until 2004/2005. This is patently unfair for self-employed Canadians who rely on RRSPs as their sole vehicle for retirement planning. The CMA recommends: 10. That the dollar limit of RRSPs at $13,500 increase to $14,500 and $15,500 in 1999/00 and 2000/01, respectively. Subsequently, dollar limits increase at the growth in the yearly maximum pensionable earnings (YMPE). Under current federal tax legislation, 20% of the cost of an RRSP, RRIF or Registered Pension Plan's investments can be made in "foreign property." The rest is invested in "Canadian" investments. If the 20% limit is exceeded at the end of a month, the RRSP pays a penalty of 1% of the amount of the excess. In its December 1998 pre-budget consultation , the Standing Committee on Finance made the following recommendation (p. 66): "...that the 20% Foreign Property Rule be increased in 2% increments to 30% over a five year period. This diversification will allow Canadians to achieve higher returns on their retirement savings and reduce their exposure to risk, which will benefit all Canadians." A recent study by Ernst & Young, demonstrated that Canadian investors would have experienced substantially better investment returns over the past 20 years with higher foreign content limits. As well, the Conference Board of Canada concluded that lifting the foreign content limit to 30% would have a neutral effect on Canada's economy. The CMA and believes there is sufficient evidence to indicate that Canadians would benefit from an increase in the Foreign Property Rule, from 20% to 30%. The CMA therefore recommends: 11. That the 20% foreign property rule for deferred income plans such as Registered Retirement Savings Plans and Registered Retirement Income Funds be increased in 2% annual increments to 30% over a five year period, effective 1999. As part of the process to revitalize the economy, greater expectations are being placed on the private sector to create employment opportunities. While this suggests that there is a need to re-examine the current balance between public and private sector job creation, the government, nonetheless has an important role to play in fostering an environment that will stimulate job creation. In this context, the CMA, strongly believes that current RRSPs should be viewed as an asset rather than a liability. With proper mechanisms in place, the RRSP pool of capital funds can play an integral role in bringing together venture capital and small and medium-size businesses and entrepreneurs. In this regard, the CMA would encourage the government to explore current regulatory impediments to bring together capital with small and medium-size businesses. The CMA, recommends the following: 12. That the federal government foster economic development by treating RRSP contributions as assets rather than liabilities and by exploring the regulatory changes necessary to ensure increased access to such funds by small and medium-size businesses. Non-Taxable Health Benefits In last year's federal budget, the CMA was encouraged by the federal government's announcement to extend the deductibility of health and dental premiums through private health services plans (PHSP) for the unincorporated self-employed. The CMA believes that this initiative is a step in the right direction when it comes to improving tax fairness. As well, the federal government is to be commended for its decision to maintain the non-taxable status of supplementary health benefits. This decision is an example of the federal government's serving to strengthen the relationship between good tax policy and good health care policy in Canada. If supplementary health benefits were to become taxable, it is likely that young healthy people would opt for cash compensation instead of paying taxes on benefits they do not receive. These Canadians would become uninsured for supplementary health services. It follows that employer-paid premiums may increase as a result of this exodus in order to offset the additional costs of maintaining benefit levels due to diminishing ability to achieve risk pooling. As well, in terms of fairness it would seem unfair to "penalize" 70% of Canadians by taxing supplementary health benefits to put them on an equal basis with the remaining 30%. It would be preferable to develop incentives to allow the remaining 30% of Canadians to achieve similar benefits attributable to the tax status of supplementary health benefits. The CMA therefore recommends: 13. That the current federal government policy with respect to non-taxable health benefits be maintained. Health Research in Canada At the same time that our health care system has been de-stabilized, so too has the role of health research in Canada. In response, the federal government announced in its 1998 budget that it would increase funding levels for the Medical Research Council of Canada (MRC) from $237.5 million (1997/98), to $267 million (1998/99), $270 million (1999/00) and $276 million (2000/01). While this is a step in the right direction, the $134 million over three years represents for the most part a restoration of previously cut funding - only $18 million would be considered new money. Furthermore, when compared against other countries, Canada does not fare well. Of the G-7 nations for which recent data were available, Canada ranks last in per capita spending for health research. France, Japan, the United States and the United Kingdom spend between 1.5 and 3.5 times more per capita than Canada. 20 In what is increasingly a knowledge-based world, the federal government must be reminded that a sustained and substantial commitment to health research in required. The CMA therefore recommends: 14. That the federal government establish a national target (either in per capita terms or as a proportion of total health spending), and an implementation plan for health research and development spending including the full spectrum of basic biomedical to applied health services research, with the objective of improving Canada's position relative to other G-7 countries. Brain Drain and Tuition Deregulation In June, 1998, the CMA met with the Standing Committee on Finance to discuss the issue of "brain drain" in Canada. At that time, the CMA expressed its serious concerns over the recent tuition deregulation policy in Ontario and its subsequent impact on the career choices of new medical graduates. Specifically, the CMA officially decries tuition deregulation in Canadian medical schools and believes that governments should increase funding to medical schools to alleviate the pressures driving tuition increases; that any tuition increase be regulated and reasonable; and that financial support systems be in place in advance of, or concomitantly with, any tuition increase. These measures will foster the education and training of a diverse population of health care givers, and will support culturally and socially sensitive health care for all Canadians. As new physicians graduate with substantial and growing debt loads, they will be attracted to more lucrative positions in order to repay their debts - particularly positions in the United States. As a consequence, tuition deregulation policies will have a direct and detrimental impact when it comes to retaining our best and brightest young physicians in Canada. The CMA is currently in the process of developing a position paper on this issue. VI. SUMMARY OF RECOMMENDATIONS With the future of access to quality health care for all Canadians at stake, the CMA strongly believes that the federal government must demonstrate that it is prepared to re-establish its leadership role and re-invest in the health care system that all Canadians cherish and closely identify with. The CMA therefore makes the following recommendations to the Standing Committee on Finance in its deliberations. Stabilize the System 1. That in order to ensure greater public accountability and visibility, the federal government introduce a health-specific portion of the cash transfers to the provinces and territories. 2. That in addition to the current level of federal cash transferred to the provinces and territories for health care, the federal government restore at a minimum $2.5 billion in cash on an annual basis to be earmarked for health care, effective April 1, 1999. 3. That beginning April 1, 2000, the federal government fully index the total cash entitlement allocated to health care through the use of a combination of factors that would take into account the changing needs of Canadians based on population growth, aging, epidemiology, current knowledge and new technologies, and economic growth. Looking to the Future 4. That the federal government establish a one-time Health System Renewal Fund in the amount of $3 billion to be disbursed over the three-year period beginning April 1, 1999, for the following areas of need: a. Acute care infrastructure support: assist health institutions to enhance the delivery of a continuum of quality patient care by improving their access to necessary services including new technologies, and modernizing health facilities and upgrading infrastructure. b. Community care infrastructure support: to enable communities to develop services to support the delivery of home and community-based care in the wake of the rapid downsizing of the institutional sector. c. Support Canadians at risk: to provide access to pharmacotherapy and medical devices to those in need, who are not adequately covered by public or private insurance (pending the development of a long-term solution). d. Health information technology: to allow the provinces and territories to put in place the transparent, clinically driven health information infrastructure necessary to support the adequate and appropriate management of access and delivery of health care. In implementing the health information infrastructure scrupulous attention must be paid to privacy and confidentiality issues. Tobacco Taxation Policy 5. That the federal government follow a comprehensive integrated tobacco tax policy: a. To implement selective stepwise tobacco tax increases to achieve the following objectives: (1) reduce tobacco consumption, (2) minimize interprovincial/territorial smuggling of tobacco products, and (3) minimize international smuggling of tobacco products; b. To apply the export tax on tobacco products and remove the exemption available on tobacco shipments in accordance with each manufacturers historic levels; and c. To enter into discussions with the US federal government to explore options regarding tobacco tax policy, bringing US tobacco tax levels in line with or near Canadian levels, in order to minimize international smuggling. Support for Tobacco Control Programs 6. That the federal government commit stable funding for a comprehensive tobacco control strategy; this strategy should include programs aimed at prevention and cessation of tobacco use and protection of the public from tobacco's harmful effects. 7. That the federal government clarify its plans for the distribution of the Tobacco Control Initiative funds, and ensure that the funds are invested in evidence-based tobacco control projects and programs. 8. That the federal government support the use of tobacco tax revenues for the purpose of developing and implementing tobacco control programs. Goods and Services Tax (GST) 9. That health care services funded by the provinces and territories be zero-rated. Registered Retirement Savings Plans (RRSPs) 10. That the dollar limit of RRSPs at $13,500 increase to $14,500 and $15,500 in 1999/00 and 2000/01, respectively. Subsequently, dollar limits increase at the growth in the yearly maximum pensionable earnings (YMPE). 11. That the 20% foreign property rule for deferred income plans such as Registered Retirement Savings Plans and Registered Retirement Income Funds be increased in 2% annual increments to 30% over a five year period, effective 1999. 12. That the federal government foster economic development by treating RRSP contributions as assets rather than liabilities and by exploring the regulatory changes necessary to ensure increased access to such funds by small and medium-size businesses. Non-Taxable Health Benefits 13. That the current federal government policy with respect to non-taxable health benefits be maintained. Health Research in Canada 14. That the federal government establish a national target (either in per capita terms or as a proportion of total health spending), and an implementation plan for health research and development spending including the full spectrum of basic biomedical to applied health services research, with the objective of improving Canada's position relative to other G-7 countries. 1 Angus Reid, February, 1998. 2 Angus Reid, February, 1998. 3 Canadian Medical Association. January 1998 Physician Resource Questionnaire. 4 39th Annual Premiers’ Conference, Saskatoon Saskatchewan, August 5-7, 1998. Press Communique. 5 Rock A. Speech to the Canadian Medical Association’s 130th General Council Victoria, Aug 20, 1997. 6 The Budget Plan, 1998. Building Canada for the 21st Century, February 24, 1998. 7 The tax point transfer refers to the dollar value of ?tax points? that were negotiated with the federal government and the provinces. Specifically, where the federal government reduced personal and corporate income tax rates, the ?tax room? that was created was then occupied by the provinces. This is an important point because even though the federal government collects taxes on behalf of the provinces (with the exception of Quebec), it is argued that the value of the tax point transfer belongs to the provinces and is not considered as a true “federal contribution”. The last time this issue was negotiated was in 1965. 8 Thomson A. Federal Support for Health Care - A Background Paper. Health Action Lobby, Ottawa, 1991. 9 Thomson, A., Diminishing Expectations - Implications of the CHST, [report] Canadian Medical Association, Ottawa. May, 1996. 10 Federal Department of Finance. 11 Thomson A. Federal Support for Health Care - A Background Paper. Health Action Lobby, Ottawa, 1991. 12 Currently, the CHST cash entitlement has an escalator attached to it, however, it is scheduled to begin in 2000/01, 2001/02, 2002/03, at a rate of GDP- 2% (year 1), GDP-1.5% (year 2), and GDP-1% (year 3). 13 Health Canada, Economic Costs Due to Smoking (Information Sheet). Ottawa: Health Canada, November 1996. 14 Health Canada, Economic Costs Due to Smoking (Information Sheet). Ottawa: Health Canada, November 1996. 15 Health Canada, Youth Smoking Behaviour and Attitudes (Information Sheet). Ottawa: Health Canada, November 1996. 16 Liberal Party, Securing Our Future, Liberal Party of Canada, Ottawa, 1997. p. 77. 17 In California, between 1988 and 1993, when the state was carrying on an aggressive public anti-smoking campaign, tobacco consumption declined by over 25%. Goldman LK, Glantz SA. Evaluation of Antismoking Advertising Campaigns. JAMA 1988; 279: 772-777. 18 Report of the Standing Committee on Finance. December, 1997. 19 Hall Emmett (Special Commissioner). Canada?s National-Provincial Program for the 1980s, p. 32. 20 Organization for Economic Cooperation and Development. OECD Health Data 97. Paris: OECD, 1997.
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A new vision for Canada: family practice— the patient’s medical home 2019

https://policybase.cma.ca/en/permalink/policy14024
Date
2019-03-02
Topics
Physician practice/ compensation/ forms
Health systems, system funding and performance
  1 document  
Policy Type
Policy endorsement
Date
2019-03-02
Topics
Physician practice/ compensation/ forms
Health systems, system funding and performance
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The evolving needs of patients and their communities place ever-changing demands on the health care system to maintain and improve the quality of services provided. Changing population demographics, increasing complexity, and new technology make for a dynamic system. Family physicians are at the heart of the health care system, acting as the first point of contact and a reliable medical resource to the communities they serve, caring for patients and supporting them throughout all interactions with the health care system. The Patient’s Medical Home (PMH) is a vision that emphasizes the role of the family practice and family physicians in providing high-quality, compassionate, and timely care. The success of a PMH depends on collaboration and teamwork—from the patient’s participation in their care to interprofessional and intraprofessional care providers working together, to policy-makers who can offer infrastructure support and funding. PMH 2019 was created with invaluable feedback from a broad range of stakeholders reflective of such a joint approach. Its goal is to make the PMH a reality for patients and providers across Canada. In 2011 the College of Family Physicians of Canada (CFPC) released A Vision for Canada: Family Practice - The Patient’s Medical Home.1 It outlined a vision for the future of primary care by transforming the health care system to better meet the needs of everyone living in Canada. The vision outlined the 10 pillars that make up the PMH and provided detailed recommendations to assist family physicians and their teams, as well as policy-makers and health care system administrators, to implement this new model across the country. WHY A REVISED PMH? Since 2011 many principles of the PMH vision have been embraced in primary care reforms. New models have been introduced across Canada (see Progress on the PMH to Date). To better reflect current realties, meet the evolving needs of family physicians and their teams, and support continued implementation of the PMH, the CFPC has developed this revised edition of the vision. It reflects evolving realities of primary care in Canada, including the rapid adoption of electronic medical records (EMRs)2,3 and a shift toward interprofessional practice structures.2 While progress has been made, there is still work to be done to fully achieve the PMH vision. In 2016 almost 75 per cent of Canadians rated the quality of care received from their family physicians as good or excellent.4 In 2017 a CFPC survey found that 79 per cent of respondents rate the care they receive from their family doctor as excellent or good.5 However, at the same time 55 per cent of Canadians also believed that the overall health care system still required fundamental changes.4 In addition, Canada continues to perform below the international average on certain aspects of patient-centred care; for example, same- or next-day access to appointments. While most Canadians (84.7 per cent) have a regular doctor or place of care, they generally report longer wait times for medical care than adults in comparable countries.4 PMH 2019 addresses these concerns and proposes solutions that can help further improve the primary care system for all. Although the specific components of the revised PMH have been updated (see What is the Patient’s Medical Home?), the core principles remain the same. PMH 2019 focuses on providing high-quality, patient-centred, and comprehensive care to patients and their families during their lifetime. It embraces the critical role that family physicians and family practices play in the health care system, reflecting the fact that systems with strong primary health care deliver better health outcomes, enhance efficiency, and improve quality of care.6 PMH 2019 recognizes that a patient will not be able to see their personal family physician at every visit, but can rely on the PMH’s qualified team of health professionals to provide the most appropriate care responding to patient needs with continuous support and leadership from family physicians. PMH 2019 highlights the central importance of community adaptiveness and social accountability in primary care with a new pillar. The importance of being responsive to community needs through engagement, and ensuring the provision of equitable, culturally safe, antioppressive practise that seeks to assess and intervene into social determinants of health (SDoH), is now more clearly featured. 2 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 PURPOSE OF THIS DOCUMENT PMH 2019 outlines 10 revised pillars that make up a PMH. Key attributes are defined and explained for each pillar. Supporting research is provided to demonstrate the evidence base for each attribute. This document is intended to support family physicians currently working in a PMH to better align their practice with the PMH pillars, or assist those practices looking to transition to a PMH. Furthermore, this document can guide governments, policy-makers, other health care professionals, and patients on how to structure a primary health care system that is best-suited to meet the needs of Canadians. Many resources for the PMH have been developed and will continue to be available. These include practical Best Advice guides on a range of topics and the self-assessment tool that can help quantify a practice’s progress toward PMH alignment. Moving forward, additional materials that address the new themes identified in PMH 2019 and the tools to support physicians in the transition to PMH structures—for example the PMH Implementation Kit— will be available at patientsmedicalhome.ca. What is a Patient’s Medical Home? The PMH is a family practice defined by its patients as the place they feel most comfortable presenting and discussing their personal and family health and medical concerns. The PMH can be broken down into three themes: Foundations, Functions, and Ongoing Development (see Table 1 and Figure 1). The three Foundation pillars are the supporting structures that facilitate the care provided by the PMH. All three aspects are required for the successful implementation and sustainability of a PMH. The Functions are areas central to the operation of a family practice and consist of the five core PMH pillars. These principles govern the type of care provided by the PMH practices to ensure it is effective and efficient for meeting the needs of the patients, families, and communities they serve. The pillars in this section reflect the Four Principles of Family Medicine,7 which underlines the important place they take in the overall PMH 2019. The pillars in Ongoing Development are essential to advancing the PMH vision. These areas make it possible for physicians to provide the best possible care for patients in various settings. Applying these pillars, the PMH will thrive through practising quality improvement (QI) principles to achieve the results necessary to meet the needs of their patients, their communities, and the broader health care community, now and in the future. The PMH is a vision to which every practice can aspire. Many practices across Canada have already begun transitioning to a PMH, thanks to the dedication and leadership of family physicians and their teams across Table 1. 10 Pillars of the revised PMH vision THEME PILLAR Foundations 1. Administration and Funding 2. Appropriate Infrastructure 3. Connected Care Functions 4. Accessible Care 5. Community Adaptiveness and Social Accountability 6. Comprehensive Team-Based Care with Family Physician Leadership 7. Continuity of Care 8. Patient- and Family-Partnered Care Ongoing Development 9. Measurement, Continuous Quality Improvement, and Research 10. Training, Education, and Continuing Professional Development A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 3 the country. This vision is a resource for these practices as they engage in ongoing practice assessment and QI initiatives. It can also assist other stakeholders, including government planners, policy-makers, and funders to better understand what defines an effective patientcentred family practice. By involving patients in all stages of the development, evaluation, and continuous quality improvement (CQI) activities of the practice, the PMH can contribute significantly to furthering the goals of transformation to a patient-centred health care system.8 What the Patient’s Medical Home is Not While it is important to understand what the PMH aspires to be, it is also important to highlight that it is not a one-size-fits-all solution. Solo practices in rural or remote settings or large group practices serving inner-city populations can align with PMH principles by incorporating strategies that match the realities of their unique settings. In fact, social accountability and community adaptiveness is an important new addition to the revised PMH vision to account for the need of every family practice to adapt and respond to the needs of their patients and communities. What works for one practice will not work for all. The PMH vision does not require that all practices be relocated or re-engineered, or that significant financial investments be made by physicians or other health care professionals. Instead, system level support and involvement is required to achieve the vision. The pillars and attributes listed in this document are signposts along the way to reform that aids practices on their journey. It is important to note that this vision is not intended to undermine or change any exciting initiatives involving family practice currently under way across Canada (several of which already embrace and incorporate the medical home concept; see Progress on the PMH to Date). Rather, it is meant to build on and strengthen these efforts. The more that health care initiatives meet PMH objectives, the more likely it is that the overall goals of creating a patient-centred health care system throughout Canada will be realized. Figure 1. The Patient’s Medical Home 4 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 PROGRESS ON THE PMH TO DATE Since the release of the original PMH vision document, system-level change has occurred in almost all jurisdictions in Canada. More specifically, PMH-type practices are gaining traction in various provinces and currently exist in various stages of development. The CFPC took a snapshot of PMH uptake in all provinces in the PMH Provincial Report Card, published in early 2019.9 That report contains grades and descriptions for progress in each province up to late 2018, which acts as a useful gauge for where the vision stands at the time of publication of this new edition. Alberta In Alberta, primary care networks (PCNs)10 were established to link groups of family physicians and other health care professionals. Within PCNs clinicians work together to provide care specific to community and population health care needs. Currently, there are 42 PCNs operating in Alberta, comprised of more than 3,700 (or 80 per cent of) family physicians, and over 1,100 other health care practitioners. PCNs provide care to close to 3.6 million Albertans, 80 per cent of the population in Alberta. Primary care clinics are being asked to collect data for Third Next Available (TNA) appointments to improve access for Albertans.11 TNA measures the delay patients experience in accessing their providers for a scheduled appointment. TNA is considered a more accurate system measure of access than the “next available” appointment, since the next or second next available appointment may have become available due to a cancellation or other event that is not predictable or reliable. British Columbia The British Columbia government’s new primary care strategy focuses on expanding access to team-based care through PCNs.12 PCNs are in the initial stages of adoption and when fully rolled out will provide a systemlevel change—working to connect various providers to improve access to, and quality of, care. They will allow patients to access the full range of health care options, streamline referrals, and provide better support to family physicians, nurse practitioners, and other primary health care providers. The General Practice Services Committee13 (GPSC; a partnership of the provincial government and Doctors of BC) specifically references and builds on the PMH concept in their vision for the future of British Columbia’s health care system. Manitoba In Manitoba, PMHs are Home Clinics and PCNs are My Health Teams. My Health Teams bring together teams of health care providers (physicians, nurses, nurse practitioners, etc.) to collaborate in providing highquality care based on community and patient needs.14 As suggested by the name of the initiative itself, the goal is to improve health care by developing teams of health care professionals who will work together to address primary health care needs of Manitobans.15 The first two My Health Teams were established in 2014, and there are now 15 across the province.16 The Manitoba Centre for Health Policy did some work assessing the impact of My Health Teams. New Brunswick In 2017 the government announced the New Brunswick Family Plan, which placed a specific emphasis on access to team-based care. To achieve this goal, the provincial government and the New Brunswick Medical Society established a voluntary program called Family Medicine New Brunswick. In this team-based model, physicians have their own rosters of patients, but also provide a service to all patients of doctors on their team.17 It was announced in 2018 that 25 family physicians will be added to the provincial health care system to ensure more New Brunswick residents have access to a primary care physician and to help reduce wait times.18 Newfoundland and Labrador In 2015 the Newfoundland and Labrador government released Healthy People, Healthy Families, Healthy Communities: A primary health care framework for Newfoundland and Labrador. The strategy’s goals include ensuring “timely access to comprehensive, person-focused primary health care services and supports,” and “primary health care reform should work to establish teams of providers that facilitate access to a range of health and social services tailored to meet A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 5 the needs of the communities they serve.”19 Both goals align with the general PMH principles. Primary health care teams have been introduced in St. John’s and are planned for Corner Brook and Burin.20 Many initiatives under way as a part of this strategy are in the early stages of development. Continuing in the direction laid out will move Newfoundland and Labrador closer to integrating the PMH vision in their delivery of primary health care. Northwest Territories The recent creation of a single Territorial Health Authority has enabled work on primary care improvements across the Northwest Territories. In August 2018 the NWT Health and Social Services Leadership Council unanimously voted in favour of a resolution supporting redesigning the health care system toward a team- and relationshipbased approach, consistent with PMH values. In several regions, contracted physicians are already assigned to regularly visit remote communities and work closely with local staff to provide continuity of remote support between visits. Planning is under way for implementing PMH-based multidisciplinary care teams in several larger regional centres, with enhanced continuity and access to physician and nursing staff as well as co-located mental health support and other health care disciplines. This work is facilitated by a territory-wide EMR and increased use of telehealth and other modalities of virtual care. Nova Scotia The 2017 Strengthening the Primary Health Care System in Nova Scotia report recommended establishing “health homes,” consisting of interprofessional, collaborative family practice teams. The model is based on a population health approach that focuses on wellness and chronic disease management/prevention and incorporates comprehensive, team-based care. There are approximately 50 collaborative family practice21 teams and a number of primary care teams across Nova Scotia. Ontario The model most aligned with the PMH framework is the family health team (FHT).22 FHTs are comprised of family physicians, nurse practitioners, and other health care professionals, and provide community-centred primary care programs and services. The 184 FHTs collectively serve over three million enrolled Ontarians. Based on the results of a five-year evaluation undertaken by the Conference Board of Canada in 2014, FHTs have achieved improvements at the organizational and service-delivery levels.23 Much progress has also been made through patient enrolment models. Patient enrolment, or rostering, is a process in which patients are formally registered with a primary care provider or team. Patient enrolment facilitates accountability by defining the population for which the provider is responsible. Formal patient enrolment with a primary care physician lays the foundation for a proactive approach to chronic disease management and preventive care.24 Studies show that the models have achieved some degree of success in enhancing health system efficiency in Ontario through the reducing use of emergency departments for non-emergent care.25 Prince Edward Island In Prince Edward Island, primary care is provided through five PCNs.26 Each network consists of a team that includes family physicians, nurse practitioners, registered nurses, diabetes educators, licensed practical nurses, clerical staff, and in some cases dietitians and mental health workers. They offer a broad range of health services including diagnosis, treatment, education, disease prevention, and screening. Quebec The Groupes de médecine de famille27 (GMF) is the team-based care model in Quebec most closely aligned with the PMH. GMF ranking (obligations, financial, and professional supports) is based on weighted patient rostering. One GMF may serve from 6,000 to more than 30,000 patients. The resource allocation (financial and health care professionals) depends on the weighted patient target under which the GMF falls. In a GMF, each doctor takes care of their own registered patients, but all physicians in the GMF can access medical records of all patients. GMFs provide team-based care with physicians, nurses, social workers, and other health care professionals working collaboratively to provide appropriate health care based on community needs. Saskatchewan Saskatchewan has made investments in a Connected Care Strategy, which focuses on a team approach to care that includes the patient and family, and extends from the community to the hospital and back again. It is about connecting teams and providing seamless care for people who have multiple, ongoing health care needs, with a particular focus on care in the community.28 6 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 FOUNDATIONS PMH foundations are the underlying, supporting structures that enable a practice to exist, and facilitate providing each PMH function. Without a strong foundation, the PMH cannot successfully provide high-quality, patient-centred care. The foundations are Administration and Funding (includes financial and governmental support and strong governance, leadership, and management), Appropriate Infrastructure (includes physical space, human resources, and electronic records and other digital supports), and Connected Care (practice integration with other care settings enabled by health IT). ADMINISTRATION & FUNDING PAGE 7 APPROPRIATE INFRASTRUCTURE PAGE 9 CONNECTED CARE PAGE 12 Patients as partners in health care Patient-centred or patient-partnered? Understanding and acknowledging patients as full partners in their own care is a small but powerful change in terminology. Considering and respecting patients as partners allows health care providers to better recognize and include the skills and experience each patient brings to the table. Patient perspectives and feedback can be more inclusively incorporated in the QI processes in place to improve care delivery. Understanding the nature of patient partnerships can help physicians better establish trusting relationships with those in their care.29 Pillar 1: Administration and Funding Practice governance and management Effective practice governance is essential to ensuring an integrated process of planning, coordinating, implementing, and evaluating.30 Every PMH should clearly define its governance and administrative structure and functions, and identify staff responsible for each function. While the complexity of these systems varies depending on the practice size, the number of members on the health care professional team, and the needs of the population being served, every PMH should have an organizational plan in place that helps guide the practice operations. From a governance perspective, policies and procedures should be developed and regularly reviewed and updated, especially in larger practices. These policies and procedures will offer guidance in areas such as organization of clinical services, appointment and booking systems, information management, facilities, equipment and supplies, human resources, defining PMH team members’ clinical and administrative/management roles and responsibilities, budget and finances, legal and liability issues, patient and provider safety, and CQI. In some cases, standardized defaults for these may be available based on the province of practice and existing structures supporting interprofessional teams. Structures and systems need to be in place that allow for compensated time for providers to undertake and actively participate in CQI activities. This needs to be scheduled and remunerated so that it is seen as being as important and critical as clinical time. To ensure that all PMH team members have the capacity to take on their required roles, leadership development programs should be offered. Enabling physicians to engage in this necessary professional development requires sufficient government funding to cover training A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 7 Practices need staff and financial support, advocacy, governance, leadership, and management in order to function as part of the community and deliver exceptional care. 1.1 Governance, administrative, and management roles and responsibilities are clearly defined and supported in each PMH. 1.2 Sufficient system funding is available to support PMHs, including the clinical, teaching, research, and administrative roles of all members of PMH teams. 1.3 Blended remuneration models that best support team-based, patient-partnered care in a PMH should be considered to incentivize the desired approach. 1.4 Future federal/provincial/territorial health care funding agreements provide appropriate funding mechanisms that support PMH priorities, including preventive care, population health, electronic records, community-based care, and access to medications, social services, and appropriate specialist and acute care. 8 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 costs and financial support to ensure lost income is not a barrier (see Pillar 10: Training, Education, and Continuing Professional Development). External supports Every family practice in Canada can become a PMH and an optimal learning environment will only be achievable with the participation and support of all stakeholders throughout the health care system. This includes family physicians; other health professionals who will play critical roles on PMH teams; federal, provincial, and territorial governments; academic training programs; governing bodies for physicians and allied health care providers; and most importantly, the people of Canada themselves, individually and in their communities—the recipients of care provided by the PMH. To achieve their objectives, PMHs need the support of governments across Canada through the provision of adequate funding and other resources. Given that the structure, composition, and organization of each PMH will differ based on community and population needs, funding must be flexible. More specifically, PMH practices will differ in terms of the staff they require (clinical, administrative, etc.). Funding must be available to ensure that PMH practices can determine optimal staffing levels and needs, to best meet community needs. The health care system must also ensure that all health care professionals on the PMH team have appropriate liability protection, and that adequate resources are provided to ensure that each PMH practice can provide an optimal setting for teaching students and residents and for conducting practice-based research. These characteristics are also reflected in the Four Principles of Family Medicine, reinforcing the centrality of family medicine to the delivery of care. Experience through new models of family practice, such as patient enrolment models (PEMs) in Ontario, suggests that blended funding models are emerging as the preferred approach to paying family physicians.31–33 These models are best suited to incentivizing teambased, patient-partnered care. The current fee-forservice (FFS) model incentivizes a series of short consultations that might be insufficient to address all of the patient’s needs, while blended remuneration provides for groups of physicians to work together to provide comprehensive care through office hours and after-hours care for their rostered patients. Capitation allows for more in-depth consultations depending on population need, rather than a volume-based model. Research has also found that blended capitation models can lead to small improvements in processes of care (e.g., meeting preventive care quality targets)34 and can be especially useful for supporting patients in managing and preventing chronic diseases.35 The CFPC advocates for governments to implement blended payment mechanisms across the country to achieve better health outcomes (see the Best Advice guide: Physician Remuneration in a Patient’s Medical Home36 for more information). It is important to ensure that additional practice activities such as leadership development, QI, and teaching are supported through dedicated funding or protected time intended specifically for these activities and are not seen as financially disadvantageous. The sustainability of Canada’s health care system depends on a foundation of strong primary care and family practice.37 Indeed, “high-performing primary care is widely recognized as the foundation of an effective and efficient health care system.”38 Future funding for health care—in particular from the federal government through federal, provincial, and territorial agreements—must be sustained through appropriate and well-designed funding agreements that incentivize PMH visions of primary care; other medical home priorities including preventive care, population health, EMRs; communitybased care; along with access to medications, social services, and appropriate specialist and acute care. For the PMH vision to be successful and a part of the future of family practice care in Canada, we need the commitment and support of everyone in the Canadian health care system, including decision makers and patients. By working with all levels of government and with patients, we can improve the health care system so that everyone in Canada has access to patient-centred, comprehensive, team-based care. A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 9 Pillar 2: Appropriate Infrastructure The shift in Canada from paper-based patient records to EMRs is reaching saturation. As delivery of care evolves with greater integration of technology, potential applications to improve patient care expand.39 The proportion of family physicians using EMRs has grown from 16 per cent in 2004 to 85 per cent in 2017.40 As it becomes ubiquitous in health care delivery, information technology can be of great benefit in sharing information with patients, facilitating adherence to treatment plans and medication regimes, and using health information technology (HIT) in new and innovative methods of care. However, HIT also poses new risks and can create new barriers. Providers should be mindful of how the application about new technologies may hinder good quality patient care. When properly implemented, EMRs can help track data over time, identify patients who are due for preventive visits, better monitor patient baseline parameters (such as vaccinations and blood pressure readings), and improve overall quality of care in a practice.1 EMRs can enhance the capacity of every practice to store and recall medical information on each patient and on the practice population as a whole. They can facilitate sharing information needed for referrals and consultations. The information in an electronic record can be used for teaching, carrying out practice-based research, and evaluating the effectiveness of the practice change as part of a commitment to CQI.1 EMRs and HIT actively support other pillars in the PMH vision. In addition to storing and sharing information, the biggest benefit of this technology is the ability to collect data for practice performance and health outcomes of patients served by family practices.41 The data allow practices to measure progress through CQI goals. Larger-scale collection allows for the aggregation of anonymized data sets and measuring performance beyond the practice level.41 Strict privacy regulations ensure that patient data remain secure and confidential. Overall, QI and research benefit patients by guiding more appropriate and efficient care, which forms the basis of another key pillar of Physical space, staffing, electronic records and other digital supports, equipment, and virtual networks facilitate the delivery of timely, accessible, and comprehensive care. 2.1 All PMHs use EMRs in their practices and are able to access supports to maintain their EMR systems. 2.2 EMR products intended for use in PMHs are identified and approved by a centralized process that includes family physicians and other health care professionals. Practices are able to select an EMR product from a list of regionally approved vendors. 2.3 EMRs approved for PMHs will include appropriate standards for managing patient care in a primary care setting; e-prescribing capacity; clinical decision support programs; e-referral and consultation tools; e-scheduling tools that support advanced access; and systems that support data analytics, teaching, research, evaluation, and CQI. 2.4 Electronic records used in a PMH are interconnected, user-friendly, and interoperable. 2.5 Co-located PMH practices are in physical spaces that are accessible and set up to support collaboration and interaction between team members. 2.6 A PMH has the appropriate staff to provide timely access (e.g., having physician assistants and/or registered nurses to meet PMH goals). 2.7 A PMH has technology to enable alternative forms of care, such as virtual care/telecare. 2.8 Sufficient system funding and resources are provided to ensure that teaching faculty and facility requirements will be met by every PMH teaching site. the PMH vision— Pillar 9: Measurement, Continuous Quality Improvement, and Research. As EMR use becomes common, issues shift from rollout to optimization in the practice. Ideally, EMRs must be adequately supported financially and use a universal terminology to allow for standardized data management, and be interoperable with other electronic health records relevant to patient care.1 Training and ongoing technical support for effective use of technology must also be available. Digital information sources, especially in the sensitive areas of patient information and care planning, require a higher level of technical support to maintain faith in their use and application across stakeholder groups. A comprehensive, systematic analysis of peer-reviewed and grey literature found that cost sharing or financial sponsorship from governments is required to support the high cost of EMR adoption and maintenance. Governments in several European countries equip all primary care practices with interoperable, ambulatory care-focused electronic health records (EHRs) that allow information to flow across settings to enhance the continuity and coordination of care.1 Ensuring that government supports enable adoption, maintenance and effective use, coordination, and interoperability of electronic tools is crucial for meaningful use of this technology. A PMH will also use technology for alternative forms of care. Virtual care is clinical interactions that do not require patients and providers to be in the same room at the same time.42 Virtual visits will be financially compensated by provincial health plans. Consultations may be asynchronous, where patients answer structured clinical questions online and then receive care from a physician at a later time (e-visits), or synchronous, where patients interact with physicians in real time via telephone (teleconsultations), videoconference (virtual visits), or text.43 Virtual care increases accessibility for those living in rural and remote areas, but also in urban areas where some patients do not have a regular primary care physician or cannot access their physician for in-person appointments within a time frame that meets their current needs.43 Virtual care can also be an alternative solution for patients living in long-term care facilities and/or with mobility issues.43 Strong communication between team members allows PMH practices to function on a virtual basis when the health care professionals are not stationed in the same physical space. It is important to recognize when colocation is not feasible and maintain effective information flow in these situations, which may be especially relevant in rural and remote areas. Practices should ensure the electronic records they use are set up to support collaboration and interaction between all members of the team as much as possible, which includes all health care providers within the PMH as well as the patient’s circle of support. For example, ensuring that when patients see someone other than their most responsible provider is logged into the system and is easy to review to maintain the continuity of care. This becomes complex in situations where providers are not co-located, and further system level supports up to the level of more interoperable and universal electronic records is a prerequisite for full application of this principle. Appropriate infrastructure in a PMH is not just about technology—it includes efficient, effective, and ergonomically well-designed reception, administration, and clinical areas in the office. This is of significant benefit to staff and patients alike.44 Having a shared physical and/or virtual space where multiple team members can meet to build relationships and trust, and communicate with each other regarding patient care is essential to creating a collaborative practice. Team-based care thrives when care is intentional, when planned and regular patient care meetings are incorporated into usual PMH practice, and when these steps are included in remuneration. This collaboration ensures that patients are involved in all relevant Satisfaction with virtual visits A British Columbia study found that over 93 per cent of patients indicated that their virtual visit was of high quality, and 91 per cent reported that their virtual visit was very or somewhat helpful to resolve their health issue.43 10 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 11 discussions and are receiving the best care from professionals with a comprehensive set of skills. A family practice should be physically accessible to patients and their families. This includes ensuring all public areas, washrooms, and offices are wheelchair accessible.44 An examination room should comfortably accommodate the patient and whatever appropriate companion, or health care professionals, who may be in the room at the same time. Having multi-purpose rooms also reduces or eliminates the need to wait for an appropriate room to be available. To achieve their objectives, PMHs need the support of governments across Canada through the provision of adequate funding and other resources. Research demonstrates that in the case of EMRs, key barriers to adoption by family physicians include financial and time constraints, lack of knowledgeable support personnel, lack of interoperability with hospital and pharmacy systems,45 as well as provincial/territorial EHR systems. Therefore, government must assure funding to support the PMH team in their clinical, research, and administrative responsibilities. There must also be support for core practice components such as EMRs, patient-centred practice strategies such as group visits, and electronic communications between patients and health professionals (see Pillar 1: Administration and Funding). EMRs should help improve the delivery of care in community-based practices by enhancing productivity and processes. They are not intended to reduce time with patients, nor should they cause physician burnout or have a negative impact on physician wellness. While the structures supporting the PMH practices differs by province, it is important they cover a common set of principles enabling the base functionalities described in this document. The system must also ensure that all health professionals on the PMH team have appropriate liability protection and that adequate resources are provided so that each PMH practice can provide an optimal setting for teaching students and residents and for conducting practice-based research. Provider autonomy is critical to provider wellness: as physician leadership within the PMH is one of the key pillars, preservation of physician autonomy, while respecting the autonomy and ensuring the accountability of both patients and other health care professionals, must be addressed. Figure 2. The Patient’s Medical Neighbourhood Pillar 3: Connected Care Canada Health Infoway Established in 2001, Canada Health Infoway47 is an independent, not-for-profit organization funded by the federal government. It seeks to improve health care access, moving beyond traditional in-person care models to innovative strategies that accelerate the development, adoption, and effective use of digital health solutions across Canada. Key digital health priorities include electronic records, telehomecare, virtual visits, and patient portals. Connectivity and effective communication within and across settings of care is a crucial concept of a PMH. This ensures that the care patients receive is coordinated and continuous. To achieve this, each PMH should establish, maintain, and use defined links with secondary and tertiary care providers, including local hospitals; other specialists and medical care clinics; public health units; and laboratory, diagnostic imaging, physiotherapy, mental health and addiction, rehabilitation, and other health and social services. Connected care is a priority for many health care organizations in Canada. For example, the Canadian Foundation for Healthcare Improvement (CFHI) has established a unique program that looks at improving care connections between providers through improved use of technology.41 (See the Canadian Foundation for Healthcare Improvement textbox for more information). The Canadian Nurses Association (CNA), Canadian Medical Association (CMA), and HEAL recognize that giving Canadians the best health and health care requires creating a functionally integrated health system along the full continuum of care—a system based on interprofessional collaborative teams that ensure the right provider, at the right time, in the right place, for the right care.46 Similarly, Canada Health Infoway focuses on expanding digital health across the system to improve quality of and access to care. The PMH exists within the broader patient’s medical neighbourhood (see Figure 2), with links to all other providers in the community. It is important to maintain connections with colleagues in health care as well as social support organizations within the community, as described in Pillar 5: Community Adaptiveness and Social Accountability. Through links within the neighbourhood, PMH practices work with other providers to ensure timely access for referrals/consultations and define processes for information sharing. Establishing and maintaining these links requires open and frequent communication between all those involved in patient care. 12 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 Practice integration with other care settings and services, a process enabled by integrating health information technology. 3.1 A PMH is connected with the health and social services available in the community for patient referrals. 3.2 Defined links are established between the PMH and other medical specialists, and medical care services in the local or nearest community to ensure timely referrals. 3.3 The PMH serves as a hub for collecting and sharing relevant patient information through information technology. It ensures the continuity of patient information received throughout the medical and social service settings. Ideally PMH practices act as the central hub for patient care by collecting and coordinating relevant patient information from external care providers and patients. This includes medical care and care accessed through other health and social services; for example, services received through home care programs. PMH practices should also be able to share relevant information with external providers where and when appropriate, while strictly adhering to relevant privacy regulations. This two-way flow of information ensures that all providers in the network of care have access to the most accurate and comprehensive information available, allowing them “… to spend less time looking for information and more time on what matters: treating the patient.” 49 Overall, connected care in the PMH and the health system is enabled through HIT systems. PMH practices continuously strive to work efficiently with other providers in the patient’s medical neighborhood by taking advantage of developing technologies that make links quicker to establish and easier to maintain. To use HIT systems for coordinated care, the following are required:51 Data standardization Interoperable EMR and other health information systems Real-time access to data and the ability to relay accurate information in a timely manner Reliable communication mechanisms between various health and social service providers and the PMH Privacy for patient information It is important to keep in mind that any patient information, generated during the provision of care, belongs to the patient, as outlined in the Personal Information Protection and Electronics Document Act (PIPEDA). The practice is responsible for secure and confidential storage and transfer of the information. Refer to the Data Stewardship module of the Best Advice guide: Advanced and Meaningful Use of EMRs50 for more information. Canadian Foundation for Healthcare Improvement The Canadian Foundation for Healthcare Improvement supports the RACE (Rapid Access to Consultative Expertise) and BASE eConsult services, which use telephone and web-based systems to connect patients with specialists.48 These programs have been successful and demonstrate that remote consultations can reduce wait times for accessing specialty care by enabling family physicians to more efficiently manage their patients in primary care settings. A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 13 14 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 FUNCTIONS The functions describe the heart of the PMH and the care provided by PMH practices. These are the key elements that differentiate a PMH from other forms of primary care. A PMH offers: Accessible Care; Community Adaptiveness and Social Accountability; Comprehensive Team-Based Care with Family Physician Leadership; Continuity of Care; and Patient- and Family-Partnered Care. ACCESSIBLE CARE PAGE 15 COMMUNITY ADAPTIVENESS & SOCIAL ACCOUNTABILITY PAGE 17 COMPREHENSIVE TEAM-BASED CARE WITH FAMILY PHYSICIAN LEADERSHIP PAGE 20 CONTINUITY OF CARE PAGE 23 PATIENT & FAMILY PARTNERED CARE PAGE 25 Equitable and ethical practices The CMA has identified equitable access to care as a key priority for reform in the health care system.53 Similarly, accessibility is a key component of the primary health care approach, which is advocated for by the CNA.54 Through the CNA’s Social Justice Gauge, and with the further development of the social justice initiative, the CNA maintains its position as a strong advocate for social justice and a leader in equitable and ethical practices in health care and public health.55 Pillar 4: Accessible Care A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 15 Accessible primary care is fundamental to a highperforming health care system and is considered by patients52 and other health care organizations as one of the most important characteristics of primary health care. For care to be accessible, all patients should have access to a family physician who acts as their most responsible provider and is supported by a team of qualified health professionals. Patients must be able to access medical care and treatment when needed. While most Canadians currently have a regular family doctor,4 it is important that the goal be for everyone in Canada to have access to their own family physicians. Accessible care is about more than just quick access to appointments. It does include timely access principles, but also advanced access, virtual access, and teambased approaches to care that ensure patients can be seen by the most appropriate provider when they need to be seen. Because visits occur for different reasons it is not useful to define appropriate wait times for each type of visit unlike in other areas of health care, such as surgery. Therefore, the focus in family practice should be on enhancing access to ensure patients can access care when they feel it is necessary. This is not to say that family physicians in a PMH must be on call 24/7/365, but that methods for patients to access care through the design of practice operations and scheduling should be given more attention. On the other hand, as patients are offered more choice (e.g., by phone or e-communication), they should also expect practices to establish realistic parameters for what is reasonable. Practices should communicate clearly about what kind of provider availability and response time is reasonable to expect depending on access method and availability of resources. Obtaining this understanding from a practice’s patients and striving to meet these expectations is a By adopting advanced and timely access, virtual access, and team-based approaches, accessible care ensures that patients can be seen quickly. 4.1 A PMH ensures patients have access to medical advice, and information on available care options 24 hours a day, 7 days a week, 365 days a year. 4.2 Every patient is registered with a PMH. 4.3 PMH practices offer scheduling options that ensure timely access to appropriate care. 4.4 When the patient’s personal family physician is unavailable, appointments are made with another physician, nurse, or other qualified health professional member of the PMH team. 4.5 Patients are able to participate in planning and evaluation of their medical home’s appointment booking system. 4.6 Panel sizes for providers in a PMH should be appropriate to ensure timely access to appointments and safe, high-quality care. After-hours care A Waterloo, Ontario, study found that providing after-hours clinical services reduced wait times, with services from other health care providers seen as a key for improving patient access.59 Accessible care Accessible care reduces redundancy and duplication of services (e.g., when a patient takes a later appointment and also consults another provider in the interim), improves health outcomes, leads to better patient and provider satisfaction, and reduces emergency visits.56–58 16 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 good way to maintain the patient-centred focus of the practice as described in Pillar 1: Administration and Funding. Significant shifts in providing alternative access must be supported by funding bodies. Same-day scheduling has been introduced in many PMH practices to better accommodate patient needs. Frequently referred to as doing “today’s work today,” advanced access offers the vast majority of patients the opportunity to book their appointments on the day they call regardless of the reason for the visit.60 Read more about same day scheduling in the Best Advice guide: Timely Access to Appointments in Family Practice.61 Whenever possible, patients should have clear reasons for the appointment at the time of booking. This ensures that adequate time is planned for each patient visit. If the need to address multiple problems arises, the problems can be triaged on the spot by one of the team and arrangements made to have these concerns dealt with in a timely manner either during the same visit or at another time. It is not always possible for patients to book appointments with their most responsible family physician. To ensure continuity, appointments can be made with other physicians or health care professionals in the team. The decision about who provides care in these cases is based on the patient’s needs, the availability of team members, and the scope of practice for each team member. In these cases, any relevant information from the appointment is communicated to the most responsible provider and taken into account in the long-term care of the patient. PMH practices can further meet patients’ needs through extended office hours, in which the responsibilities for coverage and care are shared by family physicians in one or more practices, as well as by increased involvement of other team members. PMH practices also provide their patients with email, after-hours telephone, and virtual services to guide them to the right place at the right time for the care they need. Appropriately directing patients to the next available appointment, or to a hospital or another emergency service, is critical to the effective management and sustainability of our health care system.62,63 A PMH can help ensure that patients are aware of where they can go to access care and health information 24 hours a day, 365 days a year by providing this information to patients in person or via other systems (website, voice mail messages, etc.). In alignment with Pillar 9: Measurement, Continuous Quality Improvement, and Research, PMH practices offer opportunities for patients to provide feedback on the accessibility of the practice. Specifically, patients should have the opportunity to evaluate and provide input for the appointment booking system. Mechanisms and supports need to be in place to ensure that practices and governing bodies can review and respond to feedback appropriately and communicate this back to patients. Determining the optimal panel size for each PMH practice is critical to ensuring accessible and safe, high-quality care.64 Establishing and incorporating recommendations from the PMH vision may enable practices to consider increasing their panel size. Actual panel size will vary depending on the number of physicians and other team members in the practice, the practice’s obligations and A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 17 Social accountability refers to the family physicians’ obligation to meet the needs of Canada’s communities.66 For health care to be socially accountable, it must be accessible by everyone and responsive to the needs of patients, communities, and the broader population.4 This obligation is embedded in the Family Medicine Professional Profile and the Four Principles of Family Medicine, highlighting that family physicians are community-adaptive, responding to the needs of their patients and communities. These principles of family medicine align well with the principles of social accountability. Family practice is relationship-based care that embraces all issues of need and endures over time and place of care. A generalist keeps the whole in mind while attending to the individual parts, the system in mind when fixing individual problems, and the end in mind when commencing the journey. Tools exist to help family physicians and other health care providers enhance their skills and training regarding social accountability and cultural safety through many professional organizations and cross-Canada resource hubs like the National Collaborating Centre of Determinants of Health67 and the National Collaborating Centre on Aboriginal Health,68 as examples. PMH practices are aware of how the SDoH influence the health of patients and communities. Family physicians are often the best-situated primary care professionals to act on Pillar 5: Community Adaptiveness and Social Accountability A PMH is accountable to its community, and meets their needs through interventions at the patient, practice, community, and policy level. 5.1 PMHs strive to assess and address the social determinants of health (e.g., income, education, housing, immigration status) as relevant for the individual, community, and policy levels. 5.2 Panel size will consider the community’s needs and patients’ safety. 5.3 PMHs use data about marginalized/at-risk populations to tailor their care, programming, and advocacy to meet unique community needs. 5.4 Family doctors in the PMH act as health advocates at the individual, community, and policy levels, using the CanMEDs–Family Medicine (CanMEDS-FM) Framework as a guide to advocacy and are supported in doing so. 5.5 Family doctors and team members within the PMH provide care that is anti-oppressive and culturally safe, seeking to mitigate the experiences of discrimination faced by many patients based on their age, gender, race, class, sexual orientation, gender identity, ability, etc. commitment to teaching and research, and the needs of the population being served (see Pillar 5: Community Adaptiveness and Social Accountability). When deciding panel size, each practice must determine how accepting more patients into the practice might impact the current population, the sustainability of the workload for physicians and other members of the PMH team, and the consequences of panel size on experience of care. Refer to the Best Advice guide: Panel Size for more information.65 issues that affect patients’ SDoH. Advocating for patients and the health care system overall is a natural part of a PMH structure. Advocacy can occur at three levels:69 Micro: In the immediate clinical environment, daily work with individual patients and predicated on the principles of caring and compassion Meso: In the local community, including the patient’s cultural community, the local community of medical providers, and the larger civic community, in which health professionals are citizens as well as practitioners Macro: In the humanitarian realm, where physicians are concerned with the welfare of their entire patient population and seek to improve human welfare through healthy public policy (such as reducing income inequality, supporting equitable and progressive taxation, and expanding the social safety net) The principles of advocacy in family practice are found in the CanMEDS–Family Medicine 201769 competency framework, under the Health Advocate role. The Best Advice guide: Social Determinants of Health70 describes how family physicians in the PMH can make advocacy a practical part of their practice. Poverty is a significant risk factor for chronic disease, mental illness, and other health conditions. Low income and other SDoH also present significant barriers to accessing care.71 To meet the needs of these patients, practices may need to extend hours, be more flexible and responsive, and spend additional time helping patients navigate and access necessary care. PMH practices consider other specific community needs when determining appropriate panel size. Demographics and health status of the patient population can influence the length and frequency of appointments needed, thereby impacting a physician’s caseload.65 For example, a PMH in a community with high rates of chronic conditions may need to reduce the panel size to provide timely and high-quality care, given that patients require more care time and resources. Similarly, a patient’s social situation may impact the time a family physician spends with them. Family physicians and team members may need to use a translator at clinical appointments, and may need to provide written resources in alternative languages, all factors affecting the time required to provide care. Enabling PMH practices to adjust panel size based on community needs requires governments to establish blended payment mechanisms. These remuneration systems ensure family physicians are adequately compensated, and are not financially disincentivized from spending the necessary time with patients (see Pillar 1: Administration and Funding, for more information). Social accountability and cultural competency Part of the response to being more socially accountable with care offered to the community resides within each and every health professional. While courses on cultural competency are now a standard part of medical education, physicians can take this learning further by seeking to reflect on, be aware of, and correct any unconscious biases that naturally forms and holds as a result of individual life experiences. Working to resolve implicit biases is a lifelong effort, but done diligently, can contribute to improving the quality of care provided,72 as well as the satisfaction of being an effective healer—of ourselves, our patients and our societies. Importance of social accountability Social accountability is a key value for health care organizations and professionals. For example, the Royal College of Physicians and Surgeons of Canada (Royal College), Resident Doctors of Canada, and the Association of Faculties of Medicine amongst others, have adopted policies that highlight the importance social accountability within their organizations and the work they do. 18 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 Family physicians and their PMH teams are situated at the nexus of individual and population health, and can engage with their patients in addressing health promotion and disease prevention in creative ways. From accompanying individual patients through teachable moments (e.g., the smoker with pneumonia ready to quit) to influencing civic policy to address homelessness, the stories entrusted to family physicians in daily practice are powerful tools for healthy change. These teams are also key providers in many important public health areas, including illness and injury prevention; health promotion; screening and managing chronic diseases; immunizations; and health surveillance. PMH practices prioritize delivering evidence-based care for illness and injury prevention and health promotion, reinforcing them at each patient visit and other counselling opportunities. PMHs and local or regional public health units should cultivate and maintain strong links with one another. Health care professionals who are part of PMH teams may take on advisory, educational, supportive, or active roles in public health initiatives, in many different occupational, educational, or recreational settings throughout the community. An effective public health system should be inextricably linked to communitybased family physicians and PMHs, recognizing and supporting them as essential to the achievement of the broader population and public health goals. While PMHs focus primarily on the care of individuals and their families, it is important for team members to understand and address the health challenges facing their practice populations and the larger community. These broader challenges represent upstream factors (SDoH) that have greater impact on the health of patients than do the efforts of individual physicians. However, the relationships embedded in individual and collective practices can be central to engaging patients and citizens in building more just and healthier communities and societies. For example, with the help of HIT, details about the needs of populations can be more easily accessed through extraction from practice EMRs, or participation in programs such as the Canadian Primary Care Sentinel Surveillance Network (CPCSSN).73 The CPCSSN networks collect health information from EMRs of participating primary care providers, extract anonymous data, and share information on chronic conditions with governments, health care providers, and researchers to help inform meaningful systems and practice change. Programs like the CPCSSN allow practices to better understand the needs of their communities and implement specific health promotion and prevention programs that can contribute to the population’s overall well-being. Initiatives like this also ensure the avoidance of data duplication, and recognise that practices do not need (or have the resources) to collect data on their own. However, these data are just a part of caring—the heart of generalism is keeping the whole in mind while attending to its parts, whether it is at the level of the whole patient, the whole family, or the whole society. To meet the needs of their diverse panel of patients, family physicians and other team members in the PMH work to provide anti-oppressive and culturally-safe care, seeking to mitigate experiences of discrimination faced by many patients based on their SDoH. This requires understanding how historical and current injustices have impacted the well-being of certain populations, and working to ensure a safe and welcoming practice environment by focusing on the principles of caring and compassion. Sociodemographic data benefits The FHT at St Michael’s Hospital routinely collects sociodemographic data on all patients. Patients are surveyed about income, housing status, gender identity, and other key SDoH factors, and their responses are integrated into the secure EMR. This information is used to inform and direct individualized patient-centred care. The data will also be used for planning and evaluating the FHT’s programs.74 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 19 Pillar 6: Comprehensive Team-Based Care with Family Physician Leadership Primary care practice teams Many allied health professional organizations have prioritized the importance of working together in a team to provide patients with the best possible care. The CFPC worked collaboratively with organizations—such as the CNA, the Canadian Association of Social Workers, the Canadian Psychological Association, and the Dieticians of Canada—to create the Best Advice guide: Team-Based Care in the Patient’s Medical Home.75 The guide includes implementation strategies for creating a primary practice team, and general descriptions of roles found in a collaborative team. 20 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 A broad range of services is offered by an interprofessional team. The patient does not always see their family physician but interactions with all team members are communicated efficiently within a PMH. The team might not be co-located but the patient is always seen by a professional with relevant skills who can connect with a physician (ideally the patient’s own personal physician) as necessary. 6.1 A PMH includes one or more family physicians, who are the most responsible provider for their own panel of registered patients. 6.2 Family physicians with enhanced skills, along with other medical specialists, are part of a PMH team or network, collaborating with the patient’s personal family physician to provide timely access to a broad range of primary care and consulting services. 6.3 On-site, shared-care models to support timely medical consultations and continuity of care are encouraged and supported as part of each PMH. 6.4 The location and composition of a PMH’s team is flexible, based on community needs and realities; team members may be co-located or may function as part of virtual networks. 6.5 The personal family physician and nurse with relevant qualifications form the core of PMH teams, with the roles of others (including but not limited to physician assistants, pharmacists, psychologists, social workers, physiotherapists, occupational therapists, dietitians, and chiropractors) encouraged and supported as needed. 6.6 Physicians, nurses, and other members of the PMH team are encouraged and supported in developing ongoing relationships with patients. Each care provider is recognized as a member of the patient’s personal medical home team. 6.7 Nurses and other health professionals in a PMH team will provide services within their defined roles, professional scopes of practice, and personally acquired competencies. Their roles providing both episodic and ongoing care support and complement—but do not replace—those of the family physician. Team-based care is a core function of the PMH. Building a team with a diverse mix of professional backgrounds creates an opportunity to redefine what is considered optimal, based on the needs of the practice and the community it serves. A high-performing team is essential to delivering more comprehensive, coordinated, and effective care centred on the patient’s needs. While different circumstances call for aspects of patient care to be provided by different health professionals, it is important to ensure that family physician expertise is available to all team members through consultation. To practice effectively in an interprofessional health care team, there must be a clear understanding of each member’s unique contributions, including educational background, scopes of practice and knowledge, and areas of excellence and limitations.76 Practices that draw on the expertise of a variety of team members are more likely to provide patients with the care they need and respond to community needs.77 Relationships across all dynamics within a practice, whether between a patient and family physician or between a patient and other members of the team, should be encouraged and supported in the PMH. Establishing these relationships develops trust and confidence, and works toward the ultimate goal of achieving better health outcomes. While it should be left to each practice to determine who does what (within the boundaries of professional scopes of practice), the most responsible provider for the medical care for each patient in the practice should be the patient’s personal family physician. Family physicians with enhanced skills and family physicians with focused practices play an important role in collaborating with the patient’s personal family physician and team to provide timely access to a range of primary care and consulting services. They supplement their core skills and experience with additional expertise in a particular field, while remaining committed to their core generalist principles.78 These doctors can draw extensively on their generalist training and approach to disease management and patient-centred care, enabling them to work collaboratively at different levels of care, including with other specialists, to meet patient needs.79 These clinicians also serve as a resource for other physicians in their local health system by enhancing care delivery and learning and teaching opportunities. The Best Advice guide: Communities of Practice in the Patient’s Medical Home80 provides more information about intraprofessional collaboration between family physicians. Shared care strategies provide patients with timely access to consultations with other specialists or family physicians with enhanced skills at scheduled times in the family practice office setting. The consultant might assess several patients per visit, at which time a plan for ongoing care can be developed and agreed to by the family physician, consultant, other team members, and the patient. There is no one-size-fits-all model when determining what mix of health care professionals is right. Team composition depends on the professional competencies, skills, and experiences needed to address the health needs of the patient population.81 These needs vary, depending on the communities’ defining characteristics; Additional members of practice teams Not all health care professionals in a team need to be hired as a full-time team member. For example, a practice can hire a dietician for specific days to lead a diabetes education program and see scheduled patients. Practices can also host other health care professionals, such as those employed with a regional health authority, to provide care to patients on-site. However, funding bodies should recognize that family practice clinics hosting other health care professionals often carry the overhead costs associated with these practitioners working on site, and further supports should be made available to ensure that costs do not unduly fall on the physicians. Pillar 1: Administration and Funding and Pillar 2: Appropriate Infrastructure highlight that a PMH needs to be properly funded and have access to the right infrastructure (physical and governance) to support the initiatives described in this vision. A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 21 22 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 for example, geography, culture, language, demographics, disease prevalence. Family physicians are encouraged to identify the gaps in health care provision in the local practice environment and work with other health care providers to meet those needs as much as possible. Data from EMRs—as well as input from patients, community members, and stakeholders—should inform team planning. Factors to consider include: Patient population Identified community health care needs Hours available for patient access Hours available for each physician to work Roles and number of non-physician providers Funds available81 Overlapping or variations of similar competencies can result in ambiguous expectations of what a defined role is within a practice. When teams are planned and developed, roles should be clearly outlined. This is best done at the local practice level relative to community needs and resources. This approach considers changes over the course of a health care professional’s career, including skills development, achievement of certifications, and professional interests.82 It is important to include time for team members to become comfortable in their role, at the outset of team-based care and with any changes to the team. It is also important to recognize that these arrangements are flexible and subject to change, provided the team engages in discussion and reaches consensus on needed adjustments. Team members might be in the same office or in the same building, but this is not necessary. For smaller and more remote practices, or larger urban centres where proximate physical space may be a barrier, some connections may be arranged with peers in other sites. Applying HIT judiciously allows for virtual referrals and consultations. Virtual links between PMH practices and other specialists, hospitals, diagnostic services, etc., can be enhanced with more formal agreements and commitments to provide timely access to care and services. By providing patients with a comprehensive array of services that best meet their needs, team-based care can lead to better access, higher patient and provider satisfaction, and greater resource efficiency.61,77,83 Although there are presently many systems in place that support the creation of health care teams, practices can also create a successful team on their own. To ensure team success, providers must have a clear understanding of the different role responsibilities and ensure that there are tools available to engage open dialogue and communication. Teams within the PMH are supported by a model that is flexible and adaptable to each situation. The skills that family physicians acquire during their training (as described in the CanMEDS-FM framework) make them well suited to provide leadership within interprofessional teams. As an important part of a PMH, teams are central to the concept of patient-centred care that is comprehensive, timely, and continuous. A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 23 Pillar 7: Continuity of Care Continuity of care is defined by consistency over time related to where, how, and by whom each person’s medical care needs are addressed throughout the course of their life.84 With strong links to comprehensive team-based care (see Pillar 6: Comprehensive Team-Based Care with Family Physician Leadership), continuity of care is essential to any practice trying to deliver care truly centred on the needs of the patient. Continuity of care is rooted in a long-term patient-physician partnership in which the physician knows the patient’s history from experience and can integrate new information and decisions from a whole-person perspective efficiently without extensive investigation or record review.84 From the patient’s perspective, this includes understanding each person’s life journey and the context this brings to current health status, and the trust they have in their provider that is built over time. Past studies show that when the same physician attends to a person over time, for both minor and more serious health problems, the patient-physician relationship is strengthened and understanding grows—an essential element of effective primary health care.85 The personal physician offers their medical knowledge and expertise for a more complete understanding of the patient as a person, including the patient’s medical history and their broader social context, such as personal, family, social, and work histories (see Pillar 5: Community Adaptiveness and Social Accountability). In this model, patients, their families and/or personal caregivers, and all health care providers in the PMH team are partners in care, working together to achieve the patient’s goals and engaging in shared decision making. Understanding the patient’s needs, hopes, and fears, and their patterns of response to illness, medications, and other treatments, deepens the physician’s ability to respond to larger trends, not just the medical issue presented at any given appointment. Continuity of care can ideally support the health and well-being of patients actively and in their daily lives without focusing only on care when they are ill. The strong physician-patient relationship developed over time allows them to maintain good health and prevent illness and injury, as the physician uses their deep knowledge of their patient to work with teams of qualified health professionals to best support the patient’s well-being. Family physicians in the PMH, acting as the most responsible provider, can provide continuous care over the patient’s lifespan and develop strong relationships with patients. Research demonstrates that one of the most significant contributors to better population health is continuity of care.86,87 It found that those who see the same primary care physician continuously over time have better health outcomes, reduced emergency department use, and reductions in hospitalizations versus those who receive care from many different physicians. A Canadian study found that after controlling for demographics and health status, continuity of care was a predictor of decreased hospitalization for ambulatory caresensitive conditions (such as such as COPD, asthma, diabetes, and heart failure) and decreased emergency department visits for a wide range of family practicesensitive conditions.85 Overall “the more physicians patients see, the greater the likelihood of adverse effects; seeking care from multiple physicians in Patients live healthier, fuller lives when they receive care from a responsible provider who journeys with them and knows how their health changes over time. 7.1 The PMH enables and fosters long-term relationships between patients and the care team, thereby ensuring continuous care across the patient’s lifespan. 7.2 PMH teams ensure continuity of care is provided for their patients in different settings, including the family practice office, hospitals, long-term care and other community-based institutions, and the patient’s residence. 7.3 A PMH serves as the hub that ensures coordination and continuity of care related to all the medical services their patients receive throughout the medical community. the presence of high burdens of morbidity will be associated with a greater likelihood of adverse side effects.”86 It has been reported that a regular and consistent source of care is associated with better access to preventive care services, regardless of the patient’s financial status. Continuity of care also requires continuity in medical settings, information, and relationships. Having most medical services provided or coordinated in the same place by one’s personal family physician and team has been shown to result in better health outcomes.88 As described in Pillar 3: Connected Care, when care must be provided in different settings or by different health professionals (i.e., the medical neighbourhood), continuity can still be preserved if the PMH plays a coordination role and communicates effectively with other providers. The PMH liaises with external care providers to coordinate all aspects of care provided to patients based on their needs. This includes but is not limited to submitting and following up on referrals to specialized services, coordinating home care, and working with patients before and after discharge from hospitals or other critical care centres. In addition to this coordination role, the PMH acts as a hub by sharing, collecting, storing, and acting as a steward for all relevant patient information. This ensures that the family physician, as the most responsible provider, has a complete overview of the patient’s history. A record of care provided for each patient should be available in each medical record (preferably through an EMR) and available to all appropriate care providers (see Pillar 2: Appropriate Infrastructure for more information about EMRs). Knowing that medical information from all sources (i.e., providers inside and outside the PMH) is consolidated in one location (physical or virtual) increases the comfort and trust of patients regarding their care. Continuity for patient health Research demonstrates that continuity of care is a key contributor to overall population health. Patients with a regular family physician experience better health outcomes and fewer hospitalizations as compared to those without.69 24 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 Pillar 8: Patient- and Family-Partnered Care External factors for patient health care Patient- and family-partnered care is considered a key value to stakeholders across the health care system. In 2011, the CMA and the CNA released a set of principles to guide the transformation of Canada’s health care system.91 Patient-centred care is listed as the first principle, and as a key component of improving the overall health care experience.91 Similarly, in 2016 Patients Canada called on all levels of government to ensure that patients are at the centre of any new health accords and future health care reform.92 * Family caregivers include relatives, partners, friends, neighbours, and other community members. Patient-centred care is at the core of the PMH. Dr. Ian McWhinney—often considered the “father of family medicine”—describes patient-centred care as the provider “enter[ing] the patient’s world, to see the illness through the patient’s eyes … [It] is closely congruent with and responsive to patients’ wants, needs and preferences.”89 In this model, patients, their families and/ or personal caregivers, and all health care providers in the PMH team are partners in care, working together to achieve the patient’s goals and engaging in shareddecision making. Care should always reflect the patient’s feelings and expectations and meet their individual needs. Refer to the Best Advice guide: Patient-Centred Care in a Patient’s Medical Home90 for more information. Family caregivers* play an important role in the PMH. They help patients manage and cope with illness and can assist physicians by acting as a reliable source of health information and collaborating to develop and enact treatment plans.93 The level and type of engagement from family caregivers should always be determined by the patient. Physicians “should routinely assess the patient’s wishes regarding the nature and degree of caregiver participation in the clinical encounter and strive to provide the patient’s desired level of privacy.”94 They should revisit this conversation regularly and make changes based on patient desires. PMH practices focus on providing patient-centred care and ensuring that family caregivers are included. A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 25 Family practices respond to the unique needs of patients and their families within the context of their environment. 8.1 Care and care providers in a PMH are patient-focused and provide services that respond to patients’ feelings, preferences, and expectations. 8.2 Patients, their families, and their personal caregivers are active participants in the shared-decision making process. 8.3 A PMH facilitates patients’ access to their medical information through electronic medical records as agreed upon with their care team. 8.4 Self-managed care is encouraged and supported as part of the care plans for each patient. 8.5 Strategies that encourage access to a range of care options beyond the traditional office visits (e.g., telehealth, virtual care, mobile health units, e-consult, etc.) are incorporated into the PMH. 8.6 Patient participation and formalized feedback mechanisms (e.g., patient advisory councils, patient surveys) are part of ongoing planning and evaluation. As part of their commitment to patient-centred care, PMH practices facilitate and support patient self-management. Self-management interventions such as support for decision making, self-monitoring, and psychological and social support, have been demonstrated to improve health outcomes.95 PMH team members should always consider recommendations for care from the patient’s perspective. They should work collaboratively with patients and their caregivers to develop realistic action plans and teach problem-solving and coping. This is particularly important for those with chronic conditions, who must work in partnership with their physician and health care team to manage their condition over time. (Refer to the Best Advice guide: Chronic Care Management in a Patient’s Medical Home96 for more information). The goal of self-managed care should be to build the patient’s and caregiver’s confidence in their ability to deal effectively with illnesses, improve health outcomes, and foster overall well-being. To facilitate patient- and family-partnered care, a range of user-friendly options for accessing information and care beyond the traditional office visit should be available to patients when appropriate. These include email, telehealth, virtual care, mobile health units, e-consults, home visits, same-day scheduling, group visits, self-care strategies, patient education, and treatment sessions offered in community settings. Providing a range of options allows patients to access the type of care they prefer based on individual needs. Patients also need to be informed about how they can access information and resources available to them; for example, resources such as Prevention in Hand (PiH).97 Allowing patients to access to their medical records can improve patient-provider communication and increase patient satisfaction.98,99 The specific information accessible to patients should be discussed and agreed upon by the patient and their care team. Patient education about accessing and interpreting the available information is necessary. Facilitating this type of access requires each PMH to have an EMR system that allows external users to access information securely (see Pillar 2: Appropriate Infrastructure). Patient surveys and opportunities for patients to participate in planning and evaluating the effectiveness of the practice’s services should be encouraged; practices must be willing respond and adapt to patient feedback. To strengthen a patient-centred approach, practices may consider developing patients’ advisory councils or other formalized feedback mechanisms (e.g., using patient surveys) as part of their CQI processes (see Pillar 9: Measurement, Continuous Quality Improvement, and Research). Patient self-management The Ajax Harwood Clinic (AHC) is a good example of how a practice that enables patient self-management can improve long-term health outcomes, especially for patients with chronic conditions.94 The AHC has created an environment of learning and seeks to encourage health literacy among its patients through its various programs. The clinic is focused on patient education and empowerment, and all programs at the clinic are free of charge to patients to remove financial barriers to access. 26 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 27 ONGOING DEVELOPMENT Each PMH strives for ongoing development to better achieve the core functions. The PMH and its staff are committed to Measurement, Continuous Quality Improvement, and Research; and Training, Education, and Continuing Professional Development. MEASUREMENT, CONTINUOUS QUALITY IMPROVEMENT, AND RESEARCH PAGE 28 TRAINING, EDUCATION, AND CONTINUING PROFESSIONAL DEVELOPMENT PAGE 30 28 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 Continuous quality improvement CQI is an important value among health organizations such as the CFHI.100 Pillar 9: Measurement, Continuous Quality Improvement, and Research CQI is an essential characteristic of the PMH vision. It encourages health care teams to make practical improvements to their practice, while monitoring the effectiveness of their services, the health outcomes and safety of their patients, and the satisfaction of both patients and the health professionals on the team. Every PMH is committed to establishing a CQI program that will improve patient safety, and enhance efficiency and quality of the services provided to patients. As part of CQI activities, a structured approach is used to evaluate current practice processes and improve systems and to achieve desired outcomes. To engage in CQI, the PMH team must identify the desired outcomes and determine appropriate evaluation strategies. Once the process and the desired outcome are defined with patients, the CQI activity will track performance through data collection and comparison with the baseline. Performance measures can be captured through structured observation, patient and staff surveys (see Pillar 8: Patient- and Family- Partnered Care), the PMH self-assessment tool, and the practice’s EMR (see Pillar 1: Administration and Funding and Pillar 3: Connected Care). The indicators selected should be appropriate to each practice and community setting, be meaningful to the patients and community, and the CQI process could be introduced as a practice’s self-monitoring improvement program or as an assessment carried out by an external group. In some jurisdictions, funding is tied to achieving performance targets, including those that provide evidence for the delivery of more cost-effective care and better health outcomes.101 Some provinces in Canada have begun to link financial incentives to clinical outcomes and targets that have been achieved (“pay for performance” models).102 Although there may be some benefits derived by this approach, there can also be risks if funding incentives and resource supports become overly focused on patients with certain medical problems or on those who have greater potential to reach prescribed targets, while at the same time care is being delayed or denied for others.101,103 Future development A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 28 Family practices strive for progress through performance measurement and CQI. Patient safety is always a focus, and new ideas are brought to the fore through patient engagement in QI and research activities. 9.1 PMHs establish and support CQI programs that evaluate the quality and cost effectiveness of teams and the services they provide for patient and provider satisfaction. 9.2 Results from CQI are applied and used to enhance operations, services, and programs provided by the PMH. 9.3 All members of the health professional team (both clinical and support teams), as well as trainees and patients, will participate in the CQI activity carried out in each PMH. 9.4 PMHs support their physicians, other health professionals, students, and residents to initiate and participate in research carried out in their practice settings. 9.5 PMHs function as ideal sites for community-based research focused on patient health outcomes and the effectiveness of care and services. A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 29 of financial incentive models should consider these unintended consequences that might impair the ability of practices to provide good quality patient care to their full population. The objectives that define a PMH could be used to develop the indicators for CQI initiatives in family practices across Canada. These criteria could be augmented by indicators recommended by organizations such as Accreditation Canada, Health Quality Ontario, Health Standards Organization, and the Patient-Centered Medical Home model in the United States. The CFPC is committed to collaborating with these groups to further develop the CQI process for PMHs and family practices. Consult the CFPC’s Practice Improvement Initiative (Pii)104 for a list of available resources. CQI is a team activity and should involve all members of the PMH team as well as patients and trainees. This will ensure buy-in from the team, allow for patient engagement and participation, and provide trainees with valuable learning opportunities.105 PMHs are committed to using the results of CQI initiatives to make tangible changes in their practice to improve operations, services, and programs. Time and effort invested into participation in CQI activities should be recognized as valuable and not be disincentivized through existing remuneration models. Dedicated time and capacity to perform these activities should be built into the practice operational principles. On a larger scale, PMHs function as ideal sites for community-based research focused on patient health outcomes and the effectiveness of care and services. The PMH team should be encouraged and supported to participate in research activities. They should also advocate for medical students, residents, and trainees to take part in these projects. In Canada, the Canadian Primary Healthcare Research Network (CPHRN) and the commitment of the Canadian Institutes for Health Research’s (CIHR’s) Strategy for Patient-Oriented Research (SPOR) are vitally important.106 The focus on supporting patient-oriented research carried out in community primary care settings is consistent with the priorities of the PMH. Competitions for research grants such as those announced by SPOR should be strongly encouraged and supported. PMHs are ideal laboratories for studies that embrace the principles of comparative effectiveness research (CER) and the priorities defined by the CPHRN and CIHR’s SPOR project. They provide excellent settings for multi-site research initiatives, including projects like those currently undertaken by the CPCSSN—a nationwide network of family physicians conducting surveillance of various chronic diseases. 30 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 Pillar 10: Training, Education, and Continuing Professional Development PMH practices serve as training sites for medical students, family medicine residents, and those training to become nurses and other health care professionals.107 They create space for modelling and teaching practices focused on the essential roles of family physicians and interprofessional teams as part of the continuum of a health care system. One of the goals of family medicine residency training is for residents to learn to function as a member of an interdisciplinary team, caring for patients in a variety of settings including family practice offices, hospitals, long-term care and other communitybased institutions, and patients’ residences.70,108 A PMH also models making research and QI initiatives a standard feature of a family practice. Professional development and opportunities to participate in these activities should be available and supported within PMH practices through resources, guidance, and specifically dedicated time. Family medicine training is increasingly focused on achieving and maintaining competencies defined by the CFPC’s Triple C Family Medicine Curriculum.109 Triple C includes five domains of care: care of patients across the life cycle; care across clinical settings (urban and rural); a defined spectrum of clinical responsibilities; care of marginalized/disadvantaged patients and populations; and a defined list of core procedures. Triple C also incorporates the Four Principles of Family Medicine and the CanMEDS-FM Roles. PMHs allow family medicine students and residents to achieve the competencies of the Triple C curriculum and to learn how to incorporate the Four Principles of Family Medicine, the Family Medicine Professional Profile, and the CanMEDS-FM roles into their professional lives. Learners gain experience with patient-partnered care, teams/networks, EMRs, timely access to appointments, comprehensive continuing care, management of undifferentiated and complex problems, coordination of care, practice-based research, and CQI—essential elements of family practice in Canada. Furthermore, PMH practices serve as optimal sites for trainees in other medical specialties and health professions to gain valuable experience working in interprofessional teams and providing high quality, patient-centred care. Medical schools and residency programs should encourage learners to conduct some of their training within PMH practices. Emphasis on training and education ensures that the knowledge and expertise of family physicians can be shared with the broader health care community, and also over time by creating learning organizations where both students and fully practising family physicians can stay at the forefront of best practice. 10.1 PMHs are identified and supported by medical and other health professional schools as optimal locations for the experiential training of their students and residents. 10.2 PMHs teach and model their core defining elements including patient-partnered care, teams/networks, EMRs, timely access to appointments, comprehensive continuing care, management of undifferentiated and complex problems, coordination of care, practice-based research, and CQI. 10.3 PMHs provide a training environment for family medicine residents that models, and enables residents to achieve, the competencies as defined by the Triple C Competency-based Family Medicine Curriculum, the Four Principles of Family Medicine, and the CanMEDS-FM Roles. 10.4 PMHs will enable physicians and other health professionals to engage in continuing professional development (CPD) to meet the needs of their patients and their communities both individually and as a team. 10.5 PMHs enable family physicians to share their knowledge and expertise with the broader health care community. Practising family physicians must engage in CPD to keep current on medical and health care developments and to ensure their expertise reflects the changing needs of their patients, communities, and learners. Mainpro+® (Maintenance of Proficiency) is the CFPC’s program designed to support and promote family physicians’ CPD across all CanMEDS-FM Roles and competencies. CPD refers to physicians’ professional obligation to engage in learning activities that address their own identified needs and the needs of their patients; enhance knowledge, skills, and competencies across all dimensions of professional practice; and continuously improve their performance and health care outcomes within their scope of practice.110 Three foundational principles for CPD in Canada have been recently described: Socially responsive to the needs of patients and communities Informed by scientific evidence and practicebased data Designed to achieve improvement in physician practice and patient outcomes CPD is inclusive of learning across all CanMEDS-FM Roles and competencies, including clinical expertise, teaching and education, research and scholarship, and in practice-based QI. PMH practices support their physicians, and all other staff members, to engage in CPD activities throughout their careers by creating a learning culture in the organization. This includes providing protected time for learning and team-based learning, and access to practice data both to discern patient/community need and practice gaps to inform CPD choices and to evaluate the impact of learning on patient care. This learning culture and the will to be constantly improving quality and access to care is essential to ensuring that the PMH continues to support high performing care teams. To ensure that all PMH team members have the capacity to take on their required roles, leadership development programs should be offered. Enabling physicians to engage in this necessary professional development requires sufficient funding by governments to cover costs of training and financial support to ensure lost income and practice capacity do not prevent this. Physicians in the PMH share their knowledge with colleagues in the broader health care community and with other health care professionals in the team by participating in education, training, and QI activities in collaboration with the pentagram partners.† This is particularly relevant for family physicians who are focused on a particular area of practice (possibly holding a Certificate of Added Competence) and are able to share their extended expertise with others. This can happen either informally or through more official channels. For example, physicians may participate in activities organized by the CFPC or provincial Chapters (e.g., Family Medicine Forum, provincial family medicine annual scientific assemblies), or lend their expertise to interprofessional working groups addressing specific topics in health care. Family physicians should be encouraged to engage in these types of events to share their knowledge and skills for the betterment of the overall health system. Continuing professional development CPD is an integral value across the entire health care system. Organizations such as the Royal College, CMA, and CNA emphasize the value and importance of continuing education for health care professionals to improve patient care. † Pentagram partners: policy-makers—federal, provincial, territorial, and regional health authorities; health and education administrators; university; community; health professionals—physicians and teams A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 31 32 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 CONCLUSION The revised PMH vision of a high-functioning primary care system responds to the rapidly evolving health system and the changing needs of Canadians. The pillars and attributes described in this document can guide practices at various stages in the transition to a PMH, and many characteristics are found in other foundational documents of family medicine such as the Family Medicine Professional Profile111 and the Four Principles of Family Medicine. Supporting resources, such as the PMH Implementation Kit, are available to help those new to the transition overcome barriers to change. Although the core components of the PMH remain the same for all practices, each practice will implement the recommendations according to their unique needs. The PMH is focused on enhancing patient-centredness in the health care system through collaboration, access, continuity, and social accountability. It is intended to build on the long-standing historical contribution of family physicians and primary care to the health and wellbeing of Canadians, as well as on the emerging models of family practice and primary care that have been introduced across the country. Importantly, this vision provides goals and recommendations that can serve as indicators. It enables patients, family physicians, other care health professionals, researchers, health planners, and policy-makers evaluate the effectiveness of any and all models of family practice throughout Canada. Those family practices that meet the goals and recommendations described in this vision will have become PMHs, but the concept is ever evolving. As family physicians commit to making change in their practices, the CFPC commits to supporting developments in the PMH by creating and promoting new resources, which will be available through the PMH website. The CFPC will also play an important advocacy role to ensure that the necessary supports are in place to reach the goals of a PMH. Every family practice across Canada should be supported and encouraged by the public, governments, and other health care stakeholders (the pentagram partners) to achieve this objective. Doing so will ensure that every person in Canada is able to access the best possible primary care for themselves and their loved ones. A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 33 REFERENCES 1. College of Family Physicians of Canada. A Vision for Canada: Family Practice - The Patient’s Medical Home. Mississauga, ON: College of Family Physicians of Canada; 2011. Available from: www.cfpc.ca/uploadedFiles/Resources/ Resource_Items/PMH_A_Vision_for_Canada.pdf. Accessed 2019 Jan 21. 2. National Physician Survey. 2014 National Physician Survey website. http:// nationalphysiciansurvey.ca/surveys/2014-survey/. Accessed 2019 Jan 22. 3. Canadian Medical Association. CMA Workforce Survey 2017 website. http:// cma.andornot.com/en/surveydata/default.aspx. Accessed 2019 Jan 22. 4. Canadian Institute for Health Information. How Canada Compares: Results from the Commonwealth Fund’s 2016 International Health Policy Survey of Adults in 11 Countries. Ottawa, ON: Canadian Institute for Health Information; 2017. Available from: www.cihi.ca/sites/default/files/document/text-alternativeversion- 2016-cmwf-en-web.pdf. Accessed 2019 Jan 22. 5. Ipsos Public Affairs. The College of Family Physicians of Canada: Family Medicine in Canada Report. Toronto, ON: Ipsos; 2017. 6. World Health Organization. Primary Health Care website. www.who.int/ primary-health/en/. Accessed 2019 Jan 22. 7. College of Family Physicians of Canada. Four Principles of Family Medicine website. www.cfpc.ca/Principles/. Accessed 2019 January. 8. Canadian Medical Association. Health Care Transformation in Canada: Change that works. Care that lasts. Ottawa, ON: Canadian Medical Association; 2018. Available from: http://policybase.cma.ca/dbtw-wpd/ PolicyPDF/PD10-05.PDF. Accessed 2019 Jan 22. 9. College of Family Physicians of Canada. The Patient’s Medical Home Provincial Report Card—February 2019. Mississauga, ON: College of Family Physicians of Canada; 2019. Available from: https://patientsmedicalhome.ca/ files/uploads/PMH_ReportCard_2018.pdf. Accessed 2019 February. 10. Alberta Health. Primary Care Networks website. www.health.alberta.ca/ services/primary-care-networks.html. Accessed 2018 August 16. 11. Access Improvement Measures (AIM) Alberta. Third Next Available Appointments website. https://aimalberta.ca/index.php/2016/07/19/the-world-of-third-nextavailable- appointments-2/. Accessed 2019 Jan 22. 12. Office of the Premier, Ministry of Health. B.C. government’s primary healthcare strategy focuses on faster, team-based care [news release]. Victoria, BC: Government of British Columbia; 2018. 13. General Practice Services Committee. What We Do: Patient Medical Homes website. www.gpscbc.ca/what-we-do/patient-medical-homes-and-primary-carenetworks. Accessed 2018 Aug 22. 14. Government of Manitoba. Frequently Asked Questions about My Health Teams website. www.gov.mb.ca/health/primarycare/myhts/faq.html#manitoba. Accessed 2018 Aug 15. 15. Chateau D, Katz A, Metge C, Taylor C, McDougall C, McCulloch S. Describing Patient Populations for the My Health Team Initiative. Winnipeg, MB: Manitoba Centre for Health Policy; 2017. Available from: http://mchp-appserv.cpe. umanitoba.ca/reference//hiusers_Report_web.pdf. Accessed 2019 Jan 22. 16. Government of Manitoba. Budget Paper F: Reducing Poverty and Promoting Community Involvement. Winnipeg, MB: Government of Manitoba; 2018. Available from: www.gov.mb.ca/finance/budget18/papers/F_Reducing_ Proverty_r.pdf. Accessed 2019 Jan 22. 17. Government of New Brunswick. New model for family medicine aims to improve physician access [news release]. Fredericton, NB: Government of New Brunswick; 2017. Available from: www2.gnb.ca/content/gnb/en/news/ news_release.2017.06.0849.html. Accessed 2019 Jan 22. 18. Health, Office of the Premier. Twenty-five new doctors to be added to New Brunswick’s health-care system to reduce wait times [news release]. Fredericton, NB: Government of New Brunswick; 2018. Available from: www2.gnb.ca/ content/gnb/en/news/news_release.2018.02.0140.html. Accessed 2019 Jan 22. 19. Government of Newfoundland and Labrador. Healthy People, Healthy Families, Healthy Communities: A Primary Health Care Framework for Newfoundland and Labrador 2015-2025. St. John’s, NL: Government of Newfoundland and Labrador; 2015. Available from: www.health.gov.nl.ca/health/ publications/PHC_Framework_update_Nov26.pdf. Accessed 2018 November. 20. Health and Community Services. Supporting Health Communities: Primary Health Care Team has Success at the Gathering Place [news release]. St. John’s, NL: Government of Newfoundland and Labrador; 2016. Available from: www. releases.gov.nl.ca/releases/2016/health/1124n01.aspx. Accessed 2018 Nov. 21. Nova Scotia Health Authority. Collaborative Family Practice Teams website. www. nshealth.ca/collaborative-family-practice-teams. Accessed 2019 January. 22. Government of Ontario. Family Health Teams website. www.health.gov.on.ca/ en/pro/programs/fht/. Accessed 2018 August 16. 23. Conference Board of Canada. Final Report: An External Evaluation of the Family Health Team (FHT) Initiative. Ottawa, ON: The Conference Board of Canada; 2014. Available from: www.conferenceboard.ca/e-library/abstract.aspx?did=6711. Accessed 2019 Jan 22. 24. Kralj B, Kantarevic J, OMA Economics Department. Primary care model enrolment and hospital length of stay in Ontario: patient rostering associated with reduced length of stay, significant health system savings. Ontario Medical Review. Sept 2012, 16-19. Available from: www.oma.org/wp-content/ uploads/sept2012_primary_care_model.pdf. Accessed 2019 Jan 22. 25. Tiagi R, Chechulin Y. The Effect of Rostering with a Patient Enrolment Model on Emergency Department Utilization. Healthcare Policy. 2014;9(4):105-121. Available from: www.longwoods.com/content/23809//the-effect-of-rosteringwith- a-patient-enrolment-model-on-emergency-department-utilization. Accessed 2019 Jan 22. 26. Health PEI. Health Centres Offer Primary Care [news release]. Charlottetown, PE: Government of Prince Edward Island; 2015. Available from: www. princeedwardisland.ca/en/information/health-pei/health-centres-offerprimary- care. Accessed 2019 Jan 22. 27. Gouvernement du Québec. Groupe de médecine de famille (GMF), groupe de médecine de famille universitaire (GMF-U) et super-clinique website. www. quebec.ca/sante/systeme-et-services-de-sante/organisation-des-services/gmfgmf- u-et-super-clinique/. Accessed 2019 January. 28. Government of Saskatchewan. Fact Sheet: Connected Care [news release]. Regina, SK: Government of Saskatchewan; 2018. 29. Pomey MP, Ghadiri DP, Karazivan P, Fernandez N, Clavel N. Patients as partners: a qualitative study of patients’ engagement in their health care. PLoS One. 2015;10(4):e0122499. 30. Pointer DD, Orlikoff JE. Board Work: Governing Health Care Organizations. 1st ed. San Francisco, CA: Jossey-Bass; 1999. 31. Canadian Foundation for Healthcare Improvement. Mythbusters: Most Physicians Prefer Fee-for-Services Payments. Ottawa, ON: Canadian Foundation for Healthcare Improvement; 2010. Available from: www.cfhi-fcass. ca/sf-docs/default-source/mythbusters/Myth-Fee-for-Service-E.pdf?sfvrsn=0. Accessed 2019 Jan 22. 32. Blomqvist A, Busby C. How to Pay Family Doctors: Why “Pay per Patient” is Better than Fee for Service. Toronto, ON: C.D Howe Institute; 2012. Available from: www.cdhowe.org/sites/default/files/attachments/research_papers/ mixed/Commentary_365.pdf. Accessed 2019 Jan 22. 33. Holden M, Madore O. Remuneration of Primary Care Physicians (PRB 01-35E). Ottawa, ON: Library of Parliament, Parliamentary Research Branch; 2002. Available from: http://publications.gc.ca/collections/Collection-R/LoPBdP/ PRB-e/PRB0135-e.pdf. Accessed 2019 Jan 22. 34. Carter R, Riverin B, Levesque JF, Gariepy G, Quesnel-Vallee A. The impact of primary care reform on health system performance in Canada: a systematic review. BMC Health Serv Res. 2016;16:324. 35. Kiran T, Kopp A, Moineddin R, Glazier RH. Longitudinal evaluation of physician payment reform and team-based care for chronic disease management and prevention. CMAJ. 2015;187(17):E494-502. 36. College of Family Physicians of Canada. Best Advice guide: Physician Remuneration in a Patient’s Medical Home. Mississauga, ON: 34 A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 College of Family Physicians of Canada; 2016. Available from: https:// patientsmedicalhome.ca/resources/best-advice-guides/best-advice-guidephysician- remuneration-patients-medical-home/. Accessed 2019 Jan 22. 37. Hutchison B, Levesque JF, Strumpf E, Coyle N. Primary health care in Canada: systems in motion. Milbank Q. 2011;89(2): 256-288. 38. Aggarwal M, Hutchison B. Toward a Primary Care Strategy for Canada. Ottawa, ON: Canadian Foundation for Healthcare Improvement; 2012. Available from: www.cfhi-fcass.ca/Libraries/Reports/Primary-Care-Strategy- EN.sflb.ashx. Accessed 2019 Jan 22. 39. PricewaterhouseCoopers. Canada Health Infoway: The emerging benefits of electronic medical record use in community-based care. Toronto, ON: PricewaterhouseCoopers; 2013. Available from: www.pwc.com/ca/en/healthcare/ publications/pwc-electronic-medical-record-use-community-based-care-report- 2013-06-en.pdf. Accessed 2018 Jul 3. 40. Canada Health Infoway. Use of Electronic Medical Records among Canadian Physicians, 2017 Update. Toronto, ON: Canada Health Infoway; 2017. 41. College of Family Physicians of Canada. Supporting access to data in electronic medical records for quality improvement and research [position statement]. Mississauga, ON: College of Family Physicians of Canada; 2017. Available from: www.cfpc.ca/uploadedFiles/Health_Policy/CFPC_Policy_ Papers_and_Endorsements/CFPC_Policy_Papers/CFPC-Position-Statement- Supporting-access-data-electronic-medical-records-EN.pdf. Accessed 2019 Jan 22. 42. Jamieson T, Wallace R, Armstrong K, Agarwal P, Griffin B, Wong I, et al. Virtual Care: A Framework for a Patient-Centric System. Toronto, ON: Women’s College Hospital Institute for Health Systems Solutions and Virtual Care; 2015. Available from: www.womenscollegehospital.ca/assets/pdf/wihv/WIHV_ VirtualHealthSymposium.pdf. Accessed 2019 Jan 22. 43. McGrail KM, Ahuja MA, Leaver CA. Virtual Visits and Patient-Centered Care: Results of a Patient Survey and Observational Study. J Med Internet Res. 2017;19(5):e177. 44. Canadian Medical Association. Managing your Practice website. www.cma.ca/ managing-your-practice. Accessed 2019 Jan 22. 45. Chang F, Gupta N. Progress in electronic medical record adoption in Canada. Can Fam Physician. 2015;61(12):1076-1084. 46. Canadian Nurses Association, Canadian Medical Association, Health Action Lobby. Integration: A New Direction for Canadian Health Care—A Report on the Health Provider Summit Process. Ottawa, ON: Canadian Nurses Association; 2013. Available from: www.cna-aiic.ca/~/media/cna/files/en/cna_ cma_heal_provider_summit_transformation_to_integrated_care_e.pdf. Accessed 2019 Jan 22. 47. Canada Health Infoway website. www.infoway-inforoute.ca/en/. Accessed 2019 Jan 22. 48. Canadian Foundation for Healthcare Improvement. Connected Medicine website. www.cfhi-fcass.ca/WhatWeDo/connected-medicine. Accessed 2018 Aug 15. 49. Rajakulendra N, Macintosh E, Salah H. Transforming Health: Toward decentralized and connected care. Toronto, ON: MaRS Discovery District; 2014. Available from: www.marsdd.com/wp-content/uploads/2014/09/Sep15- MaRS-Whitepapers-SmartHealth.pdf. Accessed 2019 Jan 22. 50. College of Family Physicians of Canada. Best Advice guide: Advanced and Meaningful Use of EMRs. Mississauga, ON: College of Family Physicians of Canada; 2018. Available from: https://patientsmedicalhome.ca/resources/ best-advice-guides/best-advice-guide-advanced-and-meaningful-use-ofemrs/. Accessed 2019 Jan 22. 51. Ontario Primary Care Council. Position Statement: Care Co-ordination in Primary Care. Toronto, ON: Ontario Primary Care Council; 2015. Available from: www.afhto.ca/wp-content/uploads/OPCC_Care-Coordination-Position. pdf. Accessed 2019 Jan 22. 52. Wong ST, Watson DE, Young E, Regan S. What do people think is important about primary healthcare? Healthcare Policy. 2008; 3(3):89-104. 53. Canadian Medical Association. CMA Position Statement: Ensuring Equitable Access to Care: Strategies for Government, Health System Planners and the Medical Profession. Ottawa, ON: Canadian Medical Association; 2014. Available from: www.cma.ca/sites/default/files/2018-11/PD14-04-e.pdf. Accessed 2019 Jan 22. 54. Canadian Nurses Association. Position Statement: Primary Health Care. Ottawa, ON: Canadian Nurses Association; 2015. Available from: www.cna-aiic. ca/-/media/cna/page-content/pdf-en/primary-health-care-position-statement. pdf. Accessed 2019 Jan 22. 55. Canadian Nurses Association. Social Justice … a means to an end, an end in itself; 2nd edition. Ottawa, ON: Canadian Nurses Association; 2010. Available from: www.cna-aiic.ca/~/media/cna/page-content/pdf-en/social_justice_2010_e. pdf. Accessed 2019 Jan 22. 56. Barry DW, Melhado TV, Chacko KM, Lee RS, Steiner J, Kutner JS. Patient and physician perceptions of timely access to care. J Gen Intern Med. 2006;21(2):130-133. 57. Glass DP, Kanter M, Jacobsen SJ, Minardi PM. The impact of improving access to primary care. J Eval Clin Pract. 2017;23(6):1451-1458. 58. Hudec JC, MacDougall S, Rankin E. Advanced access appointments: effects on family physician satisfaction, physicians’ office income, and emergency department use. Can Fam Phys. 2010;56(10):e361-e367. 59. Stalker CA. How have physicians and patients at New Vision Family Health Team experienced the shift to a family health team model? Final Report. Unpublished; 2010. 60. Murray M, Tantau C. Same-day appointments: exploding the access paradigm. Fam Pract Manag. 2000;7(8):45-50. 61. College of Family Physicians of Canada. Best Advice guide: Timely Access to Appointments in Family Practice. Mississauga, ON: College of Family Physicians of Canada; 2012. Available from: https://patientsmedicalhome.ca/ resources/best-advice-guides/best-advice-guide-timely-access/. Accessed 2019 Jan 22. 62. Lemire F. First contact: what does it mean for family practice in 2017? Can Fam Phys. 2017;63(3):256. 63. Williams DL. Balancing rationalities: gatekeeping in health care. J Med Ethics. 2001;27(1):25-29. 64. Murray M, Davies M, Boushon B. Panel size: How many patients can one doctor manage? Fam Pract Manag. 2007;14(4):44-51. 65. College of Family Physicians of Canada. Best Advice guide: Panel Size. Mississauga, ON: College of Family Physicians of Canada; 2012. Available from: https://patientsmedicalhome.ca/resources/best-advice-guides/bestadvice- guide-panel-size/. Accessed 2019 Jan 22. 66. Buchman S, Woollard R, Meili R, Goel R. Practising social accountability. Can Fam Phys. 2016; 62(1):15-18. 67. National Collaborating Centre of Determinants of Health website. www.nccdh. ca/. Accessed 2019 Jan 22. 68. National Collaborating Centre on Aboriginal Health website. www.nccahccnsa. ca/en/. Accessed 2019 Jan 22. 69. College of Family Physicians of Canada. CanMEDS–Family Medicine 2017: A competency framework for family physicians across the continuum. Mississauga, ON: College of Family Physicians of Canada; 2017. Available from: www.cfpc.ca/uploadedFiles/Resources/Resource_Items/Health_ Professionals/CanMEDS-Family-Medicine-2017-ENG.pdf. Accessed 2019 Jan 22. 70. College of Family Physicians of Canada. Best Advice guide: Social Determinants of Health. Mississauga, ON: College of Family Physicians of Canada; 2017. Available from: https://patientsmedicalhome.ca/resources/bestadvice- guides/best-advice-guide-social-determinants-health/. Accessed 2019 Jan 22. 71. Lightman E, Mitchell A, Wilson B. Poverty is making us sick: A comprehensive survey of income and health in Canada. Toronto, ON: The Wellesley Institute; 2008. Available from: www.wellesleyinstitute.com/wp-content/uploads/2011/11/ povertyismakingussick.pdf. Accessed 2019 Jan 18. 72. White AA 3rd, Logghe HJ, Goodenough DA, Barnes LL, Hallward A, Allen IM, et al. Self-Awareness and Cultural Identity as an Effort to Reduce Bias in Medicine. J Racial Ethn Health Disparities. 2018;5(1):34-49. 73. Canadian Primary Care Sentinel Surveillance Network website. http://cpcssn. ca/. Accessed 2019 Jan 22. 74. Pinto AD, Bloch G. Framework for building primary care capacity to address the social determinants of health. Can Fam Phys. 2017;63(11):e476-482. A NEW VISION FOR CANADA Family Practice— The Patient’s Medical Home 2019 35 75. College of Family Physicians of Canada. Best Advice guide: Team-Based Care in the Patient’s Medical Home. Mississauga, ON: College of Family Physicians of Canada; 2017. Available from: https://patientsmedicalhome.ca/resources/ best-advice-guides/best-advice-guide-team-based-care-patients-medical-home/. Accessed 2019 Jan 22. 76. Grant R, Finocchio L, Pew Health Professions Commission, California Primary Care Consortium. Interdisciplinary collaborative teams in primary care: a model curriculum and resource guide. San Francisco, CA: Pew Health Professions Commission; 1995. 77. Schottenfeld L, Petersen D, Peikes D, Ricciardi R, Burak H, McNellis R, et al. Creating Patient-Centered Team-Based Primary Care. AHRQ Pub. No. 16- 0002-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2016. 78. Department of Health. Part 3: The accreditation of GPs and Pharmacists with Special Interests, In: Implementing care closer to home: Convenient quality care for patients. London, UK: Department of Health; 2007. Available from: www.pcc-cic.org.uk/sites/default/files/articles/attachments/improved_quality_ of_care_p3_accreditation.pdf. Accessed 2019 Jan 22. 79. Department of Health. Part 1: Introduction and overview, In: Implementing care closer to home: Convenient quality care for patients. London, UK: Department of Health; 2007. Available from: www.pcc-cic.org.uk/sites/default/ files/articles/attachments/improved_quality_of_care_p1_introduction.pdf. Accessed 2019 Jan 22. 80. College of Family Physicians of Canada. Best Advice guide: Communities of Practice in the Patient’s Medical Home. Mississauga, ON: College of Family Physicians of Canada; 2016. Available from: https://patientsmedicalhome. ca/resources/best-advice-guides/communities-practice-patients-medicalhome/. Accessed 2019 Jan 22. 81. Dinh T. Improving Primary Health Care Through Collaboration: Briefing 2— Barriers to Successful Interprofessional Teams. Ottawa, ON: The Conference Board of Canada; 2012. Available from: www.conferenceboard.ca/e-library/ abstract.aspx?did=5181&AspxAutoDetectCookieSupport=1. Accessed 2019 Jan 22. 82. Nelson S, Turnbull J, Bainbridge L, Caulfield T, Hudon G, Kendel D, et al. Optimizing Scopes of Practice: New Models for a New Health Care System. Ottawa, ON: Canadian Academy of Health Sciences; 2014. 83. Mautner DB, Pang H, Brenner JC, Shea JA, Gross KS, Frasso R, et al. Generating hypotheses about care needs of high utilizers: lessons from patient interviews. Popul Health Manag. 2013;16(Suppl1):S26-33. 84. American Academy of Family Physicians. Definition of Continuity of Care website. www.aafp.org/about/policies/all/definition-care.html. Accessed 2018 July 25. 85. Canadian Institute for Health Information. Continuity of Care With Family Medicine Physicians: Why It Matters. Ottawa, ON: Canadian Institute for Health Information; 2015. Available from: https://secure.cihi.ca/free_products/UPC_ ReportFINAL_EN.pdf. Accessed 2019 Jan 22. 86. Starfield B, Chang HY, Lemke KW, Weiner JP. Ambulatory specialist use by nonhospitalized patients in us health plans: correlates and consequences. J Ambul Care Manage. 2009;32(3):216-25. 87. Pereira Gray DJ, Sidaway-Lee K, White E, Thorne A, Evans PH. Continuity of care with doctors-a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open. 2018;8(6):e021161. 88. Starfield B, Shi L. The medical home, access to care, and insurance: a review of evidence. Pediatrics. 2004;113(Supplement 4):1495. 89. McWhinney I. The Need for a Transformed Clinical Method. In: Communicating with Medical Patients. London, UK: Sage; 1989:25. 90. College of Family Physicians of Canada. Best Advice guide: Patient-Centred Care in a Patient’s Medical Home. Mississauga, ON: College of Family Physicians of Canada; 2014. Available from: https://patientsmedicalhome. ca/resources/best-advice-guides/best-advice-guide-patient-centredness/. Accessed 2019 Jan 22. 91. Canadian Medical Association, Canadian Nurses Association. Principles to Guide Health Care Transformation in Canada. Ottawa, ON: Canadian Medical Association; 2011. 92. Patients Canada. Why we need a Health Accord with Patients at the Centre [news release]. Toronto, ON: Patients Canada; 2016. Available from: https:// patientscanada.ca/2016/01/18/why-we-need-a-health-accord-with-patients-atthe- centre/. Accessed 2019 Jan 22. 93. Omole FS, Sow CM, Fresh E, Babalola D, Strothers H. Interacting with patients’ family members during the office visit. Am Fam Physician. 2011; 84(7): 780-784. 94. Mitnick S, Leffler C, Hood VL; American College of Physicians Ethics, Professionalism and Human Rights Committee. Family caregivers, patients and physicians: ethical guidance to optimize relationships. J Gen Intern Med. 2010;25(3):255-60. 95. Panagioti M, Richardson G, Small N, Murray E, Rogers A, Kennedy A, et al. Self-management support interventions to reduce health care utilisation without compromising outcomes: a systematic review and meta-analysis. BMC Health Serv Res. 2014;14:356. 96. College of Family Physicians of Canada. Best Advice guide: Chronic Care Management in a Patient’s Medical Home. Mississauga, ON: College of Family Physicians of Canada; 2016. Available from: https://patientsmedicalhome.ca/ resources/best-advice-guides/best-advice-guide-chronic-care-managementpatients- medical-home/. Accessed 2019 Jan 22. 97. Prevention in Hand website. www.preventioninhand.com. Accessed 2019 Jan 22. 98. Kruse CS, Argueta DA, Lopez L, Nair A. Patient and provider attitudes toward the use of patient portals for the management of chronic disease: a systematic review. J Med Internet Res. 2015;17(2):e40. 99. Kruse CS, Bolton K, Freriks G. The effect of patient portals on quality outcomes and its implications to meaningful use: a systematic review. J Med Internet Res. 2015;17(2):e44. 100. Health Council of Canada. Which way to quality? Key perspectives on quality improvement in Canadian health care systems. Toronto, ON: Health Council of Canada; 2013. Available from: https://healthcouncilcanada.ca/files/ QIReport_ENG_FA.pdf. Accessed 2019 Jan 22. 101. Mattison CA, Wilson MC. Rapid Synthesis: Examining the Effects of Valuebased Physician Payment Models. Hamilton, ON: McMaster Health Forum; 2017. Available from: www.mcmasterforum.org/docs/default-source/productdocuments/ rapid-responses/examining-the-effects-of-value-based-physicianpayment- models.pdf?sfvrsn=2. Accessed 2019 Jan 22. \ 102. Kaczorowski J, Hearps SJ, Lohfeld L, Goeree R, Donald F, Burgess K, et al. Effect of provider and patient reminders, deployment of nurse practitioners, and financial incentives on cervical and breast cancer screening rates. Can Fam Phys. 2013; 59(6): e282-9. 103. Hutchison B. Pay for performance in primary care: proceed with caution, pitfalls ahead. Healthc Policy. 2008; 4(1): 10-15. 104. College of Family Physicians of Canada. The Practice Improvement Initiative (Pii) website. www.cfpc.ca/pii/. Accessed 2019 Jan 22. 105. Ontario College of Family Physicians. Advancing Practice Improvement in Primary Care – Final Report. Toronto, ON: Ontario College of Family Physicians; 2015. Available from: https://ocfp.on.ca/docs/default-source/ default-document-library/hqo_final_report_advancing_practice_improvement_in_ primary_care.pdf?sfvrsn=d793f489_4. Accessed 2019 Jan 22. 106. Canadian Institutes of Health Research. Strategy for Patient-Oriented Research website. www.cihr-irsc.gc.ca/e/41204.html. Accessed 2019 Jan 22. 107. Hasley PB, Simak D, Cohen E, Buranosky R. Training residents to work in a patient-centered medical home: What are the outcomes? J Grad Med Educ. 2016; 8(2): 226-231. 108. College of Family Physicians of Canada. Specific Standards for Family Medicine Residency Programs – The Red Book. Mississauga, ON: College of Family Physicians of Canada; 2016. 109. College of Family Physicians of Canada. Triple C Competency Based Curriculum website. www.cfpc.ca/Triple_C/. Accessed 2019 Jan 22. 110. Filipe HP, Silva ED, Stulting AA, Golnik KC. Continuing professional development: Best practices. Middle East Afr J Ophthalmol. 2014; 21(2): 134-141. 111. College of Family Physicians of Canada. Family Medicine Professional Profile website. www.cfpc.ca/fmprofile/. Accessed 2019 Jan 22.
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Towards a Sustainable Health Care System in the New Millennium : Submission to the House of Commons Standing Committee on Finance 2000 Pre-Budget Consultation Process

https://policybase.cma.ca/en/permalink/policy1977
Last Reviewed
2018-03-03
Date
1999-09-10
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2018-03-03
Date
1999-09-10
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
On the cusp of the new millennium, it is appropriate to reflect with pride on our nation's past and to plan with compassion, innovation and creativity for our nation's future. The new century will present us with many challenges-an ageing population, increased knowledge with corresponding advances in technology and research, competitiveness at home and abroad- to meet the needs of Canadians. CMA recognizes that we live in a world that is increasingly interdependent. A world where globalization has meant that we, as a country, must look forward and beyond our borders when it comes to determining how we can reach our collective potential. [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] As we plan for the future it is vital to recognize the importance of the social programs that must remain essential features of our society. Our health care system is an important and defining feature of what it is to be Canadian. CMA believes a well funded, sustainable, quality health care system must be at the forefront of the federal government's strategic priorities. The haste to reduce health care costs over the past several years has left a destabilized and demoralized health system in its wake. Diminished access to critical health care services and insufficient human resources are only part of the legacy. Rebuilding Canadians' confidence in the health care system will not be easy. CMA noted the important first step that was taken by the federal government in its 1999 budget. A reinvestment of $11.5 billion earmarked for health care was an important signal to Canadians. However, with the complete restoration of funds in 2003/04 the health care system will only be back to its 1995 nominal spending levels, some seven years after the fact - with no adjustment for the increasing health care needs of an increased number of more aged Canadians, inflation or economic growth. CMA is encouraged with federal government's recent initiatives to increase health research funding. This is of direct benefit to the health of Canadians; to the health care system; to foster the development of health care as an industry and to ensure our best and brightest medical scientists and health researchers are educated and remain in Canada. However, we know that more needs to be done to ensure innovation and competitiveness. We would like to echo the words of the Prime Minister who said we consider Medicare to be the best example of how good social policy can be good economic policy, too. While reflecting the desire of Canadians to show compassion for their fellow citizens, Medicare also serves as one of our key competitive advantages. A sustained health care system will ensure a healthy population, and a healthy labour force that contributes to the productivity of the nation. In seeking to place the health care system on the road to long-term sustainability, the CMA is committed to working in close partnerships with the federal government and others in identifying, developing and implementing policy initiatives that serve to strengthen Canadians' access to quality health care The CMA looks forward to contributing to the search for solutions. To work with the federal government and others in building a responsive, flexible and sustainable health care system for all Canadians. In this spirit of co-operation the CMA offers the following recommendations: 1. That the federal government fund Canada's publicly financed health care system on a long-term, sustainable basis to ensure quality health care for all Canadians. 2. That the federal government introduce a health-specific portion of federal cash transfers to the provinces and territories to promote greater public accountability, transparency and visibility. 3. That the federal government, at a minimum, increase federal cash for health care by an additional $1.5 billion, effective April 1, 2000. 4. That beginning, April 1, 2001, the federal government fully index the total cash entitlement allocated to health care through the use of a combination of factors that would take into account the changing needs of Canadians based on population growth, ageing, epidemiology, current knowledge and new technologies, and economic growth. 5. That the federal, provincial and territorial governments adopt the guiding principle of national self-sufficiency in the production and retention of physicians to meet the medical needs of the population, including primary to highly specialized medical care, and the requirements for a critical mass for teaching and research. 6. That the federal government establish and fund a national pool of re-entry positions in postgraduate medical education. 7. That the federal government establish a National Centre for Health Workforce Research. 8. That the federal government enhance financial support systems, such as the Canada Student Loans Program, for medical students in advance of any future tuition increase, and ensure that these support systems are set at levels that meet the financial needs of students. 9. That health care services funded by the provinces and territories be zero-rated. 10. That the federal government establish a National Health Technology Fund to increase country-wide access to needed health technologies. 11. That the federal government continue to increase funding for health research on a long-term, sustainable basis. 12. That the federal government commit stable funding for a comprehensive tobacco control strategy; this strategy should ensure that the funds are invested in evidence-based tobacco control projects and programs, which would include programs aimed at prevention and cessation of tobacco use and protection of the public from tobacco's harmful effects. 13. That the federal government support the use of tobacco tax revenues for the purpose of developing and implementing tobacco control programs. 14. That the federal government place a high priority for funding tobacco prevention and evidence-based cessation programs for young Canadians as early as primary school age. 15. That the federal government follow a comprehensive integrated tobacco tax policy a) To implement selective stepwise tobacco tax increases to achieve the following objectives: (1) reduce tobacco consumption, (2) minimize interprovincial/territorial smuggling of tobacco products, and (3) minimize international smuggling of tobacco products; b) To apply the export tax on tobacco products and remove the exemption available on tobacco shipments in accordance with each manufacturers historic levels; and c) To enter into discussions with the US federal government to explore options regarding tobacco tax policy, raising Canadian tobacco price levels in line with or near the US border states, in order to minimize international smuggling. 16. That the dollar limit of RRSPs at $13,500, increase to $15,500 for the year 2000/01. 17. That the federal government explore mechanisms to increase RRSP contribution limits in the future given the delay in achieving pension parity, since 1988. 18. That the 20% Foreign Property Rule for deferred income plans such as Registered Retirement Savings Plans and Registered Retirement Income Funds be increased in 2% annual increments to 30% over a five year period, effective the year 2000. 19. That the federal government explores the regulatory changes necessary to allow easier access to RRSP funds for investment in small and medium-size businesses. 20. That the federal government undertake the necessary steps to creditor-proof RRSPs and RRIFs. I. INTRODUCTION The Canadian Medical Association (CMA) commends the federal government in its second mandate, for continuing with the pre-budget consultation process. This visible and accountable process encourages public dialogue in the consideration and development of finance, economic and social policies of the country. [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] As part of the 2000 pre-budget consultation process, the CMA welcomes the opportunity to submit its views to the House of Commons Standing Committee on Finance, and looks forward to meeting with the Committee at a later date to discuss our recommendations and their rationale in greater detail. II. POLICY CONTEXT Over the past few years, there has been a significant amount of attention placed on the fact that Canada is living in a world that is increasingly interdependent. A world where globalization has meant that we, as a country, must look forward, outward and with others when it comes to determining how we can reach our collective potential. While further political and economic change is likely to continue, it is important to recognize that there are important social programs that must remain essential features of our society. One such program is our health care system - an important and defining feature of what it is to be Canadian. The CMA believes that when it comes to maintaining and enhancing the health of Canadians, a well-funded, sustainable health care system must be at the forefront of the federal government's strategic priorities. By 2002, it is estimated that there will be 2.3 million more Canadians and 444,000 more Canadians over the age of 65. As a consequence, Canada's health care system will continue to face significant challenges in the near future. The pan-Canadian haste of governments across the country to reduce health care costs as quickly as possible over the past several years left a destabilized and demoralized health system in its wake. Diminished access to critical health care services and insufficient human resources are only part of the legacy. The initial federal reinvestment will help ease some of the pressures but it will not be much more than a short-term solution given that expectations and demands on the system will continue to rise. Rebuilding Canadians' confidence in the health care system will not be easy. Reports of overcrowded emergency rooms, physician and nursing shortages, and of patients being sent to the United States for treatment to reduce waiting times will not help restore their faith. The CMA fully recognises the importance of the first step taken by the federal government. However, fundamental questions remain about future steps needed to sustain our cherished health care system over the short-, medium- and long-term - ensuring that all Canadians will have ready access when they or their families are in need. Given this first step, the CMA believes that we must shift our focus to the vision and overarching strategic framework the federal government must develop to ensure that the health care system will be funded on a sustainable basis. In seeking to place the health care system on the road to long-term sustainability, the CMA is committed to working closely with the federal government in identifying, developing and implementing policy initiatives that serve to strengthen Canadians' access to quality health care. III. TOWARDS A SUSTAINABLE HEALTH CARE SYSTEM In its 1999 budget, the federal government took an important first step forward toward stabilizing Canada's health care system. The government announced a five-year fiscal framework, effective April 1, 1999 that reinvested $11.5 billion, on a cumulative basis, in the health care system. While this is an important first step, it must be placed in perspective. The $11.5 billion is a cumulative figure over five consecutive years. On an annual basis, this means that federal cash for health care is scheduled to increase by $2.0 billion for 1999/2000; it will remain at the same level for 2000/01 and then increase by $500 million (to $2.5 billion) in 2001/02, and remain at that level for the years 2002/03 and 2003/04. Only in year 4 does the CHST cash floor increase by a total of $2.5 billion. 1 Restoring $2.5 billion to the Canada Health and Social Transfer (CHST) cash floor in 2002/03, the fourth year of the government's five-year timetable, means that the health system will only be back to its 1995 nominal spending levels, 7 years after the fact - with no adjustment for the increasing health care needs of Canadians, inflation or economic growth. 2 [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [TABLE END] In current dollars, it is estimated that the federal government allocates approximately 41% of CHST cash for health care. Based on a cash floor of $12.5 billion this amounts to $5.13 billion. The CMA recognizes that the federal amount has increased cash by a minimum of $2.0 billion in 1999/00 to $7.13 billion, however, once again this figure must be placed in context; $7.13 billion represents only 9 cents of each dollar spent on health care in Canada. Another way to express the $11.5 billion is to adjust the figure by the number of Canadians (i.e., a per capita basis - see Figure 1). 3 Scenario 1 illustrates nominal per capita federal CHST cash for health care prior to the 1999 budget with projections to 2003/04. In absence of a five-year fiscal framework introduced by the government, federal CHST cash (formerly Established Programs Financing and the Canada Assistance Plan) would have gone from $247 in 1990/01 to $163 per Canadian in 2003/04 - a decrease of 34%. Adjusting for inflation, federal CHST cash for health care would have dropped from $247 to $131 per Canadian - a decrease of 47%. With the introduction of the $11.5 billion in 1999 (Scenario 2), nominal per capita CHST cash for health care increases from $168 to $233 in 1999/00. This, however, falls short of the $258 per capita in 1995/96. With an estimated population of 30.6 million Canadians, the CHST shortfall is estimated to be $765 million (i.e., $258 - $233 x 30.6 million). Recognizing that inflation since 1995 has eroded the value of the federal CHST cash in 1999, the figure is estimated to be closer to $1.5 billion than $1.0 billion. Furthermore, there is no escalator attached to the federal CHST cash to account for inflation, a growing and ageing population, epidemiological trends or the diffusion of new technologies. This is a departure from previous formulae under Established Programs Financing (EPF) and the CHST which included an escalator (i.e., a three-year moving average of nominal Gross Domestic Product) to grow the value of the cash transfer. 4 In summary, the context placed around $11.5 billion is important, for it underscores the importance of the initial step that has been taken by the federal government when it comes to shoring up funding for health care in Canada. However, the critical issue now becomes what immediate and successive steps will be taken by the government to place the funding of our health care system on a longer-term and sustainable basis. The CMA is not alone in its view that there must be a full restoration of CHST cash. The Communiqué issued by the First Ministers at the recent 40th Annual Premiers Conference in Quebec City was clear in the interpretation of sustainability. While we consider how to ensure that the health care system will be here for all Canadians over the short, medium and long-term, we know that our society is growing and ageing. It is projected that individuals over the age of 65 will increase from just over one in ten (12.2%) in 1996 to one in five (21.7%) in 2031. 5 [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] The combination of population growth and ageing will place additional pressure on health expenditures. Estimated per capita health expenditures by age for 1994 (see Table 1), shows that per capita expenditures for the 65 and over age group were $8,068, in comparison to $2,478 for the population as a whole-just over a three-to-one ratio. 6 Of interest, while the 65 and over population represented less than 12% of the population in 1994, it is estimated to have accounted for almost 40% of total health expenditures. The Auditor General of Canada, using age-specific per capita health spending, has projected that government health expenditures may reach 12% of GDP. 7 This is a large estimated increase given that the 1998 total health expenditures, which includes both government and private sources, is approximately 9% of GDP. [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 1 Per Capita Health Expenditures By Age Group, 1994 Age Group Expenditures per capita 0-14 $1,156 15-44 $1,663 45-64 $2,432 65+ $8,068 Source: National Health Expenditures, CIHI, 1996. [TABLE END] While it may be argued that those are only estimates, the OECD study on population shows that they are not at all atypical of the international experience. 8 This information alone will present the health care system with a number of challenges when it comes to meeting the future needs of the population. Given the current and impending pressures on the health care system, it is incumbent on the federal government - the guardian of Medicare - to think how we, as a society, will be able to maintain our health care system well beyond the new millennium. [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] The CMA therefore recommends: 1. That the federal government fund Canada's publicly financed health care system on a long-term, sustainable basis to ensure quality health care for all Canadians. 2. That the federal government introduce a health-specific portion of federal cash transfers to the provinces and territories to promote greater public accountability, transparency and visibility. 3. That the federal government, at a minimum, increase federal cash for health care by an additional $1.5 billion, effective April 1, 2000. 4. That beginning April 1, 2001, the federal government fully index the total cash entitlement allocated to health care through the use of a combination of factors that would take into account the changing needs of Canadians based on population growth, ageing, epidemiology, current knowledge and new technologies, and economic growth. Recommendation 1 is principle-based and speaks to the importance of moving away from managing Canada's health care system on a crisis-to-crisis basis. While the balance between affordability and sustainability of our system should be at the forefront of our thinking, it must not deny Canadians reasonable access to quality health care. It also recognizes that although the federal government has an essential role to play, it cannot do it alone; it must work in close partnership with the provinces and territories. Consistent with the Minister of Health's call for increased accountability and transparency in our health care system, Recommendation 2 calls on the federal government to be measured by the very same principle when it comes to funding Canada's health care system. It is also consistent with the Social Union Agreement calling for greater public accountability on all levels of government. While last year's allocation under the CHST for health care sends an important message, consideration must be given as to how the CHST can be restructured to promote greater transparency and linkage between the sources of federal funding for health care and their intended uses at the provincial/territorial level. This is particularly important when one considers the need to better understand the relationship between defined health care expenditures and their relationship to health outcomes. In fact, it could be argued that last year's federal budget implicitly re-introduced the concept of earmarking CHST cash to health care. At a time of increased demand for accountability, the CHST mechanism appears to be anachronistic by having one indivisible cash transfer that does not recognize explicitly the federal government's contribution to health in a post-Social Union Agreement world. Last year, the CMA recommended to the federal government that it reinvest a total of $3.5 billion effective April 1, 1999 into the health care system with the principal objectives of: stabilizing the health care system; and assisting in the transitional process of expanding the continuum of care. As part of the $3.5 billion, the CMA recommended the creation of a Health System Renewal Fund which focused on four discrete areas of need: (1) acute care infrastructure; (2) community care infrastructure; (3) support Canadians at risk; and (4) health information technology. Given that the government reinvested $2.0 billion in 1999/2000, the CMA recommends that the federal government move immediately to reinvest an additional $1.5 billion for health care to facilitate continued system stabilization as well as further development toward an expanded continuum of care. These additional and necessary resources would be welcomed in addressing strategic policy challenges related to health human resource requirements - particularly those associated with the need for an adequate and stable supply of physicians and nurses; the cornerstone of our health care system. Furthermore, these resources would assist in the development of necessary capital infrastructure required to assist in the transition from institutional to community-based models of care, within a more integrated framework. While more specific and substantial funding announcements would be expected with any new shared programs announced by the federal and provincial/territorial governments (e.g., home care and pharmacare), there is a need now, while the system is in flux to ensure that no one falls through the cracks. This transitional funding will assist in the stabilization of the system and will also serve to ensure that as the system evolves toward an expanding continuum of care, it will remain accessible, with minimal interruption of service to Canadians. Based on recent estimates of the government's surplus in 1999 (standing at $4.8 billion through the first three months of fiscal 1999) and beyond, (9) it would appear that the government has an opportunity to make good on its commitment to make health care a key priority for future action. [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] Recommendation 4 addresses the need for a fully indexed escalator to ensure that the federal cash contribution will continue to grow to meet the future health needs of Canadians. The escalator formula recognizes that health care needs are not always synchronized with economic growth. In fact, in times of economic hardship (e.g., unemployment, stress, and familial discord), a greater burden is placed on the health care system. If left as is, the current federal cash value will continue to erode over time with increasing demands from an ageing and growing population, and inflation. Combined, these recommendations speak not only to the fundamental principles of the necessity of having a sustainable health care system, but also in terms of the federal government continuing to take the necessary concrete leadership steps to ensure that adequate and long-term funding is available to meet the health care needs of all Canadians. The recommendations are strategic and targeted, and serve to build on and strengthen the core foundation of our health care system. If Canada's health care system is not only to survive, but thrive in the new millennium, we must give serious consideration to a range of possible solutions that place our system, and the federal role in that system, on a more secure and sustainable financial foundation. The CMA is prepared to continue to work with governments and others in developing innovative and lasting solutions to the challenges that face the health care system. IV. SUSTAINABLE HEALTH CARE AND PRODUCTIVITY In last year's report tabled in the House of Commons, the Standing Committee on Finance proposed the development of a productivity covenant. The Covenant "should subject all existing government initiatives (spending, taxation, regulation) to an assessment which evaluates their expected effects on productivity and hence the standard of living of Canadians. Every new budgetary initiative should be judged according to this productivity benchmark." 10 [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] In the context of reinvesting in health care, the Standing Committee's Covenant asks that a "business case" be made. The CMA is of the view that there exists an important relationship between a well-funded, sustainable, public health care system and economic productivity. Just as strong economic fundamentals are generally viewed as an essential requirement for Canada's prosperous future, stable, adequate and where required, increased resources for health and health care funding should also be considered as an investment in the future well-being of Canadians, and by extension, our economic ability to compete. Framed in this context, these "investments" strengthen the capacity of Canadians to live rewarding and productive lives. From a structural perspective, studies have recognized the link between a well-funded, sustainable health care system as an important contributor to Canada's economic performance. 11 [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] The studies suggest that the nature in which Canada largely finances its health care system through general taxes is more efficient compared to the United States which finances its system predominantly through employer-sponsored programs. Compared to the United States, Canada finances its health care system more equitably by spreading the financial risk across all taxpayers. As well, issues related to job mobility and the portability of health care benefits are not in question in the Canadian system. However, recent federal underfunding in health care has significantly contributed to impaired access to care by injured and sick workers delaying their return to work, decreasing productivity and increasing the cost of doing business and the cost to society. 12 A well-funded, sustainable health care system can be viewed as an important component in the decision-making process of businesses to locate in Canada. 13 In this context, there are a number of benefits that may accrue to Canadians at the individual and societal level, for example: * it can attract medium- and long-term business investment; * lead to the development of new infrastructure (e.g., facilities, equipment); * nurture the development of new long-term (value-added) jobs; * generate real and growing incomes; * increase individual and societal economic activity/consumption, wealth and investment capital; * reduce overall dependence on publicly funded social programs (e.g., employment insurance, income support programs); and * contribute to a growing and sustainable tax base. Underscoring the important linkages between the quality of life of Canadians and productivity is the important role of an efficient and well-funded public health care system and sustained economic growth. Given that policy decisions impact on the economy, health and health care should not necessarily be considered in isolation. In fact, wherever possible, good economic policy and good health and health care policy should be mutually reinforcing, or at a minimum, better synchronized. In an increasingly global, interdependent and competitive marketplace, businesses are not looking to assume greater costs. When it comes to health care, they are not looking to absorb high risk and high cost cases that are currently funded through the public sector. Instead, it would appear that they prefer a well-funded, sustainable health care system that is responsive to the health and health care needs of Canadians. 14 As well, a sustainable publicly funded health care system affords Canadians full mobility (i.e., portability) when it comes to pursuing job opportunities, which in turn, improves productivity. Good economic policy and good health care policy are compatible Canadian societal priorities. One need not be sacrificed to achieve the other nor should they be considered to be in competition with each other. Access to quality health and health care services is an important contributor towards Canada's ability to remain competitive in an increasingly complex global economic environment. Governments at all levels, must take responsibility to ensure that the health system remains on a long-term sustainable financial footing to the extent that it continues to benefit Canadians at the individual and societal level, and in terms of maximizing our quality of life and our ability to be productive. V. PHYSICIAN WORKFORCE ISSUES Canada is now beginning to experience a physician shortage that will be significantly exacerbated in the early decades of the next century. One of the chief contributing factors to the emerging shortage of physicians has been the almost singular focus of governments in their efforts to contain health care costs in the 1990s. A key policy approach introduced by governments to reduce cost growth in health has been to decrease the supply of physicians. A 12-point accord on physician resource management reached by Health Ministers in Banff, Alberta in 1992 included a recommendation for a 10% reduction in undergraduate enrolment in medical schools, which was implemented in the fall of 1993, and a recommendation for a similar percentage reduction in the number of postgraduate training positions. In addition, the introduction in 1992 of the requirement for a minimum of 2 years of prelicensure training removed most of the flexibility that used to exist in the number of postgraduate training slots. For instance, the opportunity for re-entry was no longer available to practising physicians; these re-entry opportunities ensured that young graduates (in general and family medicine) who had opted to go out and do locums or rural placements could then come back into the system at a later date for skills enhancement or speciality training. What the federal/provincial/territorial Ministers of Health did not take into account, however was that the output of Canada's medical schools peaked in the mid-1980s. Between 1986 and 1989, physician supply increased on average by 1,900 per year. This growth was halved between 1989 and 1993 - dropping to an average increase of 960 physicians per year. After 1993, total physician supply dropped in three successive years. This period of declining growth occurred well before the 1993 reductions have had an opportunity to work through the undergraduate education and post-MD training systems. Part of the reason for the decrease in supply is fewer Canadian medical graduates, but a significant part is due to increased attrition from the physician population. One factor has been increased retirement of physicians. The annual number of physicians retiring increased by 40% between the 1985-1989 and 1990-1995 periods. Although there have been up turns in the total supply of physicians in 1997 (285) and 1998 (960), this is unlikely to be sustained, given our lower levels of output from the educational system and higher attrition. The removal of most of these positions was unfortunate because re-entry can provide for more flexibility in the system and can allow for a more rapid adjustment in the physician workforce to meet the health needs of the public. For the Committee's information, appended to the Brief is the CMA's Draft Principles for a Re-entry System in Canadian Postgraduate Medical Education. According to the CMA's projection via the Physician Resource Evaluation Template (PRET), if the current levels of enrolment and attrition patterns continue, Canada will definitely experience a physician shortage in the first decades of the next century, especially after 2011, when the baby-boomer cohort of physicians will begin to retire. There is additional evidence that Canada is experiencing a physician shortage. First, it can be demonstrated that physicians are working harder than ever. Data from the CMA Physician Resource Questionnaire survey show that the mean hours per week worked by physicians (excluding on-call) have increased from 46.9 per week in 1993 to 54.1 hours in 1999 - an increase of 15.4%. [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] Second, population-based data suggest that it is becoming more difficult to access physician services. Tracking surveys conducted by the Angus Reid group on behalf of CMA show that in 1998, an estimated 60% of the population believed that access to specialist services has worsened in the past couple of years - up from 41% in 1996. Similarly, in 1998 27% of Canadians reported that access to services from a family physician had worsened - almost double the level of 14% that was reported in 1996. 15 An August 1999 poll conducted by Angus Reid asked Canadians to assess the availability of physicians in their own communities. Only a little over one half of Canadians (52%) feel there are enough physicians available to meet their community's needs. Furthermore, they expect the situation to worsen over the next five years. Less than one third (29%) feel that five years from now there will be enough physicians to meet the health care needs in their communities. 16 In summary, there is ample evidence that not only is Canada heading for a severe physician shortage, but that a shortage has been developing over the past few years. At the same time, it must be recognized that it takes on average six years to train a general practitioner and 8-12 years to train a specialist from the time one enters medical school. If we are to avoid what appears to be a significantly worsening crisis, planning for the future must begin immediately. The CMA therefore recommends: 5. That the federal, provincial and territorial governments adopt the guiding principle of national self-sufficiency in the production and retention of physicians to meet the medical needs of the population, including primary to highly specialized medical care, and the requirements for a critical mass for teaching and research. 6. That the federal government establish and fund a national pool of re-entry positions in postgraduate medical education. In close consultation and collaboration with the provinces and territories, the federal government could play an increasingly vital role when it comes to ensuring that Canada produces an adequate supply of physicians. Furthermore, it could play a role in giving physicians the flexibility they need should they require additional training to meet the emerging needs of Canadians. Cost containment initiatives have also led to decreased numbers of other health care providers all across the country, particularly nurses. The federal government could play a major role in funding and coordinating research across all jurisdictions in Canada on the appropriate supply, mix and distribution of the entire health workforce. Strategic planning in the short, medium and long-term would be greatly facilitated through the establishment of a national institution that could draw on existing national databases and compile research from all the centres in the jurisdictions across the land. The CMA therefore recommends: 7. That the federal government establish a National Centre for Health Workforce Research. RURAL-REMOTE ISSUES While there are physician shortages across the country, it is particularly acute in rural and remote regions of Canada. For a number of personal and professional reasons, physicians are not finding rural and remote practice as rewarding nor sustainable. In 1999, CMA conducted a survey of rural physicians who were asked to rate their level of satisfaction with rural medical practice both from a personal and professional perspective; this study was funded by Health Canada. A similar survey was previously done in 1991. 17 There has been little change in the level of satisfaction for the personal and family factors. However, the level of satisfaction with the professional factors has fallen significantly. In 1991, the proportion indicating they were very satisfied with work hours, professional backup, availability of specialty services and continuing medical education opportunities all decreased by at least 10 percentage points. Similarly, the percentage who were very satisfied with hospital services fell by more than half from 40% in 1991 to 17% in 1999. Likewise, in 1991 42% were very satisfied with their earning potential compared with 23% in 1999. ESCALATION AND DEREGULATION OF TUITION FEES The CMA remains very concerned about high, and rapidly escalating, medical school tuition fee increases across Canada. The CMA is particularly concerned about their subsequent impact on the physician workforce and the Canadian health care system. In addition to the significant impact of high tuition fees on current and potential medical students, the CMA believes that high tuition fees will have a number of consequences, they will: (1) create barriers to application to medical school and threaten the socioeconomic diversity of future health care providers serving the public; and (2) exacerbate the physician 'brain drain' to the United States so that new physicians can pay down their large and growing debts more quickly. In support of this priority matter, the CMA Board has struck a working group to develop a position paper on tuition fee escalation and deregulation; the working group is also planning a national, multiprofession stakeholder conference on this issue. In addition to the recommendation that follows, the CMA believes that governments should increase funding to medical schools to alleviate the pressures driving tuition increases, and that any further tuition increases should be regulated and reasonable. The CMA decries tuition deregulation in Canadian medical schools and recommends: 8. That the federal government enhance financial support systems, such as the Canada Student Loans Program, for medical students in advance of any future tuition increase, and ensure that these support systems are set at levels that meet the financial needs of students. BRAIN DRAIN The net loss of physicians from Canada to other countries has doubled since the beginning of the 1990s. Whereas a net loss of 223 physicians due to migration was recorded in 1991, the corresponding figure for 1997 was 432 physicians - which represents roughly the annual output of four to five medical schools. While these physicians leave for a variety of professional and personal reasons, what is particularly telling is that the figure has doubled over the course of the 1990s. [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] For several years, the CMA has warned governments and policy makers about the impending crisis of physician shortages and their implications for the health care system. Regrettably, the calls for a more measured, responsible and deliberate approach to physician resource planning has fallen on deaf ears. There are a number of factors that contribute to physicians leaving Canada. While they would appear to be a combination of personal, professional and economic considerations, the bottom line is our brain drain is a de facto brain gain for another country - predominantly the United States. In reviewing the brain drain issue, Statistics Canada concludes that "there is significant net brain drain in the health professions. Brain gain in health is not enough to make up for brain drain to the United States." 18 This issue is very real for physicians - who are being asked to do more where colleagues are no longer practising; and to the public - who are being asked to be patient as access to the system is delayed or compromised. In the absence of timely, strategic and lasting policy measures, we are likely to continue to risk losing physicians - many of them our best and brightest - to other countries. In this regard, the CMA is of the view that the federal government has an important role to play when it comes to synchronizing policy in the areas of health care, finance and economics. One factor that may contribute to a physician's decision to leave or think about leaving Canada is our tax structure. It is important to note that Canada relies more heavily on personal income taxes than any other G-7 country. 19 While this is important, what is more of concern is how Canada's marginal tax structure compares to that of the United States. While it is understood that Canada has taken a fundamentally different approach with regard to the magnitude and role of the tax system in social policy, the gap between the two systems can no longer be ignored in a world of increasing globalization, economic interdependence and labour mobility. While Canada's personal income tax schedule should be reviewed, it should not come as a surprise to this Committee that other tax policies - such as the Goods and Services Tax (GST)/Harmonized Sales Tax (HST) only serve to remind physicians of the severity and inequity of the problem. GOODS AND SERVICES TAX (GST) In its 1997 report to the House of Commons the Standing Committee noted the concerns of the medical profession about the application of the GST and by 1998 indicated that this issue merits further consideration by the government. The CMA believes that it has rigorously documented its concerns and further study is not required (20) - the time has come for concerted action from the federal government to remove this tax impediment. [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] When it comes to tax policy and the tax system in Canada, the CMA is strongly of the view that both should be administered in a fair and equitable manner. This principle-based statement has been made to the Standing Committee on a number of different occasions. While these principles are rarely in dispute, the CMA has expressed its strong concerns regarding their application - particularly in the case of the goods and services tax (GST) and the recently introduced harmonized sales tax (HST) in Atlantic Canada. By designating medical services as "tax exempt" under the Excise Tax Act, physicians are in the unenviable position of being denied the ability to claim a GST refund (i.e., input tax credits - ITCs) on the medical supplies necessary to deliver quality health care, and on the other, cannot pass the tax onto those who purchase such services. This is a critical point when one considers the raison-d'être of introducing the GST: to be an end-stage consumer-based tax, and not having a producer of a good or a service bear the full burden of the tax. Yet this tax anomaly does precisely that. As a result, physicians are "hermetically sealed" - they have no ability to claim ITCs due to the Excise Tax Act, or pass the costs to consumers due to the Canada Health Act. The CMA has never, nor is currently asking for, 'special treatment' for physicians under the Excise Tax Act. However, if physicians, as self-employed individuals are considered as small businesses for tax purposes, then it is clearly reasonable that they should have the same tax rules extended to them that apply to other small businesses. This is a fundamental issue of tax fairness. [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] While other self-employed professionals and small businesses claim ITCs, an independent (KPMG) study has estimated that physicians have "overcontributed" in terms of unclaimed ITCs by $57.2 million per year. Furthermore, with the introduction of the HST in Atlantic Canada, KPMG has estimated that it will cost physicians an additional $4.686 million per year. By the end of this calendar year, physicians will have been unfairly taxed in excess of $500 million. As it currently applies to medical services, the GST is bad tax policy and the HST will make a bad situation much worse for physicians. There are other health care providers (e.g., dentists, physiotherapists, psychologists, chiropractors, nurses) whose services are categorized as tax exempt. However, there is an important distinction between whether the services are publicly insured or not. Health care providers who deliver services privately have the opportunity to pass along the GST costs through their fee structures. It must be remembered that physicians are in a fundamentally different position given that 99% of their professional earnings come from the government health insurance plans: under the GST and HST, "not all health care services are created equal". There are those who argue that the medical profession should negotiate the GST at the provincial/ territorial level, yet there is no province or territory that is prepared to cover the additional costs that are being downloaded onto physicians as a result of changes to federal tax policy. Nor do these governments feel they should be expected to do so. The current tax anomaly, as it affects the medical profession, was created with the introduction of the GST - and must be resolved at the federal level. The principles that underpin the fundamental issue of tax fairness outlined by Chief Justice Hall are unassailable and should be reflected in federal tax policy. Clearly, it is fairness, not special treatment that the profession is seeking. As it currently stands for medical services, the GST and HST is bad tax policy that does not reinforce good health care policy in Canada. The CMA strongly recommends: 9. That health care services funded by the provinces and territories be zero-rated. This recommendation would be accomplished by amending the Excise Tax Act as follows: (1). Section 5 part II of Schedule V to the Excise Tax Act is replaced by the following: "A supply (other than a zero-rated supply) made by a medical practitioner of a consultative, diagnostic, treatment or other health care service rendered to an individual (other than a surgical or dental service that is performed for cosmetic purposes and not for medical or reconstructive purposes)." (2). Section 9 Part II of Schedule V to the Excise Tax Act is repealed. (3). Part II of Schedule VI to the Excise Tax Act is amended by adding the following after Section 40: 41. A supply of any property or service but only if, and to the extent that, the consideration for the supply is payable or reimbursed by the government under a plan established under an Act of the legislature of the province to provide for health care services for all insured persons of the province. The CMA's recommendation fulfils at least two over-arching policy objectives: (1) it strengthens the relationship between good economic policy and good health policy in Canada; and (2) it applies the fundamental principles that underpin our taxation system (fairness, efficiency, effectiveness), in all cases. In this regard, the CMA is committed to working closely, and on an ongoing basis, with the government to develop collaborative solutions to this tax anomaly. DIFFUSION OF HEALTH TECHNOLOGIES Recently, concerns have been raised about the lack of access to necessary diagnostic and treatment technologies in Canada. Many of the technologies are essential in the early detection of cancers (e.g., breast, prostate, lung), tumours, circulatory complications (e.g., stroke, hardening of the arteries) and other illnesses. A recent study concluded that Canada is generally in the bottom third of OECD countries in availability of technology. Canada ranks 18th (of 29 OECD countries) in making available computed tomography; 19th (of 24 OECD countries) in lithotriptor availability; and 18th (of 27 OECD countries) in availability of magnetic reasonance imagers. Canada ranks favourably only in the availability of radiation equipment (5th out of 16 OECD countries). 21 [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] Given the very real concerns that have been raised with regard to waiting lists across the country, Canadians deserve better when it comes to making available needed health technologies that can effectively diagnose and treat disease. Furthermore, it is clear that we must facilitate the diffusion of new cost-effective health technologies that are properly evaluated and meet defined standards of quality. While physicians are trained to provide quality medical care to all Canadians- they must, at the same time, have the "tools" to do so. In this context, the federal government should establish a National Health Technology Fund that would allow the provinces and territories to access funds. While the provinces and territories would be responsible for determining their respective technological priorities, the federal government would very clearly link the sources of funding with their intended uses, with full recognition for an essential investment in the health care of Canadians. The CMA recommends: 10. That the federal government establish a National Health Technology Fund to increase country-wide access to needed health technologies. The CMA is prepared to work closely with the federal government to assist in the development of objectives and deliverables of such a fund within a reasonable period of time. In so doing, the federal government would work in a strategic partnership with the provinces and territories such that monies from the fund to purchase equipment would be supported by ongoing operational resources at the site of delivery. VI. SYNCHRONIZING FEDERAL GOVERNMENT POLICY: WHERE FINANCE, ECONOMICS AND HEALTH CARE COME TOGETHER In appearing before the House of Commons Standing Committee on Finance, the CMA is well aware that policy considerations in finance and economics have an important and direct impact on the funding and delivery of health care in Canada. In the world of public policy, rarely are difficult decisions portrayed as simply being black or white. In most instances, where tough choices are made amongst a series of competing ends, they are often in varying shades of grey. While this is true when it comes to health care policy in Canada or any other discipline, it is important that it be placed in a broader context in terms of being consistent with, or reinforcing other good policy choices that have been implemented. This concept is critical to ensure that, if possible, all policy decisions are moving consistently in the same direction. In effect, synchronized in a way that the "policy whole" is greater than the sum of its individual parts. Such an approach also ensures that policy decisions taken in one sector are not countering decisions taken in other sectors. HEALTH RESEARCH IN CANADA In previous submissions to the Standing Committee on Finance, the CMA has encouraged the federal government to take the necessary steps to establish a national target and implementation plan for health research in Canada. [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] The CMA was very encouraged with the federal government's announcement in last year's budget to set aside significant resources to develop the Canadian Institute for Health Research (CIHR). By 2001, funding for the CIHR is expected to increase to $484 million. The CMA was also pleased with the Minister's recent announcement to earmark $147 million to attract and retain health researchers in Canada. In offering a vision and structure to facilitate health research in Canada, the government should be congratulated. The CMA believes that significantly increasing funding in support of health research is of direct benefit to: (1) the health of Canadians; (2) Canada's health care system; and (3) to foster the development of health care as an industry. This is where good economic policy goes hand-in-hand with good health and health care policy in Canada. The CMA strongly supports the CIHR model and is prepared to work closely with government and others to do what is necessary to make this become a reality. Recognizing that Canada is moving into a new phase when it comes to funding and undertaking health research, the government is taking an important step to ensure our best and brightest medical scientists and health researchers are developed and remain in Canada. [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] As a national organization representing the views of practising physicians across the country, the CMA strongly believes it has a meaningful contribution to make in moving the CIHR model forward. Specifically, in the areas of: * knowledge management (the CMA contributed greatly to stimulating clinical and health services research in Canada) * contributing to the research agenda (the CMA contributes to the research agenda in health services research, for example the Western Waiting List project funded by the Health Transition Fund) * ensuring quality peer-reviewed research (the CMA publishes the leading peer-reviewed medical journal in Canada) * research transfer (the CMA plays a leading role in developing tools to transfer research into practice - such as the Clinical Practice Guideline Database) * ethics (the CMA maintains a standing committee on ethics) * sustainability (the CMA has advocated for a strong Canadian presence in health research) While the CIHR will have a broad mandate for health research, physicians will have a key role to play in medical and health services research. The CMA looks forward to playing a more substantive role as the model moves to become reality. The CMA recommends: 11. That the federal government continue to increase funding for health research on a long-term, sustainable basis. TOBACCO CONTROL PROGRAMS Tobacco taxation policy should be used in conjunction with other strategies for promoting health public policy, such as public education programs to reduce tobacco use. The CMA continues, however, to maintain that a time-limited investment is not enough. Substantial and sustainable fund-ing is required for programs in prevention and cessation of tobacco use. 22 [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] A possible source for this type of program investment could be tobacco tax revenues or the tobacco surtax. The CMA believes that that the federal government should designate 0.6 cents per cigarette sold to a fund to defray the costs of tobacco interventions, including those provided by physicians with the expertise in the treatment of nicotine addiction. This would generate approximately $250 million per year to help smokers quit. 23 The CMA recommends: 12. That the federal government commit stable funding for a comprehensive tobacco control strategy; this strategy should ensure that the funds are invested in evidence-based tobacco control projects and programs, which would include programs aimed at prevention and cessation of tobacco use and protection of the public from tobacco's harmful effects. 13. That the federal government support the use of tobacco tax revenues for the purpose of developing and implementing tobacco control programs. 14. That the federal government place a high priority for funding tobacco prevention and evidence-based cessation programs for young Canadians as early as primary school age. TOBACCO TAXATION POLICY Smoking is the leading preventable cause of premature mortality in Canada. The most recent estimates suggest that more than 45,000 deaths annually in Canada are directly attributable to tobacco use. The estimated economic cost to society from tobacco use in Canada has been estimated from $11 billion to $15 billion. 24 Tobacco use directly costs the Canadian health care system $3 billion to $3.5 billion (25) annually. These estimates do not consider intangible costs such as pain and suffering. CMA is concerned that the 1994 reduction in the federal cigarette tax has had a significant effect in slowing the decline in cigarette smoking in the Canadian population, particularly in the youngest age groups - where the number of young smokers (15-19) is in the 22% to 30% range and 14% for those aged 10-14. 26 A 1997 Canada Health Monitor Survey found that smoking among girls 15-19 is at 42%. 27 A Quebec study found that smoking rates for high school students went from 19% to 38%, between 1991 and 1996. 28 The CMA congratulates the federal government's initiatives to selectively increase federal excise taxes on cigarettes and tobacco sticks. This represents the first step toward the development of a federal integrated tobacco tax strategy, and speaks to the importance of strengthening the relationship between good health policy and good tax policy in Canada. The CMA understands that tobacco tax strategies are extremely complex. Strategies need to consider the effects of tax increases on reduced consumption of tobacco products with increases in interprovincial/ territorial and international smuggling. In order to tackle this issue, the government could consider a selective tax strategy. This strategy requires continuous stepwise increases to tobacco taxes in those selective areas with lower tobacco tax (i.e., Ontario, Quebec and Atlantic Canada). The goal of selective increases in tobacco tax is to increase the price to the tobacco consumer over time (65-70% of tobacco products are sold in Ontario and Quebec). The selective stepwise tax increases will approach but may not achieve parity amongst all provinces; however, the tobacco tax will attain a level such that interprovincial/territorial smuggling would be unprofitable. The selective stepwise increases would need to be monitored so that the new tax level and US/Canadian exchange rates do not make international smuggling profitable. The selective stepwise increase in tobacco taxes can be combined with other tax strategies. The federal government should be congratulated for reducing the export exemption available on shipments in accordance with each manufacturers' historic levels, from 3% of shipments to 2.5%. However the CMA believes that the federal government should remove the exemption. The objective of implementing the export tax would be to make cross-border smuggling unprofitable. The federal government should establish a dialogue with the US federal government. Canada and the US should hold discussions regarding harmonizing US tobacco taxes with Canadian levels at the factory gate. Alternatively, Canadian tobacco tax policy should raise price levels such that they approach US tobacco prices. The CMA therefore recommends: 15. That the federal government follow a comprehensive integrated tobacco tax policy (a) To implement selective stepwise tobacco tax increases to achieve the following objectives: (1) reduce tobacco consumption, (2) minimize interprovincial/territorial smuggling of tobacco products, and (3) minimize international smuggling of tobacco products; (b) To apply the export tax on tobacco products and remove the exemption available on tobacco shipments in accordance with each manufacturers' historic levels; and (c) To enter into discussions with the US federal government to explore options regarding tobacco tax policy, raising Canadian tobacco price levels in line with or near the US border states, in order to minimize international smuggling. REGISTERED RETIREMENT SAVINGS PLANS (RRSPS) There are at least two fundamental goals of retirement savings: (1) to guarantee a basic level of retirement income for all Canadians; and (2) to assist Canadians in avoiding serious disruption of their pre-retirement standard of living upon retirement. Reviewing the demographic picture in Canada, we know that an increasing portion of society is not only aging, but is living longer. Assuming that current trends will continue and peak in the first quarter of the next century, it is important to recognize the role that private RRSP savings will play in ensuring that Canadians may continue to live in dignity well past their retirement from the labour force. In its 1996 budget statement, the federal government announced that the contribution limits of RRSPs was to be frozen at $13,500 through to 2002/03, with increases to $14,500 and $15,500 in 2003/04 and 2004/05 respectively. As well, the maximum pension contribution limit for defined benefit registered pension plans will be frozen at its current level of $1,722 per year of service through 2004/05. This is a de facto increase in tax payable. This policy runs counter to the 1983 federal government White Paper on The Tax Treatment of Retirement Savings where the House of Commons Special Committee on Pension Reform recommended that the limits on contributions to tax-assisted retirement savings plans be amended so that the same comprehensive limit would apply regardless of the retirement savings vehicle or combination of vehicles used. In short, the principle of 'pension parity' was explicitly recognized and endorsed. Since that time, in three separate papers released by the federal government (1983, 1984, 1987), the principle of pension parity would have been achieved between money-purchase (MP) plans (i.e., RRSPs) and defined-benefit (DB) plans (i.e., Registered Pension Plans) had RRSP contribution limits risen to $15,500 in 1988. As a founding member of the RRSP Alliance, the CMA, along with others has been frustrated that eleven years of careful and deliberate planning by the federal government around pension reform has not come to fruition. In fact, if the current policy remains in place it will have taken more than 17 years to implement needed reforms to achieve parity (from 1988 to 2005). While pension parity will be achieved between RRSP plans and RPP plans in 2004/05, it will have been accomplished on the backs of Canadians whose RRSP contribution levels have been frozen for far too long. As a consequence, the current policy of freezing RRSP contribution limits and RPP limits without adjusting the RRSP contribution limits to achieve pension parity serves to maintain inequities between the two plans until 2004/05. This situation is further compounded by the implementation of this policy because the RRSP/RPP plans are frozen and therefore unable to grow at the rate in the yearly maximum pensionable earnings (YMPE) Specifically, if the recommended policy of pension parity had been implemented in 1988, the growth in RRSP and RPP contribution limits could have grown in line with the yearly maximum pensionable earnings - and would be approximately $21,000 today. [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] TABLE 2 - RRSP Contribution Limits Adjusted by the Yearly Maximum Pensionable Earnings (YMPE Earnings (YMPE) Year YMPE % change RRSP Limits 1988 $27,700 $15,500 1989 $28,500 2.89 $15,948 1990 $28,900 1.40 $16,171 1991 $30,500 5.54 $17,067 1992 $32,200 5.57 $18,018 1993 $33,400 3.73 $18,690 1994 $34,400 2.99 $19,249 1995 $34,900 1.45 $19,529 1996 $35,400 1.43 $19,809 1997 $35,800 1.13 $20,032 1998 $36,900 3.07 $20,648 1999 $37,400 1.36 $20,928 YMPE Source: Revenue Canada, April 1999 [TABLE END] Each year the Department of Finance publishes revenue cost to the federal treasury of a number of policy initiatives. For RRSP contributions, the net tax expenditure (i.e., tax revenue not collected) is estimated to be $7.5 billion in 1998. The net tax expenditure associated with registered pension plans is estimated to be $6.2 billion in 1998. In this context, it is critical to understand the difference between tax avoidance and tax deferral. RRSPs allow Canadians to set aside necessary resources to provide for their retirement years. In the medium and longer-term, when RRSPs are converted to annuities, they bring increased tax revenues to government. While current contributions exceed withdrawals, this will not continue indefinitely as the baby boom generation retires at an accelerated rate. In sum, at a time when the government is reviewing the role of public benefits in society, there is a social responsibility placed on government to ensure a stable financial planning environment is in place which encourages greater self-reliance on private savings for retirement. From the standpoint of synchronizing good tax policy with good social policy, it is essential that the RRSP system be expanded such that it gives Canadians the means and incentive to prepare for retirement, while at the same time, lessening any future burden on public programs. The CMA recommends: 16. That the dollar limit of RRSPs at $13,500 increase to $15,500 for the year 2000/01. 17. That the federal government explore mechanisms to increase RRSP contribution limits in the future given the delay in achieving pension parity, since 1988. Under current federal tax legislation, 20% of the cost of an RRSP, RRIF or Registered Pension Plan's investments can be made in 'foreign property'. The rest is invested in 'Canadian' investments. If the 20% foreign content limit is exceeded at the end of a month, the RRSP pays a penalty of 1% of the amount of the excess. In its December 1999 pre-budget consultation, the Standing Committee on Finance made the following recommendation (p. 58): "The Committee recommends that the 20% Foreign Property Rule be increased in 2% increments to 30% over a five year period. This diversification will allow Canadians to achieve higher returns on their retirement savings and reduce their exposure to risk, which will benefit all Canadians when they retire." A study by Ernst and Young demonstrated that Canadian investors have experienced substantially better investment returns over the past 20 years with higher foreign content limits. As well, the Conference Board of Canada concluded that lifting the foreign content limit to 30% would have a neutral effect on Canada's economy. The CMA strongly supports the Standing Committee's position that there is sufficient evidence to indicate that Canadians would benefit from an increase in the Foreign Property Rule, from 20% to 30%. The CMA therefore recommends: 18. That the 20% Foreign Property Rule for deferred income plans such as Registered Retirement Savings Plans and Registered Retirement Income Funds be increased in 2% annual increments to 30% over a five year period, effective the year 2000. As part of the process to revitalize and sustain our economy, greater expectations are being placed on the private sector to create long-term employment opportunities. While this suggests that there is a need to re-examine the current balance between public and private sector job creation, the government nonetheless has an important responsibility in fostering an environment that will accelerate job creation. In this context, the CMA strongly believes that current RRSPs should be viewed as an asset rather than a liability. With proper mechanisms in place, the RRSP pool of capital funds can play an integral role in bringing together venture capital and small and medium-size business and entrepreneurs. The CMA would encourage the federal government to explore current regulatory impediments to bring together capital with small and medium-size businesses. The CMA recommends: 19. That the federal government explores the regulatory changes necessary to allow easier access to RRSP funds for investment in small and medium-size businesses. Currently, if an individual declares bankruptcy, creditors are able to launch a claim against their RRSP or RRIF assets. As a consequence, for self-employed Canadians who depend on RRSPs for retirement income, their quality of life in retirement is at risk. In contrast, if employees declare bankruptcy, creditors are unable to lay claim on their pensionable earnings. This is an inequitable situation that would be remedied if RRSPs were creditor-proofed. The CMA recommends: 20. That the federal government undertake the necessary steps to creditor-proof RRSPs and RRIFs. ENDNOTES: 1. It is important to keep in mind that in addition to the CHST, a separate accounting procedure was established through what is called a CHST Supplement. The Supplement, which totals $3.5 billion, was charged to the 1998 federal government public accounts, but is allocated over a three-year period (i.e., $2.0 billion, $1.0 billion, and $0.5 billion). However, at any point in time, a province or territory can take its portion of the $3.5 billion. 2. The $2.5 billion dollars to be reinvested represents the amount of federal cash that was removed with the introduction of the Canada Health and Social Transfer (CHST) beginning in April 1996 through to 1998. The amount is calculated on the basis of the recent historical federal cash allocation (approximately 41%) under EPF and CAP (now the CHST) to health care as a proportion of the $6.0 billion required to restore the CHST cash floor to $18.5 billion (1995/96 level). 3. The data sources for Figure 1 are: (1) CHST: Canadian Medical Association, Looking Toward Tomorrow, September 1998, p. 4.; (2) Historical national cash transfer to health from Established Programs Financing Reports, Federal-Provincial Relations Division, Department of Finance; (3) Population Statistics: Statistics Canada Catalogue no. 91-213; (4) CPI annual % change: Source for 1990-96 is Canadian Economic Observer, cat. No. 11-210-XPB, Historical Statistical Supplement 1996/97, p. 45. For 1996, 1997 and 1998 the source is Canadian Economic Observer, cat. No. 11-010-XPB, April 1999. For 1999 and 2000 the source is Royal Bank of Canada Econoscope, May 1999, p.14. For 2001, 2002 and 2003 CPI % change is assumed to stay constant at the 2000 level of 1.3%. 4. Thomson A. Federal Support for Health Care. Health Action Lobby. June 1991, p. 13. 5. Statistics Canada, Population Projections for Canada, Provinces and Territories, Medium Growth Scenario, 1993-2016, December, 1994 (Catalogue #91-520). 6. Health Canada. National Health Expenditures in Canada, 1975-1994. January 1996. 7. 1998 Report of the Auditor General of Canada, Chapter 6, Population Aging and Information for Parliament: Understanding the Choices, April. WWW: http://www.oag-bvg.gc.ca/domino/reports.nsf/html/9860xe12.html, available on 06/09/99 at 17:38:37. 8. Maintaining Prosperity in an Ageing Society. Organization for Economic Cooperation and Development, Paris, 1998. 9. The Fiscal Monitor, Department of Finance. August 1999. Current Analysis, The Royal Bank of Canada, August 1999. The Bank estimates that the fiscal dividend will reach $25.9 billion in 2004/05, and $41.2 billion in 2007/08. 10. Facing the Future - Challenges and Choices for A New Era. Report of the Standing Committee on Finance, December 1998, p. 30-31. 11. Green JP, MacBride-King J. Corporate Health Care Costs in Canada and the U.S.: Does Canada's Medicare System Make a Difference? Conference Board of Canada, 1999. Purchase B. Health Care and Competitiveness. School of Policy Studies, Queen's University, 1996. KPMG. The Competitive Alternative: A Comparison of Business Costs in Canada and the United States, 1996. Amanor-Boadu, Martin LJ. Canada's Social Programs, Tax System and the Competitiveness of the Agri-Food Sector, Guelph, Agri-Food Competitiveness Council, 1994. 12. Green JP, MacBride-King J. Corporate Health Care Costs in Canada and the U.S.: Does Canada's Medicare System Make a Difference? Conference Board of Canada, 1999. 13. KPMG. The Competitive Alternative: A Comparison of Business Costs in Canada and the United States, 1996. 14. Baillie C. Health Care in Canada: Preserving a Competitive Advantage, Speech to the Vancouver Board of Trade, April, 1999. 15. National Angus Reid Poll, 1998. 16. National Angus Reid Poll, 1999. 17. Canadian Medical Association. The 1991 Survey of Physicians in Rural Medical Practice, 1991. Canadian Medical Association. Survey on Rural Medical Practice in Canada, 1999. 18. Presentation by Statistics Canada Officials to the Standing Committee on Industry, May 1999. 19. Business Council on National Issues: Creating Opportunity, Building Prosperity. October 1998, p. 6. 21. KPMG, Review of the Goods and Services Tax on Canadian Physicians, June 12, 1992. KPMG, Review of the Impact of a Provincial Value Added Tax on Physicians in New Brunswick, Nova Scotia and Newfoundland, August 12, 1996. 21. Harriman D, McArthur W, Zelder M. The Availability of Medical Technology in Canada: An International Comparative Study. The Fraser Institute. August 1999. 22. In California, between 1988 and 1993, when the state was carrying on an aggressive public anti-smoking campaign, tobacco consumption declined by over 25%. Goldman LK, Glantz SA. Evaluation of Antismoking Advertising Campaigns. JAMA 1988; 279: 772-777. 23 In 1998, 45.613 billion cigarettes were sold in Canada. Statistics Canada, Catalogue #32-022, December, 1998. In 1997/98, total tobacco revenues were $2.04 billion, Public Accounts, Volume II, Part 1, Excise Tax Revue. The rationale for 0.6 cents per cigarette is based on a total amount of 25 cents per pack, of which the federal and provincial/territorial governments would contribute on an equal basis (i.e., 12 cents each). Recently, California passed Proposition 99 which added 25 cents to each pack of cigarettes. 24. Health Canada, Economic Costs Due to Smoking (Information Sheet). Ottawa: Health Canada, November 1996. 25. Health Canada, Economic Costs Due to Smoking (Information Sheet). Ottawa: Health Canada, November 1996. 26. Health Canada, Youth Smoking Behaviour and Attitudes (Information Sheet). Ottawa: Health Canada, November 1996. 27. Canada Health Monitor, Highlights Report, Survey #15. Price Waterhouse, January-February 1997. 28. Editorial. Raise Tobacco Taxes. The Gazette [Montreal] 1997 Sept 23. Sect B:2.
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Funding the continuum of care

https://policybase.cma.ca/en/permalink/policy9719
Last Reviewed
2018-03-03
Date
2009-12-04
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2009-12-04
Topics
Health systems, system funding and performance
Text
FUNDING THE CONTINUUM OF CARE The continuum of care may be defined as the array of health services that spans the range over the life course from primary care (including prevention and health promotion) through institutionally based secondary and tertiary care to community and home-based services that promote health maintenance, rehabilitation and palliation at the end of life. Given the ever-increasing diversity of service offerings and providers, and aging populations, governments worldwide face the ongoing challenge of what to fund for whom. After a lengthy period of examination that began in the 1930s, Canada arrived at a social consensus on universal, first-dollar coverage provision of hospital (1957)1 and physician (1966)2 services. All provinces bought into "Medicare" by the early 1970s and the 1984 Canada Health Act (CHA)3 was the capstone of the national hospital and medical insurance program, adding the principle of accessibility, which effectively prohibited user charges for insured hospital and physician services. Notwithstanding the more recent legislation, the foundation of Medicare was set in the health and health care reality of 1957. Hospital and medical services accounted for two-thirds of health spending (65%).4 Prescription drugs accounted for just 6% of spending, less than half of their 14.6% share in 2008. Life expectancy was almost a decade shorter than it is today, hence there was less concern about long-term care. The first knee replacement was not done until a decade later. The 1957 Hospital and Diagnostic Services Act specifically excluded tuberculosis hospitals, sanitaria and psychiatric hospitals as well as nursing homes/homes for the aged. These exclusions carried forward to the CHA. By all accounts the CHA has taken on an iconic status, but at the same time it is agreed that it is an impediment to modernizing Medicare through its definitions and program criteria and how they are interpreted by the provinces and territories. The CHA narrowly defines insured health services as "hospital services, physician services and surgical dental services provided to insured persons." While the CHA recognizes "extended" health services such as home care and ambulatory health care services, these are not subject to the program criteria. Over the years, the CHA has been extremely effective in preserving the publicly funded character of physician and hospital services. As of 2008, the Canadian Institute for Health Information (CIHI) has estimated that 98.4% of physician and 90.7% of hospital expenditures are publicly funded.5 The dividing line of the CHA may be seen in virtually all other categories of service. Fewer than one-half of prescription drugs (44.5%) and less than one-tenth (6.9%) of the services of other health professionals (e.g., dentistry and vision care) are publicly covered. Canada is unique among industrialized countries in its approach to Medicare. Countries with social insurance (Bismarck) funded systems tend to provide a similar total level of public expenditure over a wider range of services. Over time, as health care has moved from institutions to the community, the CHA is diminishing with respect to the share of total health spending it covers. At the time the CHA was passed, physician and hospital services represented 57% of total health spending; this has declined to 41% as of 2008. It must be emphasized that there is significant public spending beyond CHA-covered services (in excess of 25% of total spending) for programs such as seniors' drug coverage and home care; however, those programs are not subject to the CHA's program criteria. In addition, they can be subject to arbitrary cutback. While a majority of the working age population and their families are covered by private health insurance, those with lower incomes are less likely to have such benefits. Since the late 1990s, notwithstanding the widely shared concern about the sustainability of Canada's Medicare program, several high profile studies have advocated for its expansion, starting with the 1997 Report of the National Forum on Health6 and latterly with the Kirby7 and Romanow8 reports in 2002, both of which strongly recommended home care and catastrophic drug coverage. There is also growing concern about the availability of so-called "orphan drugs" that treat rare diseases such as Fabry disease, and can cost hundreds of thousands of dollars per patient for a single year of treatment. First Ministers have concluded three health accords in 20009, 200310 and 200411, each of which addresses expanding the boundaries of Medicare. To date there are a series of unfulfilled commitments from these accords, including a national basket of home care services and first-dollar coverage for home care and catastrophic drug coverage. In its 2007 report, the Health Council of Canada summarized progress on catastrophic drug costs as "disappointing."12 There is no appetite among governments in Canada to implement new universal programs with first-dollar coverage. In fact, recently governments have removed services that had previously been publicly insured, as evidenced by recent examples such as physiotherapy and chiropractic services in some jurisdictions. General Principles The CMA puts forward the following principles for funding the continuum of care in a national context, recognizing that there will continue to be a mix of public-private funding. * Canadians should take personal responsibility to plan ahead for the contingency that they may eventually require support with their activities of daily living; * home care and long-term care should be delivered in appropriate and cost-effective settings that respect patient and family preferences; * there should be quality and accreditation standards for both public and private service delivery; * there should be uniform approaches to needs assessment for home care and long-term care; * there should be a uniform means of distinguishing the medically necessary component of home care and long-term care from the accommodation component; * there should be a means of mitigating against open-ended public coverage of pharmaceutical, home care and long-term care coverage; * there should be recognition and financial support for informal care givers; * there should be consideration of risk-pooling, risk adjustment and risk sharing1 between public and private funders/providers of pharmaceutical, home care and long-term care coverage; * there should be a uniform approach to individual/household cost-sharing (e.g., copayments and deductibles); and * provision should be made for pre-funding long-term care from public and private sources. Prevention and Health Promotion The continuum of care begins with prevention and this requires a strong public health foundation that includes the core elements of population health assessment, health surveillance, health promotion, disease and injury prevention and health protection.13 An investment in public health, including health promotion and disease prevention, is critical to the future health of Canadians. One important component of effective prevention is immunization. The National Immunization Strategy was implemented in 2001 with the goal of reducing vaccine preventable diseases and improving vaccine coverage rates. The 2004 federal budget allocated $400 million to support this strategy and in 2007, $300 million was set aside in the federal budget for a Human Papillomavirus Immunization program. However, permanent funding should be allocated towards immunization programs for all illnesses that are preventable through vaccinations. The federal government also has a role to play in establishing and promoting partnerships that will enhance prevention and promotion programming down to the local level. The CMA recommends that: the federal government continue funding of the national immunization strategy consistent with the original three-year funding program; governments fund appropriate additions to the vaccination schedule, as new vaccines are developed, within the context of a national immunization strategy; and the federal government establish a Public Health Infrastructure Renewal Fund ($350 million annually) to build partnerships between all levels of government to build capacity at the local level. Pharmaceuticals Prescription drugs are the fastest growing item in the health envelope. Over the past two decades, prescription drugs as a proportion of total health spending have doubled from 7% in 1986 to an estimated 14.6% in 2008, and they are now the second largest category of health expenditure. It is estimated that less than one-half (44.5%) of prescription drug costs were paid for publicly in 2008; just over one-third (37.1%) were paid by private insurers and almost one-fifth (18.4%) out-of-pocket. The studies reported in 2002 by the Senate Standing Committee on Social Affairs, Science and Technology (Kirby) and by the Commission on the Future of Health Care in Canada (Romanow) have forged a consensus on the need for "catastrophic" pharmaceutical coverage, which may be defined as out-of-pocket prescription drug expenditures that exceed a certain threshold of household income. In the Kirby proposal, in the case of public plans, personal prescription drug expenses for any family would be capped at 3% of total family income. The federal government would then pay 90% of prescription drug expenses in excess of $5,000. In the case of private plans, sponsors would have to agree to limit out-of-pocket costs to $1,500 per year, or 3% of family income (whichever is less). The federal government would then agree to pay 90% of drug costs in excess of $5,000 per year. Both public and private plans would be responsible for the difference between out-of-pocket and $5,000, and private plans would be encouraged to pool their risk. Kirby estimated that this plan would cost approximately $500 million per year. For his part, Romanow recommended a Catastrophic Drug Transfer through which the federal government would reimburse 50% of the costs of provincial and territorial drug insurance plans above a threshold of $1,500 per year. Romanow estimated that this would cost approximately $1 billion. The National Pharmaceuticals Strategy (NPS) has continued to explore cost projections of catastrophic pharmaceutical coverage, leaning toward a variable percentage threshold linked to income but there has been no public reporting on progress since 2006.14 At their September 2008 meeting, provincial/territorial health ministers called for the federal government to be an equal partner (50/50) to support a national standard of pharmacare coverage so that prescription drug costs will not exceed 5% (on average) of the net income base of provincial/territorial populations. The total estimated cost of such a program for 2006 was estimated at $5.03 billion.15 Data from Statistics Canada indicate that there is wide variation in levels of household spending on prescription drugs in Canada. In 2006 almost one in twenty (3.8%) households in Canada spent more than 5% of net income on prescription drugs; there was almost a five-fold variation across the provinces, ranging from 2.2% in Ontario to 10.1% in Prince Edward Island.16 Canada does not have a nationally coordinated policy in the area of very costly drugs that are used to treat rare diseases. Moreover, there is also an issue of expensive drugs that may be used for common diseases (wide variation has been documented across provinces/territories). Thus far the term "catastrophic" has been used by First Ministers and the NPS to describe their vision of national pharmaceutical coverage. As defined by the World Health Organization catastrophic expenditure reflects a level of out-of-pocket health expenditures so high that households have to cut down on necessities such as food and clothing and items related to children's education.17 From the CMA's perspective, this does not go far enough and what must be strived for is "comprehensive" coverage that covers the whole population and effectively pools risk across individuals and public and private plans in various jurisdictions. The CMA recommends that: governments, in consultation with the life and health insurance industry and the public, establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies; such a program should include the following elements: * a mandate for all Canadians to have either private or public coverage for prescription drugs; * a uniform income-based ceiling (between public and private plans and across provinces/territories) on out-of-pocket expenditures on drug plan premiums and/or prescription drugs (e.g., 5% of after-tax income); * FPT cost-sharing of prescription drug expenditures above a household income ceiling, subject to capping the total federal and/or provincial/territorial contributions either by adjusting the federal share of reimbursement or by scaling the household income ceiling or both; * group insurance plans and administrators of employee benefit plans to pool risk above a threshold linked to group size; and, * a continued strong role for private supplementary insurance plans and public drug plans on a level playing field (i.e., premiums and co-payments to cover plan costs); the federal government establish a program for access to expensive drugs for rare diseases where those drugs have been demonstrated to be effective; the federal government assess the options for risk pooling to cover the inclusion of expensive drugs in public and private drug plan formularies; the federal government provide adequate financial compensation to the provincial and territorial governments that have developed, implemented and funded their own public prescription drug insurance plans; governments provide comprehensive coverage of prescription drugs and immunization for all children in Canada; and the Canadian Institute for Health Information and Statistics Canada conduct a detailed study of the socio-economic profile of Canadians who have out-of-pocket prescription drug expenses to assess barriers to access and to design strategies that could be built into a comprehensive prescription drug coverage program. Home Care Home care began in Canada in the late 19th century as a charitable enterprise delivered by non-profit groups such as the Victorian Order of Nurses. In the expansionary period of the 1960s and 1970s, governments moved increasingly into this area. The New Brunswick Extra-Mural Program, arguably Canada's most successful/ambitious home care program, accepted its first clients in 1981. The Established Programs Financing Act of 1977 recognized home care as one of several extended health services and included a fund initially set at $20 per capita to cover such services. These extended services are also recognized in the CHA but are not subject to the five program criteria (principles). The 1997 Report of the National Forum on Health recommended that home care be added to Medicare (along with pharmacare). The $150 million Health Transition Fund supported several demonstration projects in the home care area. Both the Kirby and Romanow reports recommended expanded home care funding. In February 2003, First Ministers concluded an accord in which they committed to determine a basket of home care services by 30 Sept. 2003, covering short-term acute home care, community mental health and end-of-life care. To date this has not happened. The federal government implemented a Compassionate Care Benefit in 2003 to support family caregivers; however, this only applies to those who are in the paid labour force.18 According to the Canadian Institute for Health Information, there is almost a five-fold variation in the use of home care across provinces/territories.19 The extent of private expenditure on home care services is not presently known. However, Statistics Canada has reported that the proportion of Canadians living in the community who require assistance with their personal activities of eating, bathing and dressing who are receiving government-subsidized home care declined from 46% in 1994-1995 to 35% in 2003; the suggestion is that some of the burden may have shifted to home care agencies or family and friends.20 Statistics Canada has reported that in 2002, over 1.7 million adults aged 45 to 64 provided informal care to almost 2.3 million seniors with long-term disabilities or physical limitations.21 In light of the foregoing, the CMA believes that: optimal management of the continuum of care requires that patients take an active part in developing their care and treatment plan, and in monitoring their health status; the issue of the continuum of care must go beyond the question of financing and address questions related to the organization of the delivery of care and to the shared and joint responsibilities of individuals, communities and governments in matters of health care and promotion, prevention and rehabilitation; support systems should be established to allow elderly and disabled Canadians to optimize their ability to live in the community; strategies should be implemented to reduce wait times for accessing publicly funded home and community care services; integrated service delivery systems should be created for home and community care services; and any request for expanding the public plan coverage of health services, in particular for home care services and the cost of prescription drugs, must include a comprehensive analysis of the projected cost and potential sources of financing for this expansion. The CMA recommends that: governments adopt a policy framework and design principles for access to publicly funded medically necessary services in the home and community setting that can become the basis of a "Canada Extended Health Services Act;" governments initiate a national dialogue on the Canada Health Act in relation to the continuum of care; governments and provincial/territorial medical associations review physician remuneration for home and community-based services; and governments undertake pilot studies to support informal caregivers and long-term care patients, including those that: a) explore tax credits and/or direct compensation to compensate informal caregivers for their work, b) expand relief programs for informal caregivers that provide guaranteed access to respite services in emergency situations, c) expand income and asset testing for residents requiring assisted living and long-term care, and d) promote information on advance directives and representation agreements for patients. Mental Health Care In 2000 mental illness was the fourth-ranking contributor to the total economic burden of illness in Canada.22 The exclusion of psychiatric hospitals from the CHA means that they are not subject to the five principles and were not included in the original basis of the federal transfer payments. While a major Senate Committee report has pointed out that the closure of psychiatric facilities means that this exclusion is no longer pertinent, the Committee also noted that many essential services for persons with mental illness such as psychological services or out-of-hospital drug therapies are not covered under provincial health insurance plans.23 Moreover, there remain 53 psychiatric hospitals in Canada.24 The CMA recommends that: the federal government make the legislative and/or regulatory amendments necessary to ensure that psychiatric hospital services are subject to the five program criteria of the Canada Health Act; in conjunction with legislative and/or regulatory changes, funding to the provinces/territories through the Canada Health Transfer be adjusted to provide for federal cost sharing in both one-time investment and ongoing cost of these additional insured services; and Canadian physicians and their organizations advocate for parity of allocation of resources (relative to other diseases) toward the continuum of mental health care and research. Long-term Care According to Statistics Canada's most recent population projections, the proportion of seniors in the population (65+) is expected to almost double from its present level of 13% to between 23% and 25% by 2031.25 The Organization for Economic Cooperation and Development has projected that the share of Gross Domestic Product devoted to long-term care will at least double from its 2005 level of 1.2% to 2.4% by 2050, and could almost triple to (3.2%) depending on the success of efforts to contain cost.26 The potential need for long-term care is not confined to the senior population. Based on the results of its 2006 Participation and Activity Limitation Survey, Statistics Canada estimated that there were 2 million adults aged 15-64 with disabilities, of whom 40% were severely disabled; in addition there were 202,000 children with disabilities, of whom 42% were severely disabled.27 A lack of appropriate long term care is imposing a bottleneck in the acute care system. The term Alternate Level of Care (ALC) is used to describe a situation when a patient is occupying a bed in a hospital and does not require the acute care provided in this setting. According to a 2009 CIHI report, in 2007-08, there were more than 74,000 ALC patients and more than 1.7 million ALC hospital days in Canada (excluding Manitoba and Quebec), accounting for 5% of hospitalizations and 14% of hospital days. In other words, every day almost 5,200 beds in acute care hospitals were occupied by ALC patients28. This has significant consequences; emergency departments are being used as holding stations while admitted patients wait for a bed to become available, surgeries are being postponed, and the care for ALC patients may not be as good as it might be in an alternate site that is better equipped to suit their specific needs. Insufficient access to long term care at all ages is an obstacle to improving the health care system. Major investment is required in community and institutionally based care. Most of the discussion in Canada since the mid-1990s has focused on the sustainability of the current Medicare program and the prospect for enhancements such as pharmacare. There has been little attention since the early 1980s on the future funding of long-term care. Internationally, in contrast, the United Kingdom has had a Royal Commission on long-term care, and Germany has moved to put in place a contributory social insurance fund. A cursory assessment of the literature would suggest that there is a consensus that long-term care cannot/should not be financed on the same pay-as-you-go basis (i.e., current expenditures funded out of current contributions) as medical/hospital insurance programs. The federal government has several options available to promote the pre-funding of long-term care: Long-term care insurance: Policies are offered in Canada and are of fairly recent origin. There has been little take-up of such policies to date. At the end of 2005, about 52,700 Canadians were covered under long-term care insurance. One option could be to make long-term care insurance premiums deductible through a tax credit, similar to what Australia has done for private health insurance. Tax-deferred savings: The Registered Retirement Savings Plan (RRSP) has been a very popular method for Canadians to save for retirement. As of 2007, an estimated 7 out of 10 (68%) of Canadians reported having an RRSP. However, in 2002, just 27% of all tax returns filed in Canada reported deductions for RRSP contributions. In 1998, Segal proposed a Registered Long-term Care Plan that would allow Canadians to save against the possibility of their need for a lengthy period of care. Another option to consider would be to add a provision to RRSPs similar to the Lifelong Learning Plan and the Home Buyer's Plan. This would be referred to as the Long-term Care Plan and would allow tax-free withdrawals from RRSPs to fund long-term care expenses for either the RRSP investor's own care or their family members' care. Tax-prepaid saving: In Canada, the Registered Education Savings Plan (RESP) is an example of a plan whereby after-tax earnings are invested and allowed to grow tax-free until they are distributed and included in the recipient's income. In the 2007 federal budget, the government announced the introduction of a Registered Disability Savings Plan. Parents and guardians will be able to contribute to a lifetime maximum of $200,000 and similar to the RESP program there will be a related program of disability grants and bonds, scaled to income. This approach could have more general applicability to long-term care. The 2008 federal budget has introduced a tax-free savings account (TFSA) that, starting in 2009, enables those 18 and over to contribute up to $5,000 per year in after-tax income to a TFSA, whose investment growth will not be taxed; however, funds can be withdrawn at any time for any purpose29. Payroll deduction (Social Insurance): A compulsory payroll tax that would accumulate in a separate fund along the lines of the Canada Pension Plan has been recommended in provincial reports in Quebec and Alberta. In summary, whatever vehicle might be chosen, governments need to impress upon younger Canadians the need to exercise personal responsibility in planning for their elder years, given continuing gains in longevity. The CMA recommends that: governments study the options for pre-funding long-term care, including private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance; and the federal government review the variability in models of delivery of community and institutionally based long-term care across the provinces and territories as well as the standards against which they are regulated and accredited. End-of-life Care The Senate of Canada, and the Honourable Sharon Carstairs in particular, have provided leadership over the last decade in highlighting both the progress and the persistent variability across Canada in access to quality end-of-life care. In the latest (2005) of three reports issued since 1995, the Senate again calls for the development of and support for a national strategy for palliative and end-of-life care.30 In that report Still Not There it is noted that it is commonly estimated that no more than 15% of Canadians have access to hospice palliative care, and that for children, the figure drops further to just over 3%. To date, palliative care in Canada has primarily centred on services for those dying with cancer. However, cancer accounts for less than one-third (30%) of deaths in Canada. Diseases at the end of life such as dementia and multiple chronic conditions are expected to become much more prevalent in the years ahead. The demand for quality end-of-life care is certain to increase as the baby boom generation ages. By 2020 it is estimated that there will be 40% more deaths per year. While there has been a decreasing proportion of Canadians dying in hospital over the past decade, many more Canadians would prefer to have the option of hospice palliative care at the end of life than current capacity will permit. In its April 2009 report, the Special Senate Committee on Aging recommended a federally funded national partnership with provinces, territories and community organizations to promote integrated quality end-of-life care for all Canadians, the application of gold standards in palliative home care to veterans, First Nations and Inuit and federal inmates, and renewed research funding for palliative care.31 The CMA recommends that: governments work toward a common end-of-life care strategy that will ensure all Canadians have equitable access to and adequate standards of quality end-of-life care. References 1 Risk pooling is defined by the World Health Organization as the practice of bringing several risks together for insurance purposes in order to balance the consequences of the realization of such individual risk. Risk adjustment and risk sharing are means of adjusting or compensating for risk differentials between risk pools. 1 Canada. Hospital Insurance and Diagnostic Services Act. Statutes of Canada 1956-57 Chap 28. Ottawa: Queen's Printer, 1957. 2 Canada. Medical Care Act 1966-67, C. 64, 5.1. Revised Statutes of Canada 1970 Volume V. Ottawa: Queen's Printer, 1970. 3 Canada. Canada Health Act. Chapter C - 6. Ottawa, 1984. 4 Hall, E. Royal Commission on Health Services, Volume 1. Ottawa: Queen's Printer, 1964. 5 Canadian Institute for Health Information. National Health Expenditure Trends 1975-2008. Ottawa, 2008. 6 National Forum on Health. Canada Health Action: Building on the legacy - Volume 1 - the final report. Ottawa: Minister of Public Works and Government Services, 1997. 7 Standing Senate Committee on Social Affairs, Science and Technology. The health of Canadians - the federal role Volume six: recommendations for reform. Ottawa, 2002. 8 Commission on the Future of Health Care in Canada. Building values: the future of health care in Canada. Ottawa, 2002. 9 Canadian Intergovernmental Conference Secretariat. First Ministers' meeting communiqué on health. September 11, 2000. http://www.scics.gc.ca/cinfo00/800038004_e.html. Accessed 09/24/09. 10 Canadian Intergovernmental Conference Secretariat. 2003 First Ministers' Accord on Health Care Renewal. February 5, 2003. http://www.scics.gc.ca/pdf/800039004_e.pdf. Accessed 08/05/08. 11 Canadian Intergovernmental Conference Secretariat. A 10-Year plan to strengthen health care. September 16, 2004. http://www.scics.gc.ca/cinfo04/800042005_e.pdf. Accessed 08/05/08. 12 Health Council of Canada. Health care renewal in Canada: Measuring up? Toronto, 2007. 13 Canadian Institutes of Health Research. The future of public health in Canada: Developing a public health system for the 21st century. Ottawa, 2003. 14 Federal/Provincial/Territorial Ministerial Task Force on the National Pharmaceuticals Strategy. National Pharmaceuticals Strategy Progress Report. June 2006. http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2006-nps-snpp/2006-nps-snpp-eng.pdf. Accessed 08/05/08. 15 Canadian Intergovernmental Conference Secretariat. Backgrounder: National Pharmaceutical Strategy Decision Points. September 24, 2009. http://www.scics.gc.ca/cinfo08/860556005_e.html. Accessed 09/24/09. 16 Statistics Canada. Survey of Household Spending 2006. Detailed table 2, 62FPY0032XDB. 17 Xu K, Evans D, Carrin G, Aguilar-Riviera A. Designing health financing systems to reduce catastrophic health expenditure. Geneva: World Health Organization, 2005. 18 Service Canada. Employment insurance (EI) compassionate care benefits. http://142.236.154.112/eng/ei/types/compassionate_care.shtml. Accessed 09/24/09. 19 Canadian Institute for Health Information. Public sector expenditures and utilization of home care services in Canada: exploring the data. Ottawa, 2007. 20 Wilkins K. Government-subsidized home care. Health Reports 2006;17(4):39-42. 21 Pyper W. Balancing career and care. Perspectives on labour and income 2006;18(4): 5-15. 22 Public Health Agency of Canada. Table 2 Summary - Economic burden of illness in Canada by diagnostic category, 2000. Ottawa, 2000. 23 Standing Committee on Social Affairs, Science and Technology. Out of the shadows at last: transforming mental health, mental illness and addiction services in Canada. Ottawa, 2006. 24 Canadian Healthcare Association. September 2009. 25 Statistics Canada. Population projections. The Daily, Thursday, December 15, 2005. 26 Organization for Economic Co-operation and Development. Projecting OECD health and long-term care expenditures. What are the main drivers? Paris, 2006. 27 Statistics Canada. Participation and Activity Limitation Survey 2006: Tables. Catalogue no. 89-628-XlE-No. 003. Ottawa: Minister of Industry, 2007. 28 Canadian Institute for Health Information. Alternate level of care in Canada. Ottawa, 2009. 29 Canada Revenue Agency. Tax-free savings account (TFSA). http://www.cra-arc.gc.ca/E/pub/tg/rc4466/rc4466-e.html#P44_1114. Accessed 09/24/09. 30 Carstairs S. Still not there. Quality end-of-life care: a status report. http://sen.parl.gc.ca/scarstairs/PalliativeCare/Still%20Not%20There%20June%202005.pdf. Accessed 09/24/09. 31 Special Senate Committee on Aging. Final report: Canada's aging population: Seizing the opportunity. Apr 2009.
Documents
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Health and health care for an aging population

https://policybase.cma.ca/en/permalink/policy11061
Last Reviewed
2018-03-03
Date
2013-12-07
Topics
Health care and patient safety
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2013-12-07
Replaces
PD00-03 - Principles for medical care of older persons
Topics
Health care and patient safety
Health systems, system funding and performance
Text
In 2010, 14% of Canada's population was 65 or older. With the aging of the baby boom generation, this proportion is estimated to rise to about 25% in 2036 (1). The aging of Canada's population is expected to have a major impact on the country's economy, society and health care system over the next 25 to 30 years. Though age does not automatically mean ill health or disability, the risk of both does increase as people age. In 2006, 33% of Canadians aged 65 or older had a disability; the proportion climbed to 44% among people aged 75 or older (2). Nearly three-quarters of Canadians over 65 have at least one chronic health condition (3). Because of increasing rates of disability and chronic disease, the demand for health services is expected to increase as Canada's population ages. Currently Canadians over 65 consume roughly 44% of provincial and territorial health care budgets (4), and governments are concerned about the health care system's capacity to provide quality services in future. The CMA believes that to provide optimal care and support for Canada's aging population, while taking care to minimize pressure on the health-care system as much as possible, governments at all levels should invest in: * programs and supports to promote healthy aging; * a comprehensive continuum of health services to provide optimal care and support to older Canadians; and * an environment and society that is "age friendly." This policy describes specific actions that could be taken to further these three goals. Its recommendations complement those made in other CMA policies, including those on "Funding the Continuum of Care" (2009), Optimal Prescribing (2010) and Medication Use and Seniors (Update 2011). 2) Providing Optimal Health and Health Care for Older Persons: This section discusses in detail the three general areas in which the CMA believes governments should invest: a) Promotion of "Healthy Aging" The Public Health Agency of Canada (PHAC) defines healthy aging as "the process of optimizing opportunities for physical, social and mental health to enable seniors to take an active part in society without discrimination and to enjoy independence and quality of life." It is believed that initiatives to promote healthy aging, and enable older Canadians to maintain their health, will help lower health-care costs by reducing the overall burden of disability and chronic disease. Such initiatives could focus on: Physical activity. Being physically active is considered the most important step that older Canadians can take toward improving health, even if they do not start being active until later in life. However in 2008, 57% of seniors reported being physically inactive (5). Injury prevention. Falls are the primary cause of injury among older Canadians; they account for 40% of admissions to nursing homes, 62% of injury-related hospitalizations, and almost 90% of hip fractures (6). The causes of falls are complex, and both physiology (e.g. effect of illness) and environment (e.g. poorly maintained walkways) can contribute. Most falls can be prevented through a mix of interventions: for the person (such as strength and balance training); and for the person's environment, (such as grab bars and railings, slip-proof floor surfaces, walkways that are cleared of snow and ice in winter.) Nutrition. In 2008, 28% of men and 31% of women over 65 were obese (BMI = 30); this is higher than the population average. Underweight is also a problem among seniors, 17% of whom report a BMI of 20 or less (7). The reasons for nutrition problems among older Canadians are complex; they may be related to insufficient income to purchase healthy foods, or to disabilities that make shopping or preparing meals difficult. Mental health. An estimated 10-15% of seniors report depression, and the rate is higher among those with concomitant physical illness, or those living in long-term care facilities (8). Depression among older people may be under-recognized and under-treated, since it might be dismissed as a normal consequence of aging. Poor mental health is often associated with social isolation, a common problem among seniors. Recommendations: Governments and National Associations The CMA recommends that: 1. Governments at all levels support programs to promote physical activity, nutrition, injury prevention and mental health among older Canadians. Health Service Delivery The CMA recommends that: 2. Older Canadians have access to high-quality, well-funded programs and supports to help them achieve and maintain physical fitness and optimal nutrition. 3. Older Canadians have access to high-quality, well-funded programs aimed at determining the causes and reducing the risk of falls. 4. Older Canadians have access to high-quality, well-funded programs to promote mental health and well-being and reduce social isolation. Physicians and Patients The CMA recommends that: 5. Older Canadians be encouraged to follow current guidelines for healthy living, such as the 2012 Canadian Physical Activity Guidelines for adults 65 and over. 6. Physicians and other health care providers be encouraged to counsel older patients about the importance of maintaining a healthy and balanced life style. 7. All stakeholders assist in developing health literacy tools and resources to support older Canadians and their families in maintaining health. b) A Comprehensive Continuum of Health Services Though, as previously mentioned, age does not automatically mean ill health, utilization of health services does increase with increasing age. Patients over 65 have more family physician visits, more hospital admissions and longer hospital stays than younger Canadians (the overall length of stay in acute inpatient care is about 1.5 times that of non-senior adults) (9). In addition, seniors take more prescription drugs per person than younger adults; 62% of seniors on public drug programs use five or more drug classes, and nearly 30% of those 85 and older have claims for 10 or more prescription drugs (10). Heavy medication use by people over 65 has a number of consequences: * The risk of adverse drug reactions is several-fold higher for seniors than for younger patients. * Medication regimes, particularly for those taking several drugs a day on different dosage schedules, can be confusing and lead to errors or non-adherence. * Patients may receive prescriptions from multiple providers who, if they have not been communicating with each other, may not know what other medications have been prescribed. This increases the risk of harmful drug interactions and medication errors. For seniors who have multiple chronic diseases or disabilities, care needs can be complex and vary greatly from one person to another. This could mean that a number of different physicians, and other health and social-services professionals, may be providing care to the same person. A patient might, for example, be consulting a family physician for primary health care, several medical specialists for different conditions, a pharmacist to monitor a complex medication regime, a physiotherapist to help with mobility difficulties, health care aides to clean house and make sure the patient is eating properly, and a social worker to make sure his or her income is sufficient to cover health care and other needs. Complex care needs demand a flexible and responsive health care system. The CMA believes that quality health care for older Canadians should be delivered on a continuum from community based health care, (e.g. primary health care, chronic disease management programs), to home care (e.g. visiting health care workers to give baths and footcare), to long-term care and palliative care. Ideally, this continuum should be managed so that the patient can remain at home, out of emergency departments, hospitals and long term care unless appropriate, can easily access the level of care he or she needs, and can make a smooth transition from one level of care to another when needed. Care managers are an essential part of this continuum, working with caregivers and the patient to identify the most appropriate form of care from a menu of alternatives. Care managers can co-ordinate the services of the various health professionals who deliver care to a given patient, and facilitate communication among them so that all work to a common care plan. A family physician who has established a long-standing professional relationship with the patient and is familiar with his or her condition, needs and preference is ideally placed to serve as manager of a patient's overall care, supported by geriatric and other specialists as appropriate. Not all of the patient's caregivers may be health professionals; more than 75% of the care of older Canadians is delivered by unpaid informal caregivers, usually relatives. The role of the family caregiver can be demanding financially, physically and emotionally. Though governments have instituted tax credits and other forms of support for caregivers, more may be required. The Special Senate Committee on Aging has called for a National Caregiving Strategy to help put in place the supports that caregivers need. (11) Finally, many of the services required by seniors, in particular home care and long-term care, are not covered by the Canada Health Act. Funding of these services varies widely from province to province. Long-term care beds are in short supply; as a result more than 5,000 hospital beds are occupied by patients waiting for long-term care placement (12), making them unavailable for those with acute-care needs. CMA's Health Care Transformation Framework (2010) makes a number of recommendations aimed at improving access to continuing care in Canada. Recommendations: Governments and National Associations The CMA recommends that: 8. Governments and other stakeholders work together to develop and implement models of integrated, interdisciplinary health service delivery for older Canadians. 9. Governments continue efforts to ensure that older Canadians have access to a family physician, supported by specialized geriatric services as appropriate. 10. Governments and other stakeholders work together to develop and implement a National Caregiver Strategy, and expand the support programs currently offered to informal caregivers. 11. All stakeholders work together to develop and implement a national dementia strategy. 12. Governments and other stakeholders work together to develop and implement a pan-Canadian pharmaceutical strategy that addresses both comprehensive coverage of essential medicines for all Canadians, and programs to encourage optimal prescribing and drug therapy. 13. Governments work with the health and social services sector, and with private insurers, to develop a framework for the funding and delivery of accessible and sustainable home care and long-term care services. Medical Education The CMA recommends that: 14. Medical schools enhance the provision, in undergraduate education and in residency training for all physicians, of programs addressing the clinical needs of older patients. 15. Medical students and residents be exposed to specialty programs in geriatric medicine and other disciplines that address the clinical needs of older patients. 16. Continuing education programs on care for older patients be developed and provided to physicians of all specialties, and to other health care providers, on a continuous basis. Health System Planners The CMA recommends that: 17. Health systems promote collaboration and communication among health care providers, through means such as: a. Interdisciplinary primary health care practice settings, that bring a variety of physicians and other health professionals and their expertise into a seamless network; b. Widespread use of the electronic health record; and c. A smooth process for referral between providers. 18. All stakeholders work toward integration of health care along the continuum by addressing the barriers that separate: a. acute care from the community; b. health services from social services; and c. provincially-funded health care services such as physicians and hospitals, from services funded through other sources, such as pharmacare, home care and long term care. 19. Programs be developed and implemented that promote optimal prescribing and medication management for seniors. 20. Research be conducted on a continuous basis to identify best practices in the care of seniors, and monitor the impact of various interventions on health outcomes and health care costs. Physicians in Practice The CMA recommends that: 21. Continuing education, clinical practice guidelines and decision support tools be developed and disseminated on a continuous basis, to help physicians keep abreast of best practices in elder care. c) An Age-Friendly Environment: One of the primary goals of seniors' policy in Canada is to promote the independence of older Canadians in their own homes and communities, avoiding costly institutionalization for as long as feasible. To help older Canadians successfully maintain their independence, it is important that governments and society ensure that the social determinants of health care addressed when developing policy that affects them. This includes assuring that the following supports are available to older Canadians: * Adequate Income: Poverty among seniors dropped sharply in the 1970s and 1980s. In 2008, 6% of Canada's seniors were living in low income, as opposed to nearly 30% in 1978. However, there has been a slight increase in poverty levels since 2007, and it may be necessary to guard against an upward trend in future (13). Raising the minimum age for collecting Old Age Security, as has been proposed, may weigh heavily on seniors with lower incomes, and make prescription drugs, dental care and other needed health services unaffordable. * Employment Opportunities: it has been recommended that seniors be encouraged to work beyond age 65 as a means of minimizing a future drain on pension plans (14). Many older Canadians who have not contributed to employee pension plans may be dependent on employment income for survival. However, employment may be difficult to find if workplaces are unwilling to hire older workers. * Housing. Nearly all of Canada's seniors live in their own homes; fewer than 10% live in long-term care facilities. Options are available that permit older Canadians to live independently even with disabilities and health care needs, such as: o Home support for services such as shopping and home maintenance; and o Assisted-living facilities that provide both independent living quarters and support services such as nursing assistance, and cafeterias if desired. * An Age-friendly built environment. To enable seniors to live independently, the World Health Organization's "Age-Friendly Communities" initiative recommends that their needs be taken into consideration by those who design and build communities. For example, buildings could be designed with entrance ramps and elevators; sidewalks could have sloping curbs for walkers and wheelchairs; and frequent, accessible public transportation could be provided in neighbourhoods where a large concentration of seniors live. * Protection from Abuse. Elder abuse can take many forms: physical, psychological, financial, or neglect. Often the abuser is a family member, friend, or other person in a position of trust. Researchers estimate that 4 to 10% of Canadian seniors experience abuse or neglect, but that only a small portion of this is reported (15). CMA supports awareness programs to bring the attention of elder abuse to the public, as well as programs to intervene with seniors who are abused, and with their abusers. * A Discrimination-Free society. Efforts to boost income and employment security, health care standards and community support for older Canadians are hampered if the pervasive public attitude is that seniors are second-class citizens. An age-friendly society respects the experience, knowledge and capabilities of its older members, and accords them the same worth and dignity as it does other citizens. Recommendations: Governments and National Associations The CMA recommends that: 22. Governments provide older Canadians with access to adequate income support. 23. Governments devote a portion of national infrastructure funding to providing an adequate supply of accessible and affordable housing for seniors. 24. Older Canadians have access to opportunities for meaningful employment if they desire. 25. Communities take the needs and potential limitations of older Canadians into account when designing buildings, walkways, transportation systems and other aspects of the built environment. Health System Planners The CMA recommends that: 26. The health system offer a range of high-quality, well-funded home care and social support services to enable older Canadians to remain independent in the community for as long as possible. 27. Physicians receive advice and education on optimal community supports and resources to keep seniors independent and/or at home. Physicians in Practice The CMA recommends that: 28. Training and programs be provided to physicians and other care providers to enable them to identify elder abuse, and to intervene with abused people and their abusers. 3) Conclusion: Aging is not a disease, but an integral part of the human condition. To maximize the health and well-being of older Canadians, and ensure their continued functionality and independence for as long as possible, CMA believes that the health care system, governments and society should work with older Canadians to promote healthy aging, provide quality patient-centered health care and support services, and build communities that value Canadians of all ages. 1 Public health Agency of Canada. "Growing Older: Adding Life to Years. Annual report on the state of public health in Canada, 2010." Accessed at http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2010/fr-rc/index-eng.php 2 Statistics Canada: A Portrait of Seniors in Canada (2008). Accessed at http://www.statcan.gc.ca/pub/89-519-x/89-519-x2006001-eng.htm 3 Canadian Institute for Health Information. "Seniors and the health care system: What is the impact of multiple chronic conditions?" (January 2011.) Accessed at https://secure.cihi.ca/free_products/air-chronic_disease_aib_en.pdf 4 Canadian Institute for Health Information. National Health Expenditure Trends, 1975 to 2010. Accessed at http://www.cihi.ca/cihi-ext-portal/internet/en/document/spending+and+health+workforce/spending/release_28oct10 5 PHAC 2010 6 PHAC 2010 7 PHAC 2010 8 Mood Disorders Society of Canada. "Depression in Elderly" (Fact sheet). Accessed at http://www.mooddisorderscanada.ca/documents/Consumer%20and%20Family%20Support/Depression%20in%20Elderly%20edited%20Dec16%202010.pdf 9 Canadian institute for Health Information. Health Care in Canada, 2011: A Focus on Seniors and Aging. Accessed at https://secure.cihi.ca/free_products/HCIC_2011_seniors_report_en.pdf 10 CIHI 2011 11 Special Senate Committee on Aging. "Canada's Aging Population: Seizing the Opportunity." (April 2009). Accessed at http://www.parl.gc.ca/Content/SEN/Committee/402/agei/rep/AgingFinalReport-e.pdf 12 CIHI 2009 13 PHAC 2010 14 Department of Finance Canada. Economic and fiscal implications of Canada's Aging Population (October 2012). Accessed at http://www.fin.gc.ca/pub/eficap-rebvpc/report-rapport-eng.asp#Toc01. 15 PHAC 2010
Documents
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Health Care Transformation in Canada: Change that Works, Care that Lasts

https://policybase.cma.ca/en/permalink/policy9837
Last Reviewed
2018-03-03
Date
2010-07-13
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2010-07-13
Topics
Health systems, system funding and performance
Text
Canada's prized Medicare system is facing serious challenges on two key fronts: in meeting the legitimate health care needs of Canadians and in being affordable for the public purse. The founding principles of Medicare are not being met today either in letter or in spirit. Canadians are not receiving the value they deserve from the health care system. In both 2008 and 2009, the Euro-Canada Health Consumer Index ranked Canada 30th of 30 countries (the U.S. was not included in the sample) in terms of value for money spent on health care. Canadians deserve better. Canada cannot continue on this path. The system needs to be massively transformed, a task that demands political courage and leadership, flexibility from within the health care professions and far-sightedness on the part of the public. It is a lot to demand, but nothing less than one of Canada's most cherished national institutions is at stake. Unwillingness to confront the challenges is not an option. With this report, "Health Care Transformation in Canada: Change that Works, Care That Lasts" the Canadian Medical Association (CMA) declares its readiness to take a leadership position in confronting the hard choices required to make health care work better for Canadians. The focus of reform must better serve the patient. The system must adjust to changing needs for care and do so without crowding out other societal needs; many of them determinants of health themselves, such as education and sanitation, and the challenges posed by Canada's geographic, cultural, economic and emerging demographic realities. This report sets out an ambitious but realizable roadmap to ready the system for the future. Its triple aim is to improve the health of the population at large, to improve the health care experiences of patients, and to improve the value for money spent on health and health care. The CMA seeks to spark a spirited discussion among physicians, other health care providers, governments and the public at large so that an urgent effort can be undertaken to put an improved system on a path to sustainability by the time the federal-provincial/territorial Health Accord expires on March 31, 2014. By so doing, a renewed Health Accord will be enabled to maximize value for patients and sustain a strong health care system for future generations. This report is divided into three parts: The Problem; Our Vision; and The Framework for Transformation. It is in this last section that the CMA puts forth a five-pillar transformational plan, including a Charter for Patient-Centred Care, for securing Canada's public health care future. These policy directions have been influenced by our consultations with patients, patient advocacy groups and the public. These initiatives are necessary to support the important work already underway in illness prevention and health promotion, in enhancing capabilities for diagnosis and treatment, and in monitoring system performance. They also represent directions we must take towards preparing for the needs of future generations of Canadians. The CMA, our partner provincial/territorial medical associations and the physicians of Canada are committed to the changes that will allow us to fulfill our objective to provide patients with optimal care within an effective, accountable and sustainable system today and for generations to come. EXECUTIVE SUMMARY Medicare has enjoyed the resounding support of Canadians for nearly half a century. But new times bring new challenges to the health care system and so it has been forced from time to time to adapt and evolve. This document is predicated on the belief of the CMA that new demands for adaptation must be addressed starting now, and in a manner consistent with the spirit and principles that have guided Medicare from the beginning. This report is divided into three Parts. The first lays out the underlying problem confronting the system; the second outlines a vision for Canada's health system by modernizing the guiding principles of Medicare, and the third provides the CMA's prescription for improving the system within and beyond the five original principles that are set out in the Canada Health Act (universality, accessibility, comprehensiveness, portability and public administration). Following the main report, Appendix A addresses the issue of health care funding and sustainability. This is meant to inform readers regarding the complexities inherent in the challenge of sustaining health care provision and funding for current and future populations. Part 1: The Problem Canada's health care system is valued by its citizens. At the same time, it is increasingly recognized that the system is inadequate to meet 21st Century needs and is in urgent need of reform. Canadians wait too long for care. Care providers feel overworked and discouraged. There are insufficient mechanisms to monitor system performance. Technical support needs modernizing. Closer examination of how the five Medicare principles are being met reveals a number of concerns. While there is universal coverage for a narrow range of medically-necessary services, access to other essential health care services is inconsistent, both within and across jurisdictions. Exceedingly long waits for necessary medical care is prevalent. Efficiencies in the management of our health care system must also be found as Canada has recently been ranked last out of 30 countries in terms of value for money spent. Part 2: Our Vision There are numerous steps required to transform Canada's health care system so that it becomes highly effective and meets the health needs of Canadians. A first step is to re-examine the five principles of the Canada Health Act and modernize them as they are no longer sufficient to meet current and evolving needs. All Canadians must have timely access to an appropriate array of medically-necessary services across the full continuum of care, independent of their ability to pay. All health care must be patient-centred. Care must be delivered effectively and must be well-coordinated among all care providers. The health care system must be properly resourced to deliver care in a sustainable way that can accommodate our ever-changing health care needs. Part 3: The Framework for Transformation The CMA's Health Care Transformation Plan has three core goals: improving population health, improving the patient experience of health care, and improving the value for money spent on health care. The CMA has created a Framework for Transformation listing the actions needed for change - organized under five pillars: 1. Building a culture of patient-centred care * Creation of a Charter for Patient-centred Care 2. Incentives for enhancing access and improving quality of care * Changing incentives to enhance timely access * Changing incentives to support quality care 3. Enhancing patient access along the continuum of care * Universal access to prescription drugs * Continuing care outside acute care facilities 4. Helping providers help patients * Ensuring Canada has an adequate supply of health human resources * More effective adoption of health information technologies 5. Building accountability/responsibility at all levels * Need for system accountability * Need for system stewardship The CMA recognizes that none of these directions, taken separately, will transform our health care system. Nor do they represent an exhaustive list of steps, as there are many other directions that can be taken to support our vision. This framework does, however, contain the necessary directions toward the more efficient, high-functioning, patient-focused system that Canadians deserve. Summary of CMA Recommended Directions Implementation of these recommendations will require the collaboration of all levels of government and medical and other health organizations. 1. Gain government and public support for the CMA's Charter for Patient-Centred Care. 2. Implement partial activity-based funding for hospitals, whereby facilities are funded based on the number of patients they treat and the types of illnesses they have, to improve timely access to facility-based care. 3. Implement appropriate pay-for-performance systems to encourage quality of care at both the clinician and facility level. 4. Establish an approach to comprehensive prescription drug coverage to ensure that all Canadians have access to medically necessary drug therapies. 5. Begin construction immediately on additional long-term care facilities. 6. Create national standards, with input from both federal and provincial/territorial governments, for continuing care provision in terms of eligibility criteria, care delivery and accommodation expenses. 7. Develop options to facilitate pre-funding long-term care needs. 8. Initiate a national dialogue on the Canada Health Act in relation to the continuum of care. 9. Explore ways to support informal caregivers and long-term care patients. 10. Develop a long-term health human resources plan through a national body using the best available evidence to support its deliberations. Within this plan: a) Increase medical school and residency training positions. b) Invest in recruitment and retention strategies for physicians, nurses and other health care workers. c) Ease the process of integration into our health care workforce for international medical graduates and Canadian physicians returning from abroad. d) Introduce new providers such as physician assistants to the health care workforce and enhance collaborative, team-based care where appropriate. 11. Adopt the CMA's five-year plan to set out clear targets for accelerating the adoption of Health Information Technology (HIT) in Canada. 12. Accelerate the introduction of e-prescribing in Canada to make it the main method of prescribing by 2012. 13. Require public reporting on the performance of the system, including outcomes. 14. Establish an arm's-length mechanism to monitor the financing of health care programs at the federal and provincial/territorial levels. PART 1: THE PROBLEM Summary: Canada's health care system is valued by its citizens. However, not only is our Medicare system failing to meet the five principles - universality, accessibility, portability, comprehensiveness and public administration - originally laid out in the 1984 Canada Heath Act, but those five principles, while still relevant, need to be expanded in scope to serve the current and future health needs of Canadians. Canadians believe that the relief of suffering and the promotion of health and human dignity are vitally important - for philosophical as well as pragmatic reasons. Simply stated, there is a broad recognition that health is a valued "good" allowing all Canadians to flourish as individuals and groups. Notwithstanding this fundamental belief, neither of the imperatives of our health care system - optimizing function and the compassionate relief of suffering and promotion of dignity - is being met for many people. Our population and our health providers encounter these failures on a daily basis. Polls show that most Canadians unwaveringly support the five principles laid out in the 1984 Canada Health Act - universality, accessibility, portability, comprehensiveness and public administration.1 In fact, since Medicare was first introduced - in Saskatchewan in 1962 and throughout the rest of Canada soon afterward - the idea of universal health care has become central to our national identity. Nearly half a century after Medicare was first introduced, however, Canada's health care system is falling short of the demands being placed on it from patients and providers. Canadians well understand that universal health care requires significant public resources to maintain. While the escalating costs of health care are often perceived as the overriding problem, there are other factors contributing to the crisis. Surveys have repeatedly shown that Canadians are highly satisfied with the care they receive once it is delivered. However, the general view among most Canadians is that their health care system is not as well managed as it must be. They are increasingly concerned about the lack of timely access to see their family physician, the long wait times for diagnostic testing, a widespread lack of access to specialists and specialized treatment, and the compromised quality of care in overburdened emergency rooms, or the unavailability of nearby ER facilities altogether. With our aging population, end of life issues are becoming increasingly important, yet many do not have access to expert palliative care. The founding principles of Medicare are not being met today either in letter or in spirit. Canadians are not receiving the value they deserve from the health care system. Issues such as quality of care, accountability and sustainability are now recognized as key aspects of a high-performing health system. "Health" by today's standards is not just the assessment and treatment of illness, but also the prevention of illness, and the creation and support of social factors that contribute to health. Also missing from our current system, but vitally important to proper care, is health information technology (HIT). In this area, Canada is woefully lacking in both resources and coordinated efforts toward a plan of HIT implementation. Before addressing the missing elements in Canada's health care system, a proper diagnosis of the current system requires a closer look at how the health care system fails to deliver on all five founding principles of Medicare. 1. Universality Studies have consistently shown that poorer, marginalized populations do not access necessary care. Wealthier populations use health care services more frequently than lower-income populations despite higher illness rates in low-income populations. Poorer communities have fewer services to support good health. The most vulnerable populations are least able to access and navigate the health care system. At the same time, these are the people most likely to need health care because the essential determinants of health - housing, education and food security - are often not available to them. Canada's system of universality resonates strongly with Canadians. However, while there is universal first-dollar coverage for insured hospital and medical services, there is uneven coverage of other services also essential to health and quality of life (e.g., prescription drugs and home care). 2. Accessibility The principle of accessibility in the Canada Health Act does not define "timely access" to necessary care. For many patients, the months of waiting for necessary treatment amount to a complete lack of "accessibility." While wait times have been reduced for a limited number of surgical procedures, many Canadians are still waiting far too long to receive necessary medical care for a wide variety of conditions. For many types of treatments, Canadians wait longer than citizens in most other industrialized countries that have similar universal health systems. Approximately five million Canadians do not have a family doctor, severely restricting access to adequate primary medical care. 3. Comprehensiveness Provincial/territorial health insurance plans must insure all "medically necessary" hospital and physician services. Canadians are entitled to all medically necessary (evidence-informed) services to the greatest extent possible. However, since Medicare was established in the 1960s, care patterns have shifted dramatically - away from being primarily acute care in nature, to broader health needs including prevention, treatment and long-term management of chronic illnesses. In addition, new technologies, treatments and medications that were not foreseen by the original planners of Medicare have been developed to diagnose and treat illnesses. At the time the Canada Health Act was passed, physician and hospital services represented 57% of total health spending; this has declined to 41% in 2008.2 Notwithstanding these changes, there is significant public spending beyond services covered by the Act (in excess of 25% of total spending) for programs such as seniors' drug coverage and home care; however, these programs are not subject to the Act's program criteria and are often subject to arbitrary cutbacks. While a majority of the working-age population and their families are covered by private health insurance, those with lower incomes are less likely to enjoy such benefits. Furthermore, the proportion of Canadians working in non-standard employment conditions (e.g., part-time, temporary or contract work) is increasing and these workers are less likely to have supplementary benefits.3 In addition, while most jurisdictions provide some form of seniors' drug coverage, access to other supplementary benefits post-retirement is most likely highly variable. Some of the more severe gaps in coverage include: * the lack of access to prescription medications for those without private health insurance or who are ineligible for government drug benefit programs; this problem is particularly significant for many residents in Atlantic Canada * the lack of continuing care, including both support for people to stay in their home (home care) or appropriate residential care (e.g., facility-based long-term care) * a lack of adequate mental health services. Mental illness is one of the leading burdens of illness in Canada. Access to mental health services for both children and adults is poor. Psychiatric hospitals are not covered under the Canada Health Act. Many essential services, such as psychological services or out-of-hospital drug therapies, are not covered under provincial/territorial health insurance plans. 4. Portability Canadians should receive coverage while travelling outside of their home province or territory. Portability under the Canada Health Act does not cover citizens who seek non-urgent and non-emergency care outside their home province or territory. Canadians who obtain such care in another province or territory are not covered by their health insurance program unless they receive prior approval (usually for services not available in their home province or territory). This principle is honoured by some jurisdictions but has never been fully implemented in Québec. Québec did not sign bilateral reciprocal billing agreements with the other provinces and territories stipulating that providers would be reimbursed at host-province rates. Consequently, Québec patients who receive medical care outside of their province must often pay cash for medical services received and then apply to recoup a portion of their costs from the Québec health insurance program. 5. Public administration Health care insurance plans must be administered and operated on a non-profit basis. The principle of public administration is often misinterpreted to mean public financing of publicly delivered services. In fact, while Medicare services (medically necessary hospital and physician services) are overwhelmingly publicly financed, most services are privately delivered. Most physicians are independent contractors while most hospitals are private organizations governed by community boards. This misconception of what constitutes public administration has inhibited the development of innovative models for publicly funded, privately delivered services. While Canada's system of Medicare is administered publicly, a case can certainly be made that Canada's health care system is not delivering value for the money spent: Canada is one of the highest spenders of health care when compared to other industrialized countries that offer universal care - Canada is the fifth-highest spender per capita on health care and sixth-highest in terms of spending on health as a percentage of GDP. Canadians spent an estimated $183 billion on health care in 2009, or $5452 per person.2 Of this amount, $3829, or 70%, is spent through the publicly funded system. Health care spending in Canada has increased by 6.8 annually over the past five years and has been increasing faster than the growth in the economy and more importantly faster than revenues at the federal and provincial/territorial levels. Canada's health care system is under-performing on several key measures, such as timely access, despite the large amounts we spend on health care. Experts agree that Canada's current health care system is not delivering the level of care that other industrialized countries now enjoy. The Conference Board of Canada4, the World Health Organization5, the Commonwealth Fund6 and the Frontier Centre for Public Policy7 have all rated Canada's health care system poorly in terms of "value for money" and efficiency. New governance models should be considered to improve both system effectiveness and accountability. FISCAL SUSTAINABILITY In addition to the need for improving the performance of our health system is the issue of fiscal sustainability. In 1998, the Auditor General of Canada, Denis Desautels, was among the first to sound an alarm about sustainability with a report on the implications of the aging population. His report projected that government spending on health as a share of GDP; if increases continued apace at an annual rate of 2% of real growth; could as much as double from its 1996 level of 6.4% to 12.5% by 2031.8 According to the most recent estimates from the Canadian Institute for Health Information (CIHI), government health spending as a percentage of GDP reached 8.4% in 2009i - a level which has already exceeded the 8.1% estimate for 2011 set out in the high-growth scenario of the 1998 report.2 Most recently, Parliamentary Budget Officer Kevin Page has again sounded the alarm in his February 2010 Fiscal Sustainability report.9 He projects that total provincial-territorial government health expenditure could rise to over 14% of GDP by 2040-41. This report presents estimates of the fiscal gap (which is defined as the increase in taxes and/or reduction in spending, measured relative to GDP) that is required to achieve sustainability over the long term. Under their baseline scenario, the government would need to increase revenue and/or reduce spending by $15.5 billion annually, starting immediately. Given that most commentators expect the demand for health care services to increase, reduced spending seems unlikely; hence the need to increase revenue is the most likely option. If there is no political appetite or public support for increasing public revenues for health on the basis of universality and risk pooling then we will be faced with choosing among options for raising funds from private sources. A more detailed analysis of health care funding and sustainability is contained in Appendix A. PART 2: OUR VISION Summary: There are numerous steps required to transform Canada's health care system so that it becomes highly effective and meets the health needs of Canadians. A first step is to re-examine the five principles of the Canada Health Act - universality, accessibility, comprehensiveness, portability, and public administration - and modernize them to meet current and evolving needs. MODERNIZING THE PRINCIPLES OF MEDICARE Change must be undertaken with the patients' interests at the centre. To the CMA, this means meaningful implementation and modernization of the Canada Health Act. Transformational change will refocus our system so that serves the patient - not the other way around as is so often the case today. Canada must follow the lead of other developed countries with universal health care systems that have succeeded in this fundamental objective. Below are the modernized principles for Canada's health system recommended by the CMA: 1. Universality All Canadians must have access to the full range of necessary (evidence-informed) health care services using a variety of funding options as necessary to ensure universal coverage regardless of ability to pay. This includes meeting the needs of vulnerable populations who may not be able to access services due to a variety of barriers (e.g., geographical, socio-economic and demographic). 2. Accessibility All Canadians must have timely access to the full array of health care services over their life span, from primary care (including health promotion and illness prevention) through institutionally based secondary and tertiary care, to community and home-based services that promote rehabilitation and health maintenance, and to palliation at the end of life. There should be clear, measurable wait-time targets/benchmarks for access to necessary care, with publicly funded alternatives available in situations where timely care is not locally available to patients in need. 3. Comprehensiveness All Canadians must have access to the full complement of health services, with incentives in the system to encourage the prevention of illness and to promote optimum health while addressing the complex causative pathways affecting health and disease (i.e., social determinants of health). A defined set of nationally comparable, publicly funded core services should be available to all Canadians chosen through an evidence-informed and transparent manner. There should be an ongoing monitoring of the comparability of access to a full range of medically necessary health services across the country. 4. Portability All Canadians must be eligible for coverage while travelling within Canada, outside of their home province/territory. This principle must be honored in all jurisdictions, and apply to all levels of necessary care. 5. Public administration Services must be appropriately, efficiently and effectively delivered, with providers and patients working together to determine how that is done. The system must ensure that care is integrated and coordinated among providers and services to maintain continuity of care. From the patients' perspective, care must be well-coordinated among providers and between levels (i.e., physician to hospital, hospital back to home, etc.), supported by a functional and secure electronic health information system. The system should be guided by properly structured incentives to reward efficient provision of timely, high-quality patient care. This would include incentives such as activity-based funding of hospitals (i.e., paying on the basis of services provided), and pay-for-performance measures for health care providers, with competition based on valid measures of quality and efficiency. The system would utilize both public and private service providers, and put uniform requirements and regulations in place for measuring quality.ii The system must be able to demonstrate good value for money. There must be accountability mechanisms and performance measurements in place to ensure responsibility for monitoring and managing system performance (e.g., efficiency and effectiveness) at all levels. Regular public reporting on system performance will be required. Societal health goals and targets focused on outcomes will be set and monitored. Health care providers and the community will be actively involved in system decision-making. 6. Patient-centred The system needs to be patient-centred. Patient-centred care is seamless access to the continuum of care in a timely manner, based on need and not the ability to pay, that takes into consideration the individual needs and preferences of the patient and his/her family, and treats the patient with respect and dignity. 7. Sustainability The system must be properly resourced in a sustainable manner. Funding must be sufficient to meet ongoing health care needs. The system must be resilient; that is, capable of withstanding or accommodating demand surges and fiscal pressures. It must have the capacity to innovate and improve and be able to anticipate emerging health needs. Prospective monitoring and documentation of emerging health needs and the burden of illness must be undertaken on an ongoing basis. Strategies must be developed and implemented to meet those needs properly. PART 3: THE FRAMEWORK FOR TRANSFORMATION Summary: The CMA's Health Care Transformation Plan has three core goals: improving population health, improving the patient experience of health care, and improving the value of money spent on health care. There are numerous steps required to transform Canada's health care system so that it becomes highly effective and meets the health needs of Canadians. The next steps are contained in a Framework for Transformation, organized under five pillars, with specific recommendations for action. 1. Building a culture of patient-centred care * Creation of a Charter for Patient-centred Care 2. Incentives for enhancing access and improving quality of care * Changing incentives to enhance timely access * Changing incentives to support quality care 3. Enhancing patient access along the continuum of care * Universal access to prescription drugs * Continuing care outside acute care facilities 4. Helping providers help patients * Ensuring Canada has an adequate supply of health human resources * More effective adoption of health information technologies 5. Building accountability/responsibility at all levels * Need for system accountability * Need for system stewardship The CMA recognizes that none of these directions, taken separately, will transform our health care system. Nor do they represent an exhaustive list of steps, as there are many other directions that can be taken to support our vision. This framework does, however, contain the necessary directions toward the more efficient, high-functioning, patient-focused system that Canadians deserve. For the transformation plan to succeed, the following key enablers must be in place: * leadership at all levels including strong political leadership * well-informed Canadians who understand the need for, and characteristics of, a high-performing health system * patients, physicians and other providers actively involved in the reform and management of the system * a commitment to sustainability with adequate levels of resources to ensure that services are in place * health information technology in place to improve service delivery, manage care within and between services, and monitor and evaluate organization and system performance * incentives properly aligned to support a variety of funding and delivery models that can meet system goals (e.g., to improve access, to improve quality) * co-ordinated health human resources planning at the provincial/territorial and national levels * a commitment to support continuous quality improvement and evidence-informed decision-making at both the policy and clinical levels. These five pillars contain the directions which the CMA believes are necessary to successfully transform our health care system. Many other reforms have been proposed in Canada and elsewhere but based on international experience, these should receive priority attention. 1. BUILDING A CULTURE OF PATIENT-CENTRED CARE The concept of "patient-centred care" is taking hold in other developed countries which are also in the process of reforming their health care systems. The essential principle is that health care services are provided in a manner that works best for patients. Health care providers partner with patients and their families to identify and satisfy the range of needs and preferences. Health providers, governments and patients each have their own specific roles in creating and moving toward a patient-centred system. Patients have consistently emphasized the importance of being respected, having open communication and confidentiality of personal information, in addition to quality medical care. While building a patient-centred system is clearly better for patients, it is also better for physicians and all health care providers and administrators. In a patient-centred system, physicians are provided the optimal environment to give the best possible medical care. From the perspective of health administrators, recruitment and retention of providers who are satisfied with their work and their environment can have many tangible benefits. For instance, hospitals employing patient-centred care principles have found improvements in patient outcomes in areas ranging from decreased length of stay and fewer medication errors to enhanced staff recruitment.10 It is recognized that health care providers strive to practise patient-centred care. Often the issue is that the system - intended to serve as a network of services - is where patient-centred care breaks down. CHARTER FOR PATIENT-CENTRED CARE An important first step in building a culture of patient-centred care is to establish a Charter for Patient-centred Care. As a vision statement, the Charter is built on a foundation of reasonableness and fairness, while acknowledging resource constraints. Notwithstanding resource constraints, governments have the duty to ensure availability of the resources required to provide high quality care. This Charter is a mutually reciprocal covenant among patients, physicians, other health care providers, funders and organizers of care. Dignity and respect * All persons are treated with compassion, dignity and respect. * Health care is provided in an environment that is free from discrimination and/or stigma of any kind. * Health care services respond to individual needs and give consideration to personal preferences. Access to care (timeliness, continuity, comprehensiveness) * Access to and timeliness of appropriate medical and psychiatric services is determined by health need. * Access to appropriate services is not limited by the patient's ability to pay. * Care is continuous between health care providers and across settings. Safety and appropriateness * Care is provided in accordance with the applicable professional standard of care, by appropriately qualified health care providers, regardless of the location of service. * Care is based upon the best available evidence and is provided in the safest possible environment. * The quality of all health care services is evaluated, monitored and improved proactively. * Care is informed and influenced by lessons learned from any critical incident or adverse event and by patient experiences. Privacy and security of information * Personal health information is collected, stored, accessed, used, disclosed and accessible to patients in accordance with applicable law and professional codes of ethics. * Providers and recipients of care share responsibility for the accuracy and completeness of information in personal health records. Decision-making * Patients participate actively with providers in decisions about their medical care and treatment. * Personal support and assistance with communication is available when required. * Patients may appoint another person (proxy decision-maker) to act on their behalf and to be aware of their personal health information. * Decisions for care are made with full disclosure of all relevant information. * Patients may consent to or refuse any examination, intervention or treatment, and may change or vary their decisions without prejudice. * Individuals may decline to participate in research without prejudice. Insurability and Planning of health services * All parties use health care resources appropriately. * Recipients and providers are informed and are able to be involved directly, or through representatives, in the planning, organization, delivery and evaluation of health care services. * Decisions about the provision and insurability of drugs and all other treatments or services are made in accordance with evidence and best practices. * Government decision-making with respect to the planning, regulation and delivery of health care products and services is transparent. Concerns and complaints * Patients may comment on any aspect of their personal health care and have concerns investigated and addressed without repercussions. * Patients receive timely information and an expression of regret and sympathy if there is any adverse event during their care, regardless of the reason for such event. * Providers speak publicly and advocate on behalf of Canadians for the provision of high quality care. Direction The creation of a Charter for Patient-centred Care, as presented above, is a solid foundation on which to build a culture of patient-centred care. In order for the Charter to work, it needs to have supporting mechanisms to ensure accountability. Metrics must be identified to track the elements of the Charter. The Charter needs to be accepted by governments, providers and patients to have an impact on the health system culture and care. Other examples of activities to promote a culture of patient-centred care may include: * increasing availability of programs to prevent illness * increasing involvement of patients and their families in the delivery of care when desired (e.g., if preferred by the patient, family and friends may be trained to help provide care for patients while in the hospital or community) * soliciting patients' feedback on health care services received, and readiness to make changes based on that feedback * establishing patient and family advisory councils for hospitals or health regions * establishing a process for patients or their family members to quickly and efficiently raise a concern about care * providing patients with information about how to access medical records while in the hospital or in the community Progress to date/Next steps The final report of Saskatchewan's Patient First Review, For Patients' Sake (2009),11 devoted considerable attention to the need to re-orient health care to a more patient-centred system. As Commissioner Tony Dagnone stated in his report, "patient-first must be embedded as a core value in health care and be ingrained in the 'DNA' of all health care organizations". The report recommended the adoption of a Charter of Patient Rights and Responsibilities for that province. More recently, an advisory committee to the Alberta Minister of Health has also recommended the creation of a Patient Charter for that province.12 Lessons can be learned from the effects of patient charters in other developed countries. The National Health Service in England recently adopted a constitution which establishes its principles and values: sets out the rights to which patients, public and staff are entitled; includes pledges that the National Health Service is committed to achieve; delineates the responsibilities which the public, patients and staff owe to one another to ensure that the National Health Service operates fairly and effectively.13 The Australian Charter of Healthcare Rights describes seven charter rights to which patients, consumers, carers and families are entitled and the ways they can contribute to ensuring their rights are upheld.14 Those rights are: access, safety, respect, communication, participation, privacy and a right to comment on care and have concerns addressed. 2. PROVIDING INCENTIVES TO ENHANCE ACCESS AND IMPROVE QUALITY OF CARE Canadians have consistently identified timely access as Canada's most pressing health issue. Many other health systems around the world have been successful in dealing with timely access and now are examining the quality of care being delivered. This direction looks at changing incentives to accomplish two related objectives: improving timely access and supporting quality care. A. Enhance timely access Most provinces have taken steps to improve timely access to certain components of their health system. For instance, the Saskatchewan Surgical Initiative has set a target for specialty wait times to be no longer than three months within the next four years.15 At the physician level, several initiatives are underway across Canada. In late 2009, the Primary Care Wait Time Partnership involving the College of Family Physicians of Canada (CFPC) and the CMA released its final report entitled, The Wait Starts Here.16 The report identifies several strategies for improving timely access to primary care. Efforts are also underway in some jurisdictions, such as in Manitoba, to improve the referral process from family physician to specialist (i.e., the timeliness and the appropriateness of referrals). Activity-based funding - an idea raised in the Kirby Commission's final report17 - is another strategy to improve timely access at the facility level. Activity-based funding is a reimbursement mechanism that pays hospitals for each patient treated on the basis of the complexity of their case. A reimbursement level is set for each type of case then applies to all hospitals within the jurisdiction. It is also known as service-based funding, case-mix funding or patient-focused funding. As such, funding is viewed as "following the patient" since the hospital is paid only if the service is provided, resulting in increased productivity and in some instances, competition among hospitals to treat patients. Financing of hospital services in most industrialized countries involves some portion of activity-based funding. Canada, although it has been a pioneer in the methodology that underlies activity-based funding, has had limited application for funding purposes. Most hospitals in Canada receive their funding in the form of a global budget that is usually based on historical funding levels. As a result, a well-performing hospital emergency room does not receive any additional funding for seeing more patients. Direction Canada should move toward partial activity-based funding for hospitals to improve hospital productivity. It is almost impossible to decrease wait times and reward productivity without this change in funding. While some countries have implemented 100% activity-based funding, other countries have shown that productivity can increase when even 25% of hospital funding is allocated in this manner. Progress to date/Next steps A number of provinces have taken steps to introduce activity-based funding for facility-based care. The government of British Columbia announced that it will provide "patient-focused funding" for the province's 23 largest hospitals.18 Ontario already has some limited activity-based funding for its hospitals and the government has announced that it will introduce patient-based payment for hospitals on April 1, 2011 as part of a multi-year implementation plan.19 Alberta announced in 2009 that it would be adopting a form of activity-based funding for long-term care facilities that started April 1, 2010 and for hospitals the year after.20 While not yet in place in Québec, the adoption of activity-based funding was recommended in the 2008 Castonguay report.21 Much of the work involved in supporting the adoption of partial activity-based funding has already been undertaken by CIHI and its well-developed Case Mix Group program supported by case-costing data from BC, Alberta and Ontario. B. Support quality care Timely access is one dimension of quality. But there are many other dimensions of quality including safety, effectiveness, appropriateness and acceptability. More recently in Canada, attention is now focused on incentives to improve quality in the processes of care to achieve better outcomes. Incentives for providers Pay-for-performance involves the use of an incentive payment to reward a hospital or physician provider for achieving a target for the quality of patient care. This may be linked to processes or outcomes of care and could be related to the attainment of a specified threshold and/or percentage improvement. Performance incentives may also be linked to the structure of health care delivery as well as the process of that delivery. 22 It is important to note that pay-for-performance, which refers to incentive payments for achieving quality targets, is not the same as activity-based funding, which is a reimbursement mechanism that pays hospitals for each patient treated on the basis of the complexity of their case. Performance incentives can be targeted at both group output provided by a team of providers (nurses, physical therapists, physicians, etc.) as well as individual members of the team. The incentives may also be targeted at measuring the process involved in delivering the desired health care output. Canada will likely follow the lead of other countries in increasing the focus on the outputs and outcomes of the health care system. The promise of pay-for-performance programs is that they can improve access, quality and accountability. Pink et al. 23 have tried to synthesize the international experience with pay-for-performance and its implications for Canada. Based on this assessment they offer four key considerations: 1. Pay-for-performance could potentially be used to target individual providers, provider groups/organizations, or health regions. 2. The selection of quality measures should consider provincial/territorial health goals and objectives, measures included in existing report cards, evidence and the ability to risk-adjust and the extent of provider acceptance. 3. Development of pay for performance should consider factors that are within the scope of control of providers, use positive incentives over disincentives and consider size/timing and perceived fairness of awards. 4. Program evaluation should consider the impact on patients and providers, quality measurement and how payments are used to improve quality. In addition, they cite the need to address enablers/barriers including information technology, consultation, implementation costs and resistance. Direction Implement appropriate pay-for-performance systems. Adopt principles that secure equity and efficiency in pay-for-performance programs in Canada that will ensure the best outcomes for patients, physicians and the health care system at large. Progress to date/Next steps Pay-for-performance has already started in a number of provinces as seen in the table below. Examples of pay-for-performance programs already in effect in Canada [SEE PDF FOR CORRECT DISPLAY OF TABLE INFORMATION] Province Type of program Nova Scotia Family Physician Chronic Disease Management Incentive Program Ontario Cumulative Preventive Care Bonuses for achieving specified thresholds of preventive care for their patients in five areas: influenza vaccine, pap smear, mammography, childhood immunizations and colorectal cancer screening Manitoba Physician Integrated Network has a Quality Based Incentive component24 Alberta Performance and Diligence Indicator (PDI) Fund for Family Physicians: The PDI Fund provides payments to family physicians who meet specific indicators in the care of their patients. The PDI program "will provide payments to individual family physicians, in and out of primary care networks, who meet specific performance and/or diligence indicators that deliver substantive clinical value"25 British Columbia Full Service Family Practice Incentive Program: this includes an obstetrical care bonus payment and an expansion of the Full Service Family Practice Condition Payments that were introduced in 2003. The condition-based bonus payments are related to the monitoring patients' course of care according to BC Clinical Guidelines for diabetes, congestive heart failure and hypertension26 Pay-for-performance programs will continue to expand in Canada. Governments and insurance companies are introducing pay-for-performance incentive programs throughout the industrialized world with the goal of improving health care delivery efficiencies and especially to improve patient care. These are lofty goals because measuring improvements in patient care is complicated. It is vital that physicians, patients and the health care system establish principles that can guide them to make the best decisions concerning pay-for-performance. The scope of the program and what is measured will surely evolve. Full-scale adoption requires an electronic medical record (EMR) to be in place. Incentives for patients At a macro level, public policies can be instituted to encourage healthy behaviours and environmental improvements (e.g., water quality standards). At the individual level, consideration should be given to empowering patients through the use of patient incentives. A rapidly emerging dimension of pay-for-performance is the use of incentives directed at the patient for health maintenance and healthy behaviours. Hall has reported that a number of US employers are offering tangible rewards to employees such as cash, merchandise, vacation days, and reductions in health care premiums or deductibles.27 These incentives are targeted variously at: * activity (e.g., completing a health risk assessment) * achievement (e.g., quitting smoking, lowering Body Mass Index) * adherence (e.g., remaining tobacco-free for 12 months) Positive incentives are used to promote healthy behaviours by transferring funds or alternate benefits to an individual. They work by providing immediate rewards for behaviours that usually provide only long-term health gains. Positive incentives have been shown to be effective in promoting singular, discrete behaviours, such as vaccinations, screening programs, and attending follow-up appointments. An example of an existing Canadian federal government incentive is the children's fitness tax credit. This credit is intended to promote physical activity among children by off-setting some of the cost incurred by families for sports and leisure programs. In Germany, bonuses for healthy behaviours are integrated into the health system. They are offered for both primary and secondary prevention, including check-up programs, achieving healthy weights, smoking cessation, memberships in sports clubs, and other health-promoting activities. The bonuses take the form of points that can be redeemed for items, including sports equipment, health books or reduction in insurance premiums, or in some cases cash. There are also bonuses, in the form of a reduction in co-payments, for adhering to the treatment plan and participating in special care plans.28 Negative incentives or disincentives by governments largely involve the use of regulation and taxation in order to change individual behaviour. This helps to create an environment in which healthy choices are easier to make. For example, the taxation of tobacco, alcohol or unhealthy foods (such as those high in fat, salt or sugar) are commonly cited interventions. Taxes on tobacco products have been highly effective in reducing use. Studies linking cost to consumption of high-sugar content beverages demonstrate a strong link between higher prices and reduced consumption.29 3. ENHANCING PATIENT ACCESS ALONG THE CONTINUUM OF CARE The continuum of care may be defined as the array of health services, regardless of the age of the recipient, ranging from primary care (including health promotion and illness prevention), through institutionally based secondary and tertiary care for acute medical situations, to community- and home-based services that promote health maintenance and rehabilitation for people with chronic problems, and finally to palliation at the end of life. There is a strong realization that Canada's Medicare system covers a decreasing portion of this continuum. An example of where deficits exist is mental health. The CMA's 2008 annual meeting (General Council) tackled the issue of improving access to mental health services as part of a greater effort led by the Mental Health Commission of Canada. The CMA is currently working toward the several resolutions that were adopted, but there are two other areas that are in urgent need of attention. Crucial to improved care is (A) universal access to comprehensive prescription drug coverage and; (B) improving access to continuing care (long-term care, home care and palliative care/hospice). Physicians currently spend a significant amount of time assisting patients to obtain access to necessary prescription drugs. Physicians and families are also heavily engaged in time-consuming efforts to place patients in long-term care facilities or secure assistance in the home. Improving access for Canadians in these two areas would help create a more patient-centred health care system, and enhance efficiency for providers. CMA approved a new policy on Funding the Continuum of Care in December 2009 that identifies a number of overall principles to enhance the continuum of care: * optimal management of the continuum of care requires that patients take an active part in developing their care and treatment plan, and in monitoring their health status * the issue of the continuum of care must go beyond the question of financing and address questions related to the organization of the delivery of care and to the shared and joint responsibilities of individuals, communities and governments in matters of health care and promotion, prevention and rehabilitation * support systems should be established to allow elderly and disabled Canadians to optimize their ability to live in the community * strategies should be implemented to reduce wait times for accessing publicly funded home and community care services * integrated service delivery systems should be created for home and community care services * any request for expanding the public plan coverage of health services, in particular for home care services and the cost of prescription drugs, must include a comprehensive analysis of the projected cost and potential sources of financing for this expansion A. Universal access to prescription drugs Prescription drugs represent the fastest-growing item in the health budget, and the second-largest category of health expenditure. It is estimated that less than one-half of prescription drug costs were publicly paid for in 2008.2 Moreover, Canada does not have a nationally coordinated policy in the area of very costly drugs that are used to treat rare diseases. The term "catastrophic" has been used by First Ministers and in the National Pharmaceutical Strategy to describe their vision of national pharmaceutical coverage. As defined by the World Health Organization, catastrophic expenditure reflects a level of out-of-pocket health expenditures so high that households have to cut down on necessities such as food and clothing and items related to children's education. From the CMA's perspective, the goal is comprehensive coverage for the whole population, pooling risk across individuals and public and private plans in various jurisdictions. Direction Governments, in consultation with the life and health insurance industry and the public, should establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies. Such a program should include the following elements: * a mandate for all Canadians to have either private or public coverage for prescription drugs * uniform income-based ceiling (between public and private plans and across provinces/territories) on out-of-pocket expenditures on drug plan premiums and/or prescription drugs (e.g., 5% of after-tax income) * federal/provincial/territorial cost-sharing of prescription drug expenditures above a household income ceiling, subject to capping the total federal and/or provincial/territorial contributions either by adjusting the federal/provincial/territorial sharing of reimbursement or by scaling the household income ceiling or both * group insurance plans and administrators of employee benefit plans to pool risk above a threshold linked to group size * a continued strong role for private supplementary insurance plans and public drug plans on a level playing field (i.e., premiums and co-payments to cover plan costs) Furthermore the federal government should: * establish a program for access to expensive drugs for rare diseases where those drugs have been demonstrated to be effective * assess the options for risk pooling to cover the inclusion of expensive drugs in public and private drug plan formularies * provide adequate financial compensation to the provincial and territorial governments that have developed, implemented and funded their own public prescription drug insurance plans * provide comprehensive coverage of prescription drugs and immunization for all children in Canada * mandate the CIHI and Statistics Canada to conduct a detailed study of the socio-economic profile of Canadians who have out-of-pocket prescription drug expenses, in order to assess barriers to access and to design strategies that could be built into a comprehensive prescription drug coverage program Progress to date/Next steps Provinces and territories have begun to establish public programs of income-based prescription drug coverage. Québec was the first, starting in 1997, and it remains the only province to mandate universal coverage - that is, citizens must have either public or private coverage. Alberta is the most recent to move in this direction, with a seven-point pharmaceutical strategy that was introduced in 2009.30 Overall, however, there is significant variation between the coverage levels of the various plans across Canada. For example, the Manitoba Pharmacare Program is based on adjusted total income (line 150 of the Income Tax return). For families with incomes above $75,000 the deductible is set at 6.08% of total family income.31 In Newfoundland and Labrador, the ceiling on drug costs is set at 10% of net family income (line 236 of the Income Tax return).32 There is wide variation in the burden of out-of-pocket expenditure on prescription drugs in Canada. In 2006 there was almost five-fold variation in the percentage of households spending more than 5% of net income on prescription drugs between PEI (10.1%) and Ontario (2.2%).33 There is some concern about access to cancer drugs, particularly those that are administered outside of hospital. The Canadian Cancer Society has recently reported that of the 12 cancer drugs approved since 2000 that are administered outside a hospital or clinic, three-quarters cost $20,000 or more annually.34 In 2009, Ontario Ombudsman André Morin issued a report critical of the Ministry of Health's decision to limit public funding of the colorectal cancer drug Avastin to 16 cycles.35 Subsequently the government announced that it would cover the cost beyond the 16 cycles if medical evidence from a physician indicates that there has been no disease progression.36 Most, if not all, key national health stakeholders (hospitals,37 pharmacists,38 nurses,39 brand name pharmaceuticals,40 life and health insurance industry41 plus the health charities) have adopted policy statements on catastrophic coverage. There seems to be an unprecedented consensus among health stakeholders on this issue. The most likely window of opportunity to urge the federal government to take action in this area will be the renegotiation of the Health Accord that is set to expire on March 31, 2014. B. Continuing care Continuing care includes services to the aging and to the disabled of all ages provided by long-term care, home care and home support.42 Because continuing care services are excluded from the Canada Health Act, they are, for the most part, not provided on a first-dollar coverage basis. As this kind of care moves away from hospitals and into the home, the community or into long-term care facilities, the financial burden has shifted from governments to the general public. Furthermore, there is tremendous variation across the country in the accessibility criteria for both placement in long-term care facilities and for home care services. According to Statistics Canada's most recent population projections, the proportion of seniors in the population (65+) is expected to almost double from its present level of 13% to between 23% and 25% by 2031.43 While the impact of an aging population on our health care system must not be overlooked, the continuing care needs of the disabled population at all ages must also be appropriately addressed. In the 2004 Health Accord, the provinces and territories agreed to publicly fund two weeks of acute home care after hospital discharge, two weeks of acute community mental health care and end-of-life care.44 Outside of these areas, the types of services offered and funding models vary widely. Continuing care in Canada faces three key challenges: 1. Lack of capacity and access: There is tremendous variation among regions in the levels of public funding for facility-based long-term care. Part of the reason is the lack of national standards for home care services, which results in a wide range of the types of services available, their accessibility, wait times and eligibility for funding. The widespread scarcity of long-term care facilities and home care services has had deleterious consequences: emergency departments are being used as holding stations while admitted patients wait for a bed to become available, surgeries are being postponed, and the care for Alternate Levels of Care patientsiii is compromised in areas that may not suit each patient's specific needs. Major investment is required in community and institutionally based care. 2. Lack of support for informal caregivers: Much of the burden of continuing care falls on informal (unpaid) caregivers. More than one million employed people aged 45-64 provide informal care to seniors with long-term conditions or disabilities45 and 80% of home care to seniors is provided by unpaid informal caregivers.46 3. Lack of funding for long-term care: It is impractical to expect future requirements for long-term care to be funded on the same "pay-as-you-go" basis as other health expenditures. While there is general agreement that, wherever possible, residents should contribute at least a partial payment toward the cost of accommodation at a long-term care facility, the calculation for these charges is inconsistent across the country. Direction Ensure that all Canadians have affordable and timely access to all elements of any continuing care they require. The CMA recommends the following actions: * Construction should begin immediately on additional long-term care facilities. With the senior population projected to increase to around 24% of the population by 2031, and with 3.5% of seniors currently living in these facilities, in order to simply maintain the same occupancy rates, we will need roughly 2,500 additional homes by then. The Building Canada Fund is an ideal source of initial infrastructure funding. * The federal government should work with the provinces and territories to create national standards for continuing care provision in terms of eligibility criteria, care delivery and accommodation expenses, using the Veterans Independence Plan as a starting point. * The federal government should make long-term care insurance premiums tax deductible, introduce a Registered Long-term Care Plan and/or consider adding a third special provision for the Registered Retirement Savings Plan (RRSP) that is similar to the Lifelong Learning Plan and the Home Buyers' Plan, which will allow working adults to draw from their RRSP, without penalty, to pay for their long-term care or home care needs; and consider adding a third payroll tax for continuing care purposes. * Governments initiate a national dialogue on the Canada Health Act in relation to the continuum of care. * Governments should adopt a policy framework and design principles for access to publicly funded medically necessary services in the home and community setting that can become the basis of a "Canada Extended Health Services Act". * Governments and provincial/territorial medical associations review physician remuneration for home- and community-based services. * Governments undertake pilot studies to support informal caregivers and long-term care patients, including those that a) explore tax credits and/or direct compensation to compensate informal caregivers for their work b) expand relief programs for informal caregivers that provide guaranteed access to respite services in emergency situations c) expand income and asset testing for residents requiring assisted living and long-term care d) promote information on advance directives and representation agreements for patients Progress to date/Next steps Many other groups have released reports on this issue, including the Canadian Healthcare Association's 2009 reports on home care and long-term care. Among many other recommendations, both of these reports call for the introduction of national minimum standards for care and additional support for caregivers.47, 48 New Brunswick announced an ambitious long-term care strategy in early 2008 and the province has invested $167 million in long-term care facilities since 2007. There are plans to open 318 nursing home beds over the next three years, with plans to open a total of 700 in the next 10 years.49 The federal government should use New Brunswick as an example to encourage all other provinces and territories to follow suit. In its final report released in April 2009, the Special Senate Committee on Aging made 32 recommendations; eight of them specifically address health care for seniors in terms of care provision, accommodation and affordability.50 As with improving access to prescription drugs, the most likely window of opportunity to press the federal government to take action in the area of continuing care will be the renegotiation of the 2004 Health Accord that is set to expire on March 31, 2014. 4. HELPING PROVIDERS HELP PATIENTS The fourth pillar of health care transformation speaks to creating necessary resources to support patient-centred care. Two areas that are absolutely essential are: (A) an adequate supply of health human resources; and (B) health information technology at the level in which care is provided or point of care. A. Health human resources Every high-performing health system begins with a strong primary care system in place. Yet roughly 5 million Canadians do not have a regular family physician, and once Canadians do access primary care, they often face long waits to see consulting specialists, and further waits for advanced diagnostics and ultimately treatment. Part of the reason for these delays is the shortage of health care professionals in Canada. An Organization for Economic Co-operation and Development (OECD) study of countries with wait times shows that the availability of physicians has the strongest association with lower wait times than any other factor.51 Notably, Canada's physician supply relative to the population is far below the OECD average. Statistics indicate that in 2006 Canada had only 2.15 practising physicians per 1,000 population compared to the OECD average of 3.07.52 With the number of medical graduates similarly low in comparison to the OECD average, Canada cannot expect to make up the difference without some new sources for physicians. Nurses and other health professionals are also in short supply, in Canada and across the globe. The Canadian Nurses Association is projecting a shortage of 60,000 full-time equivalent nurses in Canada by 2022 if no new policies are adopted,53 and Western Europe is also experiencing a significant nursing shortage. The global shortage of health professionals compounds the problem - while Canadian training programs still lack sufficient seats to produce enough new providers to meet current and future demands, Canadian-educated physicians, nurses, technicians, etc, are being lured away by ample opportunities to train and work outside of Canada. Initiatives such as the Nursing Sector Study,54 Task Force Two,55 the 2004 Federal/Provincial/ Territorial 10-year Plan to Strengthen Health Care44 and the 2005 Framework for Collaborative Pan-Canadian Health Human Resources Planning56 have all yielded abundant information and recommendations, yet Canada still seems unable to maintain a stable supply of physicians, nurses, technicians or other health care professionals to provide the care and treatment patients need. In its 2008 election platform, the federal government announced that it would contribute funds to the provinces and territories to create 50 new residency positions ($10 million/year for four years), ease repatriation of Canadian physicians living abroad ($5 million/year for four years) and help fund the development of nursing recruitment and retention pilot projects ($5 million over three years). On May 10, 2010, Health Minister Leona Aglukkaq announced funding of $6.9 million for 15 additional family medicine residents in the University of Manitoba's Northern and Remote Family Medicine Program. This is a promising start.57 Collaborative care models - whereby health professionals work together with, and in the best interests of, the patient - can help address some of the gaps in health human resources. Over the past decade there have been three key trends pertinent to collaboration in health care: * the contention/recognition that collaboration is an important element of quality patient-centred care * the growing interest in inter-professional education among health professions * the sustained efforts by governments to foster multidisciplinary teams by creating competitive conditions in primary care through expanding the scope of other non-physician providers Physicians recognize the value of collaboration. The Royal College of Physicians and Surgeons of Canada (RCPSC), the CFPC and the CMA have all released policy documents that identified collaboration with other health professionals as a key role of the physician.58,59,60 The RCPSC has since been working to incorporate these roles and competencies in postgraduate medical training programs across Canada. In 2006, the national boards of ten health professional organizations including CMA and CFPC each ratified the principles and framework for interdisciplinary collaboration in primary health care that were developed by a consortium of staff of these organizations, sponsored by the federal Primary Health Care Transition Fund.61 In an effort to find ways to better distribute the workload and improve access to care, much attention has been turned to the role of physician extenders such as physician assistants. Physician assistants can be trained to work autonomously to evaluate, diagnose and treat patients in a partnership and with the supervision of a licensed physician. In Canada, four programs exist to train physician assistants. The Canadian Forces Medical Services School at the Canadian Forces Base Borden in Ontario trains Canadian Forces members while civilian physician assistants can train at McMaster University, the University of Toronto and the University of Manitoba. After the CMA Board approved the inclusion of the physician assistant profession as a designated health science profession within the accreditation process in 2003, its Conjoint Accreditation Services accredited the Canadian Forces' Physician Assistant Program in 2004. Although this program is currently the only one accredited, the other three schools are undergoing the process. Working smarter, Canada needs to be more systematic about innovations and adoption of health sector resources. There is no national body in Canada equivalent to the Institute for Healthcare Improvement in the US, or the National Health Service's Institute for Innovation and Improvement in England, that is charged with promoting innovation in the delivery of health services. In Canada, the $800-million 2000 Primary Health Care Transition Fund and its fore-runner the $150-million 1997 Health Transition Fund were intended to buy transformation in areas linked to primary care. For the most part, this resulted in short-term pilot demonstration projects that ended when the money ran out. Arguably only Ontario and Alberta have achieved lasting results through the development and proliferation of new models of primary care delivery. Direction Ensure Canada's health care system has an adequate supply of human resources. Addressing health human resource shortages is critical to ensuring a sustainable, accessible and patient-centred health care system. The evaluation of and long-term planning for health human resources needs to be performed by a national body using the best available evidence to support its deliberations. Based on the defined need, there are four main mechanisms to address the shortage of health human resources in the Canadian health care system. These are: 1. increase medical school and residency positions to replenish and increase our physician supply for the future 2. invest in recruitment and retention strategies for physicians, nurses and other health care workers 3. ease the process of integration into our health care workforce for international medical graduates and Canadian physicians returning from abroad 4. introduce new providers such as physician assistants to the health care workforce Progress to date/Next steps Immediate specific steps for increasing Canada's supply of health human resources are as follows: 1. Urge the federal government to honour the remainder of its 2008 commitment to fund residency positions, repatriation of Canadian physicians abroad and pilot projects to recruit and retain nurses. 2. Secure comprehensive funding plans for physician assistant compensation. 3. Continue to work with the Federation of Medical Regulatory Authorities of Canada and provincial/territorial medical associations to monitor the impact of the new labour mobility provision of the Agreement on Internal Trade on the distribution and mobility of physicians. 4. Work with provincial/territorial medical associations to carry out an inventory and assessment of the payment arrangements across Canada that foster the emergence of new practice models based on an interdisciplinary approach and the use of new information technologies. 5. Work with other stakeholders to promote the idea of a national locus for innovation in the delivery of health care. Since it can take ten years or longer to train a new physician depending on specialty, the results of increasing medical school placements and residency positions will not be immediate. However, this plan would ultimately increase the future supply of physicians, and serve as a step toward becoming more self-sufficient in the future. As medical education and postgraduate training extend beyond academic health science centres to the community, and as inter-professional education takes on greater emphasis, educational programs need to ensure quality training experiences. Physicians-in-training require adequate human, clinical and physical resources to train appropriately. Programs must ensure that all new teaching sites are properly equipped to take learners. Training new providers, such as physician assistants, is a medium-term option since it takes fewer years (as few as two depending on the program) to train them. Increasing their numbers within the health workforce and permitting them to share some tasks will allow physicians to devote more one-on-one time with patients. Similarly, integrating international medical graduates and repatriating Canadian physicians currently practising outside the country could be a quicker method of increasing physician numbers than training new physicians, provided that appropriate immigration policies and licensure processes are in place. Removing certain constrains, such as limited operating room times, and providing support for collaborative models of care would allow the health human resources currently available to optimize their ability to practise. These options could see results in the shorter term. B. More effective adoption of health information technologies (HIT) Over the past decade, Canada's ministers and deputy ministers of health have been developing strategies to relieve mounting pressures within the health care sector. In all of these strategies, HIT has been viewed as a foundational component. Five main reasons for implementing HIT have been identified: improved health outcomes (patient safety, wait time reduction), increased accessibility, better integration of health care "silos," cost efficiencies and improved patient-provider satisfaction. Multi-billion dollar investments made in Canada on HIT, however, have not yet resulted in significant benefits to providers or patients. In large measure this is due to the fact that all jurisdictions have taken a top-down approach to their HIT strategies and focused their investment on large-scale HIT systems and architecture, with very little investment being made at the points of care where the actual benefits of HIT will be realized. The majority of health care occurs at the local level. Some 400 million patient encounters take place in Canada each year with most occurring in primary care settings with physicians, clinical teams, in home care and long-term care facilities.62 Patient-physician office interactions outnumber patient-hospital interactions by a ratio of 18 to 1. In Ontario (Diagram 1), just 3,000 out of an average of 247,000 patient visits per day - or 1.2% - are made in hospitals. Diagram 1. Patient visits per day in Ontario (Canada Health Infoway) Compared to a select group of other industrialized countries, Canada ranks last in terms of "health information practice capacity" (i.e., the use of EMRs in primary care practice). According to the most recent Commonwealth Fund study (Figure 1) conducted in 2009, only 37% of Canadian primary care physicians use some form of EMR. That compares to 99% in the Netherlands, 97% in New Zealand, 96% in the UK and 95% in Australia. 63 Direction We need to move from a top-down approach to one that gives all providers, and in particular physicians, the lead role in determining how best to use HIT to improve care, improve safety, improve access and help alleviate our growing health human resource issue. HIT adoption needs to be accelerated, but in a way that focuses on the individual patient and where he or she interacts with the health care delivery system, with the intent of improving quality of care and patient safety. An important priority must be a clear, target-driven plan that meets the needs of Canadian physicians and their patients. The CMA and provincial/territorial medical associations will develop a five-year plan with clear targets for accelerating the adoption of HIT in Canada. This includes working with governments to accelerate the introduction of e-prescribing in Canada to make it the main method of prescribing by 2012. Progress to date/Next steps In February 2009, the federal government announced a $500 million investment in HIT, with specific focus on EMRs and point of care integration, as part of their Economic Stimulus package. Transfer of these funds to Canada Health Infoway was delayed due to concerns over accountability and lack of progress on the electronic health record (EHR) agenda on the part of Infoway and most jurisdictions. The Office of the Auditor General's report on Infoway, and six provincial audits on jurisdictional EHR progress addressed these concerns and the funds were finally transferred in spring 2010. CMA is working to ensure that the bulk of this investment is allocated to physician EMRs, as well as local interoperability solutions and applied research on EMR use and patient tools. How to achieve this goal will be described in detail in the CMA's upcoming five-year strategy for HIT investment in Canada, a plan to connect the delivery points at the front lines of care. Provincially, BC, Alberta, Saskatchewan, Ontario and Nova Scotia have established EMR funding programs and are the most likely to meet targets and realize the value of HIT. The addition of $500 million federal stimulus funding to this environment will allow the remaining provinces and territories to implement similar programs. The key will be to focus HIT efforts and investment directly at the point of care. The CMA five-year HIT plan takes a grassroots, bottom-up approach and identifies ways to quickly implement local and regional solutions that will deliver short-term, tangible benefits without building un-scalable, expensive point-to-point solutions. The five-year HIT plan in and of itself is not the goal of this undertaking. The key to effectiveness lies in ensuring any HIT plan sets clear benchmarks and targets for reporting progress and demonstrating value of accelerated HIT adoption in terms of patient care - access, quality and safety. The CMA five-year HIT strategy will set out clear targets and metrics for benchmarking progress and demonstrating value. Tracking and reporting on progress against these targets would occur over the following three to five years, with a final report card to be released at the end of this period. 5. BUILDING ACCOUNTABILITY/RESPONSIBILITY AT ALL LEVELS Two key issues confronting the Canadian health care system are (A) the lack of accountability for system quality of care and performance, and (B) the lack of stewardship for the integrity of the public health insurance program and its long-term financial sustainability. A. Need for system accountability The past decade has seen growing demand for accountability for performance and outcomes at all levels of the health care system, which has been impossible to deliver due to a lack of direction, resources or accountability. As a result, Canada's ability to report publicly on the performance of the Canadian health care system has been piecemeal at best. A main stumbling block is the federal/provincial/territorial dynamic, with provinces and territories being primarily responsible for health care. In 2000, First Ministers made a commitment to develop common indicators to report to their citizens and in 2003 they set out some 40 indicators in the areas of timely access, quality, sustainability and health status and wellness. Subsequently, the Health Council of Canada was set up to monitor the 2003 Health Accord, but since 2004 only the federal government has honoured its commitment to produce indicators, and Québec and Alberta do not participate on the Health Council. The December 2008 report of the federal Auditor General criticized Health Canada for a lack of interpretation in its report and on the limited number of indicators specific to the First Nations and Inuit Health, for which Health Canada is responsible.64 Some national organizations and private organizations are reporting on health system performance at the macro level. CIHI has been producing annual wait time reports in the past years. Think tanks that have also reported on health system performance include: the Commonwealth Fund, the Conference Board of Canada (which has ranked Canada as a middle-of-the-pack performer) and the Euro-Canada Health Consumer Index, which has ranked Canada 30th out of 30 countries in terms of value for money spent on health care in both 2008 and 2009 (the US was not included).7 The Wait Time Alliance65 has produced five report cards on wait times, assessing national and provincial/territorial performance on access to elective care. The CMA has been releasing an annual report card as part of the General Council meetings for the past nine years. At the provincial/territorial level, reporting on health system performance varies widely. All provinces and territories have been reporting wait times, albeit in varying degrees and quality, for some elective surgical care. Several provinces have quality health councils which are producing reports on the quality of care being received. The Ontario Health Quality Council has released several reports on the performance of Ontario's health system, reporting on nine attributes of a high-performing health system.66 Many of these reports call for the need to accelerate the adoption of electronic health records to acquire better data and properly assess health system performance. Ontario has been a leader in health care reporting within Canada. Since the early 1990s, the Ontario Cardiac Care Network has been the gold standard for the comparison of cardiac centres on the basis of wait time and crude and risk adjusted mortality and length of stay data.67 In 1997, a research team at the University of Toronto, funded by the Ontario Hospital Association, began developing a hospital report that focused on key areas of hospital activity including patient perceptions of hospitals.68 In 2007, CIHI released Canada-wide Hospital Standardized Mortality Ratios (HSMR) for the first time. The HSMR is the ratio of actual (observed) deaths to expected deaths, and is adjusted for several factors that affect in-hospital mortality.69 Most recently, the Saskatchewan Health Quality Council issued its first Quality Insight report which reports at the health region (and, in some cases, hospital) level on 121 indicators in the areas of chronic diseases (asthma, diabetes, post heart attack), drug management and patient experience.70 The quest to improve quality of care is a dominant issue in European health systems. The UK, Denmark and the Netherlands have all implemented mechanisms to monitor the performance of their health system. Accountability and monitoring instruments in place in these three countries include: ratings of hospitals, ratings of doctors and system performance reports. In addition, the UK has organizations devoted to monitoring and improving the quality of its health care system. Public reporting on health system performance enjoys high public acceptability. This was the finding of CMA's consultation process for its health care transformation project. Seventy percent of the public surveyed by Ipsos Reid supported independent reviews of hospitals on quality and performance. National Health Goals were developed by the Government of Canada and approved in a broad consensus by all of the provinces and territories in 2005.71 While there was universal acceptance of these goals at the time, there has been limited action on developing a framework and indicators for monitoring achievements. Comprehensive approaches to population health require coordinated action across governments, supported by a common vision, such as national health goals. The CMA strongly supports the advancement of the National Health Goals agenda and believes that public reporting of supporting indicators reflecting the determinants of health as well as health services and outcomes are an important component of improving the health status of Canadians.72 Direction Improve the accountability of the Canadian health care system by reporting publicly on the performance of the system including outcomes. What is needed is a systemic approach to public reporting that shifts the focus from "blame and shame" to quality improvement. Progress to date/Next steps Based on the foregoing, the most likely opportunity for advancing the idea of increased public reporting in the short term will be to work with existing national and provincial/territorial organizations involved in acquiring and analyzing data related to health system performance. At the federal level, the renegotiation of the Health Accord in the lead-up to March 31, 2014 is the best opportunity to see a heightened commitment to improve public reporting at a coordinated federal-provincial-territorial level. Provincially, Québec's recent budget devoted considerable attention to the issue of system accountability. That government announced the annual publication of health accounts to improve transparency and public awareness on health care spending. The accounts, released with the budget, list health and social services spending and revenues. It also includes a breakdown of health sector resources including the number of physicians and nurses and hospitalization days. B. Need for system stewardship To ensure accountability and responsibility, it will be necessary to establish an arm's-length, independent body to monitor, in a transparent manner, the medium to longer-term prospects of the comparability and financing of health care programs for Canada and the provinces and territories. Since its establishment, Canada's national Medicare program has been a funding partnership between the federal and provincial/territorial governments. Since the mid-1990s, this partnership has been beset by problems, due in part to the exclusive jurisdiction of the provinces/territories to administer health programs and to the federal government's unilateral cut to cash transfers of some $6 billion with the implementation of the Canada Health and Social Transfer in 1996. Three broad concerns have been expressed: 1. Lack of accountability of the provincial/territorial governments for use of health transfer funds: at the provincial level, the reports of both the Ménard (2005)73 and Castonguay (2008)21 commissions in Québec called for the establishment of a health account which would provide accountability for how revenues collected for health are used and to inform the public about issues such as financial sustainability of health programs. 2. Canada is a "patchwork quilt" in terms of the continuum of care: there is increasing concern about the wide variation in the level of services provided across the country. The Canada Health Act program criteria only apply to hospital and medical services, and those represent just 41% of total health spending. There is roughly a further 25% of health spending that is public but there is wide variability across jurisdictions with respect to coverage of broader continuum care, such as home care and prescription drugs. For example, Statistics Canada estimates that there was almost five-fold variation in the proportion of households spending more than 5% of net income on prescription drugs in 2006, ranging from 2.2% in Ontario to 10.1% in PEI.33 3. Canada may not be able to sustain Medicare on a "pay-as-you-go" basis: in 1998 the Auditor General of Canada published a report on the implications of the aging population which projected that government spending on health as a share of GDP could as much as double from its 1996 level of 6.4% to 12.5% by 2031 if it increased at an annual rate of 2% real growth.8 In 1998 the Auditor General recommended that the government produce long range financial projections on the basis of status quo policies and alternatives that would be presented to Parliament. In its response, the government indicated that it would continue its fiscal planning on the basis of setting and meeting short-run targets. Clearly we need to be able to look beyond year-over-year budgeting and reporting. The Parliamentary Budget Officer has recently published a report on Canada's emerging "structural deficit" that estimated this shortfall will reach a level of $19 billion in 2013-14.74 The Parliamentary Budget Officer's mandate does not extend to the provincial/territorial governments. While a number of agencies and organizations are doing work related to long-term system sustainability, each is constrained in some manner from carrying out the forward looking cross-jurisdictional analyses that are required. Direction Establish an arm's-length mechanism to monitor the financing of health care programs for the federal and provincial/territorial levels, to assess the comparability of coverage across jurisdictions, to assess value for money and to make recommendations to governments on the sustainability of the current Medicare program and mechanisms to fund additional programs that cover the continuum of care. Progress to date/Next steps At the federal level, the renegotiation of the Health Accord in the lead-up to March 31, 2014 is the best opportunity to see if such a concept could be acceptable at the federal/provincial/territorial level. The CMA met with federal and provincial auditors general on March 16, 2010 to discuss system accountability and sustainability. The auditors general were very interested in this issue and some anticipate examining the matter in the coming months. PART 4: AN ACTION PLAN FOR 2010-2014 With the CMA's ambitious triple aim of improving the health of the population at large, patients' health care experience and value for money spent, the transformation of health care will inevitably be a multi-year and multi-pronged initiative. The first priority has been the release of this document, with its emphasis on adopting a Charter for Patient-centred Care. The final goal is to ensure that the First Ministers' Agreement in 2014 addresses longer-term fundamental issues, such as providing appropriate access to comprehensive pharmaceuticals and continuing care for all Canadians, and implementing a proper accountability framework. As a multi-year initiative, the CMA will pursue the actions described under the health care transformation directions between now and 2013, in time for the negotiation of the next potential Health Accord expected to take effect after the current 2004 agreement expires. As previously mentioned, the directions listed do not represent an exhaustive list. Rather, they are intended to serve as a foundation for change that will build momentum for health care transformation leading to better care. It will be important to demonstrate tangible results - early wins - so that the public, health care providers and system funders can sense the move toward a more patient-focused system and become energized to implement subsequent actions. Summary timeline of key health care transformation deliverables Release of Framework and Charter for Patient-centred Care Summer 2010 IT: Federal support for EMRs 2010 Partial Activity-Based Funding Beginning 2010 Interoperability/e-prescribing 2011-2012 Health human resources - new funding models (physician assistants) 2011 Comprehensive pharmacare/long-term care 2014 Accord Accountability Framework 2014 Accord PART 5: CONCLUSION The policy directions contained in this document, while fundamental, do not represent the entire array of possible choices. This document focuses on the "what" of health care transformation. The "how to" of implementation will require considerable further work, tailored to the needs and circumstances of the various jurisdictions and their populations. Some of the directions in this document are meant to be carried out by government, some by providers, and some by patients. Many, but not all, of the ideas set out in this document will require additional investment by governments. It will not be possible to implement all of these policy directions at the same time. Much of what is outlined here will be put in place at the provincial/territorial level and will be phased in as each jurisdiction deems fit. Provinces and territories must be encouraged to share the lessons they learn as changes are made so that other jurisdictions can build on their successes. Provision must be made for evaluation and mid-course correction to ensure that the proposed directions achieve their intended objectives. The CMA, our partner provincial/territorial medical associations and the physicians of Canada are committed to inspiring change, for the benefit of the patients we serve and in the interests of our members. The aspirations embodied in this document will foster transformation that allows us to accomplish our goals as physicians - to serve the public, provide for our patients' health needs optimally, and to make our health care system more effective, accountable and sustainable now and for the generations to come. APPENDIX A - HEALTH CARE FUNDING AND THE SUSTAINABILITY CHALLENGE Highlights: The ability to pay for health care, which is in competition with all the other legitimate uses for public funds, and the ability to maintain a health workforce are both central to the concept of sustainability. While there is ample evidence that health spending continues to outpace other areas of public expenditure and the growth of government revenue, there is no consensus that we need to act on it. The section notes the necessity of raising funds from private sources if there is no political appetite or public support for increasing public revenues for health. Other key points in this section: * Appropriate investments in health care result in improved health, which reduces health care demand in the future by decreasing the burden of illness in the population. Better health and the resultant improved productivity of the population pays economic dividends for the country. * Given our changing population demographics, governments in Canada will face challenges finding new revenue streams to fund appropriate initiatives such as long-term care, home care or enhanced pharmaceutical coverage over the next two decades. * A large unfunded liability will be created as a consequence of the need to address our growing, aging population that is increasingly burdened with multiple chronic illnesses. Only recently have a few jurisdictions recognized the unfairness of saddling this economic burden on future generations. * Overall health spending is consuming a rising proportion of total government program spending. It also is rising faster than the growth in our GDP, so our ability to pay for health care is increasingly in question. Other important societal programs will be increasingly jeopardized in order to pay for health care programs. * Methods to manage the gap between current levels of expenditure and what will be required to maintain and respond to future health care demands include, a) reducing services and therefore reducing expenditures, b) raising taxes and c) developing new sources of revenue (such as patient co-payments, population health premiums and private insurance). * Our system and culture relies on the principle of collective risk-pooling so as to lessen individual burden. To sustain health care for current and future Canadians and to expand the basket of required coverage, given our changing demographic reality, creative approaches to managing and funding our health system are necessary. The ability to pay for health care is increasingly in question. The challenge of sustaining our health care system is what makes it imperative to move forward now with health care transformation. Sustainability in health care may be defined as the ability to deliver universal publicly funded health care services without compromising other government programs or the ability of future generations to pay. In 2001 the Honourable Roy Romanow was tasked by the federal government to study and make recommendations in order to "ensure over the long-term the sustainability of a universally accessible, publicly funded health system." The Romanow Commission put forward 47 recommendations in 2002 with a view to "buying change".75 Similarly, the Kirby Commission in its review of the Canadian health care system recommended an additional $5 billion of federal funding per year to restructure and renew Medicare.17 These reports were followed by additional federal funding in the amounts of $34.8 billion and $41.3 billion in the 200376 and 200444 First Ministers' Accords respectively. Eight years later it is evident that, for the most part, these Accords bought time, not change. The directions set out in Part 3 of this report rest on two critical assumptions with respect to sustainability. The first is that there is a business case for quality. That is to say, investments in quality today will pay off in improved health that, in turn, will reduce health care demand and expenditures down the road. The resultant improved productivity from the reduction of illness in the population will generate economic dividends for the country. A second assumption is that timely and appropriate interventions will relieve access bottlenecks currently generating unproductive costs. A study conducted for the CMA in 2008 makes the case: it estimated the cost of excess waiting for four procedures at almost $15 billion.77 Hence, the introduction of activity-based funding for hospitals might not reduce hospital costs in total, but if it increases throughput and timely access there will be offsets in improved quality of life and productivity of the population. Clearly, the gains resulting from these assumptions will not be realized in the short term. All the numbers on sustainability, including the projections by Desautels and Page (highlighted in Part 1), assume the status quo in terms of publicly funded programs. But the current system is hardly sustainable on a quality of care basis, particularly given the demographic changes that will see fewer working-age Canadians supporting more and more elderly citizens weighed down by drug costs and the need, over time, for nursing home care. Given our changing population demographics, governments in Canada cannot avoid the challenge of finding new revenue streams to fund appropriate initiatives, such as long-term care, home care or enhanced pharmaceutical coverage over the next two decades. Since the 1990s, there have been repeated recommendations for expanded public coverage of prescription drugs and home care. Health ministers have estimated it would cost $5 billion for governments to provide "catastrophic" pharmaceutical coverage, meaning no household has to spend more than 5% of net income on prescription drugs.78 In contrast, there has been no national policy discussion about the funding of long-term care. Alberta made an exploratory move in this direction in 2005 when it commissioned Aon Consulting to develop health insurance models for continuing care.79 Aon estimated that in order to pre-fund projected costs to 2050, a flat dollar charge of $779 per capita, indexed at 4% per year, would be required for all Albertans aged 16 or over.80 Similarly, the Organization for Economic Co-operation and Development (OECD) has estimated that long-term care accounted for 1.2% GDP in Canada in 2005 and that, at a minimum, the burden will double to 2.4% by 2050.81 A significant amount of this share will almost certainly be publicly funded. Canada will soon have to grapple with how to finance a more comprehensive - and expensive - system of health and continuing care. This, in turn, raises issues about intergenerational equity, that is to say the fairness with which the costs of the system are distributed between generations. If these escalating costs are not addressed now, future generations will be unfairly, and possibly untenably, saddled with the burden flowing from today's growing elderly population. Academics have developed a technique called generational accounting to measure this effect.82 Hagist has applied generational accounting to estimate the revenue gap for health expenditures in six countries. The revenue gap is the percentage increase in taxes that would have to be applied immediately for both living and future generations to bring current fiscal policy on a sustainable track. The same study also estimated a delayed revenue gap, which is the percentage increase that will be required if increases are postponed until 2050. The results for the six countries are shown in Table 1. [SEE PDF FOR CORRECT DISPLAY OF TABLE INFORMATION] Table 1 Estimates of current and delayed revenue gap for health expenditures Selected countries (% increase) Country Switzerland Austria France Germany UK US Revenue Gap 27.1 13.2 9.0 25.9 23.6 27.0 Delayed Revenue Gap 63.1 28.0 17.4 60.7 47.7 46.9 Source: Hagist, C. Demography and Social Health Insurance. Baden-Baden:Nomos, 2008. As one can see, significant immediate increases in revenues are required in all six countries and much more drastic increases will be required if action is delayed. Klumpes and Tang have also applied generational accounting to the funding of the UK National Health Service. They found that under the base assumption of a 2% real interest rate, future tax payers will need to contribute about ten-fold what 2005 new tax payers did.83 In Canada, Robson has applied similar methods to estimate the "unfunded liability" that will result from an aging population. He estimates that between 2007 and 2050, provincial and territorial health budgets will experience an aggregate liability of almost $1.9 trillion if things continue along as they are.84 Total health spending in Canada reached an historic high of 11.9% of GDP in 2009. While this reflects, in part, the effect of the recession in lowering GDP, health spending grew by 5.5% in nominal terms and 3.3% in real terms over 2008. Table 2 shows the average percentage increases in health and total program spending from 1999 to 2008 and the most recent experience of the provinces and territories as presented in their 2010-11 budgets. Table 2? Health and Program Spending 1999-2008 and Selected Indicators 2010 Provincial Territorial Budgets Province / Territory 1999-2008 Average Annual % Increase in Health Spendinga 1999-2008 Average Annual % Increase in Program Spendinga Health as % Program Spending 2010-11 % Increase in Health Spending 2010-11 over 2009-10 % Increase in Program Spending 2010-11 over 2009-10 % Increase in Revenue 2010-11 over 2009-10 NL 6.2 6.9 37.8 12.4 8.4 3.8 PE 8.4 5.9 37.3 3.9 0.3 2.9 NS 7.2 5.9 46.4 6.8 -0.3 3.5 NB 7.0 4.5 36.7 3.5 1.2 1.8 QC 6.4 5.4 44.7 3.7 2.9 2.9 ONb 7.7 6.0 39.8 6.0 6.5 10.8 MB 6.7 5.4 45.1 5.0 0.8 1.8 SK 7.2 6.6 43.4 6.4 0.6 -0.8 AB 10.2 10.2 44.7 16.6 5.6 1.3 BCc 6.4 3.6 45.6 5.1 4.8 5.8 NT 5.2 4.9 25.2 0.3 5.7 5.0 YT 8.1 7.4 21.9 -7.6 -0.8 8.0 NU 9.3 9.1 24.3 -3.7 1.9 5.9 Average 7.4 6.3 37.9 4.5 2.9 4.1 Data sources available upon request a Source: Canadian Institute for Health Information b Note the budget also contains an estimate that health is 45% of program spending in 2010-11 c Total health spending by function is estimated at 42.1% of all government spending The evidence is incontrovertible that health spending has continuously outpaced other areas of public expenditure. All provinces are expecting further health spending increases in 2010-11 - ranging from 3.7% in Québec to 16.6% in Alberta. In eight out of ten provinces, increases in health spending exceed increases in both total program spending and provincial/territorial revenue. As a percentage of program spending, health stands near or just over 45% in six provinces. Aside from Québec (which is discussed below), few measures have been taken to address the problem. It may well require a province or territory to exceed the psychological barrier of 50% to incite a concerted response. This is suggested by a February 2010 poll done for CMA by Ipsos Reid in which respondents were also asked to estimate the actual, appropriate and maximum proportions of their provincial/territorial budget that are or should be devoted to health. The averages estimated by the public are as follows: * actual current percentage - 38% * appropriate percentage - 47% * maximum percentage - 52%. The prospect of going beyond the 50% threshold of the share of government program spending on health might be likened to the proverbial "crossing the Rubicon," which means following a course of action on which there is no turning back. To follow the 50%+ trajectory under the current parameters of Medicare, taxes will surely have to increase, either through general taxation or a dedicated health premium or some variant thereof. Another option that would still pool risk would be the establishment of a contributory social insurance fund. If, however, there is no political appetite or public support for increasing public revenues for health on the basis of universality and risk pooling then we will be faced with options for raising funds from private sources. These could include co-payments for publicly insured services, private insurance or out-of-pocket payment for uninsured/deinsured services, and deductibles linked to utilization. Québec has been the first among the provinces and territories to acknowledge that the current approach to funding health care is neither sustainable in the long term nor fair to future generations - and to announce measures to address the problem. It has taken three major task forces over the past decade to get to this point. In 2001 the Clair Commission recommended a capitalized (pre-funded) insurance plan to cover loss of autonomy.85 Clair also put forward the idea of the creation of a provincial health insurance corporation apart from the Health Ministry. In 2005 the Ménard Committee again recommended the establishment of an insurance scheme for persons experiencing loss of autonomy, as well as the creation of a health and social services account that would provide transparency and accountability for the sources and uses of funds.73 In 2008 the Castonguay Task Force recommended a dedicated "health stabilization fund" that would be funded in part by a deductible linked to medical visits that would be collected at year-end through the income tax system. Castonguay also recommended a health account.21 In response to these studies, the 2010-11 Québec budget contained the following measures: * starting July 1, 2010 a health contribution (premium) will be introduced, to be collected through the tax system; starting at $25 per adult, this will increase to $200 by 2012 at which time it is expected to raise $945 million * further study of the introduction of a health deductible as proposed by Castonguay * the introduction of an annual health account86 Other jurisdictions will also need to give consideration to options for at least partially pre-funding future health care expenditures. The findings of the February 2010 survey conducted for CMA by Ipsos Reid suggest that Canadians would prefer an option that would assure that funds raised would be dedicated to health care over an option that would simply add additional funds to the consolidated revenue account (Figure 2). In considering such options, however, one must be mindful of the current experience with existing mechanisms that are available to Canadians to accumulate savings. According to Canada Revenue Agency Statistics for the 2007 tax year, one in four (26.4%) Canadians with a taxable return reported making a RRSP contribution.87 The likelihood of making RRSP contributions was strongly correlated with income - 15% or fewer with those with incomes less than $25,000 reported one, rising to greater then 60% among those with incomes of $80,000 or greater. There may be greater uptake with the Tax-free Savings Account (TFSA) that was introduced in 2009. A poll done by Ipsos Reid in June 2009 found that 21% of households had opened a TFSA.88 No research has been done on the salience of saving for future health needs as compared to RRSPs and TFSAs. The CMA's 2006 discussion paper It's About Access: Informing the Debate on Public and Private Health Care provides a comprehensive overview and discussion of the international application and pros and cons of a range of public and private funding options. It also sets out ten policy principles to guide policy decision-making related to the public-private interface. In brief, these are: 1. Timely Access 6. Quality 2. Equity 7. Professional Responsibility 3. Choice 8. Transparency 4. Comprehensiveness 9. Accountability 5. Clinical Autonomy 10. Efficiency89 We believe that these principles will serve to guide a national debate. REFERENCES i Derived as the .7023 public share of the estimate of 11.9% of GDP going to total health expenditure. ii The CMA's 2007 policy statement 'It's still about access! Medicare Plus' sets out comprehensive recommendations for the public-private interface in the delivery and funding of health care. iii Patients who remain in hospital while waiting for placement in long-term care facilities or for home care arrangements to be made. 1 Department of Justice Canada. Canada Health Act (R.S., 1985, c. C-6). www.laws.justice.gc.ca/PDF/Statute/C/C-6.pdf. Accessed 06/28/2010. 2 Canadian Institute for Health Information. National health expenditure trends 1975 to 2009. Ottawa, 2009. 3 Bowlby G. Studies in "non-standard" employment in Canada. www.wiego.org/reports/statistics/nov-2008/bowlby_presentation_2008.pdf. Accessed 06/28/2010. 4 Conference Board of Canada. How Canada performs 2009: A report card on Canada. www.conferenceboard.ca/HCP/Details/Health.aspx. Accessed 06/27/2010. 5 World Health Organization. World health report 2000. Health systems: Improving performance. Geneva, 2000. 6 Commonwealth Fund. Mirror, mirror on the wall. How the performance of the U.S. health care system compares internationally. 2010 update. www.commonwealthfund.org/~/media/files/Publications/Fund%20Report/2010/Jun/1400_Davis_Mirror_Mirror_on_the_wall_2010.pdf 7 Eriksson D, Björnberg A. Euro-Canada Health Consumer Index 2009. Winnipeg: Frontier Centre for Public Policy, 2009. 8 Auditor General of Canada. April 1998 Report. Chapter 6 population aging and information for Parliament: understanding the choices. www.oag-bvg.gc.ca/internet/English/parl_oag_199804_06_e_9312.html. Accessed 01/26/10. 9 Parliamentary Budget Officer. Fiscal sustainability report. February 18, 2020. www2.parl.gc.ca/sites/pbo-dpb/documents/FSR_2010.pdf. Accessed 04/27/10. 10 Stone S. A Retrospective Evaluation of the Planetree Patient-Centred Model of Care on Inpatient Quality Outcomes. Health Environments Research and Design Journal. 2008;1(4):55-69. 11 Dagnone T. For patients' sake. www.health.gov.sk.ca/patient-first-commissioners-report. Accessed 06/28/2010. 12 Minister's Advisory Committee on Health. A foundation for Alberta's health system. www.health.alberta.ca/documents/MACH-Final-Report-2010-01-20.pdf. Accessed 06/28/2010. 13 Department of Health. The NHS Constitution. www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113645.pdf. Accessed 06/28/2010. 14 Australian Commission on Safety and Quality in Healthcare. Australian charter of healthcare rights. www.health.gov.au/internet/safety/publishing.nsf/content/com-pubs_ACHR-roles/$file/17537-charter.pdf. Accessed 06/28/2010. 15 Saskatchewan Health. Sooner, safer, smarter: A plan to transform the surgical patient experience. www.health.gov.sk.ca/Default.aspx?DN=545d9e1d-6cfe-447d-ac42-3b35f0dc8f5d&l=English. Accessed 06/28/2010. 16 Canadian Medical Association, College of Family Physicians of Canada. The wait starts here. The Primary Care Wait Time Partnership. 2 Dec 2009. www.cfpc.ca/.../PCWTP%20FINAL%20-%20FINAL%20ENGLISH%20(DEC%202009).pdf 17 Standing Senate Committee on Social Affairs, Science and Technology. The health of Canadians - the federal role. Volume six: Recommendations for reform. Ottawa, 2002. 18 British Columbia Ministry of Health Services. B.C. launches patient-focused funding provincewide. News release April 12, 2010. www2.news.gov.bc.ca/news_releases_2009-2013/2010HSERV0020-000403.pdf. Accessed 06/28/2010. 19 Ontario Ministry of Health and Long Term Care. Patient-based payment for hospitals. Backgrounder May 3,2010. www.health.gov.on.ca/en/news/release/2010/may/bg_20100503.pdf.Accesed 06/06/2010 20 Duckett S. "Thinking Economically in the health Sector". Presented to the Economics Society of Northern Alberta. 13 Nov 2009. 21 Task Force on the Funding of the Health System. Getting our money's worth. Québec: Gouvernement du Québec, 2008. 22 Donabedian A.Evaluating the quality of medical care. Milbank Quarterly 1966; 44:166-203. 23 Pink GH, Brown AD, Studer ML, Reiter KL, Leatt P. Pay-for-Performance in publicly financed healthcare: Some international experience and considerations for Canada. Healthcare Papers 2006; 6(4):8-26. 24 PIN is a Manitoba Health and Healthy Living primary care renewal initiative that focuses on fee-for-service (FFS) physician groups. Its goal is to facilitate systemic improvements in the delivery of primary care. See: www.gov.mb.ca/health/phc/pin/index.html 25 Alberta Medical Association President's Letter September 16, 2009. See: www.albertadoctors.org/bcm/ama/ama-website.nsf/AllDoc/4C2E247349659BD58725763300532A11/$File/preslet_sept16_09.pdf 26 British Columbia Medical Association. Full service family practice incentive program: frequently asked questions. Vancouver, 2006. 27 Hall B. Health incentives: the science and art of motivating healthy behaviours. Benefits Quarterly 2008; 24(2):12-22. 28 Schmidt H. Bonuses as incentives and rewards for healthy responsibility: A good thing? Journal of Medicine and Philosophy 2008; 33: 198-220. 29 Andreyeva T, Long M, Brownell K. The impact of food prices on consumption: a systematic review of research on the price elasticity of demand for food. Am J Public Health. 2010 Feb; 100(2):216-22. 30 Alberta Health and Wellness. Alberta Pharmaceutical Strategy. www.health.alberta.ca/documents/Pharmaceutical-Strategy-2009.pdf Accessed 11/02/09. 31 Manitoba Health. Manitoba Pharmacare Program. www.gov.mb.ca/health/pharmacare/index.html Accessed 11/02/09. 32 Newfoundland and Labrador Health and Community Services. Enhancements to program make drugs more affordable. April 23, 2007. www.releases.gov.nl.ca/releases/2007/health/0423n01.htm Accessed 11/02/09. 33 Statistics Canada. CANSIM Table 109-5012 Household spending on prescription drugs as a percentage of after-tax income, Canada and provinces. 2008. 34 Canadian Cancer Society. Cancer drug access for Canadians. Toronto, 2009. 35 Marin A. A vast injustice. Toronto, 2009. 36 Ontario Ministry of Health and Long-Term Care. Ontario expands access to cancer drug. News release November 29, 2009. www.health.gov.on.ca/en/news/release/2009/nov/nr_20091129.pdf. Accessed 06/06/2010. 37 Canadian Healthcare Association. Catastrophic pharmaceutical coverage. Ottawa, 2006. 38 Canadian Pharmacists Association. Catastrophic drug coverage - CphA position statement. Ottawa, 2008. 39 Canadian Nurses Association. CNA Presentation to House of Commons Standing Committee on Health Study on Prescription Drugs. September, 2003. 40 Canada's Research Based Pharmaceutical Companies (Rx&D). Catastrophic drug coverage. Ottawa, 2006. 41 Canadian Life and Health Insurance Association. Towards a sustainable, accessible, quality public health care system. Ottawa, 2009. 42 Canadian Institute for Health Information. Development of National Indicators and a Reporting System for Continuing Care (Long Term Care Facilities). Ottawa, 2000. 43 Statistics Canada. Population projections: Canada, the province and territories, 2009 to 2036. The Daily, Wednesday, May 26, 2010. 44 Canadian Intergovernmental Conference Centre. A 10-year plan to strengthen health care. Available from: scics.gc.ca/cinfo04/800042005_e.pdf Accessed 06/07/2010. 45 Pyper W. Balancing career and care. Perspectives on Labour and Income 2006;7(11):5-15. 46 National Advisory Council on Aging. 1999 and beyond: Challenges of an aging Canadian society. Ottawa, 1999. dsp-psd.pwgsc.gc.ca/Collection/H88-3-28-1999E.pdf. Accessed 02/29/2010. 47 Canadian Healthcare Association. Home Care in Canada: From the margins to the mainstream. Available from: www.cha.ca/documents/Home_Care_in_Canada_From_the_Margins_to_the_Mainstream_web.pdf. Accessed 06/04/2010 48 Canadian Healthcare Association. New Directions for Facility-Based Long Term Care. Available from: www.cha.ca/documents/CHA_LTC_9-22-09_eng.pdf. Accessed 06/04/2010. 49 Smith L. There is nothing for nothing any longer, especially for seniors. The Daily Gleaner. 21 Oct 2009. Available from: dailygleaner.canadaeast.com/rss/article/830881. Accessed 11/10/2009. 50 Special Senate Committee on Aging. Is Canada ready for an aging population? Senate Special Committee on Aging Identifies Serious Gaps for Older Canadians in Canada's Aging Population: Seizing the Opportunity. Available from: www.parl.gc.ca/40/2/parlbus/commbus/senate/com-e/agei-e/subsite-e/Aging_Report_Home-e.htm. Accessed 06/07/2010 51 Siciliani L, Hurst J. Explaining waiting times for elective surgery across OECD countries. OECD Health Working Papers No 7. Paris, 2003. 52 OECD Health Data 2009, June 2009. 53 Canadian Nurses Association. Tested solutions for eliminating Canada's registered nursing shortage. Ottawa, 2009 54 Nursing Sector Study Corporation (May 2006). Building the Future: An integrated strategy for nursing human resources in Canada, retrieved from www.cna-aiic.ca/CNA/documents/pdf/publications/Phase_II_Final_Report_e.pdf. Accessed 06/09/09. 55 Task Force Two. A physician human resource strategy for Canada: final report. Ottawa, 2006 56 Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources (2005, revised 2007). Framework for Collaborative Pan-Canadian Health Human Resources Planning, retrieved from www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/hhr/2007-frame-cadre/2007-frame-cadre-eng.pdf. Accessed 06/04/2010 57 Health Canada. Government of Canada announces funding to support 15 new family medicine positions for Canada's north. News release. May 10, 2009. http://www.hc-sc.gc.ca/ahc-asc/media/nr-cp/_2010/2010_72-eng.php. Accessed 06/29/2010. 58 Frank J (ed.) The CanMEDS 2005 Physician Competency Framework. Ottawa: Royal College of Physicians and Surgeons of Canada; 59 College of Family Physicians of Canada. Four principles of family medicine. www.cfpc.ca/English/cfpc/about%20us/principles/default.asp?s=1. Accessed 06/07/2010 60 Canadian Medical Association. CMA Policy on Scopes of Practice. Ottawa, 2001. 61 Enhancing Interdisciplinary Collaboration in Primary Health Care. The principles and framework for interdisciplinary collaboration in primary health care. www.eicp.ca/en/principles/march/EICP-Principles-and-Framework-March.pdf. Accessed 04/28/10. 62 Sources: CIHI Reports for Physician visits: Physicians in Canada: Fee-for-Service Utilization 2005-2006. Table 1-21. Hospital contacts: Trends in Acute Inpatient Hospitalizations and Day surgery Visits in Canada 1995-1996 to 2005-2006 and National Ambulatory Care Reporting System: Visit Disposition by Triage Level for All Emergency Visits - 2005-2006. 63 Schoen C, Osborn R, Doty MM, Squires D, Peugh J, Applebaum S. A survey of primary care physicians in eleven countries, 2009: Perspectives on care, costs and experiences. Health Affairs 2009; 28(6):1179-83. 64 Auditor General of Canada. 2008 December report of the Auditor General of Canada. Chapter 8 - reporting on health indicators - Health Canada. www.oag-bvg.gc.ca/internet/docs/parl_oag_200812_08_e.pdf. Accessed 06/27/2010. 65 www.waittimealliance.ca 66 www.ohqc.ca 67 www.ccn.on.ca 68 www.hospitalreport.ca 69 Canadian Institute for Health Information. HSMR: A New Approach for Measuring Hospital Mortality Trends in Canada. secure.cihi.ca/cihiweb/products/HSMR_hospital_mortality_trends_in_canada.pdf. Accessed 06/09/09. 70 Saskatchewan Health Quality Council. Quality Insight, 2008. www.hqc.sk.ca/download.jsp?oLYnotVGsC60FgKBEcq12DBIzBf0QfLQkUwK4QBZaJtXhmSAKqZibA==. Accessed 06/07/10 71 Public Health Agency of Canada. Health goals for Canada. www.phac-aspc.gc.ca/hgc-osc/pdf/goals-e.pdf. Accessed 06/20/2010. 72 Canadian Medical Association. National Health Goals for Canada: A Review of Successes, Challenges, and Opportunities for the Canadian Medical Association. Ottawa 2010 73 Comité de travail sur la pérennité du système de santé et des services sociaux du Québec. Pour sortir de l'impasse : la solidarité entre nos générations. Québec : Ministère de la santé et des services sociaux du Québec, 2005. 74 Parliamentary Budget Officer. Estimating potential GDP and the government's structural budget balance. www2.parl.gc.ca/Sites/PBO-DPB/documents/Potential_CABB_EN.pdf. Accessed 01/26/10. 75 Romanow, R. Building on values: the future of health care in Canada. Ottawa: Commission on the Future of Health Care in Canada, 2002. 76 Canadian Intergovernmental Conference Centre. 2003 First Ministers' Accord on Health Care Renewal. February 5, 2003. www.scics.gc.ca/pdf/800039001_e.pdf. Accessed 04/27/10. 77 The Centre for Spatial Economics. The economic cost of wait times in Canada 2008. www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/pdf/2008/EconomicReport.pdf Accessed 07/06/2010. 78 Canadian Intergovernmental Conference Centre. National Pharmaceutical Strategy decision points. http://www.scics.gc.ca/cinfo08/860556005_e.html. Accessed 04/27/10. 79 Aon Consulting. Health benefit design options for Alberta Health & Wellness: Executive summary 29 March 2006. http://www.health.alberta.ca/documents/Options-Aon-2006-summary.pdf. Accessed 04/27/10. 80 Aon Consulting. Continuing care. http://www.health.alberta.ca/documents/Options-Aon-2006-Care.pdf. Accessed 04/27/10. 81 Organization for Economic Cooperation and Development. Projecting OECD health and long-term care expenditures: what are the main drivers? Economics Department Working Papers No. 477. http://www.oecd.org/dataoecd/57/7/36085940.pdf. Accessed 04/28/10 82 Auerbach A., Gokhale J., Kotlikoff L. Generational accounts: a meaningful alternative to deficit acccounting. Tax Policy and the Economy 5. Cambridge, MA: MIT Press and the NBER, 1991. 83 Klumpes P, Tang L. The cost incidence of the UK's National Health Service system. Geneva Papers 2008;33:744-67. 84 Robson W. Boomer bulge: dealing with the stress of demographic change on government budgets in Canada. www.cdhowe.org/pdf/ebrief_71.pdf. Accessed 04/28/10. 85 Commission d'étude sur les services de santé et les services sociaux. Emerging solutions : report and recommendations. Québec : Gouvernement du Québec, 2001. 86 Finances Québec. For a more efficient and better funded health-care system. www.budget.finances.gouv.qc.ca/Budget/2010-2011/en/documents/MoreEfficient.pdf. Accessed 04/27/10. 87 Canada Revenue Agency. Income Statistics 2009 - 2007 tax year. Interim Table 2 - Universe data. www.cra-arc.gc.ca/gncy/stts/gb07/pst/ntrm/pdf/table2-eng.pdf. Accessed 04/28/10. 88 Ipsos Reid. Canadians embracing tax-free savings accounts. October 20, 2009. www.ipsos-na.com/news-polls/pressrelease.aspx?id=4557. Accessed 04/28/10. 89 Canadian Medical Association. It's about access: informing the debate on public and private health care. Ottawa, 2006.
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Advancing Inclusion and quality of life for seniors

https://policybase.cma.ca/en/permalink/policy13729
Date
2017-10-26
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
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Policy Type
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Date
2017-10-26
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
Canadians are living longer, healthier lives than ever before. The number of seniors expected to need help or care in the next 30 years will double, placing an unprecedented challenge on Canada’s health care system. That we face this challenge speaks to the immense success story that is modern medicine, but it doesn’t in any way minimize the task ahead. Publicly funded health care was created about 50 years ago when Canada’s population was just over 20 million and the average life expectancy was 71. Today, our population is over 36 million and the average life expectancy is 10 years longer. People 85 and older make up the fastest growing age group in our country, and the growth in the number of centenarians is also expected to continue. The Canadian Medical Association is pleased that the House of Commons Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities is studying ways Canada can respond to these challenges. Here, for your consideration, we present 15 comprehensive recommendations that would help our seniors remain active, contributing citizens of their communities while improving the quality of their lives. These range from increasing capital investment in residential care infrastructure, to enhancing assistance for caregivers, to improving the senior-friendliness of our neighbourhoods. The task faced by this committee, indeed the task faced by all of Canada, is daunting. That said, it is manageable and great advances can be made on behalf of seniors. By doing so, we will ultimately deliver both health and financial benefits to all Canadians. Dr. Laurent Marcoux, CMA President The Canadian Medical Association (CMA) is pleased to submit this brief to the Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities as part of its study regarding how the Government can support vulnerable seniors today while preparing for the diverse and growing seniors population of tomorrow. This brief directly addresses the three themes considered by this Committee:
How the Government can improve access to housing for seniors including aging in place and affordable and accessible housing;
How the Government can improve income security for vulnerable seniors; and
How the Government can improve the overall quality of life and well-being for seniors including community programming, social inclusivity, and social determinants of health. Improving access to housing for seniors As part of a new National Housing Strategy, the federal government announced in the 2017 Budget that it will invest more than $11.2 billion in a range of initiatives designed to build, renew, and repair Canada’s stock of affordable housing and help to ensure that Canadians have adequate and affordable housing that meets their needs. While a welcome step, physicians continue to see the problems facing seniors in relation to a lack of housing options and supports — problems that cascade across the entire health care system. A major hindrance to social equity in health care delivery and a serious cause of wait times is the inappropriate placement of patients, particularly seniors, in hospitals. Alternate level of care (ALC) beds are often used in acute care hospitals to accommodate patients — most of whom are medically stable seniors — waiting for appropriate levels of home care or access to a residential care home/facility. High rates of ALC patients in hospitals affect all patients by contributing to hospital overcrowding, lengthy waits in emergency departments, delayed hospital admissions, cancelled elective surgeries, and sidelined ambulance services waiting to offload new arrivals (often referred to as code gridlock).1 Moreover, unnecessarily long hospital stays can leave patients vulnerable to hospital-acquired illnesses and disabilities such as delirium, deconditioning, and falls. Daily costs - Ontario $842: acute care hospital, per patient $126: long-term care residence, per patient $42: home care, per patient # of acute care hospital beds = 18,571 14% waiting for placement = 2,600 beds Providing more cost-effective and appropriate solutions will optimize the use of health care resources. It has been estimated that it costs $842 per day for a hospital bed versus $126 per day for a long-term care bed and $42 per day for care at home.2 An investment in appropriate home or residential care, which can take many forms, will alleviate inappropriate hospital admissions and facilitate timely discharges. The residential care sector is facing significant challenges because of the rising numbers of older seniors with increasingly complex care needs. The demand for residential care will increase significantly over the next several years because of the growing number of frail elderly seniors requiring this service. New facilities will need to be constructed and existing facilities will need to be upgraded to comply with enhanced regulatory requirements and respond to residents’ higher care needs. The Conference Board of Canada has produced a residential care bed forecast tied to population growth of age cohorts. It is estimated that Canada will require an average of 10,500 new beds per year over the next 19 years, for a total of 199,000 new beds by 2035. This forecast does not include the investments needed to renovate and retrofit existing long-term care homes.3 A recent report by the Canadian Institute for Health Information indicated that residential care capacity must double over the next 20 years (assuming no change in how care is currently provided), necessitating a transformation in how seniors care is provided across the continuum of care.4 These findings provide a sense of the immense challenges Canada faces in addressing the residential care needs of older seniors. Investments in residential care infrastructure and continuing care will improve care for seniors while significantly reducing wait times in hospitals and across the system, benefiting all patients. Efforts to de-hospitalize the system and address the housing and residential care options for Canada’s aging population are key. The federal government can provide significant pan-Canadian assistance by investing in residential care infrastructure. RECOMMENDATION 1 The CMA recommends that the federal government include capital investment in residential care infrastructure, including retrofit and renovation, as part of its commitment to invest in social infrastructure. Improving income security for vulnerable seniors Income is a key factor impacting the health of individuals and communities. Higher income and social status are linked to better health.5 Adequate Income: Poverty among seniors in Canada dropped sharply in the 1970s and 1980s but it has been rising in recent years. In 2012, the incidence of low income among people aged 65 years and over was 12.1%. This rate was considerably higher for single seniors at 28.5%.6 Incidence of low income (2012) Seniors overall: 12.1% Single seniors: 28.5% Most older Canadians rely on Old Age Security (OAS), the Canada Pension Plan (CPP), and their personal pensions or investments to maintain their basic standard of living in retirement. Some seniors are also eligible for a Guaranteed Income Supplement (GIS) to improve their financial security. The CMA recognizes the federal government’s actions to strengthen these programs and initiatives to ensure their viability and to provide sustainable tax relief. These measures must continue and evolve to support aging Canadians so they can afford to live at home or in age-friendly communities as they get older. The government’s actions to ensure adequate income support will also assist aging Canadians to take care of their health, maintain independence, and continue living safely without the need for institutional care. On the topic of seniors’ income security, the financial abuse of seniors cannot be overlooked. Elder abuse can take many forms: financial, physical, psychological, sexual, and neglect. Often the abuser is a family member, friend, or other person in a position of trust. Researchers estimate that 4 to 10% of Canadian seniors experience abuse or neglect, but that only a small portion of this is reported. The CMA supports public awareness initiatives that bring attention to elder abuse, as well as programs to intervene with seniors who are abused and with their abusers. RECOMMENDATION 2 The CMA recommends that the federal government take steps to provide adequate income support for older Canadians, as well as education and protection from financial abuse. Improving the overall quality of life and well-being for seniors Improving how we support and care for Canada’s growing seniors population has been a priority for CMA over the past several years. For the first time in Canada’s history, persons aged 65 years and older outnumber those under the age of 15 years.7 Seniors are projected to represent over 20% of the population by 2024 and up to 25% of the population by 2036.8 People aged 85 years and over make up the fastest growing age group in Canada — this portion of the population grew by 127% between 1993 and 2013.9 Statistics Canada projects, on the basis of a medium-growth scenario, that there will be over 11,100 Canadians aged 100 years and older by 2021, 14,800 by 2026 and 20,300 by 2036.7 Though age does not automatically mean ill health or disability, the risk of both increases with age. Approximately 75 to 80% of Canadian seniors report having one or more chronic conditions.10 Because of increasing rates of disability and chronic disease, the demand for health services is expected to increase as Canada’s population ages. The Conference Board of Canada has estimated 2.4 million Canadians 65 years and older will need continuing care, both paid and unpaid, by 2026 — a 71% increase since 2011.11 When publicly funded health care was created about 50 years ago, Canada’s population was just over 20 million and the average life expectancy was 71. Today, our population is over 36 million and the average life expectancy is 10 years longer. The aging of our population is both a success story and a pressing health policy issue. National seniors strategy Canada needs a new approach to ensure that both our aging population and the rest of Canadians can get the care they need, when and where they need it. The CMA believes that the federal government should invest in seniors care now, guided by a pan-Canadian seniors strategy. In doing so, it can help aging Canadians be as productive as possible — at work, in their communities, and in their homes. The CMA is pleased with the June 2017 Report of the Standing Senate Committee on National Finance that called for the federal government to develop, in collaboration with the provinces and territories and Indigenous partners, a national seniors strategy in order to control spending growth while ensuring appropriate and accessible care.12 The CMA is also pleased that MP Marc Serré (Nickel Belt) secured support for his private members’ motion calling for the development of a national seniors strategy. Over 50,000 Canadians have already lent their support to this cause (see www.DemandaPlan.ca). RECOMMENDATION 3 The CMA recommends that the federal government provide targeted funding to support the development of a pan-Canadian seniors strategy to address the needs of the aging population. Improving assistance for home care and Canada’s caregivers Many of the services required by seniors, in particular home care and long-term care, are not covered by the Canada Health Act. Funding for these services varies widely from province to province. The disparity among the provinces in terms of their fiscal capacity in the current economic climate will mean improvements in seniors care will advance at an uneven pace. The funding and delivery of accessible home care services will help more aging Canadians to recover from illness, live at home longer, and contribute to their families and communities. Multi-year funding arrangements to reinforce commitment to and financial investment in home care should be carefully considered.13 The development of innovative partnerships and models to help ensure services and resources for seniors’ seamless transition across the continuum of care are also important. RECOMMENDATION 4 The CMA recommends governments work with the health and social services sectors, and with private insurers, to develop a framework for the funding and delivery of accessible and sustainable home care and long-term care services. Family and friend caregivers are an extremely important part of the health care system. A 2012 Statistics Canada study found that 5.4 million Canadians provided care to a senior family member or friend, and 62% of caregivers helping seniors said that the care receiver lived in a private residence separate from their own.14 According to a report by Carers Canada, the Canadian Home Care Association, and the Canadian Cancer Action Network, caregivers provide an array of services including personal and medical care, housekeeping, advocacy, financial management, and social/emotional support. The report also indicated that caregivers contribute $25 billion in unpaid labour to our health system.15 Given their enormous contributions, Canada’s caregivers need support in the form of financial assistance, education, peer support, and respite care. A pan-Canadian caregiver strategy is needed to ensure caregivers are provided with the support they require.15 Caregivers provide... Personal and Medical Care Housekeeping worth $25 billion in Advocacy unpaid labour Financial Managemen Social-emo ional Suppor RECOMMENDATION 5 The CMA recommends that the federal government and other stakeholders work together to develop and implement a pan-Canadian caregiver strategy, and expand the support programs currently offered to informal caregivers. Canadians want governments to do more to help seniors and their family caregivers.16 The federal government’s new combined Canada Caregiver Credit (CCC) is a non-refundable credit to individuals caring for dependent relatives with infirmities (including persons with disabilities). The CCC will be more accessible and will extend tax relief to more caregivers by including dependent relatives who do not live with their caregivers and by increasing the income threshold. Making the new CCC a refundable tax credit for caregivers whose tax owing is less than the total credit would result in a refund payment to provide further financial support for low-income families. RECOMMENDATION 6 The CMA recommends that the federal government improve awareness of the new Canada Caregiver Credit and amend it to make it a refundable tax credit for caregivers. The federal government’s recent commitment to provide $6 billion over 10 years to the provinces and territories for home care, including support for caregivers, is a welcome step toward improving opportunities for seniors to remain in their homes. As with previous bilateral funding agreements, it is important to establish clear operating principles between the parties to oversee the funding implementation and for the development of clear metrics to measure performance. RECOMMENDATION 7 The CMA recommends that the federal government develop explicit operating principles for the home care funding that has been negotiated with the provinces and territories to recognize funding for caregivers and respite care as eligible areas of investment. The federal government’s recent funding investments in home care and mental health recognize the importance of these aspects of the health care system. They also signal that Canada has under-invested in home and community-based care to date. Other countries have more supportive systems and programs in place — systems and programs that Canada should consider. RECOMMENDATION 8 The CMA recommends the federal government convene an all-party parliamentary international study that includes stakeholders to examine the approaches taken to mitigate the inappropriate use of acute care for elderly persons and provide support for caregivers. Programs and supports to promote healthy aging The CMA believes that governments at all levels should invest in programs and supports to promote healthy aging, a comprehensive continuum of health services to provide optimal care and support to older Canadians, and an environment and society that is “age friendly”.17 The Public Health Agency of Canada (PHAC) defines healthy aging as “the process of optimizing opportunities for physical, social and mental health to enable seniors to take an active part in society without discrimination and to enjoy independence and quality of life.”18 It is believed that initiatives to promote healthy aging and enable older Canadians to maintain their health will help lower health care costs by reducing the overall burden of disability and chronic disease. Such initiatives should focus on physical activity, good nutrition, injury (e.g. falls) prevention, and seniors’ mental health (including depression). RECOMMENDATION 9 The CMA recommends that governments at all levels support programs to promote physical activity, nutrition, injury prevention, and mental health among older Canadians. For seniors who have multiple chronic diseases or disabilities, care needs can be complex, and they may vary greatly from one person to another and involve many health care providers. Complex care needs demand a flexible and responsive health system. The CMA believes that quality health care for older Canadians should be delivered on a continuum from community-based health care (e.g. primary health care, chronic disease management programs), to home care (e.g. visiting health care workers to give baths and foot care), to long-term care and palliative care. Ideally, this continuum should be managed so that the senior can remain at home and out of emergency departments, hospitals, and long-term care unless appropriate; easily access necessary care; and make a smooth transition from one level of care to another when necessary. RECOMMENDATION 10 The CMA recommends governments and other stakeholders work together to develop and implement models of integrated, interdisciplinary health service delivery for older Canadians. Every senior should have the opportunity to have a family physician or to be part of a family practice that serves as a medical home. This provides a central hub for the timely provision and coordination of the comprehensive menu of health and medical services. A medical home should provide patients with access to medical advice and the provision of, or direction to, needed care 24 hours a day, seven days a week, 365 days a year. Research in 2014 by the Commonwealth Fund found that the percentage of Canadian seniors who have a regular family physician or place of care is very high (98%); however, their ability to get timely access based on same-day or next-day appointments was among the lowest of 11 nations.19 Compared to seniors in most other countries surveyed, Canadian seniors were also more likely to use the emergency department and experience problems with care coordination. RECOMMENDATION 11 The CMA recommends governments continue efforts to ensure that older Canadians have access to a family physician, supported by specialized geriatric services as appropriate. Prescription drugs represent the fastest-growing item in the health budget and the second-largest category of health expenditure. As the population of seniors grows, there will be an ongoing need for detailed information regarding seniors’ drug use and expenditure to support the overall management of public drug programs.20 Despite some level of drug coverage for seniors in all provinces and territories, some seniors still skip doses or avoid filling prescriptions due to cost, and more research into the extent of this problem is required.21 The CMA supports the development of an equitable and comprehensive pan-Canadian pharmacare program. As a step toward comprehensive, universal coverage, the CMA has repeatedly called on the federal government to implement a system of catastrophic coverage for prescription medication to reduce cost barriers of treatment and ensure Canadians do not experience undue financial hardship. Moreover, with more drugs available to treat a large number of complex and chronic health conditions, the CMA supports the development of a coordinated national approach to reduce polypharmacy among the elderly. RECOMMENDATION 12 The CMA recommends governments and other stakeholders work together to develop and implement a pan-Canadian pharmaceutical strategy that addresses both comprehensive coverage of essential medicines for all Canadians, and programs to encourage optimal prescribing and drug therapy. Optimal care and support for older Canadians also depends on identifying, adapting, and implementing best practices in the care of seniors. PHAC’s Best Practices Portal22 is one noteworthy initiative, and the system needs to spread and scale best practices by leveraging and enhancing pan-Canadian resources that build capacity and improve performance in home care and other sectors.13 RECOMMENDATION 13 The CMA recommends that governments and other stakeholders support ongoing research to identify best practices in the care of seniors, and monitor the impact of various interventions on health outcomes and costs. An environment and society that is “age friendly” One of the primary goals of seniors policy in Canada is to promote the independence of older Canadians, avoiding costly institutionalization for as long as feasible. To help older Canadians successfully maintain their independence, governments and society must keep the social determinants of health in mind when developing and implementing policy that affects seniors. It is also important to eliminate discrimination against seniors and promote positive messaging around aging. An age-friendly society respects the experience, knowledge, and capabilities of its older members and accords them the same worth and dignity as it does other citizens. Employment is also important for seniors who need or desire it. Many seniors are choosing to remain active in the workplace for a variety of reasons, such as adding to their financial resources or staying connected to a social network.23 The CMA recognizes the federal government’s support for seniors who opt to continue working. And, while many employers encourage older workers and accommodate their needs, employment may be difficult to find in workplaces that are unwilling to hire older workers. RECOMMENDATION 14 The CMA recommends that governments at all levels and other partners give older Canadians access to opportunities for meaningful employment if they desire. The physical environment, including the built environment, can help to promote seniors’ independence and successful, healthy aging. The World Health Organization defines an “age-friendly environment” as one that fosters health and well-being and the participation of people as they age.24 Age-friendly environments are accessible, equitable, inclusive, safe and secure, and supportive. They promote health and prevent or delay the onset of disease and functional decline. They provide people-centered services and support to enable recovery or to compensate for the loss of function so that people can continue to do the things that are important to them.24 These factors should be taken into consideration by those who design and build communities. For example, buildings should be designed with entrance ramps and elevators; sidewalks could have sloping curbs for walkers and wheelchairs; and frequent, accessible public transportation should be provided in neighbourhoods with large concentrations of seniors. RECOMMENDATION 15 The CMA recommends that governments and communities take the needs of older Canadians into account when designing buildings, walkways, transportation systems, and other aspects of the built environment. Conclusion The CMA recognizes the federal government’s commitment to support vulnerable seniors today while preparing for the diverse and growing seniors’ population of tomorrow. The CMA’s recommendations in this submission can assist the government as it seeks to improve access to housing for seniors, enhance income security for vulnerable seniors, and improve the overall quality of life for seniors in ways that will help to advance inclusion, well-being, and the health of Canada’s aging population. To maximize the health and well-being of older Canadians, and ensure their active engagement and independence for as long as possible, the CMA believes that the health care system, governments, and society should work with older Canadians to promote healthy aging, provide quality patient-centred health care and support services, and build communities that value Canadians of all ages. References 1 Simpson C. Code Gridlock: Why Canada needs a national seniors strategy. Address to the Canadian Club of Ottawa by Dr. Christopher Simpson, President, Canadian Medical Association; 2014 Nov. 18; Ottawa, Ontario. Available: https://www.cma.ca/En/Lists/Medias/Code_Gridlock_final. pdf#search=code%20gridlock (accessed 2016 Sep 22). 2 North East Local Health Integration Network. HOME First shifts care of seniors to HOME. LHINfo Minute, Northeastern Ontario Health Care Update. Sudbury: The Network; 2011. Cited by Home Care Ontario. Facts & figures - publicly funded home care. Hamilton: Home Care Ontario; 2017 Jun. Available: http://www.homecareontario.ca/home-care-services/facts-figures/publiclyfundedhomecare (accessed 2016 Sep 22). 3 Conference Board of Canada. A cost-benefit analysis of meeting the demand for long-term care beds. Ottawa: Conference Board of Canada; Manuscript submitted for publication. 4 Canadian Institute for Health Information (CIHI). Seniors in transition: exploring pathways across the care continuum. Ottawa: The Institute; 2017. Available: https://www.cihi.ca/sites/default/files/document/seniors-in-transition-report-2017-en.pdf (accessed 2017 Jun 30). 5 World Health Organization. Health Impact Assessment (HIA). The determinants of health. Available: http://www.who.int/hia/evidence/doh/en/ (accessed 2017 Oct 23). 6 Statistics Canada. Persons in low income (after-tax low income measure), 2012. The Daily. Ottawa: Statistics Canada; 2014 Dec 10. Available: http://www.statcan.gc.ca/daily-quotidien/141210/t141210a003-eng.htm (accessed 2017 Oct 17). 7 Statistics Canada. Population projections: Canada, the provinces and territories, 2013 to 2063. The Daily. Ottawa: Statistics Canada; 2014 Sep 17. Available: http://www.statcan.gc.ca/daily-quotidien/140917/dq140917a-eng.pdf (accessed 2016 Sep 19). 8 Statistics Canada. Canada Year Book 2012, seniors. Ottawa: Statistics Canada; 2012. Available: https://www.statcan.gc.ca/pub/11­ 402-x/2012000/chap/seniors-aines/seniors-aines-eng.htm (accessed 2017 Oct 18). 9 Public Health Agency of Canada. The Chief Public Health Officer’s report on the state of public health in Canada, 2014: public health in the future. Ottawa: Public Health Agency of Canada; 2014. Available: https://www.canada.ca/content/dam/phac-aspc/migration/phac-aspc/ cphorsphc-respcacsp/2014/assets/pdf/2014-eng.pdf (accessed 2016 Sep 19). 10 Canadian Institute for Health Information (CIHI). Health Care in Canada, 2011: A Focus on Seniors and Aging. Ottawa: The Institute; 2014 Nov. Available: https://secure.cihi.ca/free_products/HCIC_2011_seniors_report_en.pdf (accessed 2016 Sept 19). 11 Stonebridge C, Hermus G, Edenhoffer K. Future care for Canadian seniors: a status quo forecast. Ottawa: Conference Board of Canada; 2015. Available: http://www.conferenceboard.ca/e-library/abstract.aspx?did=7374 (accessed 2016 Sep 20). 12 Report of the Standing Senate Committee on National Finance. Getting ready: For a new generation of active seniors. Ottawa: The Committee; 2017 Jun. Available: https://sencanada.ca/content/sen/committee/421/NFFN/Reports/NFFN_Final19th_Aging_e.pdf (accessed 2017 Oct 18). 13 Canadian Home Care Association, The College of Family Physicians of Canada, Canadian Nurses Association. Better Home Care in Canada: A National Action Plan. 2016. Ottawa: Canadian Home Care Association, The College of Family Physicians of Canada, Canadian Nurses Association; 2016. Available: http://www.thehomecareplan.ca/wp-content/uploads/2016/10/Better-Home-Care-Report-Oct-web.pdf (accessed 2017 Oct 23). 14 Turcotte M, Sawaya C. Senior care: differences by type of housing. Insights on Canadian society. Cat. No. 75-006-X. Ottawa: Statistics Canada; 2015 Feb 25. Available: http://www.statcan.gc.ca/pub/75-006-x/2015001/article/14142-eng.pdf (accessed 2016 Sep 22). 15 Carers Canada, Canadian Home Care Association, Canadian Cancer Action Network. Advancing Collective Priorities: A Canadian Carer Strategy. 2017. Mississauga: Canadian Home Care Association, Canadian Cancer Action Network; 2017. Available: http://www.cdnhomecare.ca/media. php?mid=4918 (accessed 2017 Oct 23). 16 Ipsos Public Affairs, HealthCareCAN, Canadian College of Health Leaders. National Health Leadership Conference report. Toronto: Ipsos Public Affairs; 2016 Jun 6. Available: http://www.nhlc-cnls.ca/assets/2016%20Ottawa/NHLCIpsosReportJune1.pdf (accessed 2016 Jun 06). 17 Canadian Medical Association. Health and Health Care for an Aging Population. Ottawa: The Association; December 2013. Available: https:// www.cma.ca/Assets/assets-library/document/en/advocacy/policy-research/CMA_Policy_Health_and_Health_Care_for_an_Aging-Population_ PD14-03-e.pdf (accessed 2017 Oct 20). 18 Government of Canada. The Chief Public Health Officer’s Report on the State of Public Health in Canada 2010 – Canada’s experience in setting the stage for healthy aging. Ottawa: Government of Canada; 2014. Available: https://www.canada.ca/en/public-health/corporate/publications/ chief-public-health-officer-reports-state-public-health-canada/annual-report-on-state-public-health-canada-2010/chapter-2.html (accessed 2017 Oct 23). 19 Commonwealth Fund. 2014 International Health Policy Survey of Older Adults in Eleven Countries. 2014. New York: Commonweath Fund; 2014. Available: http://www.commonwealthfund.org/~/media/files/publications/in-the-literature/2014/nov/pdf_1787_commonwealth_fund_2014_intl_ survey_chartpack.pdf (accessed 2017 Oct 23). 20 Canadian Institute for Health Information. Drug Use among Seniors on Public Drug Programs in Canada, 2002 to 2008. (2010). Ottawa: The Institute; 2010. Available: https://secure.cihi.ca/free_products/drug_use_in_seniors_2002-2008_e.pdf (accessed 2017 Oct 23). 21 Law MR, Cheng L, Dhalla IA, Heard D, Morgan SG. The effect of cost on adherence to prescription medications in Canada. CMAJ. 2012 Feb21;184(3):297-302. Available: http://www.cmaj.ca/content/184/3/297.short. (accessed 2017 Oct 23). 22 Public Health Agency of Canada. Canadian Best Practices Portal. Ottawa: Public Health Agency of Canada; 2016. Available: http://cbpp-pcpe. phac-aspc.gc.ca/public-health-topics/seniors/ (accessed 2017 Oct 23). 23 Government of Canada. Action for Seniors report. 2014. Ottawa: Government of Canada; 2014. Available: https://www.canada.ca/en/ employment-social-development/programs/seniors-action-report.html (accessed 2017 Oct 23). 24 World Health Organization (WHO). Age-friendly environments. Geneva: WHO; 2017. Available: http://www.who.int/ageing/projects/age­ friendly-environments/en/ (accessed 2017 Oct 23).
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A new mission for health care in Canada: Addressing the needs of an aging population. 2016 pre-budget submission to the Minister of Finance

https://policybase.cma.ca/en/permalink/policy11803
Date
2016-02-09
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2016-02-09
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) is pleased to confirm its strong support for the federal government's health and social policy commitments, as identified in the ministerial mandate letters. In this brief, the CMA outlines seven recommendations for meaningful and essential federal action to ensure Canada is prepared to meet the health care needs of its aging population. The CMA's recommendations are designed to be implemented in the 2016-17 fiscal year in order to deliver immediate support to the provinces and territories and directly to Canadians. Immediate implementation of these recommendations is essential given the current and increasing shortages being experienced across the continuum of care in jurisdictions across Canada. In 2014, the CMA initiated a broad consultative initiative on the challenges in seniors care, as summarized in the report A Policy Framework to Guide a National Seniors Strategy for Canada. This report highlights the significant challenges currently being experienced in seniors care and emphasizes the need for increased federal engagement. Finally, if implemented, the CMA's recommendations will contribute to the federal government's strategic commitments in health, notably the commitment to the development of a new Health Accord. 1) Demographic Imperative for Increased Federal Engagement in Health Canada is a nation on the threshold of great change. This change will be driven primarily by the economic and social implications of the major demographic shift already underway. The added uncertainties of the global economy only emphasize the imperative for federal action and leadership. In 2015, for the first time in Canada's history, persons aged 65 years and older outnumbered those under the age of 15 years.1 Seniors are projected to represent over 20% of the population by 2024 and up to 25% of the population by 2036.2 It is increasingly being recognized that the projected surge in demand for services for seniors that will coincide with slower economic growth and lower government revenue will add pressure to the budgets of provincial and territorial governments.3 Today, while seniors account for about one-sixth of the population, they consume approximately half of public health spending.4 Based on current trends and approaches, seniors care is forecast to consume almost 62% of provincial/territorial health budgets by 2036.5 The latest National Health Expenditures report by the Canadian Institute of Health Information (CIHI) projects that health spending in 2015 was to exceed $219 billion, or 10.9% of Canada's gross domestic product (GDP).6 To better understand the significance of health spending in the national context, consider that total federal program spending is 13.4% of GDP.7 Finally, health budgets are now averaging 38% of provincial and territorial global budgets.8 Alarmingly, the latest fiscal sustainability report of the Parliamentary Budget Officer explains that the demands of Canada's aging population will result in "steadily deteriorating finances" for the provinces and territories, who "cannot meet the challenges of population aging under current policy."9 Taken together, the indicators summarized above establish a clear imperative and national interest for greater federal engagement, leadership and support for the provision of health care in Canada. 2) Responses to Pre-Budget Consultation Questions Question 1: How can we better support our middle class? A) Federal Action to Help Reduce the Cost of Prescription Medication The CMA strongly encourages the federal government to support measures aimed at reducing the cost of prescription medication in Canada. A key initiative underway is the pan-Canadian Pharmaceutical Alliance led by the provinces and territories. The CMA supports the federal government's recent announcement that it will partner with the provinces and territories as part of the pan-Canadian Pharmaceutical Alliance. In light of the fact that the majority of working age Canadians have coverage for prescription medication through private insurers10, the CMA recommends that the federal government support inviting the private health insurance industry to participate in the work of the pan-Canadian Pharmaceutical Alliance. Prescription medication has a critical role as part of a high-quality, patient-centred and cost-effective health care system. Canada stands out as the only country with universal health care without universal pharmaceutical coverage.11 It is an unfortunate reality that the affordability of prescription medication has emerged as a key barrier to access to care for many Canadians. According to the Angus Reid Institute, more than one in five Canadians (23%) report that they or someone in their household did not take medication as prescribed because of the cost during the past 12 months.12 Statistics Canada's Survey of Household Spending reveals that households headed by a senior spend $724 per year on prescription medications, the highest among all age groups and over 60% more than the average household.13 Another recent study found that 7% of Canadian seniors reported skipping medication or not filling a prescription because of the cost.14 The CMA has long called on the federal government to implement a system of catastrophic coverage for prescription medication to ensure Canadians do not experience undue financial harm and to reduce the cost barriers of treatment. As a positive step toward comprehensive, universal coverage for prescription medication, the CMA recommends that the federal government establish a new funding program for catastrophic coverage of prescription medication. The program would cover prescription medication costs above $1,500 or 3% of gross household income on an annual basis. Research commissioned by the CMA estimates this would cost $1.57 billion in 2016-17 (Table 1). Table 1: Projected cost of federal contribution to cover catastrophic prescription medication costs, by age cohort, 2016-2020 ($ million)15 Age Cohort 2016 2017 2018 2019 2020 Share of total cost Under 35 years 113.3 116.3 119.4 122.5 125.2 7% 35 to 44 years 177.2 183.5 190.5 197.8 204.3 11% 45 to 54 years 290.2 291.9 298.0 299.2 301.0 18% 55 to 64 years 383.7 400.6 417.6 433.1 444.6 25% 65 to 74 years 309.2 328.5 348.4 369.8 391.6 21% 75 years + 303.0 315.5 329.8 345.2 360.1 20% All ages 1,566.8 1,617.9 1,670.5 1,724.2 1,773.1 100% B) Deliver Immediate Federal Support to Canada's Unpaid Caregivers There are approximately 8.1 million Canadians serving as informal, unpaid caregivers with a critical role in Canada's health and social sector.16 The Conference Board of Canada reports that in 2007, informal caregivers contributed over 1.5 billion hours of home care - more than 10 times the number of paid hours in the same year.17 The economic contribution of informal caregivers was estimated to be about $25 billion in 2009.18 This same study estimated that informal caregivers incurred over $80 million in out-of-pocket expenses related to caregiving in 2009. Despite their tremendous value and important role, only a small fraction of caregivers caring for a parent receive any form of government support.19 Only 5% of caregivers providing care to parents reported receiving financial assistance, while 28% reported needing more assistance than they received.20 It is clear that Canadian caregivers require more support. As a first step, the CMA recommends that the federal government amend the Caregiver and Family Caregiver Tax Credits to make them refundable. This would provide an increased amount of financial support for family caregivers. It is estimated that this measure would cost $90.8 million in 2016-17.21 C) Implement a new Home Care Innovation Fund The CMA strongly supports the federal government's significant commitment to deliver more and better home care services, as released in the mandate letter for the Minister of Health. Accessible, integrated home care has an important role in Canada's health sector, including addressing alternate level of care (ALC) patients waiting in hospital for home care or long-term care. As highlighted by CIHI, the majority of the almost 1 million Canadians receiving home care are aged 65 or older.22 As population aging progresses, demand for home care can be expected to increase. Despite its importance, it is widely recognized that there are shortages across the home care sector.23 While there are innovations occurring in the sector, financing is a key barrier to scaling up and expanding services. To deliver the federal government's commitment to increasing the availability of home care, the CMA recommends the establishment of a new targeted home care innovation fund. As outlined in the Liberal Party of Canada's election platform, the CMA recommends that the fund deliver $3 billion over four years, including $400 million in the 2016-17 fiscal year. Question 2: What infrastructure needs can best help grow the economy...and meet your priorities locally? Deliver Federal Investment to the Long-term Care Sector as part of Social Infrastructure All jurisdictions across Canada are facing shortages in the continuing care sector. Despite the increased availability of home care, research commissioned for the CMA indicates that demand for continuing care facilities will surge as the demographic shift progresses.24 In 2012, it was reported that wait times for access to a long-term care facility in Canada ranged from 27 to over 230 days. More than 50% of ALC patients are in these hospital beds because of the lack of availability of long-term care beds25. Due to the significant difference in the cost of hospital care (approximately $846 per day) versus long-term care ($126 per day), the CMA estimates that the shortages in the long-term care sector represent an inefficiency cost to the health care system of $2.3 billion a year.26 Despite the recognized need for infrastructure investment in the continuing care sector, to date, this sector has been unduly excluded from federal investment in infrastructure, namely the Building Canada Plan. The CMA recommends that the federal government include capital investment in continuing care infrastructure, including retrofit and renovation, as part of its commitment to invest in social infrastructure. Based on previous estimates, the CMA recommends that $540 million be allocated for 2016-17 (Table 2), if implemented on a cost-share basis. Table 2: Estimated cost to address forecasted shortage in long-term care beds, 2016-20 ($ million)27 Forecasted shortage in long term care beds Estimated cost to address shortage Federal share to address shortage in long term care beds (based on 1/3 contribution) 2016 6,028 1,621.5 540.5 2017 6,604 1,776.5 592.2 2018 8,015 2,156.0 718.7 2019 8,656 2,328.5 776.2 2020 8,910 2,396.8 798.9 Total 38,213 10,279.3 3,426.4 In addition to improved delivery of health care resources, capital investment in the long-term care sector would provide an important contribution to economic growth. According to previous estimates by the Conference Board of Canada, the capital investment needed to meet the gaps from 2013 to 2047 would yield direct economic benefits on an annual basis that include $1.23 billion contribution to GDP and 14,141 high value jobs during the capital investment phase and $637 million contribution to GDP and 11,604 high value jobs during the facility operation phase (based on an average annual capital investment). Question 3: How can we create economic growth, protect the environment, and meet local priorities while ensuring that the most vulnerable don't get left behind? Deliver new Funding to Support the Provinces and Territories in Meeting Seniors Care Needs Canada's provincial and territorial leaders are struggling to meet health care needs in light of the demographic shift. This past July, the premiers issued a statement calling for the federal government to increase the Canada Health Transfer (CHT) to 25% of provincial and territorial health care costs to address the needs of an aging population. It is recognized that as an equal per-capita based transfer, the CHT does not currently account for population segments with increased health needs, specifically seniors. The CMA was pleased that this issue was recognized by the Prime Minister in his letter last spring to Quebec Premier Philippe Couillard. However, the CMA is concerned that an approach to modify the transfer formula would potentially delay the delivery of federal support to meet the needs of an aging population. As such, rather than the transfer formula, the CMA has developed an approach that delivers support to jurisdictions endeavoring to meet the needs of their aging populations while respecting the transfer arrangement already in place. The CMA commissioned the Conference Board of Canada to calculate the amount for the top-up to the CHT using a needs-based projection. The amount of the top-up for each jurisdiction is based on the projected increase in health care spending associated with an aging population. To support the innovation and transformation needed to address the health needs of the aging population, the CMA recommends that the federal government deliver additional funding on an annual basis beginning in 2016-17 to the provinces and territories by means of a demographic-based top-up to the Canada Health Transfer (Table 3). For the fiscal year 2016-17, this top-up would require $1.6 billion in federal investment. Table 3: Allocation of the federal demographic-based top-up, 2016-20 ($million)28 Jurisdiction 2016 2017 2018 2019 2020 All of Canada 1,602.1 1,663.6 1,724.2 1,765.8 1,879.0 Ontario 652.2 677.9 692.1 708.6 731.6 Quebec 405.8 413.7 418.8 429.0 459.5 British Columbia 251.6 258.7 270.3 270.1 291.3 Alberta 118.5 123.3 138.9 141.5 157.5 Nova Scotia 53.6 58.6 62.3 64.4 66.6 New Brunswick 45.9 50.7 52.2 54.1 57.2 Newfoundland and Labrador 29.7 30.5 33.6 36.6. 46.1 Manitoba 28.6 30.6 33.5 32.5 36.6 Saskatchewan 3.5 4.9 7.3 12.7 15.4 Prince Edward Island 9.1 9.7 10.6 10.9 11.5 Yukon 1.4 2.6 2.1 2.5 2.5 Question 4: Are the Government's new priorities and initiatives realistic; will they help grow the economy? Ensure Tax Equity for Canada's Medical Professionals is Maintained Among the federal government's commitments is the objective to decrease the small business tax rate from 11% to 9%. The CMA supports this commitment to support small businesses, such as medical practices, in recognition of the significant challenges facing this sector. However, it is not clear whether as part of this commitment the federal government intends to alter the Canadian-Controlled Private Corporation (CCPC) framework. The federal government's framing of this commitment, as released in the mandate letter for the Minister of Small Business and Tourism, has led to confusion and concern. Canada's physicians are highly skilled professionals, providing an important public service and making a significant contribution to our country's knowledge economy. Canadian physicians are directly or indirectly responsible for hundreds of thousands of jobs across the country, and invest millions of dollars in local communities, ensuring that Canadians are able to access the care they need, as close to their homes as possible. In light of the design of Canada's health care system, the majority of physicians are self-employed professionals and effectively small business owners. As self-employed small business owners, they typically do not have access to pensions or health benefits. In addition, as employers, they are responsible for these benefits for their employees. In addition to managing the many costs associated with running a medical practice, Canadian physicians must manage challenges not faced by many other small businesses. As highly-skilled professionals, physicians typically enter the workforce with significant debt levels and at a later stage in life. For some, entering practice after training requires significant investment in a clinic or a practice. Finally, it is important to recognize that physicians cannot pass on the increased costs introduced by governments, such as changes to the CCPC framework, onto patients, as other businesses would do with clients. For a significant proportion of Canada's physicians, the CCPC framework represents a measure of tax equity for individuals taking on significant personal financial burden and liability as part of our public health care system. As well, in many cases, practices would not make economic sense if the provisions of the CCPC regime were not in place. Given the importance of the CCPC framework to medical practice, changes to this framework have the potential to yield unintended consequences in health resources, including the possibility of reduced access to much needed care. The CMA recommends that the federal government maintain tax equity for medical professionals by affirming its commitment to the existing framework governing Canadian-Controlled Private Corporations. 3) Conclusion The CMA recognizes that the federal government must grapple with an uncertain economic forecast and is prioritizing measures that will support economic growth. The CMA strongly encourages the federal government to adopt the seven recommendations outlined in this submission as part of these efforts. In addition to making a meaningful contribution to meeting the future care needs of Canada's aging population, these recommendations will mitigate the impacts of economic pressures on individuals as well as jurisdictions. The CMA would welcome the opportunity to provide further information and its rationale for each recommendation. Summary of Recommendations 1. The CMA recommends that the federal government establish a new funding program for catastrophic coverage of prescription medication; this would be a positive step toward comprehensive, universal coverage for prescription medication. 2. The CMA recommends that the federal government support inviting the private health insurance industry to participate in the work of the pan-Canadian Pharmaceutical Alliance. 3. The CMA recommends that the federal government amend the Caregiver and Family Caregiver Tax Credits to make them refundable. 4. To deliver the federal government's commitment to increasing the availability of home care, the CMA recommends the establishment of a new targeted home care innovation fund. 5. The CMA recommends that the federal government include capital investment in continuing care infrastructure, including retrofit and renovation, as part of its commitment to invest in social infrastructure. 6. The CMA recommends that the federal government deliver additional funding on an annual basis beginning in 2016-17 to the provinces and territories by means of a demographic-based top-up to the Canada Health Transfer. 7. The CMA recommends that the federal government maintain tax equity for medical professionals by affirming its commitment to the existing framework governing Canadian-Controlled Private Corporations. References 1 Statistics Canada. Population projections: Canada, the provinces and territories, 2013 to 2063. The Daily, Wednesday, September 17, 2014. Available: http://www.statcan.gc.ca/daily-quotidien/140917/dq140917a-eng.htm 2 Statistics Canada. Canada year book 2012, seniors. Available: www.statcan.gc.ca/pub/11-402-x/2012000/chap/seniors-aines/seniors-aines-eng.htm 3 Conference Board of Canada. A difficult road ahead: Canada's economic and fiscal prospects. Available: http://canadaspremiers.ca/phocadownload/publications/conf_bd_difficultroadahead_aug_2014.pdf. 4 Canadian Institute for Health Information. National health expenditure trends, 1975 to 2014. Ottawa: The Institute; 2014. Available: www.cihi.ca/web/resource/en/nhex_2014_report_en.pdf 5 Calculation by the Canadian Medical Association, based on Statistics Canada's M1 population projection and the Canadian Institute for Health Information age-sex profile of provincial-territorial health spending. 6 CIHI. National Health Expenditure Trends,1975 to 2015. Available: https://secure.cihi.ca/free_products/nhex_trends_narrative_report_2015_en.pdf. 7 Finance Canada. Update of Economic and Fiscal Projections 2015. http://www.budget.gc.ca/efp-peb/2015/pub/efp-peb-15-en.pdf. 8 CIHI. National Health Expenditure Trends,1975 to 2015. Available: https://secure.cihi.ca/free_products/nhex_trends_narrative_report_2015_en.pdf. 9 Office of the Parliamentary Budget Officer. Fiscal sustainability report 2015. Ottawa: The Office; 2015. Available: www.pbo-dpb.gc.ca/files/files/FSR_2015_EN.pdf 10 IBM for the Pan-Canadian Pharmaceutical Alliance. Pan Canadian Drugs Negotiations Report. Available at: http://canadaspremiers.ca/phocadownload/pcpa/pan_canadian_drugs_negotiations_report_march22_2014.pdf . 11 Morgan SG, Martin D, Gagnon MA, Mintzes B, Daw JR, Lexchin J. Pharmacare 2020: The future of drug coverage in Canada. Vancouver: Pharmaceutical Policy Research Collaboration, University of British Columbia; 2015. Available: http://pharmacare2020.ca/assets/pdf/The_Future_of_Drug_Coverage_in_Canada.pdf 12 Angus Reid Institute. Prescription drug access and affordability an issue for nearly a quarter of Canadian households. Available: http://angusreid.org/wp-content/uploads/2015/07/2015.07.09-Pharma.pdf 13 Statistics Canada. Survey of household spending. Ottawa: Statistics Canada; 2013. 14 Canadian Institute for Health Information. How Canada compares: results From The Commonwealth Fund 2014 International Health Policy Survey of Older Adults. Available: www.cihi.ca/en/health-system-performance/performance-reporting/international/commonwealth-survey-2014 15 Conference Board of Canada. Research commissioned for the CMA, July 2015. 16 Statistics Canada. Family caregivers: What are the consequences? Available: www.statcan.gc.ca/pub/75-006-x/2013001/article/11858-eng.htm 17 Conference Board of Canada. Home and community care in Canada: an economic footprint. Ottawa: The Board; 2012. Available: http://www.conferenceboard.ca/cashc/research/2012/homecommunitycare.aspx 18 Hollander MJ, Liu G, Chappeel NL. Who cares and how much? The imputed economic contribution to the Canadian health care system of middle aged and older unpaid caregivers providing care to the elderly. Healthc Q. 2009;12(2):42-59. 19 Government of Canada. Report from the Employer Panel for Caregivers: when work and caregiving collide, how employers can support their employees who are caregivers. Available: www.esdc.gc.ca/eng/seniors/reports/cec.shtml 20 Ibid. 21 Conference Board of Canada. Research commissioned for the CMA, July 2015. 22 CIHI. Seniors and alternate level of care: building on our knowledge. Available: https://secure.cihi.ca/free_products/ALC_AIB_EN.pdf. 23 CMA. A policy framework to guide a national seniors strategy for Canada. Available: https://www.cma.ca/Assets/assets-library/document/en/about-us/gc2015/policy-framework-to-guide-seniors_en.pdf. 24 Conference Board of Canada. Research commissioned for the CMA, January 2013. 25 CIHI. Seniors and alternate level of care: building on our knowledge. Available: https://secure.cihi.ca/free_products/ALC_AIB_EN.pdf 26 CMA. CMA Submission: The need for health infrastructure in Canada. Available: https://www.cma.ca/Assets/assets-library/document/en/advocacy/Health-Infrastructure_en.pdf. 27 Ibid. 28 Conference Board of Canada. Research commissioned for the CMA, July 2015.
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2015 Pre-budget consultations: Federal leadership to support an aging population

https://policybase.cma.ca/en/permalink/policy11753
Date
2015-07-31
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2015-07-31
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Text
Helping physicians care for patients Aider les médecins à prendre soin des patients Canada is a nation on the precipice of great change. This change will be driven primarily by the economic and social implications of the major demographic shift already underway. The added uncertainties of the global economy only emphasize the imperative for federal action and leadership. In this brief, the Canadian Medical Association (CMA) is pleased to present four recommendations to the House of Commons Standing Committee on Finance for meaningful federal action in support of a national seniors strategy; these are essential measures to prepare for an aging population. Canada's demographic and economic imperative In 2011 the first of wave of the baby boomer generation turned 65 and Canada's seniors population stood at 5 million.1 By 2036, seniors will represent up to 25% of the population.2 The impacts of Canada's aging population on economic productivity are multi-faceted. An obvious impact will be fewer workers and a smaller tax base. Finance Canada projects that the number of working-age Canadians for every senior will fall from about 5 today to 2.7 by 2030.3 The projected surge in demand for services for seniors that will coincide with slower economic growth and lower government revenue will add pressure to the budgets of provincial and territorial governments. Consider that while seniors account for about one-sixth of the population, they consume approximately half of public health spending.4 Based on current trends and approaches, seniors' care is forecast to consume almost 62% of provincial/territorial health budgets by 2036.5 The latest fiscal sustainability report of the Parliamentary Budget Officer explains that the demands of Canada's aging population will result in "steadily deteriorating finances" for the provinces and territories and they "cannot meet the challenges of population ageing under current policy."6 Theme 1: Productivity A) New federal funding to provincial/territorial governments Canada's provincial and territorial leaders are aware of the challenges ahead. This July, the premiers issued a statement calling for the federal government to increase the Canada Health Transfer to 25% of provincial and territorial health care costs to address the needs of an aging population. To support the innovation and transformation needed to address these needs, the CMA recommends that the federal government deliver additional funding on an annual basis beginning in 2016-17 to the provinces and territories by means of a demographic-based top-up to the Canada Health Transfer (Table 1). For the fiscal year 2016-17, this top-up would require $1.6 billion in federal investment. Table 1: Allocation of the federal demographic-based top-up, 2016-20 ($million)7 Jurisdiction 2016 2017 2018 2019 2020 All of Canada 1,602.1 1,663.6 1,690.6 1,690.3 1,879.0 Newfoundland and Labrador 29.7 30.5 33.6 35.3 46.1 Prince Edward Island 9.1 9.7 10.6 10.6 11.5 Nova Scotia 53.6 58.6 62.3 61.9 66.6 New Brunswick 45.9 50.7 52.2 52.0 57.2 Quebec 405.8 413.7 418.8 410.2 459.5 Ontario 652.2 677.9 692.1 679.0 731.6 Manitoba 28.6 30.6 33.5 31.1 36.6 Saskatchewan 3.5 4.9 7.3 11.9 15.4 Alberta 118.5 123.3 138.9 134.9 157.5 British Columbia 251.6 258.7 270.3 258.4 291.3 Yukon 1.4 2.6 2.1 2.4 2.5 Northwest Territories 1.4 1.6 1.7 1.7 2.1 Nunavut 0.9 0.6 0.8 0.9 1.0 B) Federal support for catastrophic drug coverage A major gap in Canada's universal health care system is the lack of universal access to prescription medications, long recognized as the unfinished business of medicare. Canada stands out as the only country with universal health care without universal pharmaceutical coverage.8 According to the Angus Reid Institute, more than one in five Canadians (23%) report that they or someone in their household did not take medication as prescribed because of the cost during the past 12 months.9 Statistics Canada's Survey of Household Spending reveals that households headed by a senior spend $724 per year on prescription medications, the highest among all age groups and over 60% more than the average household.10 Another recent study found that 7% of Canadian seniors reported skipping medication or not filling a prescription because of the cost.11 In addition to the very real harms to individuals, lack of coverage contributes to the inefficient use of Canada's scarce health resources. While there are sparse economic data in Canada on this issue, earlier research indicated that this inefficiency, which includes preventable hospital visits and admissions, represents an added cost of between $1 billion and $9 billion annually.12 As an immediate measure to support the health of Canadians and the productivity of the health care sector, the CMA recommends that the federal government establish a new funding program for catastrophic coverage of prescription medication. The program would cover prescription medication costs above $1,500 or 3% of gross household income on an annual basis. Research commissioned by the CMA estimates this would cost $1.48 billion in 2016-17 (Table 2). This would be a positive step toward comprehensive, universal prescription drug coverage. Table 2: Projected cost of federal contribution to cover catastrophic prescription medication costs, by age cohort, 2016-2020 ($ million)13 Age cohort 2016 2017 2018 2019 2020 Share of total cost Under 35 years 107.0 107.6 108.2 108.8 109.3 7% 35 to 44 years 167.4 169.8 172.7 175.7 178.4 11% 45 to 54 years 274.2 270.2 270.2 265.7 262.8 18% 55 to 64 years 362.5 370.7 378.6 384.6 388.2 25% 65 to 74 years 292.1 304.0 315.8 328.4 341.9 21% 75 years + 286.3 292.0 299.0 306.6 314.4 20% All Ages 1,480.4 1,497.2 1,514.2 1,531.2 1,548.1 100% Theme 2: Infrastructure and communities All jurisdictions across Canada are facing shortages in the continuing care sector. Despite the increased availability of home care, research commissioned for the CMA indicates that demand for continuing care facilities will surge as the demographic shift progresses.14 In 2012, it was reported that wait times for access to a long-term care facility in Canada ranged from 27 to over 230 days. It is estimated that 85% of "alternate level of care" patients in hospitals (i.e., patients who do not require hospital-level care) are in these beds because of the lack of availability of long-term care. Due to the significant difference in the cost of hospital care (approximately $846 per day) versus long-term care ($126 per day), the CMA estimates that the shortages in the long-term care sector represent an increased cost of $2.3 billion. Despite the recognized need for infrastructure investment in the continuing care sector, to date, this sector has been excluded from the Building Canada Plan. The CMA recommends that the federal government amend the criteria of the Building Canada Plan to include capital investment in continuing care infrastructure, including retrofit and renovation. Based on previous estimates, the CMA recommends that $540 million be allocated for 2016-17 (Table 3). Table 3: Estimated cost to address forecasted shortage in long-term care beds, 2016-20 ($ million)15 Forecasted shortage in long-term care beds Estimated cost to address shortage Federal share to address shortage in long-term care beds (based on 1/3 contribution) 2016 6,028 1,621.5 540.5 2017 6,604 1,776.5 592.2 2018 8,015 2,156.0 718.7 2019 8,656 2,328.5 776.2 2020 8,910 2,396.8 798.9 Total 38,213 10,279.3 3,426.4 Theme 3: Jobs As previously mentioned, Canada's aging population will produce significant changes in the labour force. There will be fewer Canadian workers, each with a greater likelihood of having caregiving responsibilities for family and friends. According to the report of the federal Employer Panel for Caregivers, Canadian employers "were surprised and concerned that it already affects 35% of the Canadian workforce."16 This report highlights key findings of the 2012 General Social Survey: 1.6 million caregivers took leave from work; nearly 600,000 reduced their work hours; 160,000 turned down paid employment; and, 390,000 quit their jobs to provide care. It is estimated that informal caregiving represents $1.3 billion in lost workforce productivity. These costs will only increase as Canada's demographic shift progresses. In parallel to the increasing informal caregiving demands on Canadian workers, Canada's aging population will also increase the demand for personal care workers and geriatric competencies across all health and social care professions.17 Theme 4: Taxation The above section focused on the economic costs of caregiving on the workforce. The focus of this section will be on the economic value caregivers provide while they take on an increased economic burden. Statistics Canada's latest research indicates that 8.1 million Canadians are informal caregivers, 39% of whom primarily care for a parent.18 The Conference Board of Canada reports that in 2007 informal caregivers contributed over 1.5 billion hours of home care - more than 10 times the number of paid hours in the same year.19 The economic contribution of informal caregivers was estimated to be about $25 billion in 2009.20 This same study estimated that informal caregivers incurred over $80 million in out-of-pocket expenses related to caregiving in 2009. Despite their tremendous value and important role, only a small fraction of caregivers caring for a parent received any form of government support.21 Only 5% of caregivers providing care to parents reported receiving financial assistance while 28% reported needing more assistance than they received.22 As a first step to providing increased support for Canada's family caregivers, the CMA recommends that the federal government amend the Caregiver and Family Caregiver Tax Credits to make them refundable. This would provide an increased amount of financial support for family caregivers. It is estimated that this measure will cost $90.8 million in 2016-17.23 Conclusion The CMA recognizes that in the face of ongoing economic uncertainty the federal government may face pressures to avoid new spending initiatives. The CMA strongly encourages the federal government to adopt the four recommendations outlined in this submission rather than further delay making a meaningful contribution to meeting the future care needs of Canada's aging population. The CMA would welcome the opportunity to provide further information and its rationale for each recommendation. 1 Statistics Canada. Generations in Canada. Cat. No. 98-311-X2011003. Ottawa: Statistics Canada; 2012. Available: www12.statcan.gc.ca/census-recensement/2011/as-sa/98-311-x/98-311-x2011003_2-eng.pdf 2 Statistics Canada. Canada year book 2012, seniors. Available: www.statcan.gc.ca/pub/11-402-x/2012000/chap/seniors-aines/seniors-aines-eng.htm 3 Finance Canada. Economic and fiscal implications of Canada's aging population. Ottawa: Finance Canada; 2012. Available: www.fin.gc.ca/pub/eficap-rebvpc/eficap-rebvpc-eng.pdf 4 Canadian Institute for Health Information. National health expenditure trends, 1975 to 2014. Ottawa: The Institute; 2014. Available: www.cihi.ca/web/resource/en/nhex_2014_report_en.pdf 5 Calculation by the Canadian Medical Association, based on Statistics Canada's M1 population projection and the Canadian Institute for Health Information age-sex profile of provincial-territorial health spending. 6 Office of the Parliamentary Budget Officer. Fiscal sustainability report 2015. Ottawa: The Office; 2015. Available: www.pbo-dpb.gc.ca/files/files/FSR_2015_EN.pdf 7 Conference Board of Canada. Research commissioned for the CMA, July 2015. 8 Morgan SG, Martin D, Gagnon MA, Mintzes B, Daw JR, Lexchin J. Pharmacare 2020: The future of drug coverage in Canada. Vancouver: Pharmaceutical Policy Research Collaboration, University of British Columbia; 2015. Available: http://pharmacare2020.ca/assets/pdf/The_Future_of_Drug_Coverage_in_Canada.pdf 9 Angus Reid Institute. Prescription drug access and affordability an issue for nearly a quarter of Canadian households. Available: http://angusreid.org/wp-content/uploads/2015/07/2015.07.09-Pharma.pdf 10 Statistics Canada. Survey of household spending. Ottawa: Statistics Canada; 2013. 11 Canadian Institute for Health Information. How Canada compares: results From The Commonwealth Fund 2014 International Health Policy Survey of Older Adults. Available: www.cihi.ca/en/health-system-performance/performance-reporting/international/commonwealth-survey-2014 12 British Columbia Pharmacy Association. Clinical service proposal: medication adherence services. Vancouver: The Association; 2013. Available: www.bcpharmacy.ca/uploads/Medication_Adherence.pdf 13 Supra at note 7. 14 Conference Board of Canada. Research commissioned for the CMA, January 2013. 15 Ibid. 16 Government of Canada. Report from the Employer Panel for Caregivers: when work and caregiving collide, how employers can support their employees who are caregivers. Available: www.esdc.gc.ca/eng/seniors/reports/cec.shtml 17 Stall S, Cummings G, Sullivan T. Caring for Canada's seniors will take our entire health care workforce. Available: http://healthydebate.ca/2013/09/topic/community-long-term-care/non-md-geriatrics 18 Statistics Canada. Family caregivers: What are the consequences? Available: www.statcan.gc.ca/pub/75-006-x/2013001/article/11858-eng.htm 19 Conference Board of Canada. Home and community care in Canada: an economic footprint. Ottawa: The Board; 2012. Available: http://www.conferenceboard.ca/cashc/research/2012/homecommunitycare.aspx 20 Hollander MJ, Liu G, Chappeel NL. Who cares and how much? The imputed economic contribution to the Canadian health care system of middle aged and older unpaid caregivers providing care to the elderly. Healthc Q. 2009;12(2):42-59. 21 Supra at note 16. 22 Ibid. 23 Supra at note 7.
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A Healthy Population for a Stronger Economy: CMA pre-budget consultation submission to the Standing Committee on Finance

https://policybase.cma.ca/en/permalink/policy10224
Date
2011-08-12
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2011-08-12
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) submission to the House of Commons Standing Committee on Finance examines how increasing retirement income saving options, improving access to prescription drugs, and planning for a Canadian Health Quality Alliance to promote innovation in the delivery of high quality health care can enhance our health care system and, in turn, make our economy more productive. Higher quality health care and expanded options for meeting the needs of retired and elderly Canadians will contribute to the ultimate goals of better patient care, improved population health and help our country reach its full potential. Polls show that Canadians are becoming increasingly concerned about the future of their health care system, particularly in terms of their ability to access essential care. The CMA's 2011 pre-budget submission responds to these concerns and supports a healthy population, a healthy medical profession and a healthy economic recovery. Our recommendations are as follows: Recommendation # 1 The federal government should study options to expand the current PRPP definition beyond defined contribution pension plans. Also, the federal government should expand the definition of eligible administrators of PRPPs beyond financial institutions to include organizations such as professional associations. Recommendation # 2 Governments, in consultation with the life and health insurance industry and the public, should establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies. Recommendation # 3 The federal government should convene a time-limited national steering committee that would engage key stakeholders in developing a proposal for a pan-Canadian Health Quality Alliance with a mandate to work collaboratively towards integrated approaches for a sustainable health care system through innovative practices in the delivery of high quality health care. Introduction Over the past year, the CMA has engaged Canadians across the country in a broad-based public consultation on health care and heard about their concerns and experiences with the system. This exercise was undertaken as part of the CMA's Health Care Transformation (HCT) initiative, a roadmap for modernizing Canada's health care systemi so that it puts patients first and provides Canadians with better value for money. We have heard through these consultations that Canadians do not believe they are currently getting good value from their health care system, a feeling borne out by studies comparing Canada's health care system to those in leading countries in Europe. We also heard that Canadians are concerned about inequities in access to care beyond the basic medicare basket, particularly in the area of access to prescription drugs. While all levels of government need to be involved, it is the federal government that must lead the transformation of our most cherished social program. 1. Retirement Income Improvement Issue: Increasing retirement savings options for Canadians with a focus on improving their ability to look after their long-term care needs. Background The CMA remains concerned about the status of Canada's retirement income system and the future ability of Canada's seniors to adequately fund their long-term and supportive care needs. The proportion of Canadian seniors (65+) is expected to almost double from its present level of 13% to almost 25% by 2036. Statistics Canada projections show that between 2015 and 2021 the number of seniors will, for the first time, surpass the number of children under 14 years of age.ii The CMA has been working proactively on this issue in several ways, including through the recently created Retirement Income Improvement Coalition (RIIC), a broad-based coalition of 11 organizations representing over one million self-employed professionals. The coalition has previously recommended to the federal government the following actions: * increased retirement saving options for all Canadians, particularly the self-employed; * changes to the Income Tax Act, Income Tax Regulations and the Employment Standards Act to enable the self-employed to participate in pension plans; * the approval of Pooled Retirement Pension Plans (PRPP) as a retirement savings program for the self-employed; * changes to the current tax-deferred income saving options (increase the percentage of earned income or the maximum-dollar amount contribution limit for RRSPs); * a requirement that registration to all retirement saving options be voluntary (optional); and * opportunities for Canadians to become better educated about retirement saving options (financial literacy).iii The CMA appreciates that federal, provincial and territorial finance ministers are moving ahead with the introduction of Pooled Registered Retirement Plans (PRPPs). The CMA, as part of the RIIC, has been providing input into the consultation process. However, PRPPs represent only one piece of a more comprehensive retirement savings structure. Recommendation # 1 The federal government should study options that would not limit PRPPs to defined contribution pension plans. Target benefit plans should be permitted and encouraged. Target benefit plans allow risk to be pooled among the plan members, providing a more secure vehicle than defined contribution plans. Also, the administrators of PRPPs should not be limited to financial institutions. Well-governed organizations that represent a particular membership should be able to sponsor and administer RPPs and PRPPs for their own members, including self-employed members. The CMA also continues to be concerned about the ability of Canadians to save for their long-term health care needs. The Wait Time Alliance - a coalition of 14 national medical organizations whose members provide specialty care to patients - reported recently that many patients, particularly the elderly, are in hospital while waiting for more suitable and appropriate care arrangements. Mostly in need of support rather than medical care, these patients are hindered by the lack of options available to them, often due to limited personal income. The CMA has previously recommended that the federal government should study options for pre-funding long-term care, including private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance. This remains pertinent. 2. Universal access to prescription drugs Issue: Ensuring all Canadians have access to a basic level of prescription drugs. Background Universal access to prescription drugs is widely acknowledged as part of the "unfinished business" of medicare in Canada. In 1964 the Hall Commission recommended that the federal government contribute 50% of the cost of a Prescription Drug Benefit within the Health Services Program. It also recommended a $1.00 contributory payment by the purchaser for each prescription. This has never been implemented.iv What has emerged since then is a public-private mix of funding for prescription drugs. The Canadian Institute for Health Information (CIHI) has estimated that, as of 2010, 46% of prescription drug expenditures were public, 36% were paid for by private insurance and 18% were paid for out-of-pocket.v Nationally there is evidence of wide variability in levels of drug coverage. According to Statistics Canada, 3% of households spent greater than 5% of after-tax income on prescription drugs in 2008. Across provinces this ranged from 2.2% in Ontario and Alberta, to 5.8% in P.E.I. and 5.9% in Saskatchewan.vi Moreover, there is significant variation between the coverage levels of the various provincial plans across Canada. For example, the Manitoba Pharmacare Program is based on total income, with adjustment for spouse and dependents under 18, while in Newfoundland and Labrador, the plan is based on net family income.vii,viii The Commonwealth Fund's 2010 International Health Policy Survey found that 10% of Canadian respondents said they had either not filled a prescription or skipped doses because of cost issues.ix Moreover, there have been numerous media stories about inequities in access across provinces to cancer drugs and expensive drugs for rare diseases. The high cost of prescription drugs was frequently raised during our public consultations this year. The need for a national drug strategy or pharmacare plan was mentioned by an overwhelming number of respondents, many of whom detailed how they had been affected by the high cost of drugs. The cost to the federal government of a program that would ensure universal access to prescription drugs would depend on the threshold of out-of-pocket contribution and the proportion of expenses that it would be willing to share with private and provincial/territorial public plans. Estimates have ranged from $500 millionx, and $1 billionxi, to the most recent estimate from the provincial-territorial health ministers of $2.5 billion (2006).xii Recommendation # 2 Governments, in consultation with the life and health insurance industry and the public, should establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies. Such a program should include: * a mandate for all Canadians to have either private or public coverage for prescription drugs; * a uniform income-based ceiling (between public and private plans and across provinces/territories) on out-of-pocket expenditures, on drug plan premiums and/or prescription drugs; * federal/provincial/territorial cost-sharing of prescription drug expenditures above a household income ceiling, subject to capping the total federal and/or provincial/territorial contributions either by adjusting the federal/provincial/territorial sharing of reimbursement or by scaling the household income ceiling or both; * a requirement for group insurance plans and administrators of employee benefit plans to pool risk above a threshold linked to group size; and * a continued strong role for private supplementary insurance plans and public drug plans on a level playing field (i.e., premiums and co-payments to cover plan costs). 3. Innovation for Quality in Canadian Health Care Issue: Development of a proposal to establish a Canadian Health Quality Alliance to promote innovation in the delivery of high-quality health care in Canada. Background There is general agreement that Canada's health care system is no longer a strong performer compared to similar nations. Clearly, we can do better. However, progress has been slow on a comprehensive quality agenda for our health care system. At the national level, there is no coordination or body with a mandate to promote a comprehensive approach to quality improvement. Over the past two decades, health care stakeholders in Canada have gradually come to embrace a multi-dimensional concept of quality in health care encompassing safety, appropriateness, effectiveness, accessibility, competency and efficiency. The unilateral federal funding cuts to health transfers that took effect in 1996 precipitated a long preoccupation with the accessibility dimension that was finally acknowledged with the Wait Time Reduction Fund in the 2004 First Ministers Accord. The safety dimension was recognized with the establishment of the Canadian Patient Safety Institute (CPSI) in 2003. Competence has been recognized by health professional organizations and regulatory bodies through the development of peer-review programs and mandated career-long professional development. While six provinces have established some form of health quality council (B.C., Alta., Sask., Ont., Que., N.B.), there is no national approach to quality improvement beyond safety. Given that health care stands as Canadians' top national priority and that it represents a very large expenditure item for all levels of government, the lack of a national approach to quality improvement is a major shortcoming. In the U.S., the Institute for Healthcare Improvement is dedicated to developing and promulgating methods and processes for improving the delivery of care throughout the world.xiii England's National Health Service (NHS) has also created focal points over the past decade to accelerate innovation and improvement throughout their health system. Canadian advancements in the health field have occurred when the expertise and perspective of a range of stakeholders have come together. The CPSI, for example, was established following the deliberations and report of the National Steering Committee on Patient Safety.xiv It is estimated that it would cost less than $500,000 for a multi-stakeholder committee to develop a proposal for a national alliance for quality improvement, including the cost of any commissioned research. Recommendation # 3 The federal government should convene a time-limited national steering committee that would engage key stakeholders in developing a proposal for a pan-Canadian Health Quality Alliance with a mandate to work collaboratively towards integrated approaches for a sustainable health care system through innovative practices in the delivery of high quality health care. This alliance would be expected to achieve the following in order to modernize health care services: * Promote a comprehensive approach to quality improvement in health care; * Promote pan-Canadian sharing of innovative and best practices; * Develop and disseminate methods of engaging frontline clinicians in quality improvement processes; and * Establish international partnerships for the exchange of innovative practices. Such an alliance could be established in a variety of ways: * Virtually, using the Networks of Centres of Excellencexv approach; * By expanding the mandate of an existing body; or * Through the creation of a new body. REFERENCES i Canadian Medical Association. Health Care Transformation in Canada. Change that Works. Care that Lasts. http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Advocacy/HCT/HCT-2010report_en.pdf Accessed 13/07/11. ii Statistics Canada. Population Projections for Canada, Provinces and Territories. http://www.statcan.gc.ca/pub/91-520-x/2010001/aftertoc-aprestdm1-eng.htm. Accessed 13/07/11. iii Retirement Income Improvement Coalition. Letter to the federal Minister of Finance and the Minister of State (Finance). March 17, 2011. ivHall, E. Royal Commission on Health Services. Volume 1. Ottawa: Queen's Printer, 1964. vCanadian Institute for Health Information. Drug Expenditure in Canada, 1985 to 2010. Ottawa, 2010. viStatistics Canada. CANSIM Table 109-5012 Household spending on prescription drugs as a percentage of after-tax income, Canada and provinces, annual (percent). http://www5.statcan.gc.ca/cansim/pick-choisir?lang=eng&searchTypeByValue=1&id=1095012. Accessed 05/29/11. vii Manitoba Health. Pharmacare deductible estimator. http://www.gov.mb.ca/health/pharmacare/estimator.html. Accessed 07/28/11. viii Newfoundland Department of Health and Community Services. Newfoundland and Labrador Prescription Drug Program (NLPDP). http://www.health.gov.nl.ca/health/prescription/nlpdp_application_form.pdf. Accessed 07/29/11. ixCommonwealth Fund. International health policy survey in eleven countries. http://www.commonwealthfund.org/~/media/Files/Publications/Chartbook/2010/PDF_2010_IHP_Survey_Chartpack_FULL_12022010.pdf. Accessed 05/29/11. x Senate Standing Committee on Social Affairs, Science and Technology. The health of Canadians - the federal role. Volume six: recommendations for reform. Ottawa, 2002. xi Commission on the Future of Health Care in Canada. Building on values: the future of health care in Canada. Ottawa, 2002. xii Canadian Intergovernmental Conference Secretariat. Backgrounder: National Pharmaceutical Strategy decision points. http://www.scics.gc.ca/english/conferences.asp?a=viewdocument&id=112. Accessed 23/07/11. xiii http://www.ihi.org. Accessed 29/07/10. xiv National Steering Committee on Patient Safety. Building a safer system: a national integrated strategy for improving patient safety in Canadian health care. http://rcpsc.medical.org/publications/building_a_safer_system_e.pdf. Accessed 23/07/11. xv http://www.nce-rce.gc.ca/index_eng.asp. Accessed 29/07/10.
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