Skip header and navigation
CMA PolicyBase

Policies that advocate for the medical profession and Canadians


17 records – page 1 of 1.

A Prescription for sustainability

https://policybase.cma.ca/en/permalink/policy1967
Last Reviewed
2020-02-29
Date
2002-06-06
Topics
Health systems, system funding and performance
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2002-06-06
Topics
Health systems, system funding and performance
Text
Medicare emerged from the 1990s bent, but not broken — in large measure due to the tireless efforts of health professionals whose commitment has always been, first and foremost, to their patients. However, this level of effort cannot continue. Canadian health providers and the facilities they work in are stretched to the limit. Over the past decade there have been countless studies on what is wrong with Canada’s health care system. However, very little action has been taken to solve the problems identified in the reports because very few of these reports provided a roadmap with concrete recommendations on how to achieve change. Furthermore, many decisions regarding the health care system have been made by governments without meaningful input from health professionals. As we indicated in our first submission, there is clearly a need for a collaborative approach to “change management” that is based on early, ongoing and meaningful involvement of all key stakeholders. However, before consideration is given to how to solve the woes of the health care system, it is essential to establish a shared vision of Canada’s health care system. Several attempts have been made to this end; however, few have included health care providers or the public in the process. The CMA has established its own vision for a sustainable health care system, upon which the recommendations we have presented in this submission are based. To ensure that our health care system in Canada is sustainable in the future, longer-term structural and procedural reforms are required. The CMA proposes 5 recommendations involving the implementation of three integrated “pillars of sustainability” that together will improve accountability and transparency in the system. These pillars would also serve as the basis for addressing the many short- to medium-term issues facing Medicare today and into the future. To this end, we put forward 25 recommendations suggesting specific “hows” for solving these critical problems. The three “pillars” are: a Canadian Health Charter, a Canadian Health Commission, and a renewal of the federal legislative framework. A Canadian Health Charter would underline governments’ shared commitment to ensuring that Canadians will have access to quality health care within an acceptable time frame. It would also clearly articulate a national health policy that sets out our collective understanding of Medicare and the rights and mutual obligations of individual Canadians, health care providers, and governments. The existence of such a Charter would ensure that a rational, evidence-based, and collaborative approach to managing and modernizing Canada’s health system is being followed. In conjunction with the Canadian Health Charter, a permanent, independent Canadian Health Commission would be created to promote accountability and transparency within the system. It would have a mandate to monitor compliance with and measure progress towards Charter provisions, report to Canadians on the performance of the health care system, and provide ongoing advice and guidance to the Conference on Federal-Provincial-Territorial ministers on key national health care issues. Recognizing the shared federal and provincial/territorial obligations to the health care system, one of the main purposes of the Canadian Health Charter is to reinforce the national character of the health system. The federal government would be expected to make significant commitments in a number of areas, including a review of the Canada Health Act, changes to the federal transfers to provinces and territories, and a review of federal tax legislation. While these three “pillars” will address the broader structural and procedural problems facing Canada’s health care system, there are many other changes required to meet specific needs within the system in the short to medium term. The CMA has provided specific recommendations in the following key areas: * Meaningful stakeholder input and accountability * Defining the public health system (e.g. core services, a “safety valve”, Public Health, Aboriginal health) * Investing in the health care system (e.g. human resources, capital infrastructure, surge capacity, information technology, and research and innovation) * Health system financing * Organization and delivery of services (e.g. consideration of the full continuum of care, physician compensation, rural health, the private sector, the voluntary sector and informal caregivers) The following is a summary of the key recommendations set out in A Prescription for Sustainability. While we have put an emphasis on having the recommendations as self-contained as possible, readers are encouraged to consult the corresponding section of this paper as appropriate for further details. The first five recommendations refer specifically to the three pillars. The remaining recommendations address the more specific and immediate needs of the health care system. Recommendation 1 That the governments of Canada adopt a Canadian Health Charter that * reaffirms the social contract that is Medicare * acknowledges the ongoing roles of governments in terms of overall coordination and health planning * sets out the accessibility and portability rights and responsibilities of residents of Canada * sets out the rights and responsibilities of the governments, providers and patients in Canada * provides for a “Canadian Health Commission.” Recommendation 2 That a permanent Canadian Health Commission be established and operate at arm’s length from governments. The Commission’s mandate would include * monitoring compliance with the Canadian Health Charter * reporting annually to Canadians on the performance of the health care system and the health status of the population * advising the Conference of Federal-Provincial-Territorial Ministers of Health on critical issues. Recommendation 3 That the federal government undertake a review of the Canada Health Act with the view to amending it * to embody the Canadian Health Charter within it * to provide for the Canadian Health Commission and * to allow for a broader definition of core services and for certain service charges under certain terms and conditions. Recommendation 4 (a) That the federal government’s contribution to the publicly funded health care system * be harmonized with the five-year review of the federal equalization program * be locked-in for a period of five years, with an escalator tied to a three-year moving average of per capita GDP * rise to a target of 50% of provincial/territorial per capita health spending for core services * provide for notional earmarking of funds for health. (b) That the federal government create special purpose, one-time funds totalling $2.5 billion over five years (or build on existing funds) to address pressing issues in the following areas * health human resources planning * capital infrastructure * information technology * accessibility fund. Recommendation 5 That a blue ribbon panel of Parliament be established to work with the Canadian Health Commission to review the current provisions of federal tax legislation with a view to identifying ways of enhancing support for health policy objectives through tax policy. Recommendation 6 That governments and regional health authorities initiate or enhance significant efforts to secure the participation of and input from practicing physicians at all levels of health care decision-making. Recommendation 7 That all Canadians be provided coverage for a basket of core services under uniform terms and conditions. Recommendation 8 (a) That the scope of the basket of core services be determined and be updated regularly to reflect and accommodate the realities of health care delivery and the needs of Canadians. (b) That the scope of core services should not be limited by its current application to hospital and physician services, provided that access to medically necessary hospital and physician services is not compromised. Recommendation 9 (a) That the scope of the basket of core services be determined and regularly updated by a federal-provincial-territorial process that has legitimacy in the eyes of Canadians – patients, taxpayers and health care professionals. (b) That the values of transparency, accountability, evidence-based, inclusivity and procedural fairness should characterize the process used to determine the basket of core services to include under Medicare. Recommendation 10 (a) That governments develop a new framework to govern the funding of a basket of core services with a view to ensuring that * Canadians have reasonable access to core services on uniform terms and conditions in all provinces and territories * governments, providers and patients are accountable for the use of health care resources * no Canadian is denied essential care because of her or his personal financial situation. (b) That legislation be amended to permit at least some core services to be cost-shared under uniform terms and conditions in all provinces and territories. (c) That once the basket of core services is defined, minimum levels of public funding for these services be uniformly applied across provinces and territories, with flexibility for individual governments to increase the share of public funding beyond these levels. Recommendation 11 (a) That Canada’s health system develop and apply agreed upon standards for timely access to care, as well as provide for alternative care choices – a “safety valve” – in Canada or elsewhere, if the publicly funded system fails to meet these standards. (b) That the following approach be implemented to ensure that governments are held accountable for providing timely access to quality care. * First, governments must establish clear guidelines and standards around quality and waiting times that are evidence-based and that patients, providers and governments consider reasonable. An independent third-party mechanism must be put in place to measure and report on waiting times and other dimensions of health care quality. * Second, governments must develop a clear policy which states that if the publicly funded health care system fails to meet the specified agreed-upon standards for timely access to core services, then patients must have other options available to them that will allow them to obtain this required care through other means. Public funding at the home province rate would follow the patient in this circumstance, and patients would have the opportunity to purchase insurance on a prospective basis to cover any difference in cost. Recommendation 12 (a) That governments demonstrate healthy public policy by making health impact the first consideration in the development of all legislation, policy and directives. (b) That the federal government provide core funding to assist provincial and territorial authorities in improving the coordination of prevention and detection efforts and the response to public health issues among public health officials, educators, community service providers, occupational health providers, and emergency services. (c) That governments invest in the human, infrastructure and training resources needed to develop an adequate and effective public health system capable of preventing, detecting and responding to public health issues. (d) That governments undertake an immediate review of Canada’s self-sufficiency in preventing, detecting and responding to emerging public health problems and furthermore, facilitate an ongoing, inclusive process to establish national public health priorities. Recommendation 13 That the federal government adopt a comprehensive strategy for improving the health of Aboriginal peoples which involves a partnership among governments, nongovernmental organizations, universities and the Aboriginal communities. Recommendation 14 (a) That the federal government establish a $1 billion, five-year Health Resources Education and Training Fund to (1) further increase enrolment in undergraduate and postgraduate medical education (including re-entry positions), (2) expand the infrastructure (both human and physical resources) of Canada’s 16 medical schools in order to accommodate the increased enrolment and (3) enhance continuing medical education programs. (b) That the federal government increase funding targeted to institutions of postsecondary education to alleviate some of the pressures driving tuition fee increases. (c) That the federal government enhance financial support systems for medical students that are (1) non-coercive, (2) developed concomitantly or in advance of any tuition increase, (3) in direct proportion to any tuition fee increase and (4) provided at levels that meet the needs of the students. (d) That incentives be incorporated into medical education programs to ensure adequate numbers of students choose medical fields for which there is greatest need. Recommendation 15 (a) That governments and communities make every effort to retain Canadian physicians in Canada through non-coercive measures and optimize the use of existing health human resources to meet the health needs of Canadian communities. (b) That the federal government work with other countries to equitably regulate and coordinate international mobility of health human resources. (c) That governments adopt a policy statement that acknowledges the value of the health care workforce in the provision of quality care, as well as the need to provide good working conditions, competitive compensation and opportunities for professional development. Recommendation 16 (a) That a national multistakeholder body be established with representatives from the health professions and all levels of government to develop integrated health human resource strategies, provide planning tools for use at the local level and monitor supply, mix and distribution on an ongoing basis. (b) That scopes of practice should be determined in a manner that serves the interests of patients and the public, safely, efficiently, and competently. Recommendation 17 (a) That hospitals and other health care facilities conduct a coordinated inventory of capital infrastructure to provide governments with an accurate assessment of machinery and equipment. (b) That the federal government establish a one-time catch-up fund to restore capital infrastructure to an acceptable level. (see Recommendation 4(b).) (c) That governments commit to providing adequate, ongoing funding for capital infrastructure. (d) That public-private partnerships (P3s) be explored as a viable alternative source of funding for capital infrastructure investment. Recommendation 18 That the federal government cooperate with provincial and territorial governments and with governments of other countries to ensure that a strong, adequately funded emergency response system is put in place to improve surge capacity. Recommendation 19 That federal government make an additional, substantial, ongoing national investments in information technology and information systems, with the objective of improving the health of Canadians as well as improving the efficiency and effectiveness of the health care system. Recommendation 20 That governments adopt national standards that facilitate the collection, use and exchange of electronic health information in a manner which ensures that the protection of patient privacy and confidentiality are paramount. Recommendation 21 That the federal government’s investment in health research be increased to at least 1% of national health expenditures. Recommendation 22 (a) That the provincial and territorial governments’ commitment to funding core services be locked-in for an initial five-year period with an escalator tied to provincial population demographics and inflation. (b) That governments establish a health-specific contingency fund to mitigate the effects of fluctuations in the business cycle and to promote greater stability in health care financing. Recommendation 23 That any effort to change the organization or delivery of medical care take into account the impact on the whole continuum of care. Recommendation 24 (a) That governments work with the provincial and territorial medical associations and other stakeholders to draw on the successes of evaluated primary care projects to develop a variety of templates of primary care models that would * suit the full range of geographical contexts and * incorporate criteria for moving from pilot projects to wider implementation, such as cost-effectiveness, quality of care and patient and provider satisfaction. (b) That family physicians remain as the central provider and coordinator of timely access to publicly funded medical services, to ensure comprehensive and integrated care, and that there are sufficient resources available to permit this. Recommendation 25 (a) That governments develop a national plan to coordinate the most efficient access to highly specialized treatment and diagnostic services. * This plan should include the creation of defined regional centres of excellence to optimize the availability of scarce specialist services. * Any realignment of services must accommodate and compensate for the relocation of providers. * That the federal government create an accessibility fund that would support interprovincial centres of excellence for highly specialized services. Recommendation 26 That governments respect the principles contained in the CMA’s policy on physician compensation and the terms of duly negotiated agreements. Recommendation 27 That governments work with universities, colleges, professional associations and communities to develop a national rural and remote health strategy for Canada. Recommendation 28 That Canada’s health care system make optimal use of the private sector in the delivery of publicly financed health care provided that it meets the same standards of quality as the public system. Recommendation 29 That governments examine ways to recognize and support the role of the voluntary sector in the funding and delivery of health care, including enhanced tax credits. Recommendation 30 That governments support the contributions of informal caregivers through the tax system. 1. Introduction Medicare emerged from the 1990s bent, but not broken — in large measure, due to the tireless efforts of professionals whose commitment has always been, first and foremost, to their patients. But this level of effort cannot continue. Canadian health care providers and the facilities they work in are stretched to the limit. Our system is truly at a crossroads. The Commission on the Future of Health Care in Canada has a unique opportunity to sculpt a health care system that will meet the needs and expectations of Canadians for the 21st century. Fundamentals and principles of change management must be satisfied for change to be of lasting value. Decision-making processes must become more accessible, accountable and transparent to those most affected. Canadians are tired of the “blame game,” and physicians and other health providers are tired of being marginalized. Why is it that those who have the most at stake and those who have the most invested in the health system — namely patients, physicians and other providers — have the least say in system change? All parties need to be at the table. Health professionals have not been involved in an early, ongoing or meaningful way in discussions about the future of their health and health care systems. This must change. Another prerequisite for effective change is to reaffirm that there is more to health than health care. Although Canada has led the world in thinking about the overall determinants of health, the same cannot always be said when it comes to action. Canada needs broad consensus around a multi-year, national health action plan — one that is developed in collaboration with all the key players in the system and one that has clear goals, objectives and milestones. At the same time, sustainability must be seen as ensuring that Canadians have access to required services at the time and to the extent of their need. Canadians have lost confidence that the system will be there for them and for their children. Sustainability is about the legacy of Medicare. These are some of the key issues and challenges that the CMA stressed in earlier submissions to the Commission. In our first report, entitled Getting the Diagnosis Right (November 2001; see Appendix A), we described the signs and symptoms of a system in distress. Earlier this year, in our interim submission, entitled Getting It Right (Appendix B), we outlined some of the broad choices that we have to make as a society to help stabilize the Medicare “patient” and transport it into a sustainable future. As part of this future, the interim report proposed a Canadian Health Charter, which has received considerable attention. In this, our final submission to the Commission, we have built on the earlier work and ask the Commission to consider our Prescription for Sustainability. It is important to note that the recommendations we present to the Commission are integrated; and therefore we ask that they not be “cherry-picked”. This document also refers to a number of appendices that will be available as a separate volume. A great deal of policy research has been done on what changes are needed to make progress. The weak link has been in dealing with the “how.” The CMA believes that if we get the structures and processes right in terms of accountabilities, positive health outcomes will follow for our patients and for the future sustainability of the system. 2. Vision Several attempts have been made over the years to articulate a national vision for Medicare, but they have all proven inadequate. However laudable these attempts may be, they all suffer the fatal flaw of isolationism: they were all developed by governments — federal, provincial or territorial — in isolation from health care providers and the public. Goodwill, collaboration and partnership cannot be legislated or dictated from on high. In planning for the future, we have consistently argued for a values-based approach centred on a shared vision. The CMA has established a vision for Medicare that forms the basis of our recommendations for improving the design and functioning of the health care system. CMA’s Vision for a Sustainable Health System The goal of Canada’s health system is to preserve, protect and improve the health and well-being of each Canadian. This will be achieved through timely access to services that not only keep people well or restore health, but also enhance their quality of life and add longevity. Health care is an investment in both economic and social terms, providing benefits of value to both individuals and society. The objective of publicly funded health care is timely access to quality care through a defined set of core services that — as the principal building blocks of Canada’s overall health care system — must be provided on a sustainable basis. These core services must be determined and regularly reviewed in an inclusive and transparent manner. This will result in clear choices as to which services will be fully publicly funded, partly publicly funded and fully privately funded. The special nature of care related to illness — the original focus of Medicare — must continue to be recognized. Core services must reflect the immediacy with which such care is required, the potential to place a financial burden on individuals and families, and the unpredictability as to when such care will be required by an individual. Canadians should be able to choose who will provide their care, what the treatment(s) will be and where it will be provided. Every Canadian should have access to a physician of their choice and, in particular, should be encouraged to select a primary care physician who provides continuity of care. Physicians play key roles as agents and advocates for their own patients and for the public at large; they seek a health care system that respects the integrity and primacy of the patient–physician relationship. Payment and delivery mechanisms should be structured to foster and support these roles and to protect clinical and professional autonomy. Evidence-based care with explicit standards and benchmarks (e.g., maximum, acceptable waiting times) is a prerequisite to achieving high-quality health care — a primary objective of the public system. Individuals should have the opportunity to purchase health services where they are not publicly funded and where the public system does not meet agreed-upon standards. 3. Three Pillars of Sustainability The CMA believes that the current health policy decision-making system is fundamentally flawed and that three steps must be taken to help put the health of Canadians first. The three inextricably linked “pillars of sustainability” presented here are long-term structural and procedural reforms needed to improve accountability and transparency and, thus, enhance the overall sustainability of the system. In Getting the Diagnosis Right, we contended that Canadians had lost confidence that the system would be there for them and their families at the time and to the extent of their need. In our interim report, we also indicated that Canadian health care providers have never felt more demoralized or disenfranchised. The shortages of providers, poor access, resource constraints and passive privatization that occurred through most of the 1990s have combined to create uncertainties around the scope of coverage and the standard of care Canadians can expect from their health care system. The CMA believes that these uncertainties that accompany unplanned changes have also had a deleterious effect on the Canadian economy and a demoralizing effect on the health care community. On both counts, a clarification of the social contract for health is required at the highest level. 3.1 Canadian Health Charter The need to renew the social contract underlying Medicare raises a number of fundamental questions. What will this new social contract look like? Where will it be vested? Who will oversee its development and implementation? And what difference will it make for Canadians? The answers to these questions are set out below in the CMA’s proposal for a Canadian Health Charter. 3.1.1 What is it? The concept of a Canadian Health Charter is not new. The 1964 report of the Royal Commission on Health Services chaired by Justice Emmett Hall recommended a charter that set out a vision for a universally accessible system of prepaid health care, including the roles and responsibilities for individual Canadians, providers and governments. Currently, neither the Canada Health Act nor the Charter of Rights and Freedoms offers Canadians an explicit right of access to quality health care delivered within an acceptable time-frame.1 Moreover, Canadians do not have the benefit of a clearly articulated national health policy that sets out our shared understanding of Medicare and the rights and mutual obligations of individual Canadians, health care providers and governments. Without such a national policy statement to set the broad parameters around which Canada’s health system can be managed and modernized, the Medicare debate will continue to be characterized by rhetoric, hidden agendas and fruitless finger-pointing. To be certain, the notion of a Canadian Health Charter raises many issues in a decentralized federation such as Canada, where the constitutional responsibility for health care delivery lies with provinces and territories. Having examined the relevant legal, political and health policy considerations, the CMA is proposing the development and formal approval of a Canadian Health Charter based on a renewed partnership between levels of government and with the agreement of patients and providers.2 3.1.2 What would it look like? The CMA envisions a charter with three main parts: a vision statement, a section on national planning and coordination and a section on roles, rights and responsibilities. The CMA has developed an illustrative example of a charter in a separately released paper, Charter at a Glance. Vision Although there is no shortage of vision statements for Medicare, there is no single shared vision. The federal government, provinces and territories and individual stakeholders have all developed their own visions for various purposes and at various times. In some cases, such as the September 2000 Health Accord, governments have gone as far as issuing jointly approved vision statements. What is needed is for all parties to come together and achieve consensus on a shared vision that will lay out a modern view of Canada’s health system. The CMA has articulated its own vision in section 2, above. National planning and coordination The Canadian Health Charter would set out the requirement for national planning and coordination based on such principles as collaboration, evidence-based decision-making, stable and predictable funding, regional and local flexibility, and accountability. It could also specify areas where national planning and coordination are required, particularly with respect to the determination and regular review of core health care services; the development of national benchmarks for timeliness, accessibility and quality of health care; health system resources including health human resources and information technology; and the development of national goals and targets to improve the health of Canadians. The charter would also provide for the creation of a Canadian Health Commission to monitor compliance with and measure progress towards charter provisions, report to Canadians on the performance of the health care system, and provide ongoing advice and guidance to the Conference of Federal–Provincial–Territorial Ministers on key national issues. Roles, rights and responsibilities One of the key aims of the charter would be to develop a common understanding of the roles, rights and responsibilities of the key players in the renewal of Medicare. Key aspects of understanding would include * Acknowledgement of the ongoing role of governments in terms of overall coordination and health planning * Reinforcement of the accessibility and portability rights of the residents of Canada by a clear and unequivocal statement that governments must do everything in their power to provide reasonably comparable access to timely, high-quality health care3 * Establishment of the rights and responsibilities of patients, providers and governments in Canada. 3.1.3 Development and implementation of a charter Key features of our proposed Canadian Health Charter are as follows. * National mandate: It will be an inclusive document — one that is truly national as opposed to federal or interprovincial or interterritorial. * Values-based: It will be consistent with publicly accepted values and principles. * Enforceable: It will achieve compliance to its provisions through administrative mechanisms rather than through the courts. * Non-derogational: It will respect federal, provincial and territorial jurisdictional boundaries. The Canadian Health Charter will only be as good as the process put in place to develop it and to oversee its implementation. Although it may be too early to speculate on how this would be orchestrated, we make the following observations. * The development of the Canadian Health Charter will require a broad consultative process. Although this process could be led by governments, it should be developed in an inclusive manner with all stakeholders, including organizations representing health care providers and consumers. * Once consensus is reached on a proposed Canadian Health Charter, it will be important for the federal, provincial and territorial governments to give it formal approval. This could be accomplished in a number of ways, including approval at a first ministers meeting, through the elected assemblies or by way of a royal proclamation.4 Recommendation 1 That the governments of Canada adopt a Canadian Health Charter that * reaffirms the social contract that is Medicare * acknowledges the ongoing roles of governments in terms of overall coordination and health planning * sets out the accessibility and portability rights and responsibilities of residents of Canada * sets out the rights and responsibilities of the governments, providers and patients in Canada * provides for a “Canadian Health Commission.” 3.2 Canadian Health Commission What is clear from the past decade — through numerous provincial Commissions, a three-year National Health Forum, a Senate study and now the Commission on the Future of Health Care in Canada — is that strategic health planning is a never-ending challenge. This is why we need a permanent, depoliticized forum at the national level for ongoing dialogue and debate — a Canadian Health Commission. 3.2.1 Structure, composition and mandate Our thinking on the development of a Canadian Health Commission has been guided by a number of precedents and models that have been used in the Canadian context, beginning with the Dominion Council of Health, which was provided for in the Act constituting the Department of Health in 1919. It was formed to facilitate coordination with the provinces and territories and various private organizations on health matters and was the principal advisory agency to the Minister of National Health and Welfare. Membership comprised the federal deputy minister (chair), provincial deputy ministers and external members representing women’s organizations, labour, agriculture and medical science. We also examined more recent models of national advisory and oversight bodies. More details on the structures and basic mandates of these bodies are provided in Appendix C. Our assessment of these Commissions, roundtables and councils leads us to a number of conclusions about the structure and composition of the Canadian Health Commission: * Independence: The Commission should be at arm’s length from governments and have the freedom to conduct research and advise governments on a broad range of health and health care issues. However, it should have close links with government agencies such as the Canadian Institute for Health Information and the Canadian Institutes for Health Research to facilitate its work. * Transparency: The Commission should be open and transparent. We do not want to recreate the black box of executive federalism. Government representatives would be welcome as observers, and the Commission’s deliberations would be made public. * Credibility: The composition of the Commission should reflect a broad range of perspectives and expertise necessary fulfill its mandate. Appointments should not be constituency-based, to ensure that constituency politics do not interfere with the Commission’s deliberations. * Legitimacy: Although the Commission would be established by the federal government, its structure, composition and mandate will have to be legitimate in the eyes of provincial and territorial governments. * Permanence: The Commission should be permanent and it should be afforded adequate resources to do its job, subject to a regular review of its mandate and effectiveness. * Stakeholder engagement: The Commission should include representation from the general public and should seek to engage Canadians at large through research, consultation and public education activities. * Authoritative leadership: The Commission should be chaired by a Canadian Health Commissioner, who would be an officer of Parliament (similar to the Auditor General) appointed for a five-year term by consensus among the federal, provincial and territorial governments. The Health Commissioner would not be a substitute for the federal minister of health. The minister of health would continue to be responsible to Parliament for federal health policies and programs, as well as for promoting intergovernmental collaboration on a range of health and health care issues. The Commissioner would be afforded the powers necessary to conduct the affairs of the Commission, such as the power to call witnesses before hearings of the Commission. The Commission’s mandate would include the following responsibilities: * Monitor compliance with the Canadian Health Charter * Report annually to Canadians on the performance of the health care system and the health status of the population * Advise the Conference of Federal–Provincial–Territorial Ministers of Health on critical questions such as: - defining the basket of core services that would be publicly financed - establishing national benchmarks for timeliness, accessibility and quality of health care - planning and coordinating health system resources at the national level, including health human resources, information technology, and capital infrastructure - developing national goals and targets to improve the health of Canadians. Recommendation 2 That a permanent Canadian Health Commission be established and operate at arm’s length from governments. The Commission’s mandate would include * monitoring compliance with the Canadian Health Charter * reporting annually to Canadians on the performance of the health care system and the health status of the population * advising the Conference of Federal-Provincial-Territorial Ministers of Health on critical issues. 3.3 Renewing the Federal Legislative Framework Flowing from the Canadian Health Charter will be a number of moral and political obligations directed at the federal, provincial, and territorial governments, providers and patients. Recognizing the shared federal, provincial and territorial obligations to the health care system, one of the main purposes of the Charter is to reinforce the national character of Canada’s health system. The federal government would be expected to make significant commitments in a number of areas. 3.3.1 The Canada Health Act The Canada Health Act (CHA) was adopted by Parliament in 1984 as the successor to federal legislation governing cost-sharing agreements for hospital and medical insurance. Its principles have become the cornerstone of Medicare. The CHA articulates the underlying vision and values of Medicare and sets out the five conditions with which provincial and territorial health insurance plans must comply — universality, accessibility, comprehensiveness, portability and public administration — to receive the full federal financial contribution that they are entitled to under the Canada Health and Social Transfer (CHST). Thus, the Canada Health Act is the linchpin that holds together 13 separate provincial and territorial health systems. Although the CHA has been a lightning rod for several federal–provincial–territorial disputes over the years, the reasons for these disagreements have had more to do with politics than with the substance of the act. In fact, if there is one public policy issue in Canada over which there is near unanimity across provinces and territories and across political parties, it is that the principles of the CHA are sound. Recently, federal, provincial and territorial governments agreed to establish a formal dispute avoidance and resolution mechanism to deal more openly and transparently with issues arising from the interpretation of the Canada Health Act. The CMA applauds this development. In section 5.1.3 of this report, the CMA calls for the establishment of a process at the national level to determine and review regularly the basket of core services in an open, transparent and evidence-based manner. The CHA should be amended to provide for such a process. Finally, and perhaps most importantly, the CHA should be amended to reflect the Canadian Health Charter. This would include changing the preamble to ensure that it reflects a modern vision and values of Medicare, provides for a Canadian Health Commission, recognizes the federal role and reflects the accessibility and portability rights of Canadians. Recommendation 3 That the federal government undertake a review of the Canada Health Act with the view to amending it * to embody the Canadian Health Charter within it * to provide for the Canadian Health Commission and * to allow for a broader definition of core services and for certain service charges under certain terms and conditions. 3.3.2 Transfers to provinces and territories The nature of Canada’s publicly funded health care system creates unique challenges and opportunities regarding accountability and sustainability. Provinces and territories have the constitutional responsibility for health care and provide most of the funding; the federal government’s role includes funding and is based on the desire of Canadians to have the semblance of a national health care program. The CMA has been a strong advocate of stable, predictable and adequate federal funding for health care. The federal government has responded by introducing a cash floor for the CHST and by restoring some of the cuts made during the 1990s. However, the federal government still has a long way to go. Cash transfers must be increased if the federal government is to be considered a credible partner in Medicare. A larger and continuing federal role in health care financing is required, and the allocation of funds must be done more transparently and in support of a longer planning horizon. Transparency in federal funding for health care means that the federal government can no longer claim to be spending its CHST contribution three ways. Canadians have a right to know how much of their federal tax dollars is being transferred to provinces and territories to support Medicare. The same should hold for transfers related to postsecondary education and social services. Although this may be at odds with the prevailing doctrine in the ministries of finance and intergovernmental affairs, it is the least that Canadians can expect from their governments in terms of accountability. It also serves to underscore the fact that the underlying purpose of fiscal federalism is to support Medicare and other important social programs, not the reverse. In addition to the transfer of block funds to provinces and territories, the sheer magnitude and pressing nature of many issues facing Medicare warrant the use of one-time only, targeted, special-purpose transfers. Precedents for these types of transfers include the National Health Grants Program created in 1948 to develop hospital infrastructure across the country, as well as the more recent funds created to support early child development, medical equipment, the health infoway and primary care renewal. This type of approach, coupled with more stringent accountability provisions to ensure that the funds are spent as intended, should be used to address serious system shortcomings in the areas of health human resources, capital infrastructure and information technology. Recommendation 4 (a) That the federal government’s contribution to the publicly funded health care system * be harmonized with the five-year review of the federal equalization program * be locked-in for a period of five years, with an escalator tied to a three-year moving average of per capita GDP * rise to a target of 50% of provincial/territorial per capita health spending for core services * provide for notional earmarking of funds for health. (b) That the federal government create special purpose, one-time funds totalling $2.5 billion over five years (or build on existing funds) to address pressing issues in the following areas * health human resources planning * capital infrastructure * information technology * accessibility fund. 3.3.3 Tax policy in support of health In the past, the Government of Canada has relied heavily on its spending power and legislation to influence the development of Medicare across Canada. However, increasing concern associated with Canada’s health care system has obliged the federal government to maximize all its available policy levers, including taking another look at how the tax system can be used to support renewal of the health sector. Although taxes are widely used as a public policy tool, to date the role of taxation in the area of health has been relatively small. In total, personal income tax assistance (i.e., foregone government revenue) for health was estimated at $3.8 billion in 2001, equal to only a little more than 3.7% of total health expenditures for that year. The tax system interfaces with the health sector at three levels — health care financing, health care inputs and lifestyle choices. Key questions of reform that could be addressed through a review of the tax system at these levels include the following. Health care financing * Could tax incentives be used to improve access to private supplemental insurance? * How could increased tax relief be provided to people with high out-of-pocket medical expenses? * Should the tax system be used to encourage personal savings for long-term care? Health care inputs * How could tax incentives be used to address health human resource issues (e.g., attracting physicians and nurses to rural and remote areas, off-setting high costs of medical education, promoting continuing education)? * How can the federal government proceed with changes to the tax system to ensure equitable treatment of all health providers (e.g., GST)? * Could enhanced tax credits be developed to support informal caregivers? * Could tax incentives be used to promote research and innovation in health care beyond the pharmaceutical sector? Lifestyle choices * How could the tax system be used to encourage healthy lifestyles (e.g., incentives to eat well and exercise; disincentives for unhealthy choices)? The level of support provided by the tax system for people facing high out-of-pocket expenses is a particularly pressing question. Currently, the medical expenses tax credit provides limited relief to those whose expenses exceed $1,637 or 3% of net income. The 3% threshold was established before Medicare was introduced. Does it still make sense in 2002? Are there ways to enhance this provision to reduce financial disincentives facing many Canadians when they have to pay for health services that may not be medically necessary, but are beneficial and worthy of government support? The CMA encourages the federal government to undertake a comprehensive review of these and other tax questions pertaining to health. Clearly, we do not believe tax policy will, by itself, solve all of the challenges facing Canada’s health care system. Nevertheless, the CMA believes that the tax system can play a key role in helping the system adapt to changing circumstances, thereby complementing the other two components of our renewal strategy. Recommendation 5 That a blue ribbon panel of Parliament be established to work with the Canadian Health Commission to review the current provisions of federal tax legislation with a view to identifying ways of enhancing support for health policy objectives through tax policy. 4. Meaningful Stakeholder Input and Accountability In the Commission’s interim report, the question was posed: why are those who have the most to contribute, who are the most committed — Canada’s health professionals — not at the table when the future of health and health care is being discussed by this country’s leaders? Physicians individually and collectively feel disempowered and disengaged. They feel frustrated, marginalized and left out at all levels of decision-making. Nowhere is this more evident than at the national level, where physicians and other health care providers have tried in vain to gain access to the “black box” of executive federalism. Physicians and other providers have been systematically excluded from participating in decisions about the future of health and health care. During the past decade, with the exception of successful joint management ventures at the provincial, territorial or regional levels, physicians have been increasingly marginalized in terms of policy decisions. At the federal–provincial–territorial level, physicians have been frozen out since the late 1980s. At the federal level, organized medicine had no opportunity for formal input to the National Forum on Health. Physicians were specifically excluded from many regional boards when they were established in the early 1990s. Finally, the consolidation of many local governance structures (e.g., hospital boards) into regional boards has reduced opportunities for local decision-making. A basic principle of justice states that those who are affected directly by decisions ought to be present when such decisions are made. Physicians, nurses and others bring much to the table. The grounds for exclusion are often not clear, but tend to be a result of the misguided notion that self-interest might prevail over the collective interest. In today’s environment, with the rapid turnover of senior health officials, we believe the pendulum must swing toward building a table where enlightened self-interest is promoted. Whereas elected officials are in the health business for only a short time, physicians and other providers have their careers on the line. We have the most invested, the most to give and, next to our patients, the most to lose. Why is it that we have the least say in decisions about the future of health and health care? Why is it that we learn about decisions after the fact and are then expected to support them? Canada has paid an enormous price for this policy of exclusion. Ill-informed policy decisions in human health resources planning have had catastrophic results. Recently, the shell game around investments in medical technology has typified how federal, provincial and territorial governments working behind closed doors tend to promote solutions that minimize friction between the two levels of government, but are of little or no concrete benefit to the health care system. We need a more transparent and accountable process. Recommendation 6 That governments and regional health authorities initiate or enhance significant efforts to secure the participation of and input from practicing physicians at all levels of health care decision-making. 5. Defining the Public Health Care System Sustainability and accountability are overarching themes of this submission, and our ultimate goal is timely access to quality care for all Canadians. The time has come to stop making excuses for rationing the publicly funded health care system. Our patients deserve health care that is available to them in a timely fashion in their own country. Canada’s physicians support publicly funded health care, but not if it means patients are denied timely access to quality care and not if it means rationing and denial of necessary care. We strongly believe that all Canadians, regardless of where they live, should have access to high-quality health care. 5.1 Core Services One of the pathways identified in our initial submission was the need to strike a better balance among everything and everyone. No country in the world has been able to provide first-dollar5 coverage for timely access to all services. In light of the rapidly transforming delivery system with its shift from institutional to community-based care, a re-examination of the Medicare “basket” is overdue. 5.1.1 Uniform coverage for all Canadians All Canadians should have coverage for basic health care services under uniform terms and conditions, regardless of where they live. A clearly defined basket of core services is an essential requirement for a national program in a decentralized system of health care such as Canada’s. This basket would ensure that a minimum level of coverage is applied uniformly across all provinces and territories. However, it is important to acknowledge that variation will occur in health care priorities across provinces and territories; as a result, provinces and territories may choose to add to this basket. Recommendation 7 That all Canadians be provided coverage for a basket of core services under uniform terms and conditions. 5.1.2 Redefining core services Since the inception of Medicare in Canada, core services have generally been understood to be those subject to the five program criteria set out in the Canada Health Act. These include medically necessary hospital services, physician services and surgical dental services provided to insured persons. However, as health care delivery has evolved, more and more services have migrated out of the hospital setting, effectively reducing the relative size of the basket of core services. For example, while hospital and physician expenditures accounted for 56% of total health spending in 1984, by 2000 this had declined to 45%. Many services previously provided in hospitals are now delivered through a combination of community-based services and drug therapy. Services that continue to be provided in hospitals are increasingly being provided on a “day surgery” basis (requiring no admission) or during a much shorter stay. If Medicare is to continue to meet the needs of Canadians, then the notion of core services must be changed to cover an array of services consistent with the realities of health care in the 21st century. Specifically, the definition of core services should be reviewed to determine the extent to which it should go beyond hospital and physician services. Recommendation 8 (a) That the scope of the basket of core services be determined and be updated regularly to reflect and accommodate the realities of health care delivery and the needs of Canadians. (b) That the scope of core services should not be limited by its current application to hospital and physician services, provided that access to medically necessary hospital and physician services is not compromised. 5.1.3 A process for clarifying what is in and what is out There is no simple way to decide what the basket of core services should include or exclude. It involves making difficult value judgements and trade-offs and achieving consensus among a broad cross-section of perspectives and interests. For several years, the CMA has advocated a balanced approach to the determination of core services that addresses the issues of ethics, quality (evidence) and economics (Appendix D). The risks of not making these difficult decisions have become all too clear: a health system that is locked into antiquated notions of health care and is increasingly out of touch with the needs of Canadians. The process used to determine core services should be inclusive and transparent. Decisions should be evidence-based and not biased in favour of any single provider or setting in which care is provided. The special nature of care related to illness should be recognized ? emergent vs. non-emergent conditions, the potential financial burden on individuals and families, and the inability to predict when such care will be required. Most important, whoever is assigned the task of defining and updating the basket of core services must have legitimacy in the eyes of the public. The CMA believes that the values listed below should characterize the process used to determine the basket of core services covered under Medicare. Values for Determining Core Services Transparency: The process and principles or rules on which decisions are based should be open to scrutiny and made public. Accountability: Decision makers should have proper authority to make these decisions and provisions should be in place for them to be held accountable for the decisions they make. Evidence-based: The decision-making process should incorporate relevant empirical evidence as available and appropriate. Inclusivity: Parties having an important stake in the decisions, should be identified, consulted and included in decision-making. Recommendation 9 (a) That the scope of the basket of core services be determined and regularly updated by a federal-provincial-territorial process that has legitimacy in the eyes of Canadians – patients, taxpayers and health care professionals. (b) That the values of transparency, accountability, evidence-based, inclusivity and procedural fairness should characterize the process used to determine the basket of core services to include under Medicare. 5.1.4 Funding core services - finding a new Canadian compromise Under the Canada Health Act, provinces and territories must ensure that medically necessary physician and hospital services are provided on a first-dollar basis. Beyond these core services, provinces and territories provide varying degrees of coverage for other services, which are funded through a mix of government funding and patient cost-sharing. Some services are completely funded from private sources. Beyond hospital and physician services, there is no uniformity across provinces and territories in the terms and conditions under which services may be partly covered under the public funding umbrella. If the basket of core services is to be expanded beyond its focus on physician and hospital care, then certain realities must be addressed. First, although first-dollar coverage may be required to maintain access to services for the most vulnerable in society, its universal application creates the illusion that health care services are free when they clearly are not. Second, given limited fiscal resources and political priorities, governments will likely not be able to afford first-dollar coverage for an expanded set of core services. Without additional funding, resources will have to be reallocated from hospital and physician services to finance other services added to the basket. This argues for a different approach to the funding of core services — one that is more pragmatic and less ideologically driven. Under this approach, health services would be divided into three categories: those that are exclusively publicly funded, those that are partly publicly funded, and those that are exclusively privately funded. The services in the first two categories would be defined as core services. As discussed earlier, the basket of core services would be determined and regularly updated by a legitimate, multistakeholder group using an evidence-based process; it should no longer be defined on the basis of whether the services are 100% publicly financed. If core services are redefined to include services that are currently financed through a mix of private and public funding, then Canadians must be prepared to review the use of first-dollar coverage to ensure that it is applied where it is most needed to maintain access to core services. Uniform terms and conditions for core services with mixed private–public funding must also be developed, i.e., by defining the minimum level of public funding from all provinces and territories. The development of uniform terms and conditions around those services that receive a mix of public and private funds has never been addressed in Canada. Even though the criteria of the Canada Health Act ? universality, accessibility, comprehensiveness, portability and public administration ? should be relatively easy to apply in a world of first-dollar coverage, Canada’s health system has not been able to satisfy all of them consistently. It is essential that these criteria be more diligently applied to core services that are funded on the basis of first-dollar coverage. In addition, they must be adapted to provide an effective framework of terms and conditions to govern access to services with mixed private–public funding. There is a need for a more rational discussion of the role of patient cost-sharing in the Canadian health care system. Many types of mechanisms for cost-sharing are in place today, including premiums, deductibles, co-payments, charges at point of service and taxation of health benefits. Here again, governments should adopt approaches that promote transparency and accountability, while ensuring that no one is denied care because they cannot afford to pay. Service charges are an acceptable part of the provision of many important health-related products and services such as pharmaceuticals and dental care. Furthermore, the Canada Health Act makes an explicit provision for chronic care co-payments. However, other services such as physician and hospital services are currently considered off-limits. Certain services that possess an “amenity” component, such as some pharmaceuticals, prostheses and certain elements of home care could continue to include a service charge to cover a portion of the service. However service charges are applied, it should be done in a fair and equitable manner that takes into consideration those at a financial disadvantage so that it does not impede access to necessary care, but encourages appropriate use of the health care system. In addition, patient cost-sharing arrangements for core services must be consistent across provinces and territories. Minimum thresholds for the public share of financing could be established for different categories of core services; however, any jurisdiction would be free to increase its share to a level above the minimum. Recommendation 10 (a) That governments develop a new framework to govern the funding of a basket of core services with a view to ensuring that * Canadians have reasonable access to core services on uniform terms and conditions in all provinces and territories * governments, providers and patients are accountable for the use of health care resources * no Canadian is denied essential care because of her or his personal financial situation. (b) That legislation be amended to permit at least some core services to be cost-shared under uniform terms and conditions in all provinces and territories. (c) That once the basket of core services is defined, minimum levels of public funding for these services be uniformly applied across provinces and territories, with flexibility for individual governments to increase the share of public funding beyond these levels. 5.2 Care Guarantee and “Safety Valve” A common frustration in recent years among many physicians and patients has been the lack of any recourse or alternative care in Canada when the publicly funded health system fails to provide timely access to health care. For Canadians, the only alternative since the inception of Medicare has been to turn to the United States or other countries for medical care. This may have been acceptable in the early days of Medicare when public funding was plentiful and the need to seek care outside of Canada was more theoretical than real; however, in 1998, the National Population Health survey estimated that some 17,000 Canadians traveled to the United States to seek medical care. Clearly, this is not an option for most Canadians. Recent court cases have held provincial governments accountable for providing timely care. An increasing number of Canadians are seeking private care in Canada, such as at private magnetic resonance imaging (MRI) clinics, even though this service is potentially in conflict with the principles of the Canada Health Act. The public has, in effect, built its own safety valve. This is a concrete example of what happens when the publicly funded system fails to respond to a legitimate demand. This gap in Canadian health policy must be addressed in a way that compels the system to provide timely care while preserving the right of Canadians to seek alternate care if the public system fails to deliver. The first step in addressing these issues is to define core services. The second step is to establish guidelines and standards around quality and waiting times that are evidence-based and that patients, providers and governments consider reasonable. To date, the best example of such benchmarking in Canada has been by the Cardiac Care Network in Ontario. The CMA has reviewed progress toward the development of benchmarks in A Canadian Health Charter: A Background Discussion Paper, which examines Canadian and international experience with health charters. We have also written a policy on operational principles for the measurement and management of waiting lists (Appendix E). If the publicly funded health care system fails to meet the specified agreed-upon standards for timely access to core services, then patients must have other options to allow them to obtain this required care through other means. Step three involves setting up a “safety valve” to address situations where the established time guarantees cannot be met. This safety valve provision would allow patients and their physicians to seek required care wherever it is available. Attempts would be made to find care geographically close to the patient — first within the province or territory, then in another province or territory or even out of country. The public funds that would have been used to pay for the patient’s care if the time guarantee had been met would be used to pay for the service wherever it is provided. In some cases, the cost of this service will be more than what would have been charged had the service been available in a timely manner from the public system in the patient’s home province or territory. Patients would be able to purchase supplementary private insurance on a prospective basis to cover this difference in cost. Ideally, Canadians would never have to use this “safety valve.” However, its inclusion in Canadian health policy will provide assurances and help restore public confidence in the health system. It will also remind governments about the repercussions of not living up to mutually agreed-upon commitments to provide timely access to care. Recommendation 11 (a) That Canada’s health system develop and apply agreed upon standards for timely access to care, as well as provide for alternative care choices – a “safety valve” – in Canada or elsewhere, if the publicly funded system fails to meet these standards. (b) That the following approach be implemented to ensure that governments are held accountable for providing timely access to quality care. * First, governments must establish clear guidelines and standards around quality and waiting times that are evidence-based and that patients, providers and governments consider reasonable. An independent third-party mechanism must be put in place to measure and report on waiting times and other dimensions of health care quality. * Second, governments must develop a clear policy which states that if the publicly funded health care system fails to meet the specified agreed-upon standards for timely access to core services, then patients must have other options available to them that will allow them to obtain this required care through other means. Public funding at the home province rate would follow the patient in this circumstance, and patients would have the opportunity to purchase insurance on a prospective basis to cover any difference in cost. 5.3 Public Health Canada has been a leader in recognizing that there is more to health than health care. The Hon. Marc Lalonde’s 1974 New Perspective on the Health of Canadians, which has since become world renowned, introduced the health field concept that emphasized the role of environmental and lifestyle determinants of health. Public health is often associated with measures to prevent illness, such as safe drinking water, sanitation, waste disposal, immunization programs, well-baby clinics or programs promoting healthy lifestyles. It is the organized response of society to protect and promote health and to prevent illness, injury and disability. Public health carries out its mission through organized, interdisciplinary efforts that address the physical, mental and environmental health concerns of the population at risk of disease and injury. These efforts require coordination and cooperation among individuals, governments (federal, provincial, territorial and municipal), community organizations and the private sector. Putting patients first means, among other things, making sure that the health system is capable of stretching to capacity to meet unforeseen circumstances. The need for this “surge capacity” is discussed in more detail in section 6.3. Canadian physicians have long recognized the value of health promotion and disease prevention and have incorporated these elements into their practices. The CMA and its divisions and affiliates have also been active in the field of public health. For its part, the CMA * Worked with the CBC on the first series of public health broadcasts * Was the first organization to call for a ban of smoking on airplanes * Developed a tool to help physicians determine medical fitness to drive * Launched a campaign to reduce traffic injuries (seatbelts, breathalyzers, etc) * Carried out a national Bicycle Helmet Safety Program * Supported warning labels on tobacco products. Public health is complex, and the current status of the public health system in Canada requires a full and open review. In 1999, the auditor general found Health Canada unprepared to fulfill its responsibilities in the area of public health: communication among multiple agencies was poor and weaknesses in the key surveillance system impeded the effective monitoring of communicable and noncommunicable diseases and injuries. It is imperative that various departments and sectors coordinate and communicate effectively to synergize efforts and to avoid duplication. The capacity of the public health care sector to deliver disease prevention and health promotion programs is inadequate, and its ability to respond varies across the country. This situation is due to a lack of trained professionals and a lack of operational funds. Greater commitment is needed from governments at all levels to ensure that adequate human resources and infrastructure are available to respond to public health issues when they arise. This includes the expansion of the public health training programs. Once a public health issue has been identified, it is the responsibility of professionals within the system to use effective means of control. The public health system must be supported by a strong and viable infrastructure to allow them to meet such challenges. Major public health issues facing Canadians include, but are not limited to, high rates of obesity, tobacco and other substance use, mental health challenges, ensuring a clean and safe environment and prevention of injury and violence. The ability of the public health system to respond to these issues directly affects the well-being of Canadians, in a manner as important as the ability of the acute care system to respond to medical emergencies. However, investment in public health initiatives must not be made at the expense of acute and long-term care. Since the 1970s, the World Health Organization and national governments around the world have paid increasing attention and put greater effort into establishing goals for improving public health and into monitoring achievement. Numerous examples can be cited in the United States, England and Australia. In Canada, although the federal government has not attempted to establish goals, several provinces have undertaken such an exercise. Public health priorities or goals are considered to be an asset to a health care system in that they * Provide a baseline assessment of a population’s health and a tracking system for monitoring change * Encourage an increase in the breadth and intensity of health improvement activities and improve the efficiency and effectiveness of existing activities * Facilitate evaluation of the impact of health improvement activities * Foster unity of purpose, organization, participation and spirit of cooperation through consensus * Build awareness of and support for health programs among policymakers and the public * Guide decision-making and funding allocations. At their meeting in September 2000, the first ministers made several commitments to improve public health * Promote the public services, programs and policies that extend beyond care and treatment and that make a critical contribution to the health and wellness of Canadians * Develop strategies and policies that recognize the determinants of health, enhance disease prevention and improve public health * Further address key priorities for health care renewal and support innovations to meet the current and emerging needs of Canadians * Report regularly to Canadians on health status, health outcomes and the performance of publicly funded health services, and the actions taken to improve these services. Unfortunately, there has been little progress to date. Canada must develop a strategic approach to sustain and strengthen the capacity of the public health system to prevent, detect and respond to public health issues. Recommendation 12 (a) That governments demonstrate healthy public policy by making health impact the first consideration in the development of all legislation, policy and directives. (b) That the federal government provide core funding to assist provincial and territorial authorities in improving the coordination of prevention and detection efforts and the response to public health issues among public health officials, educators, community service providers, occupational health providers, and emergency services. (c) That governments invest in the human, infrastructure and training resources needed to develop an adequate and effective public health system capable of preventing, detecting and responding to public health issues. (d) That governments undertake an immediate review of Canada’s self-sufficiency in preventing, detecting and responding to emerging public health problems and furthermore, facilitate an ongoing, inclusive process to establish national public health priorities. 5.4 Aboriginal health Despite improvements in many areas, First Nations, Métis and Inuit people continue to have a poorer health status than the general Canadian population. The current health status of Canada’s Aboriginal peoples is a result of a broad range of factors. It is generally acknowledged that improving it will take a lot more than simply increasing the quantity of health services. The underlying roots of the problem must be addressed; for example, poverty, low levels of education, unemployment and underemployment, exposure to environmental contaminants, inferior housing, substandard infrastructure and maintenance, low self-esteem and loss of cultural identity. A problem of this magnitude and complexity must be addressed in a comprehensive way, with all components of health, government and other sectors working in full partnership with the Aboriginal community. In recognition of this need, in February 2002 the CMA signed a letter of intent with the National Aboriginal Health Organization (NAHO) (Appendix F) to collaborate on activities in four areas of mutual interest: 1. Workforce initiatives: To increase recruitment and retention of physicians and other health professionals, particularly of Aboriginal descent, who serve Aboriginal communities. 2. Research and practice enhancement initiatives: To promote research into Aboriginal health issues and the translation of research into effective clinical practice through means such as dissemination of best-practice information and the development of user-friendly practice tools. 3. Public and community health programs: To address and develop initiatives to promote healthy living for Aboriginal communities. 4. Leadership programs: To develop and implement leadership development initiatives including mentoring programs for Aboriginal physicians. The exploration of these and other areas is essential to improve Aboriginal health status so that it is on par with the rest of the Canadian population. Recommendation 13 That the federal government adopt a comprehensive strategy for improving the health of Aboriginal peoples which involves a partnership among governments, nongovernmental organizations, universities and the Aboriginal communities. 6. Investing in the Health Care System 6.1 Health Human Resources Governments must demonstrate their commitment to the principle of self-sufficiency in the production of physicians to meet the medical needs of the Canadian population. Coverage means nothing without access, and access means nothing without availability of health care professionals. Unfortunately, there are shortages of human resources in various health care disciplines, and these shortages will be exacerbated by the demographics of the Canadian population and of each provider group and by changing public expectations. The population in general is becoming older. Older age groups experience an increased incidence of illness and disability, and thus place higher demands on the health care system. At the same time, significant numbers of health care providers are approaching retirement; in many cases, there are not enough young people entering the professions to replace those who will soon be leaving. Over the past two decades, one of the most striking changes in the medical workforce in Canada has been the increased proportion of female medical graduates: in 1980, women represented 32% of medical graduates; by 1996, this proportion reached 50%. Women now represent 30% of the practising profession in Canada and this will approach 40% by the end of the decade. Although more research is needed, it is clear that male and female physicians have different practice patterns. The changing gender distribution must be taken into consideration when examining the problem of physician supply. A more highly educated population and the widespread use of information sources such as the Internet are contributing to a heightened sense of patient empowerment, higher expectations and consumerism. These factors will increase pressure for high-quality health services. Although we encourage patients to be informed, we must be prepared for the added demands on the health system that this enhanced knowledge will create, especially in terms of the supply of health human resources. The human resources crisis is one of the most important issues facing health care today. Solutions must be found to address the many specific problems that are plaguing all health provider groups. The nursing field is suffering from many of the same challenges as physicians, including attrition and the “brain drain.” The accessibility crisis is compounded by shortages of laboratory technologists and others in the health care field, who directly support the work of physicians. Although these problems must all be addressed to make our health care system sustainable for the future, this document focuses on the professionals about whom the CMA has the greatest knowledge and expertise: physicians. 6.1.1 Supply, training and continuing education All areas of the health care continuum are experiencing a shortage of physicians. The key factors underlying this shortage include physician demographics (e.g., age and gender distribution), changing lifestyle choices and productivity levels (expectations of younger physicians and women differ from those of older generations) and the insufficient numbers entering certain medical fields. According to 2001 data from the Organisation for Economic Co-operation and Development (OECD), Canada ranked 21st out of 26 countries in terms of the ratio of practising physicians to the population. In addition to the factors affecting physician supply mentioned above, other drivers of change, such as technological innovation and information technology, are adding further pressure to an already overworked medical profession. The OECD report further states that empirical evidence shows that lower doctor numbers are closely linked with higher mortality, after taking other health determinants into consideration. Yet, in terms of female and male life expectancy at birth, Canada ranks 7th and 6th, respectively.6 This is a powerful testament to the efforts of Canadian health professionals in putting patients first. Increasing numbers of Canadians feel the impact of the widespread physician shortages when they are unable to find a family physician or they experience delays in seeing specialists. Physicians themselves are finding that they must reduce the time they can spend doing research, teaching and pursuing continuing medical education in order to focus on direct patient care. In November 1999, the Canadian Medical Forum7 (CMF) and the Society of Rural Physicians of Canada met with the federal, provincial and territorial governments to present a detailed report on physician supply containing five specific recommendations. The CMA and the other CMF organizations were encouraged to see that many jurisdictions across Canada agreed with the need to increase enrolment in undergraduate medical education programs, although we are still far from the 2,000 medical students by year 2000 that was recommended. The necessary increases in undergraduate enrolment in medicine require funding not only for the positions themselves, but also for the infrastructure (human and physical resources) needed to ensure high-quality training that meets North American accreditation standards. The concomitant increases in postgraduate positions that will be required three to four years later must also be resourced appropriately. This is in addition to the extra positions recommended in the November 1999 CMF report, which are needed to increase flexibility in the postgraduate training system; the capacity to provide training to international medical graduates; and opportunities for re-entry for physicians who have been in practice. The CMA remains very concerned about high and rapidly escalating increases in medical school tuition fees across Canada. According to data from the Association of Canadian Medical Colleges (ACMC), in just five years (1996 to 2001), average first-year medical school tuition fees increased by 100%. In Ontario, they went up by 223% over the same period. Student financial support through loans and scholarships has not kept pace with this rapid escalation in tuition fees. The CMA is particularly concerned about the impact this will have on the physician workforce and the Canadian health care system. High tuition fees will have a number of consequences. They create barriers to application to medical school and threaten the socioeconomic diversity of future physicians serving the public. They also exacerbate the “brain drain” of physicians to the United States where newly graduated physicians can pay down their large student debts much more quickly. Medical education does not end with earning the title MD; in fact, this is just the beginning of a physician’s learning. The continuously evolving nature of medicine requires that physicians remain up-to-date on emerging medical technologies, new treatment modalities and numerous other developments. In the early 1990s, the conventional wisdom was that medical knowledge was doubling every five years. Now, a time of less than two years is more commonly cited. Clearly, there is an increasing role for continuing medical education (CME), underscored by explicit requirements for self-directed activities to promote maintenance of certification for both family practitioners and specialists. Historically, this is an area where physicians have largely had to fend for themselves. For its part, the CMA has sponsored the Physician Manager Institute, which provides training for physicians moving into leadership positions. Although many provincial and territorial medical associations have negotiated CME benefits with their governments, it is essential that academic health science centres be supported to expand capacity in the area of CME. In the early days of Medicare, the federal government played a leadership role in building the infrastructure for health education through the Health Resources Fund, which distributed $500 million during 1966–1980. The purpose of this fund was to help provinces bear the capital costs of constructing, renovating and acquiring health training facilities and research institutions. More recently, the federal government supported a rebuilding of the university research infrastructure generally through the $800-million Canada Foundation for Innovation fund, which was announced in the 1997 budget, and the $900-million Canada Research Chairs program, which was announced in the 2000 budget to support the establishment of 2,000 research chairs by 2000. The health field will be a significant beneficiary of these funds. However, considering the shortage of health professionals that we face today and that will soon worsen, as well as the prospect of diminished access to professional education as a result of higher tuition, there is an urgent need for targeted federal funds to address this situation immediately. Recommendation 14 (a) That the federal government establish a $1 billion, five-year Health Resources Education and Training Fund to (1) further increase enrolment in undergraduate and postgraduate medical education (including re-entry positions), (2) expand the infrastructure (both human and physical resources) of Canada’s 16 medical schools in order to accommodate the increased enrolment and (3) enhance continuing medical education programs. (b) That the federal government increase funding targeted to institutions of postsecondary education to alleviate some of the pressures driving tuition fee increases. (c) That the federal government enhance financial support systems for medical students that are (1) non-coercive, (2) developed concomitantly or in advance of any tuition increase, (3) in direct proportion to any tuition fee increase and (4) provided at levels that meet the needs of the students. (d) That incentives be incorporated into medical education programs to ensure adequate numbers of students choose medical fields for which there is greatest need. 6.1.2 Physician retention and recruitment As important as investments in medical education may be, they will only begin to pay off in terms of increased supply of physicians in the medium- to long-term. In the short-term, shortages of family physicians and specialists will persist and possibly worsen. There is no quick fix for this problem; we must manage the best we can. This means making sure that we retain the physicians who are now practising in communities across the country. Physician turnover is a chronic problem in both rural and urban areas. The loss of a physician in a community has a very real impact in terms of continuity of care. There are unmeasured costs to patients, such distress and turmoil, as well as to the remaining physician(s) and communities that must cope with the repeated loss of valued physicians. Canada is both an exporter and an importer of physicians. The two-way flow, mainly between Canada and the United States, is tracked by the Canadian Institute for Health Information. Since tracking began in the 1960s, Canada has been a net exporter of physicians to the United States. During the mid-1990s, the net loss exceeded 400 ? roughly equal to 4 graduating medical classes. Since then, it has abated to 164 in 2000, but this is still the equivalent of 1.5 medical classes. Conversely, Canada is a net importer of physicians from the rest of the world. Although the figure is more difficult to quantify, it is estimated that Canada is a net importer of 200–400 international medical graduates, who are most typically recruited to work in rural and remote communities. Short-term responses to the physician shortage include repatriating Canadian physicians working abroad and integrating qualified international medical graduates and other providers. Canada must recognize that there is a global shortage of physicians ? and a global marketplace for our services; a widespread, organized recruitment of physicians from other countries, especially from those that are also experiencing physician shortages, is not the way to solve Canada’s health human resources problems.8 Recommendation 15 (a) That governments and communities make every effort to retain Canadian physicians in Canada through non-coercive measures and optimize the use of existing health human resources to meet the health needs of Canadian communities. (b) That the federal government work with other countries to equitably regulate and coordinate international mobility of health human resources. (c) That governments adopt a policy statement that acknowledges the value of the health care workforce in the provision of quality care, as well as the need to provide good working conditions, competitive compensation and opportunities for professional development. 6.1.3 The need for integrated health human resources planning Health human resource planning is complex. The CMA seeks to build consensus within the medical profession on major program and policy initiatives concerning the supply, mix and distribution of physicians and to work with major stakeholders in identifying and assessing issues of mutual importance. Planning for the provision of services by a broad array of providers to meet changing health care needs should focus on having the right providers in the right places doing the right things. This first requires the determination of the needed supply, mix and distribution of physicians, which will assist in the development of a similar assessment for all other providers. Resource planning must be based on the health care needs of Canadians rather than driven by cost. The CMA has developed principles and criteria for the determination of scopes of practice. The primary purpose is to meet health care needs and to serve the interests of patients and the public safely, efficiently and competently. These principles and criteria (listed below) have been endorsed by the Canadian Nurses Association and the Canadian Pharmacists Association. See Appendix G for more details. Principles and Criteria for the Determination of Scopes of Practice Principles: * Focus * Flexibility * Collaboration and cooperation * Coordination * Patient choice Criteria: * Accountability * Education * Competencies and practice standards * Quality assurance and improvement * Risk assessment * Evidence-based practices * Setting and culture * Legal liability and insurance * Regulation The CMA remains sensitive to Canada’s provincial and territorial realities with respect to the fact that health human resource planning requires assessment and implementation at the local or regional level. However, there is a need for a national body to develop and coordinate health human resources planning initiatives. Recommendation 16 (a) That a national multistakeholder body be established with representatives from the health professions and all levels of government to develop integrated health human resource strategies, provide planning tools for use at the local level and monitor supply, mix and distribution on an ongoing basis. (b) That scopes of practice should be determined in a manner that serves the interests of patients and the public, safely, efficiently, and competently. 6.2 Capital Infrastructure The crisis in health human resources is exacerbated by an underdeveloped capital infrastructure ? bricks, mortar and tools. This is seriously jeopardizing timely access to quality care within the health care system. In our 2001 discussion paper, Specialty Care in Canada, the CMA indicated there has been inadequate investment in buildings, machinery and equipment and in scientific, professional and medical devices. Provincial and territorial government spending on construction, machinery and equipment for hospitals, clinics, first-aid stations and residential care facilities has remained, on average, 16.5% below its peak in 1989. Specifically, real capital expenditures on new building construction decreased 5.3% annually between 1982 and 1998. Investment in new hospital machinery and equipment declined by 1.8% annually between 1989 and 1998. In 1998, hospital expenditures on scientific, professional and medical devices were nearly 17% below 1994 levels. While these cutbacks were occurring, significant innovations in medical technology were being introduced worldwide. Although hospitals are still providing most acute care services, whether patients are treated as inpatients or outpatients, the equipment required is not keeping pace with the growth of new technologies, the health needs of the patients and the increase and aging of the population. Equipment and machinery in the hospital sector are overaged due to a lack of replacement capital. In the absence of timely access to current and emerging health technologies, Canadians face the prospect of unrestrained progression of disease, increased stress and anxiety over their health status and, possibly, premature death. Meanwhile, society bears the direct and indirect costs associated with delayed access. On September 11, 2000, the federal government announced a new $1 billion transfer to provinces and territories for the purpose of purchasing new medical equipment. A recent analysis by the CMA found that just over half of this fund can be accounted for as being spent as intended (Appendix H). The question remains as to what has happened to the remainder of the fund. Governments have been placing a lower priority on capital investment when allocating financial resources for health care. It will not be enough simply to bring Canada’s health infrastructure up to par; a commitment to ongoing funding to maintain the equipment must also be made. This, in turn, requires continuous inventory maintenance for regular replacement. Therefore, it may be necessary for hospitals to develop innovative approaches to financing capital infrastructure. The CMA agrees with other organizations such as the Canadian Healthcare Association on the need to explore the concept of entering into public–private partnerships (P3s) to address capital infrastructure needs as an alternative to relying on government funding. Joint ventures and hospital bonds are but two examples of P3 financing. Recommendation 17 (a) That hospitals and other health care facilities conduct a coordinated inventory of capital infrastructure to provide governments with an accurate assessment of machinery and equipment. (b) That the federal government establish a one-time catch-up fund to restore capital infrastructure to an acceptable level. (see Recommendation 4(b).) (c) That governments commit to providing adequate, ongoing funding for capital infrastructure. (d) That public-private partnerships (P3s) be explored as a viable alternative source of funding for capital infrastructure investment. 6.3 Surge Capacity Putting patients first means, among other things, making sure that the health care system is capable of stretching its capacity to meet unforeseen circumstances, that the system is monitored for quality, that compensation is available when unintended harm occurs and that patient privacy and confidentiality are respected. The tragic events of September 11, 2001, followed closely by the distribution of anthrax through the United States postal service, provided a grim reminder of the necessity of having a strong public health infrastructure in place at all times. As was demonstrated quite vividly, we do not have the luxury of time to prepare for these events. Although it is not possible to plan for every contingency, certain scenarios can be sketched out and anticipated. 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. In addition to 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. Like our hydro system, “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 they require to meet the need. The CMA’s 2001 pre-budget submission lays out comprehensive recommendations to address this issue (Appendix I). Recommendation 18 That the federal government cooperate with provincial and territorial governments and with governments of other countries to ensure that a strong, adequately funded emergency response system is put in place to improve surge capacity. 6.4 Information Technology Much of the recent debate about the future of the health care system has focused on the need to improve its adaptability and overall integration. One critical ingredient in revitalizing the system is establishing the information technology (IT) and information systems (IS) that physicians and other health care professionals must have at their disposal. Effective and efficient networks will facilitate integrated and coordinated care, as well as better management of clinical information. Although health care is information-intensive, health care systems in Canada and abroad have generally been slow to adopt IT. Other sectors of the economy have invested heavily in IT/IS over the past two decades and have reaped enormous benefits in efficiency and service to clients. IT should be viewed as a “social investment” in the acquisition of knowledge. Patients will benefit through potential reductions in rates of mortality and morbidity due to misdiagnosis and improper treatment, as well as reductions in medication errors that come with access to online drug reference databases and the virtual elimination of handwritten prescriptions. IT will permit better access to diagnostic services and online databases, such as clinical practice guidelines, that are widely available but underused. Health promotion and disease prevention will be enhanced through superior monitoring and patient education (e.g., e-libraries), and decision-making by providers and patients will be improved. These represent only a subset of the potential benefits to Canadians. A great deal of effort is currently being devoted to the development of a secure electronic health record (EHR) that provides details of all health services provided to a patient. An EHR will not generate new information on patients; it will simply make existing information more readily accessible to the physician or appropriate health care provider. We are still at the infant stage of EHRs. Implementation will require a process of continual expansion, beginning with the most basic of patient information and evolving into a comprehensive record of all of the patient’s encounters with the health care system ? as well legislation protecting personal privacy and unwarranted access. It is widely accepted in industry that 4 – 5% of financial budgets is a reasonable target for information technology spending. It is equally widely accepted that in Canada the health care sector falls well short of this target. As part of the September 2000 Health Accord, the federal government invested $500 million to create the Canada Health Infoway with a mandate to accelerate the development and adoption of modern systems of IT, such as electronic patient records. The CMA applauds this investment, but notes that the $500-million down-payment is only a fraction of the $4.1 billion that the CMA estimates it would cost to fully connect the Canadian health care system. A number of provincial and territorial governments are also moving ahead with the development of IT in health care, but further financial support is required. The CMA is prepared to play a pivotal partnership role in achieving the buy-in and cooperation of physicians and other health care providers through a multistakeholder process. Toward this end, the CMA has developed principles for the advancement of EHRs (Appendix J). The CMA’s involvement would be a critical success factor in helping the federal government make an electronic health care system a realizable goal in the years to come. Recommendation 19 That federal government make an additional, substantial, ongoing national investments in information technology and information systems, with the objective of improving the health of Canadians as well as improving the efficiency and effectiveness of the health care system. Recommendation 20 That governments adopt national standards that facilitate the collection, use and exchange of electronic health information in a manner which ensures that the protection of patient privacy and confidentiality are paramount. 6.5 Research and Innovation Research and innovation in the health sector are producing an expanding array of treatments and therapies that improve quality of life and longevity, e.g., pharmaceuticals, surgery, human genome, etc. Health research provides substantial economic, social and health care benefits to society. It * Creates high-quality, knowledge-based jobs that drive economic growth * Supports academic institutions across the country and helps train new health professionals in the latest health care technologies and techniques * Supports health care delivery and is key to maintaining centres of excellence for highly specialized care * Leads directly to better ways to treat patients and promote a healthier population. In Canada, health research is carried out by a mix of public, voluntary and private-sector organizations with the federal government being the main player in publicly funded health research. Several provinces have their own health research funding agencies. Canada’s health charities play an important role in funding research on a range of diseases and conditions. The pharmaceutical industry, especially the name-brand companies, invests heavily to develop new drugs. Recent federal investments have begun to revitalize Canada’s health research capacity. With the creation of the Canadian Institutes for Health Research (CIHR), Canada now has a modern funding agency that integrates biomedical, clinical, health services and population health research. New programs have been introduced to attract world-class scientists, modernize research infrastructure and equipment and support research in genomics. As significant as these investments have been, Canada still ranks second-to-last among G7 countries in terms of support for health research. The United States’ National Institutes of Health has a budget that is 50 times that of the CIHR for a population only 10 times bigger than Canada’s. Other countries are increasing their investment in health research to keep pace. If Canada is to improve it position vis-à-vis our key competitors, the federal government must map out a plan to increase its investment in health research to internationally competitive levels. The federal government’s investment in health research currently stands at about 0.5% of total health expenditures. There is a broad consensus in the health community that this should be increased to at least 1% of total health expenditures. Recommendation 21 That the federal government’s investment in health research be increased to at least 1% of national health expenditures. 7. Health System Financing Governments’ contributions to funding Canada’s health system should support the long-term sustainability of the system and the provision of high-quality health care for all Canadians. Governments’ contribution to Medicare should promote greater public accountability, transparency and a linkage of sources with their uses. Changes in health system financing have played a central role in the crisis facing Medicare. Significant and unpredictable funding cuts at both federal and provincial–territorial levels have wreaked havoc in the planning and delivery of a very complex array of services. Health care costs that were previously covered by provincial and territorial health insurance plans have been gradually shifted to individuals (“passive privatization”) leaving those without private insurance coverage increasingly vulnerable. Mounting evidence of unacceptably long waits for treatment and poor access to services has underlined the risks attached to having a single-payer system, with insufficient accountability for timeliness and accessibility of care. Growing problems of access and declining provider morale, combined with constant bickering about funding between federal and provincial–territorial governments have led to deterioration of public confidence in the system. The message from the front lines is clear: restoring the health care system to a sustainable footing cannot be accomplished by simply managing our way out of this crisis. As Medicare is renewed, it is essential that its underlying financing framework is modernized, taking into account the multiple policy objectives served by health financing mechanisms. 10 Policy Objectives for Health Financing Mechanisms 1. Stable and sustainable funding 2. Risk-pooling 3. Equity (between population subgroups, across regions) 4. Responsible use 5. Administrative simplicity 6. Transparency and accountability 7. Choice 8. Efficiency 9. Meet current needs 10. Fairness between generations (intergenerational equity) Our recommended changes to the legislation governing federal transfers to provinces and territories are set out in section 3.3.2. To restore the federal–provincial–territorial partnership in health, we recommend that the federal contribution to the public health care system be locked in for a 5-year period, with a built-in escalator tied to increases in GDP, rising to a target of 50% of spending for core services. We also recommend that the federal government establish special purpose, one-time funds to address a number of pressing issues. Given their constitutional responsibility in the area of health care, provinces and territories will continue to play the lead role in regulating the flow of public funding for health care. Once the basket of core services is determined according to the process outlined in section 5.1, provinces and territories will have to commit sufficient funding to ensure that these services are available and accessible in a timely way. The funding commitment of provinces and territories will, therefore, drive the federal government’s 50% contribution. In addition to providing half of public funding for core services, provinces and territories will also have the option of funding additional health services beyond the national minimum core basket, much as they do now. Although adequate and stable funding for health care is imperative at the federal level, it is equally important at the provincial and territorial level. Provincial and territorial commitment to funding core services must also be locked-in for a five-year period with an escalator tied to provincial demographics and inflation. To ensure stability, a buffer will also be needed to protect provincial and territorial health care budgets from the ebbs and flows of the business cycle. Currently, the federal Fiscal Stabilization Program compensates provinces if their revenues fall substantially from one year to the next due to changes in economic circumstances. However, this program is not health-specific and only takes effect when provincial revenues drop by over 5%. It is also funded from general revenues, which makes it more vulnerable to economic and political factors. A more robust approach to guaranteeing stability of public funding for health care would be to create a stand-alone contingency fund to which all governments would contribute. Excess revenues would be collected into this fund during periods of high economic growth, and could be used during less prosperous periods when governments experience fiscal capacity shortfalls. Recommendation 22 (a) That the provincial and territorial governments’ commitment to funding core services be locked-in for an initial five-year period with an escalator tied to provincial population demographics and inflation. (b) That governments establish a health-specific contingency fund to mitigate the effects of fluctuations in the business cycle and to promote greater stability in health care financing. 8. Organization and Delivery of Services 8.1 The Medical Care Continuum There is a tendency to separate medical care into two areas; primary care and specialty care. However, we must recognize that medical and health care encompass a broad spectrum of services ranging from primary prevention to highly specialized care. Primary and specialty care are so closely interrelated that the renewal of either should not be attempted without considering the impact on the rest of the care continuum. Recommendation 23 That any effort to change the organization or delivery of medical care take into account the impact on the whole continuum of care. 8.1.1 Primary care services In recent years, several government task force and Commission reports have called for primary care reform. Common themes include improving continuity of care (including 24/7 coverage); establishing alternatives to fee-for-service payment of physicians; placing greater emphasis on health promotion and disease prevention; and adopting team models that involve nurse practitioners and other health care providers working collaboratively with physicians. Governments have responded by launching pilot projects to evaluate different models of primary care delivery. It is critical to evaluate these projects before moving ahead with them on a broader scale and to consider the implications of their system-wide implementation. Although some jurisdictions have moved forward with ambitious proposals to change the structure of primary care and the remuneration of physicians, the CMA urges the Commission not to view primary care renewal as a panacea for all that ails Medicare. Primary care renewal should not be used as a pretext for changing how doctors are paid nor should it focus on substituting the lowest cost provider. The focus should be on patient need. Any changes to the delivery of primary care should respect the following principles: * All Canadians should have access to a family physician. * No single model will meet the primary care needs of all communities in all regions of the country. Successful renewal of primary health care delivery cannot be accomplished without also addressing the shortage of family practitioners. Not only is the supply of these physicians affected by an aging physician population and by changes in lifestyle and productivity, but the popularity of primary care as a career choice among medical graduates is also declining. According to the Canadian Resident Matching Service (CaRMS), in 1997, only 10% of positions that were still vacant after the first round of the residency match were in family medicine. By 2000, family medicine’s share of vacant positions after the first iteration peaked at 57%; since then it has remained close to 50%. Furthermore, before 1994, more graduates were choosing family medicine than there were positions available. Since then, the situation has reversed with fewer graduates consistently choosing family medicine than there are positions available.9 A major factor in this trend may be the 1993 change in the residency program, which removed graduates’ ability to do a first-year rotation in family medicine, then have the choice of continuing in the family medicine program or switching into a specialty. Now, any graduate who chooses family medicine is committed to that program. The dramatic shift in the number of graduates choosing family medicine in 1994 is likely due to the assumption that it is easier to switch out of a specialty into family medicine than vice versa. The uncertainty of the future of primary care caused by these constant reform efforts has also contributed to the decline in popularity of family medicine among medical graduates. Efforts must be made to remove these perceived barriers so that the public’s need for primary care services can be met. Multidisciplinary teams, both formal and informal, are common in primary care today. The reliance on the team approach will likely grow because of the increased complexity of care, the exponential growth of knowledge, the greater emphasis on health promotion and disease prevention, and the choice of patients and providers. Although desirable, primary care teams ? physicians, nurses, pharmacists, dieticians and others ? will cost the system more, not less, than the traditional fee-for-service physician approach. Funding these initiatives must not come at the expense of the provision of illness care. The add-on costs of primary care teams, including informational technology (IT) and information systems (IS), must be looked upon as an investment in the health of Canadians. (IT and IS opportunities must also be available to all physicians, regardless of how they are paid or their patterns of practice.) Although multidisciplinary teams may provide a broader array of services, for most Canadians having a family doctor as the central provider of all primary medical care services is a core value. As the College of Family Physicians of Canada (CFPC) indicated in its submission to the Commission on the Future of Health Care in Canada, over 90% of Canadians seek advice from a family physician as their first resource in the health care system. The CPFC also reports that a recent Ontario College of Family Physicians public opinion survey, conducted by Decima, found that 94% of people agree that it is important to have a family physician who provides the majority of primary care and coordinates the care delivered by others.10 A family physician as the central coordinator of medical services promotes the efficient and effective use of resources. This facilitates continuity of care because the family physician generally has the benefit of developing an ongoing relationship with his or her patients and their families and, as a result, can advise and direct the patient through the system so that the patient receives the appropriate care from the appropriate provider. Canada has one of the best primary care systems in the world, but it can be improved through better integration and coordination of care. This requires investment to increase quality and productivity through improved IT and connectivity to support physicians in their expanded roles as information providers, coordinators and integrators of care, and to support the integrated care of primary care teams. Recommendation 24 (a) That governments work with the provincial and territorial medical associations and other stakeholders to draw on the successes of evaluated primary care projects to develop a variety of templates of primary care models that would * suit the full range of geographical contexts and * incorporate criteria for moving from pilot projects to wider implementation, such as cost-effectiveness, quality of care and patient and provider satisfaction. (b) That family physicians remain as the central provider and coordinator of timely access to publicly funded medical services, to ensure comprehensive and integrated care, and that there are sufficient resources available to permit this. 8.1.2 Specialty care services Much of the focus in recent years has been on primary care renewal. Countless reports indicating a major crisis in the area of primary care delivery have overshadowed the problems that are plaguing other areas of the health care continuum. For example, a severe physician shortage is occurring in specialty care at the generalist level. The Royal College of Physicians and Surgeons of Canada reports that a third of general surgeons are aged 55 or older and nearly 40% more general surgeons are retiring than are graduating from medical schools.11 Canada cannot afford to continue to ignore this key segment of the care continuum. A concerted effort must be made to increase the visibility of secondary care specialists and to encourage medical students to enter general specialties. As highly specialized care and technology have advanced, there has been increasing pressure at the tertiary level of the health care system to provide the highest level of care possible. Delivering tertiary care in the ways to which Canadians are accustomed cannot be sustained into the future; and such tertiary care cannot be available in all areas of the country. Alternative approaches to delivering and receiving high-level specialty care are both required and inevitable. The aging population, the challenges posed by Canada’s geography, rapidly expanding high-cost technologies and the lack of a critical mass of highly specialized health care providers necessitate a change in thinking. The health system has reached the point where certain types of care are neither universally nor readily available. The shortage of specialists and the high cost of technology and pharmaceuticals will exacerbate this situation. The future challenge is to design delivery systems that are built around a series of regional centres of excellence, without abandoning the concept of “reasonable” access. As these highly specialized services are realigned interprovincially, resources must also be realigned to accommodate and compensate for the relocation of providers and to ensure that patients have equitable access to treatment. At their January 2002 meeting in Vancouver, the premiers recognized that some types of surgery and other medical procedures are performed infrequently and that the necessary expertise cannot be developed and maintained in each province and territory. Building on the experience in Canada’s three territories and Atlantic Canada, they agreed to share human resources and equipment by developing sites of excellence in such fields as pediatric cardiac surgery and gamma knife neurosurgery. This should lead to better care for patients and more efficient use of health care dollars. At the provincial–territorial level, this strategy has led to regional centres and hospitals with responsibilities for province- and territory-wide programs and services. The concept of centres of excellence can be further supported by the adoption of telemedicine and telehealth technologies which will permit rapid access to or exchange of electronic diagnostic information (e.g., imaging) and enable remote consultation and treatment. Determining where care is available will become an increasingly relevant policy matter ? especially as costs such as travel and lost income could be downloaded onto patients and their families. Efforts will be required to optimize the use of scarce specialist services, improve care and availability, assure continuity and enhance provider morale. In the interests of quality care, patient safety and the economical use of scarce resources interjursidictionally, there is a need for a Canadian Accessibility Fund. This fund would be modeled after the Portability Fund established to support the Federal–Provincial–Territorial Eligibility and Portability Agreements under the Medical Care Act. The cost of the new fund, like the old, would be 50–50 cost-shared by the federal and provincial–territorial governments. It would require an initial investment of $100 million. Access to the fund would be determined by a mutually agreed upon set of criteria, and any monies withdrawn would be used to facilitate access to highly specialized health care services that are not available in the patient’s home province. Recommendation 25 (a) That governments develop a national plan to coordinate the most efficient access to highly specialized treatment and diagnostic services. * This plan should include the creation of defined regional centres of excellence to optimize the availability of scarce specialist services. * Any realignment of services must accommodate and compensate for the relocation of providers. * That the federal government create an accessibility fund that would support interprovincial centres of excellence for highly specialized services. 8.2 Physician Remuneration It is a common misconception that successful renewal of the health care system involves simply changing how physicians are paid ? specifically, abolishing fee-for-service. In their analysis of primary care in Canada, Hutchison and colleagues note that governments’ preoccupation with the “big bang” approach — that typically involves the adoption of inappropriate funding and remuneration methods — is a major contributor to the failure of many primary care projects.12 Every system of remuneration has its strengths and weaknesses. Canadians should not be led to think that movement away from fee-for-service remuneration of physicians will provide them with better care. How physicians (and other health care providers) are paid should be a means to an end, not an end unto itself. Nevertheless, physicians are willing to consider other appropriate methods of remuneration in appropriate circumstances. Physicians must be given a choice about their method of payment. Experience has taught us that a “one size fits all” approach to compensation does not work. Furthermore, any remuneration arrangement must preserve and protect physician autonomy and the ability of the physician to act as an advocate for his or her patients. In 2001, the CMA developed a policy on physician compensation (Appendix K) that is based on the following principles. CMA Policy on Physician Compensation: Basic Principles * Medical practitioners must receive fair, reasonable and equitable remuneration for the full spectrum of their professional activities. * Physicians need to receive reasonable consideration and compensation when facilities and programs are discontinued, reduced or transferred. * Individual medical practitioners have the liberty to choose among payment methods. * Payment systems must not compromise the ability of physicians to provide high-quality cost-effective medical services. * Payment mechanisms must allow for a reasonable quality of life. * Provincial and territorial government resources and funding for physician services must be allocated directly to physicians for services provided. * All physicians, including those indirectly affected, have the right to representation in negotiations on issues of payment, funding, and the terms and conditions of their work. * Paying agencies must fulfill the terms of agreement negotiated with legitimate agents of the medical profession and be obliged to honour a mutually agreed-upon and established process of negotiation with those agents. * In the event of failure of negotiations relating to physician compensation, such disagreement must be resolved by a mutually agreed-upon, timely process of dispute resolution. * The federal minister of health must enforce the provisions of the Canada Health Act relevant to physician compensation (section12.2). Recommendation 26 That governments respect the principles contained in the CMA’s policy on physician compensation and the terms of duly negotiated agreements. 8.3 Rural Health Care Canadian physicians and other health care professionals are greatly frustrated by the impact that health care budget cuts and reorganization have had, and continue to have, on the timely provision of quality care to patients and on general working conditions. For physicians who practise in rural and remote communities, this impact is exacerbated by the breadth of their practice, long working hours, lifestyle restrictions created by on-call responsibilities, geographic isolation and lack of professional backup and access to specialist services. In 2000, the CMA developed a policy statement on rural and remote practice (Appendix L) to help governments, policymakers, communities and others involved in the retention of physicians understand the various professional and personal factors that must be addressed to retain and recruit physicians to rural and remote areas. The 28 recommendations address training, compensation and work and lifestyle support issues. Training for rural practice must span the full medical career lifecycle, from recruitment of candidates likely to enter rural practice to special skills training, retraining and continuing professional development. Compensation must reflect the degree of isolation, level of responsibility, frequency of on-call duty, breadth of practice and additional skills. Consideration must also be given to the broader social issues of the physician and his or her family, as well as the need to facilitate the availability of locum tenens, particularly across jurisdictional boundaries. There is a need to ensure that there is sufficient availability of physicians so that on-call requirements are manageable and that adequate professional backup is provided, e.g., locum services currently offered through provincial and territorial medical associations. We concur with the observation made by the Society of Rural Physicians of Canada in their August 2001 submission to the Commission that Canada needs a national rural health strategy. The aim of the strategy would be to look at the systemic barriers to meeting the needs of rural Canadians and to provide strategic program funding to catalyze change. Recommendation 27 That governments work with universities, colleges, professional associations and communities to develop a national rural and remote health strategy for Canada. 8.4 Emerging and Supportive Roles in Health Care Delivery 8.4.1 Private sector Canada has a mixed system of public–private delivery and public–private financing, as illustrated in the following diagram with all four possible combinations. [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Delivery Public Private Financing Public Public delivery/ public financing (e.g., public hospital services) Private delivery/ public financing (e.g., doctor’s office care) Private Public delivery/ private financing (e.g., private room in a public hospital) Private delivery/ private financing (e.g., cosmetic surgery) [TABLE END] No issue in Canadian health policy has generated more controversy than the role of the private sector. As we move forward with the renewal of Medicare, it will be important for Canadians to understand the distinction between private delivery and private funding. The appropriate mix of public and private should not be based on ideology, but rather on the optimal use of resources. Health care is delivered mainly by private providers including physicians, pharmacists, private not-for-profit hospitals, private long-term care facilities, private diagnostic and testing facilities, rehabilitation centres. (In addition, supplies from food and laundry to drugs and technology are provided almost exclusively by the private sector.) This significant level of private-sector delivery has served Canada well. Accordingly, the CMA supports a continuing and major role for the private sector in the delivery of health care. However, we are not proposing a parallel private system. There may be a growing role for private delivery. We would encourage this as long as the services can be provided cost-effectively. As with the public sector, any private-sector involvement in health care must be patient-centred as well as open, transparent and accountable. Furthermore, it must be strictly regulated to ensure that high standards of quality care are being met and monitored. Recommendation 28 That Canada’s health care system make optimal use of the private sector in the delivery of publicly financed health care provided that it meets the same standards of quality as the public system. 8.4.2 Voluntary sector The voluntary sector, including many charities and consumer advocacy groups, has played a critical role in the development of the public health system ? providing and funding services, programs, equipment and facilities. Much of the capital infrastructure development, especially in hospitals, has been made possible through the fundraising efforts of charity foundations and service organizations. In addition, many patient support services such as “Meals on Wheels” exist only because of the efforts of volunteer groups. Although the voluntary sector is a major asset for Canada’s health care system, it is critical for governments to fulfill their obligation to support publicly financed health care. Governments must avoid passing off their responsibilities to the voluntary sector, which is already stretched to the limit. Governments should not abuse the voluntary sector, but should properly fund the public health system’s ongoing operating costs and capital expenditures. The voluntary sector should be formally recognized for the contribution it makes to the health care system. Many of these organizations operate on a shoestring budget with limited capacity to respond to the increasing demands being placed on them. Recommendation 29 That governments examine ways to recognize and support the role of the voluntary sector in the funding and delivery of health care, including enhanced tax credits. 8.4.3 Informal caregivers Informal caregivers ? particularly those who provide care for ailing relatives and friends ? play an essential role in the health care system. The massive off-loading onto these caregivers has gone unrecognized. The costs of providing this kind of care go beyond identifiable dollar amounts such as loss of income. Many indirect costs, including emotional strain on the caregivers and their families, must also be acknowledged with support provided by governments and employers. Patients often prefer to receive their care at home, but it cannot be assumed that care provided at home is better for the patient than that provided within a health care institution. Resources must be made available to ensure that the care patients receive at home is acceptable. Increased financial support should be provided to informal caregivers through the tax system. Refundable tax credits and a program for family leave are two examples of this support. Recommendation 30 That governments support the contributions of informal caregivers through the tax system. Conclusions Canada’s health care system is at a crossroads. We need to act now to ensure that our health care system will be able to meet the current and future health care needs of Canadians. Canadians are looking for real solutions that will have meaningful results. This means not only addressing the most critical issues such as health human resources, infrastructure and delivery mechanisms, but also implementing system-wide structural and procedural changes. It also means involving all key stakeholders in the decision-making process at all levels. In this second submission to the Commission on the Future of Health Care in Canada, the CMA has offered solutions that are patient-centred and reflect Canadian values of a publicly funded system that is sustainable and accountable and provides timely access to high-quality care. These recommendations form a complete, integrated package that should be implemented as a whole to be successful. The CMA would like to thank the Commission for providing this opportunity to submit our Prescription for Sustainability and we wish the Commission every success in developing a concrete plan for revitalizing our cherished Canadian health care system. 1 A recent article by Patrick Monahan and Stanley Hartt published by the C.D. Howe Institute argues that Canadians have a constitutional right to access privately funded health care if the publicly funded system does not provide access to care in a timely way. 2 Although the word “charter” has a legal connotation, it has been used in other contexts. An example is the 1986 Ottawa Charter for Health Promotion, an international call for action on health promotion that has received worldwide acclaim. 3 This could be linked to the equalization provision in Section 36(2) of the Constitution Act (1982). 4 Proclamations are issued by the Queen’s representative in the particular jurisdiction. An example of a proclamation that has been issued this way is the “Proclamation Recognizing the Outstanding Service to Canadians by Employees in the Public Service of Canada in Times of Natural Disaster” (13 May, 1998). 5 100% government-funded without patient cost-sharing. 6 Organisation for Economic Co-operation and Development. Health at a glance. Paris, France: OECD; 2001. 7 CMF membership includes: CMA, Association of Canadian Medical Colleges, College of Family Physicians of Canada, Royal College of Physicians and Surgeons of Canada, Canadian Federation of Medical Students, Canadian Association of Internes and Residents, Federation of Medical Licensing Authorities of Canada, Medical Council of Canada, and Association of Canadian Academic Healthcare Organizations. 8 See for example the Melbourne Manifesto: A Code of Practice for the International Recruitment of Health Care Professionals, which was adopted at the 5th Wonca World Conference on Rural Health in May 2002. It puts the onus on every country to train enough health professionals to meet their own needs (www.wonca.org). 9 Canadian Resident Matching Service. PGY-1 Match Report 2002. History of family medicine as a career choice of Canadian graduates. [http:// http://www.carms.ca/stats/stats_index.htm]. Ottawa: CaRMS; 2002. 10 College of Family Physicians of Canada. Shaping the Future of Health Care. Submission to the Commission on the Future of Health Care in Canada. Ottawa: CFPC; 25 Oct. 2001. 11 Royal College of Physicians and Surgeons of Canada. Health care renewal through knowledge, collaboration, and commitment. Ottawa: RCPSC; 31 Oct. 2002. 12 Hutchison B, Abelson J, Lavis J. Primary care in Canada: so much innovation, so little change. Health Aff 2001 May/Jun; 20(3):116-31.
Documents
Less detail

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.
Documents
Less detail

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.
Documents
Less detail

Notes for an address by Dr. Peter Barrett, Past-President, Canadian Medical Association : Public hearings on primary care reform : Presentation to the Standing Senate Committee on Social Affairs, Science and Technology

https://policybase.cma.ca/en/permalink/policy2011
Last Reviewed
2020-02-29
Date
2002-05-22
Topics
Health systems, system funding and performance
Health human resources
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2002-05-22
Topics
Health systems, system funding and performance
Health human resources
Text
On behalf of the 53,000 physician members of the CMA, we appreciate the opportunity to offer our thoughts on the issue of primary care reform and the recommendations made recently in your April 2002 report. I am very pleased to be presenting today with my CMA colleague, Dr. Susan Hutchison, Chair of our GP Forum along with Dr. Elliot Halparin and Dr. Kenneth Sky from the Ontario Medical Association. Before I begin presenting the CMA’s recommendations, I believe it’s important to make a few points clear in regard to primary care: * First, is that Canada has one of the best primary care systems in the world. (Just ask Canadians, we have. Our 2001 Report Card showed that 60% of Canadians believe that we have one of the best health care systems in the world and gave high marks for both quality of service and system access). * Second, is that primary care reform is not the panacea for all that ails Medicare. * And finally, primary care and specialty care are inextricably linked. I like to expand a bit on the last point because I think it’s an important consideration. There is a tendency to separate medical care into two areas; primary care and specialty care. However, we need to recognize that medical and health care encompasses a broad spectrum of services ranging from primary prevention to highly specialized quaternary care. Primary care and specialty care are so critically interdependent that we need to adapt an integrated approach to patient care. Now, in respect to the CMA’s recommendations on implementing changes for the delivery of primary care, we believe that government must respect the following four policy premises: 1. All Canadians should have access to a family physician. 2. To ensure comprehensive and integrated care, family physicians should remain as the central provider and coordinator of timely access to publicly-funded medical services. 3. There is no single model that will meet the primary care needs of all communities in all regions of the country. 4. Scopes of practice should be determined in a manner that serves the interests of patients and the public safely, efficiently, and competently. Access to Family Physicians A successful renewal of primary health care delivery cannot be accomplished without addressing the shortage of family physicians and general practitioners. The effects of an aging practitioners population, changes in lifestyle and productivity, along with the declining popularity of this field as the career choice of medical school graduates are all having an impact on the supply of family physician. Physician as Central Coordinator While multistakeholder teams offer the potential for providing a broader array of services to meet patients’ health care needs, it is also clear that for most Canadians, having a family doctor as the central provider for all primary medical care services is a core value. As the College of Family Physicians of Canada (CFPC) indicated in its submission to the Royal Commission on the Future of Health Care in Canada, research shows that over 90% of Canadians seek advice from a family physician as their first resource in the health care system. The CFPC also noted that a recent Ontario College of Family Physicians Decima public opinion survey found that 94% agree that it is important to have a family physician who provides the majority of care and co-ordinates the care delivered by others. i A family physician as the central coordinator of medical services ensures efficient and effective use of system resources as it allows for only one entry point into the health care system. This facilitates a continuity of care, as the family physician generally has developed an ongoing relationship with his or her patients and as a result is able to direct the patient through the system such that the patient receives the appropriate care from the appropriate provider. No Single Model for Reform In recent years, several government task force and commission reports, including the report of this Committee, have called for primary care reform. Common themes that have emerged include; 24/7 coverage; alternatives to fee-for-service payment of physicians; nurse practitioners and health promotion and disease prevention. Governments across the country have launched pilot projects of various models of primary care delivery. It is critical that these projects are evaluated before they are adopted on a grander scale. Moreover, we must take into account the range of geographical settings across the country, from isolated rural communities to the highly urbanized communities with advanced medical science centres. Scopes of Practice There is a prevailing myth that physicians are a barrier to change when in fact the progressive changes in the health care system have been more often than not physician lead. Canadian physicians are willing to work in teams and the CMA has developed a “Scopes of Practice” policy that clearly supports a collaborative and cooperative approach. A policy that has been supported in principle by the Canadian Nurses Association and the Canadian Pharmacists Association. Because of the growing complexity of care, the exponential growth of knowledge, and an increased emphasis on health promotion and disease prevention, primary care delivery will increasingly rely on multi-stakeholder teams. This is a positive development. However, expanding the primary care team to include nurses, pharmacists, dieticians, and others, while desirable, will cost the system more, not less. Therefore, we need to change our way of thinking about primary care reform. We need to think of it as an investment. We need to think of it not in terms of cost savings but as a cost-effective way to meet the emerging unmet needs of Canadians. Conclusion To conclude, there is no question that primary care delivery needs to evolve to ensure it continues to meet the needs of Canadians. But we see this as making a good system better, not fundamental reform. Thank you. i College of Family Physicians of Canada. Shaping The Future of Health Care: Submission to the Commission on the Future of Health Care in Canada. Ottawa: CFPC; Oct 25, 2001.
Documents
Less detail

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
Documents
Less detail

Presentation to the House of Commons Standing Committee on Finance -December 7, 2007

https://policybase.cma.ca/en/permalink/policy9057
Last Reviewed
2020-02-29
Date
2007-12-07
Topics
Health systems, system funding and performance
Health human resources
Physician practice/ compensation/ forms
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2007-12-07
Topics
Health systems, system funding and performance
Health human resources
Physician practice/ compensation/ forms
Text
It is a pleasure to address the Standing Committee on Finance today as part of your pre-budget consultations. In keeping with the theme set by the Committee, our presentation - Tax Incentives for Better Living - focuses on changing the tax system to better support the health and well being of all Canadians. Today I will share with you three recommendations improving the health of Canadians and productivity of the Canadian economy: First, tax incentives for pre-paid long-term care insurance; Second, tax incentives to retain and recruit more doctors and nurses; Third, tax incentives to enhance health system productivity and quality improvements. 1. Long Term Care insurance Canada's population is ageing fast. Yet, long-term care has received little policy attention in Canada. Unlike other countries like the UK and Germany who have systems in place, Canada is not prepared to address these looming challenges. The first of the baby-boomers will turn 65 in 2011. By 2031, seniors will comprise one quarter of the population - double the current proportion of 13%. The second challenge is the lack of health service labour force that will be able to care for this ageing population. Long-term care cannot and should not be financed on the same pay-as-you-go basis as medical/hospital insurance. Therefore the CMA urges the Committee to consider either tax-pre-paid or tax-deferred options for funding long-term care. These options are examined in full in the package we have supplied you with today. 2. Improving access to quality care Canada's physician shortage is a critical issue. Here in Quebec, 1 in 4 people do not have access to a family physician. Overall 3.5 people in Canada do not have a family Physician. Despite this dire shortage, the Canada Student Loans program creates barriers to the training of more physicians. Medical students routinely begin their postgraduate training with debts of over $120,000. Although still in training, they must begin paying back their medical school loans as they complete their graduate training. This policy affects both the kind of specialty that physicians-in-training choose, and ultimately where they decide to practice. We urge this Committee to recommend the extension of interest-free status on Canada Student Loans for all eligible health professional students pursuing postgraduate training. 3. Health System IT: increasing productivity and quality of care The last issue I will address is health system automation. Investment in information technology will lead to better, safer and cheaper patient care. In spite of the recent $400 million transfer to Canada Health Infoway, Canada still ranks at the bottom of the G8 countries in access to health information technologies. We spend just one-third of the OECD average on IT in our hospitals. This is a significant factor with respect to our poor record in avoidable adverse health effects. An Electronic Health Record (EHR) could provide annual, system-wide savings of $6.1 billion - every year - and reduce wait times and thereby absenteeism. But, the EHR potential can only be realized if physician's offices across Canada are fully automated. The federal government could invest directly in physician office automation by introducing dedicated tax credits or by accelerating the capital cost allowance related to health information technologies for patients. Before I conclude, the CMA again urges the Committee to address a long-standing tax issue that costs physicians and the health care system over $65 million a year. When you add hospitals - that cost more than doubles to over $145 million-or the equivalent of 60 MRI machines a year. The application of the GST on physicians is a consumption tax on a producer of vital services and affects the ability of physicians to provide care to their patients. And now with the emphasis on further sales tax harmonization, the problem will be compounded. Nearly 20 years ago when the GST was put into place, physician office expenses were relatively low for example: tongue depressors, bandages and small things. There was practically no use computers or information technology. How many of you used computers 20 years ago? Now Canadian physicians' could be and should be using 21st century equipment that is expensive but powerful. This powerful diagnostic equipment can save lives and save the system millions of dollars in the long run. It provides a clear return on investment. Yet, physicians still have to pay the GST (and the PST) on diagnostic equipment that costs a minimum of $500,000 that's an extra $30,000 that physicians must pay. The result of this misalignment of tax policy and health policy is that most Radiologists' diagnostic imaging equipment is over 30-years old. Canadians deserve better. It's time for the federal government to stop taxing health care. We urge the Committee to recommend the "zero-rating" publicly funded health services or to provide one-hundred percent tax rebates to physicians and hospitals. Conclusion In conclusion, we trust the Committee recognizes the benefits of aligning tax policy with health policy in order to create the right incentives for citizens to realize their potential. By supporting: 1. Tax Incentives for Long-Term Care 2. Tax Incentives to Bolster Health Human Resources and, 3. Tax Incentives to Support Health System Automation. This committee can respond to immediate access to health care pressures that Canadians are facing. Delaying a response to these pressures will have an impact on the competiveness of our economy now, and with compounding effects in the future. I appreciate the opportunity of entering into a dialogue with members of the Committee and look forward to your questions. Thank you.
Documents
Less detail

CMA Letter to the Senate Committee on Legal and Constitutional Affairs regarding Bill C-2, An Act to amend the Criminal Code and to make consequential amendments to other Acts

https://policybase.cma.ca/en/permalink/policy9110
Last Reviewed
2020-02-29
Date
2008-02-19
Topics
Health care and patient safety
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2008-02-19
Topics
Health care and patient safety
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The Canadian Medical Association (CMA) welcomes the opportunity to provide comments to the Senate Committee on Legal and Constitutional Affairs concerning its study of Bill C-2 (An Act to amend the Criminal Code and to make consequential amendments to other Acts). We will confine our comments to the portion of the proposed legislation that relates to impaired driving. Canada's physicians support measures aimed at reducing the incidence of drug-impaired driving. We believe impaired driving, whether by alcohol or another drug, to be an important public health issue for Canadians that requires action by all governments and other concerned groups. Published reports indicate that the prevalence of driving under the influence of cannabis is on the rise in Canada. We note that: * Results from the Canadian Addictions Survey suggest that 4% of the population have driven under the influence of cannabis in the past year, an increase from the 1.5% in 2003 and that rates are higher among young people.1 * It was estimated that in 2003, 27.45% of traffic fatalities involved alcohol, 9.15% involved alcohol and drugs, and 3.66% involved drugs alone while 13.71% of crash injuries involved only alcohol, 4.57% involved alcohol and drugs, and 1.83% involved drugs alone.2 * In a 2002 survey, 17.7% of drivers reported driving within 2 hours of using a prescribed medication, over-the-counter remedy, marijuana, or other illicit drug during the past 12 months. * These results suggest that an estimated 3.7 million Canadians drove after taking some medication or drug that could potentially affect their ability to drive safely. * The most common drugs used were over-the-counter medications (15.9%), prescription drugs (2.3%), marijuana (1.5%), and other illegal drugs (0.9%). * Young males were most likely to report using marijuana and other illegal drugs. * While 86% of the drivers were aware that a conviction for impaired driving results in a criminal record, 66% erroneously believed that the penalties for drug-impaired driving were less severe than those for alcohol-impaired driving. In fact, the penalties are identical. * Over 80% of drivers agreed that drivers suspected of being under the influence of drugs should be required to participate in physical coordination testing for drug impairment. However, only about 70% of drivers agreed that all drivers involved in a serious collision or suspected of drug impairment should be required to provide a blood sample.3 The CMA has, on several occasions, provided detailed recommendations on legislative changes concerning impaired driving. In 1999, the CMA presented a brief to the House of Commons Standing Committee on Justice and Human Rights during its review of the impaired driving provisions of the Criminal Code. While our 1999 brief focused primarily on driving under the influence of alcohol, many of the recommendations are also relevant to the issue of driving under the influence of drugs. In June 2007, the CMA provided comments to the Standing Committee on Justice and Human Rights of the House of Commons during their study of Bill C-32 (An Act to amend the Criminal Code (impaired driving) and to make consequential amendments to other Acts) which was later incorporated in the omnibus Bill now before your Committee. Last year, the CMA published the 7th edition of its guide, Determining Medical Fitness to Operate Motor Vehicles. It includes chapters on the importance of screening for alcohol or drug dependency and states that the abuse of such substances is incompatible with the safe operation of a vehicle. This publication is widely viewed by clinical and medical-legal practitioners as the authoritative Canadian source on the topic of driver competence. While changing the Criminal Code is an important step, the CMA believes further actions are also warranted. In our 2002 presentation to the Special Senate Committee on Illegal Drugs, the CMA put forth our long standing position regarding the need for a comprehensive long-term effort that incorporates both deterrent legislation and public awareness and education campaigns. We believe such an approach, together with comprehensive treatment and cessation programs, constitutes the most effective policy in attempting to reduce the number of lives lost and injuries suffered in crashes involving impaired drivers. Drug-impaired drivers may be occasional users of drugs or they may also suffer from substance dependence, a well-recognized form of disease. Physicians should be assisted to screen for drug dependency, when indicated, using validated instruments. Government must create and fund appropriate assessment and treatment interventions. Physicians can assist in establishing programs in the community aimed at the recognition of the early signs of dependency. These programs should recognize the chronic, relapsing nature of drug addiction as a disease, as opposed to simply viewing it as criminal behaviour. While supporting the intent of the proposed legislation, the CMA urges caution on several significant issues, with regard to Clause 20 that amends the act as follows: 254.1 (1) The Governor in Council may make regulations (a) respecting the qualifications and training of evaluating officers; (b) prescribing the physical coordination tests to be conducted under paragraph 254(2)(a); and (c) prescribing the tests to be conducted and procedures to be followed during an evaluation under subsection 254(3.1). CMA contends that it is important that medical professionals and addiction medicine specialists in particular, should be consulted regarding the training offered to officers to conduct roadside assessment and sample collection. Provisions in the Act conferring upon police the power to compel roadside examination raises the important issue of security of the person and the privacy of health information. As well, information obtained at the roadside is personal medical information and regulations must ensure that it be treated with the same degree of confidentiality as any other element of an individual's medical record. Thus, the CMA would respectfully submit that Clause 25 of Bill-C2 on the issue of unauthorized use or disclosure of the results needs to be strengthened because the wording is too broad, unduly infringes privacy and shows insufficient respect for the health information privacy interests at stake. For instance, clause 25(2) would permit the use, or allow the disclosure of the results "for the purpose of the administration or enforcement of the law of a province". This latter phrase needs to be narrowed in its scope so that it would not, on its face, encompass such a broad category of laws. Moreover, clause 25(4) would allow the disclosure of the results "to any other person, if the results are made anonymous and the disclosure is made for statistical or other research purposes" CMA would expect the federal government to exercise great caution in this instance, particularly since the results could concern individuals who are not actually convicted of an offence. One should query whether the Clause 25(4) should even exist in a Criminal Code as it would not appear to be a matter required to be addressed. If it is, then CMA would ask the government to conduct a rigorous privacy impact assessment on these components of the Bill, studying in particular, such matters as sample size, degree of anonymity, and other privacy related issues, especially given the highly sensitive nature of the material. CMA would ask whether clause 25(5) should specify that the offence for improper use or disclosure should be more serious than a summary conviction. Finally, it is important to base any roadside testing methods and threshold decisions on robust biological and clinical research. CMA also notes with interest Clause 21, specifically the creation of a new offence of being "over 80" (referring to 80mg of alcohol in 100ml of blood, or a .08 blood alcohol concentration level or BAC) and causing an accident that results in bodily harm which will carry a maximum sentence of 10 years and life imprisonment for causing an accident resulting in death. (Clause 21) We would also urge the Committee to take the opportunity that the review of this proposed legislation provides to recommend to Parliament a lower BAC level. Since 1988 the CMA has supported 50 mg% as the general legal limit. Studies suggest that a BAC limit of 50 mg% could translate into a 6% to 18% reduction in total motor vehicle fatalities or 185 to 555 fewer fatalities per year in Canada.4 A lower limit would recognize the significant detrimental effects on driving-related skills that occur below the current legal BAC.5 In our 1999 response to the Standing Committee on Justice and Human Rights' issue paper on impaired driving6 and again in 2002 when we joined forces with Mothers Against Drunk Driving (MADD), CMA has consistently called for the federal government to reduce Canada's legal BAC to .05. Canada continues to lag behind countries such as Austria, Australia, Belgium, Denmark, France and Germany, which have set a lower legal limit. 7 CMA expressed the opinion that injuries and deaths resulting from impaired driving must be recognized as a major public health concern. Therefore we once again recommend lowering the legal BAC limit to 50 mg%. or .05%. We also wanted to note our support for Clause 23 which addresses the issue of liability by extending the existing umbrella of immunity for qualified medical practitioners to the new provision under 254(3.4) 23. Subsection 257(2) of the Act is replaced by the following: (2) No qualified medical practitioner by whom or under whose direction a sample of blood is taken from a person under subsection 254(3) or (3.4) or section 256, and no qualified technician acting under the direction of a qualified medical practitioner, incurs any criminal or civil liability for anything necessarily done with reasonable care and skill when taking the sample. Finally, CMA believes that comprehensive long-term efforts that incorporate deterrent legislation, such as Bill C-2, must be accompanied by a public awareness and education strategy. This constitutes the most effective long-term approach to reducing the number of lives lost and injuries suffered in crashes involving impaired drivers. The CMA supports this multidimensional approach to the issue of the operation of a motor vehicle regardless of whether impairment is caused by alcohol or drugs. Again, the CMA appreciates the opportunity to provide input into the legislative proposal on drug-impaired driving. We stress that these legislative changes alone would not adequately address the issue of reducing injuries and fatalities due to drug-impaired driving, but support their intent as a partial, but important measure. Yours sincerely, Brian Day, MD President 1 Bedard, M, Dubois S, Weaver, B. The impact of cannabis on driving, Canadian Journal of Public Health, Vol 98, 6-11, 2006 2 G. Mercer, Estimating the Presence of Alcohol and Drug Impairment in Traffic Crashes and their Costs to Canadians: 1999 to 2003 (Vancouver: Applied Research and Evaluation Services, 2005). 3 D. Beirness, H. Simpson and K. Desmond, The Road Safety Monitor 2002: Drugs and Driving (Ottawa: Traffic Injury Research Foundation, 2003). Online: www.trafficinjuryResearch.com/whatNew/newsItemPDFs/RSM_02_Drugs_and_ Driving.pdf 4 Mann, Robert E., Scott Macdonald, Gina Stoduto, Abdul Shaikh and Susan Bondy (1998) Assessing the Potential Impact of Lowering the Blood Alcohol Limit to 50 MG % in Canada. Ottawa: Transport Canada, TP 13321 E. 5 Moskowitz, H. and Robinson, C.D. (1988). Effects of Low Doses of Alcohol on Driving Skills: A Review of the Evidence. Washington, DC: National Highway Traffic Safety Administration, DOT-HS-800-599 as cited in Mann, et al., note 8 at page 12-13 6 Proposed Amendments to the Criminal Code of Canada (Impaired Driving): Response to Issue Paper of the Standing Committee on Justice and Human Rights. March 5, 1999 7 Mann et al
Documents
Less detail

CMA's letter to Mr. James Rajotte, MP Chair, Standing Committee on Industry, Science and Technology: Review of the service sector in Canada

https://policybase.cma.ca/en/permalink/policy9114
Last Reviewed
2020-02-29
Date
2008-02-23
Topics
Health human resources
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2008-02-23
Topics
Health human resources
Health systems, system funding and performance
Text
On behalf of the Canadian Medical Association (CMA), I want to thank you for the opportunity to provide the following information to the House of Commons Standing Committee on Industry, Science and Technology during its review of the service sector in Canada. The committee's study of the strengths and challenges facing this sector, overall employment percentage, overall average of salaries across the sector its impact on Canada's overall economy and the role of the Government of Canada in strengthening this sector comes at an opportune time. CANADA'S HEALTH SERVICES SECTOR Canada's health services sector is facing a critical shortage of physicians and other health care professionals and the CMA and our over 67,000 physician members are pleased to have the opportunity to present practical solutions within the jurisdiction of the federal government - working collaboratively with provincial/territorial governments and other health system stakeholders. Health care delivery in Canada is a $160 billion industry, representing over 10% of our country's gross domestic product (GDP).1 The 30,120 physicians' offices across Canada make important contributions to our economy. In 2003, the latest year for which data are available, offices of physicians employed 142,000 Canadians and contributed $11.6 billion to the Canadian economy.2 This represents almost 39 per cent of all Health Service Delivery establishments, and almost 11% of all HSD employees. As a standard measure of economic productivity, physician offices report the highest levels of GDP per employee within the Health Service Delivery sector. On this measure, they are approximately twice as productive as other components of Health Service Delivery. THE CHALLENGE There are simply not enough physicians to continue providing the quality health care that Canadians expect and deserve. Here are the facts: - Almost 5 million Canadians do not have access to a family physician; - By 2018 an additional 4.5 million Canadians could be without a doctor; - Canada ranks 24th in Organisation for Economic Co-operation and Development (OECD) nations in terms of physicians-per-population ratio. Canada would need 26,000 more doctors right now to meet the OECD average; - Canada spends only a third of the OECD average on information technology (IT) and diagnostic equipment in our hospitals; and - Canada has the highest hospital occupancy rate of all OECD countries and among the highest waits for access to specialty care services. The lack of physicians and other health care providers has resulted in restricted access to health care services and the growth of wait times for necessary medical procedures. In January 2008, CMA released new research by the Centre for Spatial Economics that proved that, in addition to the human health cost, waiting for care results in dramatic and excessive costs to our economy. Researchers addressed just four priority areas targeted in the 2004 First Ministers Health Accord. They used government and other data to determine how many Canadians were waiting longer than the maximum medical consensus established by the Wait Time Alliance. Selected for analysis were: joint replacement, cataract surgery, heart bypass grafts, and MRI scans. Costs, as calculated for all provinces varied from $2,900 to over $26,000 per patient. The cumulative cost of waiting in 2007, for treatment in just 4 areas, was $14.8 billion. This reduced economic activity lowered government revenues in 2007 by $4.4 billion. That is equivalent to over 1/3rd of the total Ontario health budget. The reduction in economic activity included the impact of the patient's inability to work while waiting, and direct losses from decreased production of goods and services, reduced income, and lowered discretionary spending. It is important to note that the figure of 14.8 billion dollars is based only on patients that exceed designated maximum waiting times in just 4 clinical areas. In the example of hip replacements, the research only factored in costs for waits that exceed 6 months. Of those waiting longer than the maximum recommended time, average waits were 1 year for hip and knee replacement surgery, 7 months for cataract surgery, and twice maximum for heart bypass surgery. Those who didn't make the MRI target waited an average of 12 weeks. Reduced economic activity included informal caregiver costs. These costs are generated when caregivers reduce work hours to care for family members on wait lists, or attend appointments with family members. Patients languishing on wait lists also incur additional costs for drug and other treatments that timely care would eliminate. Estimates in this study are extremely conservative. They address only the wait time to treatment after a specialist's consultation and recommendation. And exclude the growing, and significant costs of waiting to see the GP or specialist. They do not include anyone who is not working. They do not include the costs, short and long term, of the deterioration that occurs while waiting. THE SOLUTIONS To solve Canada's doctor shortage, the CMA believes governments must: - Adopt a long-term policy of self-sufficiency to provide Canadians with the health care professionals they need when and where they need them; - Establish a dedicated health human resource renewal fund to educate, retain and enhance the lives of health care professionals; and - Invest in health technology, infrastructure and innovation to make our health care system more responsive and efficient. SELF-SUFFICIENCY Over the past decade, there have been increasing concerns that Canada is not producing an adequate number of health providers to meet the growing demand for health services - now and into the future. These concerns have been consistently registered by physicians, nurses, pharmacists, technicians, in addition to other groups that represent other providers and the institutional and heath facilities community. Furthermore, the policy challenges related to health human resources (HHR) have been identified in several seminal reports - including the Royal Commission on the Future of Health Care in Canada, the Standing Senate Committee on Social Affairs, Science & Technology, and the Health Council of Canada.3 A growing number of health providers are looking to retire over the next decade (or leave the health system all together) relative to the number of trainees who are entering the health system, and at a time where a growing number of Canadians will be turning to the health system for diagnosis and treatment. Over 6% of physicians who responded to the National Physician Survey 20074 said they plan to retire from clinical practice and 1% plan to permanently leave practice for other reasons in the next 2 years. The effect of these changes could mean that, as the baby boom generation gets older, over 4,000 physicians will cease their medical practice within the next 2 years, making it even more difficult for Canadians to find a family physician. At the same time, the HHR challenges facing Canada's health care system are not unique to our country - over the next decade all western developed countries can expect intensified global competition for talent when it comes to health providers.5 While there are, no doubt, other provider groups who are also concerned about the future supply of health providers, there is a growing national consensus that, in addition to the primary role that the provinces and territories play in supporting the training of health providers across the country, there is a significant, catalytic and strong complementary role for the federal government in the area of health human resources. CMA, like many health care organizations, is of the view that there is a legitimate role for the federal government to strengthen its working relationship with the provinces and territories, and health providers through the creation of a time-limited, issue-specific and strategically-targeted fund to accelerate training capacity in the health system. The World Medical Association's ethical guidelines for international recruitment of physicians16 (2003), fully supported by the CMA, recommend that every country "should do its utmost to educate an adequate number of physicians, taking into account its needs and resources. A country should not rely on immigration from other countries to meet its need for physicians."7 However, in reality Canada continues to rely heavily on recruitment of internationally educated health professionals. Approximately one-third of the increase in physician supply each year is due to International Medical Graduates (IMGs) who are either recruited directly to practice or who have taken significant postgraduate medical training in Canada. In nursing, the number of internationally educated nurses applying for licensure is increasing rapidly, almost tripling from 1999 to 2003. Previous recommendations of the CMA to the House of Commons included improved medium- to longer-term supply projection models; sufficient opportunities for Canadians to train for health professional careers in Canada; and integration of international graduates, who are permanent residents or citizens of Canada, into practice. The CMA recognizes that professionals are working in an increasingly global world in terms of the exchange of scientific information, mutual recognition of qualifications between countries and the movement of people. The greatest barrier to enhancing Canada's ability to become more self-sufficient, in terms of physician resources, is the capacity of our medical schools. Despite recent increases in enrolment, Canada continues to turn away approximately 3 equally qualified students for every 1 that is accepted into an undergraduate medical program. This has resulted in over 1500 Canadian students, with the financial means to do so, who are training in medical schools outside of Canada. INTERNATIONAL MEDICAL GRADUATES In the larger context, Canada's current fertility rate is not sufficient to support self-sufficiency in general in relation to any professions. And, while self-sufficiency in the production of physicians is a desirable goal, it is also important to promote the international exchange of teaching and research, particularly in an increasingly global society. In this regard, IMGs should be considered as a planning component for a sustainable Canadian physician workforce. Historically IMGs have entered the practice of medicine through a variety of routes, which most typically include a recognized period of post-MD training in Canada. CMA's best estimate is that there are about 400 IMGs newly licensed to practice in Canada each year who have not completed postgraduate training in Canada. In addition, there are another 300 or so who are exiting Canadian postgraduate training programs and heading into practice. In fact, for the past few years, the College of Physicians and Surgeons of Ontario has licensed more IMGs than new Ontario medical graduates. In recent years, there have been an increasing number of opportunities for IMGs already living in Canada to achieve the required credentials for licensure. The number of ministry-funded IMG postgraduate residents has more than tripled in the past seven years from 294 to 1065 trainees. In 2007, there were almost 1500 IMGs who were qualified to compete in the Canadian Resident Matching Service (CaRMS) match. By the end of the second round, close to 300 had matched and about 60 were placed through other provincial programs. Recommendation The federal government should make a clear policy commitment to increasing self-sufficiency in the education and training of health professionals in Canada that would incorporate the following. - Short term - increase number of community preceptors to train Canadian graduates and assess internationally educated health professionals already living in Canada. Recognition of the time and value of community teaching is needed. - Medium term - support increased capacity for academic health science centres and other institutions that train health professionals. - Long term - creation of new academic health science centres to increase capacity for self-sufficiency. REPATRIATING CANADIAN DOCTORS WORKING ABROAD It is known that there are thousands of Canadian-trained health professionals practising in the United States and abroad. Between 1991 and 2004, almost 8,000 physicians left Canada (although some 4,000 returned for a net loss of 4,000).8 Of this number, roughly 80% went to the US.9 During the 1990s, approximately 27,000 nurses migrated from Canada to the US.1011 A more recent indicator of nursing outmigration is that in 2006, 943 Canadian-trained Registered Nurses and Licensed Practical Nurses wrote the US licensing board examination for the first time.12 Data for other health professional disciplines are not readily available. In 2007, with the assistance of the American Medical Association, the Canadian Medical Association (CMA) surveyed all (n=5,156) Canadian-trained physicians practicing in the US who were age 55 or under, with regard to the likelihood of their return to Canada and the importance of various factors that might be incentives to return. A 32% response rate was achieved with a single mailing with no follow-up - this is considered exceptionally high. While only 13% of respondents indicated that they were likely or very likely to return to Canada, a further 25% were neutral in their opinion. What is more telling is that more than one-half of respondents indicated that they would be willing to be contacted by CMA to explore practice opportunities and provided their contact information for this purpose. When asked about a range of potential incentives to return to Canada, 57% agreed that a relocation allowance would be somewhat or very important.13 It must be stressed, however, that it is clear from the results that a number of factors would need to be taken into consideration, such as practice opportunities. This would also be true of other disciplines; in the case of nursing, nurses will only come back for full-time jobs and healthy work environments.14 Nonetheless, expatriate Canadian medical graduates should be good candidates for recruitment on the basis of the greater likelihood that they will meet Canadian standards for full medical licensure, and it is expected that this would also apply to nursing and other disciplines. As well, significant progress has been made in restoring and adding capacity to our medical schools but, to achieve self-sufficiency, much more needs to be done. For example, we must try and repatriate Canadian medical students and doctors who are studying and working abroad. There are currently some 1500 Canadian medical students and residents training abroad, we must act now, before things get worse. During that past few years there have been efforts to enhance national coordination in the health human resources arena. One area of national focus has been the integration of International Medical Graduates, since extended to nursing and other disciplines. There have been several initiatives undertaken in this area such as the establishment of the Canadian Information Centre for International Medical Graduates15 which provides a clearinghouse of information and links to provincial/territorial jurisdictions. Relocation grants, from $10,000 up to $20,000 could be offered to Canadian-trained physicians practising in the US. It is suggested that advertising be concentrated in and around US cities where Canada maintains a consulate/office (in states with a significant concentration with recruitment candidates) and in major national and selected state health professional journals. The cost of a repatriation secretariat is estimated at $162,500 per year. Assuming that 1,500 health professionals are recruited back over the 3-year period, the total cost would range from $21.5 million to $36.5 million. This would further translate to a per recruit cost that ranges from $14,325 to $24,325. Even at the high end of the range this would be cost-effective as compared to the total cost of training a practice-entry level graduate of any licensed health professional discipline in Canada. Recommendation In light of the foregoing, the CMA has recommended that the federal government should establish a Health Professional Repatriation Program in the amount of $30 million over 3 years that would include the following: - secretariat within Health Canada that would include a clearinghouse function on issues associated with returning to Canada such as licensure, citizenship and taxation; - An advertising campaign in the US to encourage health professionals practicing south of the border to return home; and - A program of one-time relocation grants for health professionals returning to active practice in Canada. NATIONAL HEALTH HUMAN RESOURCES INFRASTRUCTURE FUND The implementation of Medicare in Canada in the 1960s required a major investment in the capacity to train more health professionals. The 1966 Health Resources Fund Act played a key role in enabling a significant expansion in training capacity across the provinces for a range of health professionals. Forty years later, Canada faces growing shortages across most health disciplines. Clearly another giant step up is required in the human and physical infrastructure needed to train health professionals if Canadians are to have timely access to care. During the years of fiscal famine of the 1990s, health professional enrolment was either reduced (e.g., 10% in the case of medicine) or flat-lined. While there have been increases since 2000, we are about to face the double impact of both an aging population as the first of the baby boomers reach 65 in 2011 and aging health professions. For example, more than 1 out of 3 physicians (35%) are aged 55 or older. As mentioned, as many as 4,000 physicians are expected to retire in the next 2 years. If we are going to have sufficient numbers of health providers to meet the needs of the next few decades, it is imperative to expand the human and physician infrastructure capacity of our health professional education and training system. The federal investments in health human resources over 2003-2005 of some $200 million have been welcome, but fall far short of what is needed. It is proposed that the federal government implement a National Health Human Resources Infrastructure Fund in the amount of $1 billion over 5 years that would be made available to the provinces/territories on an equal per capita basis, and awarded through a competitive process that would include federal/ provincial/territorial representation with consultation/engagement of health professional organizations. The fund would address the following elements: 1. The direct costs of training providers and developing leaders (e.g., cost of recruiting and supporting more community- based teachers/preceptors). 2. The indirect or infrastructure costs associated with the educational enterprise (e.g., physical plant [housekeeping, maintenance]; support for departments [information systems, library resources, occupational health, etc.]; education offices, and the materials and equipment necessary for clinical practice and practical training. 3. Resources that improve the country's overall data management capacity when it comes to health human resources, and in particular, facilitate the ability to model and forecast health human resource requirements in the face of the changing demand for health services. Clearly it would be necessary to develop guidelines around the types of expenditures that would be eligible as was done for the 1966 Health Resources Fund, and more recently for the Medical Equipment Fund II. CMA Recommendation The federal government should establish a National Health Human Resources Fund in the amount of $1 billion over 5 years to expand health professional education and training capacity by providing funding to support the: - direct costs of training providers - indirect or infrastructure costs associated with the educational enterprise - resources that improve Canada's data collection and management capacity in the area of health human resources. HEALTH INNOVATION More than 85% of the health care delivered in Canada occurs within the community. This is the most under-invested segment of the health care delivery system in terms of information technology. Dr. Brian Postl in his June 2006 wait-time report16 to the federal government noted health information technology is essential in improving wait times. He quantified the investment needed at $2.4 billion with the largest portion of this investment ($1.9 billion) targeted to automating physician offices, which are located at the front line of care in community settings and are key to managing and resolving the wait time issue in Canada. Why invest in physician office automation? Because it will lead to improved productivity from the provider community through more efficient resource usage and through improved coordination in the delivery of care; it will enable labour mobility of health care workers through portability of records; it will support the wait time agenda by improving the flow of timely information; it will build an electronic infrastructure platform to enhance patient care and health research and will provide a direct financing vehicle for the federal government to influence and shape the health care sector. The federal government has made similar types of infrastructure investment. The CFI Program was established to fund research infrastructure, which consists of the state-of-the-art equipment, buildings, laboratories and databases required to conduct research. Investing in EMR infrastructure will lead to the creation of state of the art clinical environments across Canada, electronic data base of health information and the foundational underpinnings of a health information network to support enhanced population health and health research. Under this scenario the federal contribution would provide a direct benefit to physicians without any need for provincial or territorial involvement. Second, the federal government could use existing government machinery to manage the program. Third, the federal contribution to infrastructure would only flow after a physician has introduced an EMR into his/her clinic ensuring that the funding is directly tied to building the EMR infrastructure platform. The recent National Physician Survey notes that some progress is being made across the country to automate community clinics. However without incentives the adoption trend will be incremental and extend over a further 20-year time frame. Financial incentives can shorten the timelines since it addresses one of the main adoption barriers physicians identify.17 Diffusion theory18 of new technologies into any sector of the economy demonstrates that without appropriate incentives it will take approximately 25 years the technology to reach the saturation point of integration. It is estimated that a financial incentive can shorten this timeline by 15 years. Recommendation The federal government, over a 5-year time frame, should provide a full tax credit to any physician who takes the steps to automate his or her clinical office. The tax credit would only apply to 1-time costs to establish a state of the art clinical environment. It is estimated, on average, 1-time costs would be $22,000. Total costs of the program if fully subscribed would amount to $880 million. CONCLUSION The health services sector makes significant contributions to the Canadian economy, both in terms of direct stimulus and by keeping Canadians healthy and productive. However, Canada's health services sector is facing a critical shortage of physicians and other health care professionals. By: - Adopting a long-term policy of self-sufficiency to provide Canadians with the health care professionals they need when and where they need them; - Establishing a dedicated health human resource renewal fund to educate, retain and enhance the lives of health care professionals; - Investing in health technology, infrastructure and innovation to make our health care system more responsive and efficient; the federal government, in partnership with provincial/territorial governments and other health system stakeholders can strengthen this sector. A strong health services sector means healthy Canadians and a vibrant Canadian economy. Again, on behalf of the Canadian Medical Association, Canada's doctors appreciate the opportunity to provide information to the Committee. Sincerely, Brian Day, MD President, Canadian Medical Association 1 National Health Expenditure Trends, 1975-2007. Canadian Institute for Health Information. 2007 2 Source: Business Register (STC 2003) and TIM (Informetrica Limited) 3 The Royal Commission on the Future of Health Care in Canada, November 2002. Senate Standing Committee on Social Affairs, Science & Technology, October 2002. The Health Council of Canada "Modernizing the Management of Health Human Resources in Canada: Identifying Areas for Accelerated Change: November 2005. 4 The National Physician Survey is a major ongoing research project conducted by the College of Family Physicians of Canada, Canadian Medical Association and Royal College of Physicians and Surgeons of Canada that gathers the opinions of all physicians, 2nd year medical residents and medical students from across the country. It is the largest census survey of its kind and is an important barometer of where the country's present and future doctors are on a wide range of critical issues. 5 The Economist, The Battle for BrainPower - A Survey of Talent, October 7, 2006. 7 World Medical Association. The World Medical Association Statement on Ethical Guidelines for the International Recruitment of Physicians. Geneva: The World Medical Association; 2003. Available: www.wma.net/e/policy/e14.htm 8 Canadian Institute for Health Information. 2. Canadian Institute for Health Information. 10 Zaho J, Drew D, Murray T. Barin drain and brain gain: the migration of knowledge workers from and to Canada. Education Quarterly Review 2000;6(3):8-35. 12 Little L, Canadian Nurses Association, personal communication, January 8, 2008. 13 Buske L. Analysis of the survey of Canadian graduates practicing in the United States. October 2007. http://www.cma.ca/multimedia/CMA/Content_Images/Policy_Advocacy/Policy_Research/US_survey_ver_4.pdf. Accessed 02/04/08. 14 Little L, Canadian Nurses Association, personal communication, January 28, 2008. 15 www.img-canada.ca 16 Postl, B. Final Report of the Federal Advisor on Wait Times. Ottawa: Minister of Health Canada, Health Council of Canada; 2005. 17 Canadian Medical Association/Canada Infoway. Physician Technology Usage and Attitudes Survey. Ottawa: CMA/CanadaInfoway; 2005. Available: www.cma.ca/index.cfm/ci_id/49044/la_id/1.htm (accessed 8 Jan 2008). 18 Bower, Anthony. The Diffusion and Value of Healthcare Information Technology. Santa Monica (CA): RAND Corporation; 2005
Documents
Less detail

CMA Presentation to the House of Commons Standing Committee on Health : Statutory review of the 10-Year Plan to Strengthen Health Care

https://policybase.cma.ca/en/permalink/policy9135
Last Reviewed
2020-02-29
Date
2008-05-27
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2008-05-27
Topics
Health systems, system funding and performance
Text
The CMA appreciates the opportunity to present to the Standing Committee on Health today. My presentation will focus on: 1. Wait Times 2. Health Human Resources; and 3. Patient Focused Care Wait Times In regard to the issue of wait times, I would echo the two main points of my colleagues from the Wait Time Alliance: * First, while progress is being made on wait times, that progress is limited and not consistent across the country; and second, * Health workforce and infrastructure capacity shortages remain the primary barriers to effectively addressing wait times. Wait times don't only exact a heavy human toll - they also carry severe economic costs. A CMA-commissioned report released earlier this year found that the economic cost of having patients wait longer than medically recommended was $14.8 billion in 2007. That stunning total was for just four of the five procedures identified as priorities in the 10-year plan - joint replacement, diagnostic imagining and cataract and bypass surgery - and it was only for one year. Over a million Canadians continue to suffer on wait lists because of deficiencies in our system. This is unacceptable. We need to "break the back" of wait times for the sake of our patients and for the economic health of Canada. This will require: * More federal leadership, not less; * A revolutionary change in the "focus" of our health care system; and * Substantial investments. Health Human Resources The 10-Year Plan to Strengthen Health Care acknowledged the need to increase the supply of health care professionals in Canada. However, not enough progress has been made. Canada is 26,000 doctors short of the average of developed countries, and we now rank a lowly 24th among OECD countries in doctors per population. A poll released today by the CMA found that Canada's doctor shortage ranked second only to the economy as a top public issue. In this same poll, 91% of Canadians say having a plan to address the doctor shortage will influence their vote in the next federal election. Federal political parties who ignore this issue in the next election could pay a price at the polls. In the 10-year plan to strengthen health care, $1-billion was set aside for the last four years (2010-2014) of the agreement. We can't afford to wait that long. This funding should be immediately fast-tracked to focus on the three priority areas in the CMA's "More Doctors. More Care" Campaign: * One, expanding health professional education and training capacity; * Two, ensuring self sufficiency in health human resources by investing in long-term health human resource planning; and. * Three, investing in health information technology to make our health care system more responsive and efficient. In terms of IT, we should be ashamed that we only spend a third of the OECD average on IT in our hospitals. Canada's poor record in avoidable adverse effects is, in part, due to our system's inability to share available information in a timely manner. Patient Focused Care Many countries have systems that provide universal care, have no wait lists and cost the same or less to run as our system does. Wait lists can and must be eliminated in Canada. The momentum to do just that depends simply on making the system work for patients, not on forcing patients to work the system. We must reposition patients to the centre of our health-care system, which requires that we move beyond block funding or global budgets for health institutions. We need a system where funds follow the patient - patient-focused funding. Block funding blocks access. Patient-focused funding will increase productivity, lead to greater efficiencies and reduce wait lists. A patient will become a value to an institution, not a cost. Canada remains the last country in the developed world to fund hospitals with block funding. In England, patient-focused funding helped eliminate wait lists in less than four years. Conclusion So, my question to the Committee is why do we wait? Why do we continue to keep patients on wait lists when research shows it costs a lot less to cut wait times then it does to have them? Why do we not make the necessary reforms and investments to provide Canadians with timely access to quality care? Thank you.
Documents
Less detail

Improving access to world-class health care by accelerating health information technology investments: CMA's 2009 pre-budget brief to the Standing Committee on Finance

https://policybase.cma.ca/en/permalink/policy9399
Last Reviewed
2020-02-29
Date
2008-08-15
Topics
Health human resources
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2008-08-15
Topics
Health human resources
Health systems, system funding and performance
Text
By many measures Canada's health care system is underperforming. One symptom of this weak performance are exceedingly long wait times that have an impact on care and cost patients, the system and governments money1. There are a number of responses to this poor performance including increasing the supply of health human resources2. Another response is to maximize the resources we have on the front lines and work smarter through information technology. This productivity approach is aligned with the assumptions set out in the federal government's Advantage Canada strategy. This strategy involves principally a 'knowledge advantage' and an 'infrastructure advantage'. Consequently, the Canadian Medical Association (CMA) is recommending that the federal government make a strategic "strings attached" $570-million investment to create an interconnected health information technology network3 through a Health Information System Transition Fund and time-limited accelerated IT tax incentives. This investment aims to integrate all Canadian patient health care records, an effort that will take time. However, there are foundations upon which to build thanks to federal government investments - most recently in providing $400 million for wait-time related health information systems. But for these investments to bear fruit further connectivity and integration is vital. In other words, our current system is like having an ATM card that only works at the bank's head office. We believe that additional investments must concentrate on connecting patient records in physician offices with hospitals and medical laboratories. Physicians also believe in accountability, and suggest investments should not be made unless the clinical community confirms a high level of system integration. The CMA recommends that the federal government should invest $570 million over five years in an interconnected pan-Canadian health information system that includes: => A $225 million, 5-year Health Information System Transition Fund aimed at change management training and support to convert 26-million patient records in 36,000 physician offices and community care facilities into interoperable electronic records across Canada. => $305 million for a 3-year time-limited and accelerated Capital Cost Allowance for software and hardware costs related to health information technologies that connect patient records from physician offices to laboratories and hospitals. => $10 million to sponsor a cross-country education campaign to inform Canadians of the health and system benefits of e-health connectivityi. => $2 million annually for Canada Research Chairs to promote and demonstrate the value of interconnectivity in health information between the faculties of Medicine, Management and Engineering. The federal government must also encourage provinces to increase their support of these initiatives and work to reduce the barriers to health information system interfacing, by ensuring patient record systems use similar codes in labs, hospitals and physician offices. Federal government guidance, encouragement and cooperation with the provinces is integral to making these connectivity investments a success. It is time that the federal government helped finish the job of health information system connectivity. A health information network will improve patient outcomes, system efficiency, increase accountability and save billions of dollars. 1. Why advance e-health interconnectivity now? Our health system e-performance is poor Both national and international studies confirm that Canada lags behind nearly every major industrial country when it comes to health information technology (Figure 8). The impact of this underinvestment is longer wait times, poorer quality, and a severe lack of financial accountability especially of federal dollars. Investments in connectivity are needed now because Canada's health care system compares poorly in both value and efficiency compared to other countries. The Conference Board of Canadaii, the OECDiii, the World Health Organizationiv, the Commonwealth Fundv, and the Frontier Centre for Public Policy all rate Canada's health care system poorly in terms of "value for money" as well as efficiency. Benchmarking health information connectivity-where we stand, where we must go According to the 2007 National Physician Survey, just 30% of physicians have an electronic interface with a medical laboratory or diagnostic imaging facility, while fewer than 5% have such an interface with a pharmacy/pharmacistvi. Imagine if just 30% of Canadian banks had ATMs throughout the country? This is a difference of not only convenience, but quality and cost savings. In comparison, Denmark and New Zealand have near 100% use of electronic medical records (EMRs) in ambulatory care. According to Dr. Allan Brookstonevii an EMR expert, "If most physicians in a health region or geographic area implemented an EMR system, the incentive for a local hospital or region to connect to those physicians would be significantly enhanced". In an emergency situation right now in Canada it is easier to access critical financial information than critical health information. This reality is not a matter of technology but the lack of will to put it in place. 2. Why the federal government should be interested in e-health interconnectivity. -Health information technology connectivity yields returns on investment: 8:1 International strategy and technology consulting firm Booz Allen Hamilton found that viii the benefits of an interconnected Electronic Health Record (EHR) in Canada could provide annual system-wide savings of $6.1 billion. These savings would come from reduced duplicate testing, transcription savings, fewer chart pulls and filing time, reductions in office supplies and reduced expenditures due to fewer adverse drug reactions. The study went on to state that the benefits to health care outcomes would equal or surpass these annual savings, thus providing a possible combined annual savings of $12.2 billion. In addition, a comprehensive literature reviewix comparing health IT productivity gains to similar industries in the U.S. concludes that effective EMR implementation and networking could eventually save more than $81 billion annually by improving health care efficiency and safety. Similarly, health information technology-enabled prevention and management of chronic disease could eventually double those savings while increasing health and other social benefits. Assuming that the Canadian health system is one-tenth the size of US system, savings would range from $8 to $16 billion annually. Connected health information technology - increasing performance and accountability A fundamental question the Standing Committee on Finance may ask is where $22 billion (growing at 6 % annually) in federal health care transfers to the provinces is going and what are the results of this support? Right now, we do not know exactly. Health care in Canada represents 10% of our economy ($160 billion annually and growing at 6% per year) and is larger than the total agricultural sector. The question Canadians are asking is not whether tax dollars should be spent on health care, but whether the money being spent is worth the services receivedx. Moreover, in health care, there are legitimate questions as to whether improvements to date have justified the associated costs. The public institutions and organizations that deliver health care in Canada could deliver more value than they do at present. With a national health information (management) system in place they could work to reduce variations in the quality of service and in the way services are used across the system. However at a national level, we do not have an accounting systemxi in place to uniformly measure quality across the country. 3. Who: Canadians - our patients - want and need e-health interconnectivity. Health information technology is critical to managing wait times Quality of care is an important concern for Canadians, but first they must be able to get the care they need. But waiting for health care is the principal concern for Canadiansxii. Excessive wait times result in mental anguish for patients and their families and also cost the Canadian economy billions of dollars each year. In 2007 a study commissioned by the CMAxiii conservatively calculated that excessive wait times in just four procedures (joint replacements, cataract surgery, coronary artery bypass grafts and MRIs) cost the economy over $14 billion in lost output and government revenues. It is important to note that beyond these hospital procedures there is potential to reduce wait times and cost in physician offices through information technology. This is why we have suggested accelerating the capital cost allowance tax for EMR related software and hardware purchases and that they go to community care and physician offices where most patient visits occur every day. Figure 1 below shows that in Ontario for example, just 3,000 out of an average of 247,000 patient visits per day or 1.2% of the total are made in hospitals. That is why this submission is aimed at (the circle area in the chart) increasing connectivity and tying investments to the 99% of the places where patients visit most. Figure 1 Patient visits per day in Ontario, Source: Canada Health Infoway Most of the emphasis on connectivity in Canadian health care to date has not focused on the point of care -even though the number of patient interactions with hospitals is greatly exceeded by the number of visits to physicians' officesxiv. Thus patient-physician office interactions outnumber patient-hospital interactions by a ratio of 18 to 1. It is also important that patients understand the value of electronic health records, which is why we are recommending a $10 million cross-country educational campaign to impact the demand side of this critical health and industrial equation. 4. Why physicians are involved in e-health interconnectivity The physician community can play a pivotal role in helping the federal governments make a connected health care system a realizable goal in the years to come. Through a multi-stakeholder process encompassing the entire health care team, the CMA will work toward achieving cooperation and buy-in. This will require a true partnership between provincial medical associations, provincial and territorial governments and Canada Health Infoway (CHI). Accelerating Advantage Canada through health information technologies The CMA's pre-budget submission, related to health system connectivity, incorporates the five tenets of Advantage Canadaxv. This submission principally addresses the infrastructure and knowledge advantages that are involved in investing in an interconnected network that is useless unless the 'knowledge' advantage to provide stewardship of the Electronic Health Record through our physicians' is in place. That is why we recommend that the federal government help support research, development and knowledge transfer at our major universities in health information technology by supporting 10 Canada Research Chairs in the faculties of Medicine, Management and Engineering. In addition, a pan-Canadian health information technology network will provide the kind of infrastructure that supports labour mobility where for example a migrant worker from Atlantic Canada can access his health records in Fort McMurray Alberta. 5. How to speed-up health information technology connectivity -a green tax incentive approach Thus far the strategy applied to health information connectivity in Canada has been focused on a top-down approach that has produced limited success. That is why the CMA is suggesting that the federal government accelerate the Capital Cost Allowance (CCA) on EMR-related software and hardware equipment over the next three years - an early-bird special or incentive. The CMA does not pretend to be tax policy experts however we do appreciate the federal governments' recent increase in the CCA rates for software and hardware. Our recommendation would mean changing the current software CCA (Class 12xvi) from 100% over two years to 100% in the first year specifically for EMR related investments. And for EMR hardware (Class 50xvii) accelerate the CCA to 100% in the first year from the current 55% rate for a limited time only of three years. These accelerated CCA rate proposals are also consistent with the governments' environmentally friendly CCA initiative as EMRs would save tonnes of paper for years. Mixed results for Canada Health Infoway => Health Information System Transition Fund The CMA lauds the federal government's 2008 Budget for making a $400-million investment in Canada Health Infoway (CHI) to support early movement toward patient wait time guarantees through the development of health information systems and electronic health records. At the same time the physician community believes that CHI has had mixed results, especially when it comes to digitizing and integrating patient records at the places where most patients contact the health care system: physician offices, laboratories and emergency rooms. However, we believe with targeted, conditional policies CHI can be an effective vehicle to accelerate the transition of current health centre paper practices into electronic operations through a time limited five-years Health Information Transition Fund. We also believe that federal transition funds should be matched at a fifty-fifty rate by the provinces. Although this may not be easy, there are other non-monetary policy levers (e.g. regulatory) that the federal government could and should use to persuade the provinces of the value of investing in electronic health record system integration. This is particularly true since the provinces will yield most of the return on the investment. It is imperative that the current health information technology gap be closed and be set at levels for similar service-intensive industries (see Figure 2 in the Appendix 1). That is why; beyond the figures outlined in this submission, the CMA recommends continued federal health information technology support for the next 10 years. Conclusion - Big investments. but big payoffs too As the Health Council of Canada stated in their 2008 annual reportxviii, "Change is underway, but too slowly". The OECD, WHO, The Commonwealth Fund and the Conference Board of Canada's research all strongly suggest that Canada lags behind the rest of the industrialized world in terms of health information technology investments and system integration. The investments made so far may seem large but they will be wasted if a second effort in connecting the entire system is not made now. It is time that the federal government finishes the job of health information system connectivity at the point of care. A Pan-Canadian network of health information will improve patient outcomes, health system efficiency and dramatically increase system accountability. The Health Council of Canada also said that, "These [health information technology] are big investments but the payoff is big too". Accordingly we suggest that over the next five years the following investments will improve the running of Medicare as well as the Canadian economy. The CMA recommends that the federal government should invest $570 million over five years in an interconnected pan-Canadian health information system that includes: => A $225 million, 5-year Health Information System Transition Fund aimed at change management training and support involved in converting 26 million patient records in 36,000 physician offices and community care facilities into interoperable electronic records across Canada. => $305 million for a 3-year time limited accelerated Capital Cost Allowance for EMR software and hardware costs related to health information technologies that connect patient records from physician offices to laboratories and hospitals. => $10 million to sponsor a cross-country education campaign to inform Canadians of the health and system benefits of e-health connectivityxix. => $2 million annually for Canada Research Chairs promoting the value of interconnectivity in health information between the faculties of Medicine, Management and Engineering. References 1The cumulative economic cost of waiting for treatment across just 4 priority areas in 2007 was an estimated $14.8 billion. This reduction in economic activity lowered federal and provincial government revenues in 2007 by a combined $4.4 billion. See:www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/pdf/2008/EconomicReport.pdf 2 Almost 5-million Canadians do not have a family physician. Canada would need 26,000 more doctors to meet the OECD average of physicians per population. Physicians spend more time on paperwork and less with patients than they did 20 years ago. See: "More Doctors. More Care.": www.moredoctors.ca/take_action/ 3 Please see Table l in Appendix 1 for full investment horizon details. i Patient perspective on electronic medical record. Meldgaard M; International Society of Technology Assessment in Health Care. Meeting (19th : 2003 : Canmore, Alta.). Annu Meet Int Soc Technol Assess Health Care Int Soc Technol Assess Health Care Meet. 2003; 19: abstract no. 148. CONCLUSIONS: Patient confidence and perceived quality of care is influenced by a well informed forward-looking staff as can be obtained in settings where EPR is successfully implemented. Patient satisfaction and the functional level of EPR implementation are interdependent. ii A Report Card on Canada see: http://sso.conferenceboard.ca/HCP/overview/health-overview.aspx iii Organization for Economic Co-operation and Development [OECD] (2007). OECD Health Data 2007. Version 07/18/2007. CD-ROM. Paris: OECD. iv World Health Organization [WHO] (2007). World Health Statistics 2007. see: http://www.who. v Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care May 15, 2007 (updated May 16, 2007)
Volume 59 Authors: Karen Davis, Ph.D., Cathy Schoen, M.S., Stephen C. Schoenbaum, M.D., M.P.H., Michelle M. Doty, Ph.D., M.P.H., Alyssa L. Holmgren, M.P.A., Jennifer L. Kriss, and Katherine K. Shea Editor(s):Deborah Lorber see: www.commonwealthfund.org/publications/publications_show.htm?doc_id=482678 vi See Tables Q39 and Q40a in the 2007 National Physician Survey at:www.nationalphysiciansurvey.ca/nps/ vii Dr. Alan Brookstone is a family physician in Richmond, BC and the founder of CanadianEMR. The quote was taken from: Online resource enables MDs to rate EMRs. See: www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Future_Practice/English/2007/November/Online-e.pdf The CanadianEMR Physician Resource Directory provides access to a province specific searchable list of vendors of products and services to support the EMR-based practice. http://www.canadianemr.ca/ viii Booz, Allan, Hamilton Study, Pan-Canadian Electronic Health Record, Canada's Health Infoway's 10-Year Investment Strategy, March 2005-09-06. ix Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, And Costs Richard Hillestad, James Bigelow, Anthony Bower, Federico Girosi, Robin Meili, Richard Scoville and Roger Taylor, Health Affairs, 24, no. 5 (2005): 1103-1117. x In November 2008 the Auditor General of Canada will present it's performance audit on, "Reporting on Health Indicators-Health Canada" to Parliament. See: www.oag-bvg.gc.ca/internet/English/oag-bvg_e_29401.html xi There has been heavy emphasis is being placed on "accountability" and "performance measurement," endorsed by the Romanow Commission (Commission on the Future of Healthcare in Canada 2002), the Kirby Committee (Standing Senate Committee on Social Affairs, Science and Technology 2002), and the First Ministers' accord (First Ministers 2004). See Raisa Deber Why Did the World Health Organization Rate Canada's Health System as 30th? Some Thoughts on League Tables. Some Thoughts on League Tables xii The results of an Ipsos Reid poll (January 2008) finds that eight in ten (78%) Canadians believe that hospital and other health care wait times cost Canada money because people who are waiting for treatment are less productive and miss work. This is compared to just two in ten (19%) who think that wait times save Canada money because governments don't have to put as many resources into healthcare. xiii The economic cost of wait times in Canada, January 2008. This study was commissioned by the Canadian Medical Association (CMA) to analyze the economic costs of wait times in Canada's medical system. The CMA's membership includes more than 67,000 physicians, medical residents and medical students. It plays a key role by representing the interests of these members and their patients on the national stage. Located in Ottawa, the CMA has roots across the country through its close ties to its 12 provincial and territorial divisions. See: www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/pdf/2008/EconomicReport.pdf xiv Sources: Physician visits - CIHI - Physicians in Canada: Fee-for-Service Utilization 2005-2006. Table 1-21. Hospital contacts - CIHI - Trends in Acute Inpatient Hospitalizations and Day surgery Visits in Canada 1995-1996 to 2005-2006 and CIHI -National Ambulatory Care Reporting System - Visit Disposition by Triage Level for All Emergency Visits - 2005-2006. xvAdvantage Canada builds on Canada's strengths and seeks to gain a global competitive advantage in five areas: 1. Tax Advantage-Reducing taxes for all Canadians and establishing the lowest tax rate on new business investment in the G7. 2. Fiscal Advantage-Eliminating Canada's total government net debt in less than a generation. 3. Entrepreneurial Advantage-Reducing unnecessary regulation and red tape and increasing competition in the Canadian marketplace. 4. Knowledge Advantage-Creating the best-educated, most-skilled and most flexible workforce in the world. 5. Infrastructure Advantage-Building the modern infrastructure we need. xvi Software: CLASS 12 , (100 per cent) Property not included in any other class that is.... (o) computer software acquired after May 25, 1976, but not including systems software or property acquired after August 8, 1989 and before 1993 that is described in paragraph (s). xvii Hardware: CLASS 45 , (45 per cent) Property acquired after March 22, 2004 (other than property acquired before 2005 in respect of which an election is made under subsection 1101(5q)) that is general-purpose electronic data processing equipment and systems software for that equipment, including ancillary data processing equipment. Draft Regulation (a) electronic process control or monitor equipment; (b) electronic communications control equipment; (c) systems software for equipment referred to in paragraph (a) or (b); or (d) data handling equipment (other than data handling equipment that is ancillary to general-purpose electronic data processing equipment). Class 50 (55 per cent) Property acquired after March 18, 2007 that is general-purpose electronic data processing equipment and systems software for that equipment, including ancillary data processing equipment, but not including property that is principally or is used principally as (a) electronic process control or monitor equipment; (b) electronic communications control equipment; (c) systems software for equipment referred to in paragraph (a) or (b); or (d) data handling equipment (other than data handling equipment that is ancillary to general-purpose electronic data processing equipment). xviii Health Council of Canada, Rekindling Reform: Health Care Renewal in Canada, 2003 - 2008, June 2008 (page 23). See: www.healthcouncilcanada.ca/docs/rpts/2008/HCC%205YRPLAN%20(WEB)_FA.pdf Appendix 1 (Table does not display correctly -- See PDF) Table 1 -Health Interconnectivity investments over five years. Figure 2 -Major Canadian health centers are well below industry IT investment standard
Documents
Less detail

Emergency federal measures to care for and protect Canadians during the COVID-19 pandemic

https://policybase.cma.ca/en/permalink/policy14132
Date
2020-03-16
Topics
Health care and patient safety
  2 documents  
Policy Type
Parliamentary submission
Date
2020-03-16
Topics
Health care and patient safety
Text
It is with a sense of urgency that the Canadian Medical Association (CMA) submits the recommendations herein for emergency federal measures that, taken together, will ensure Canadians receive appropriate care and that supportive measures are implemented for public health protection during the COVID-19 pandemic. While Canada has made significant strides since SARS to establish and implement effective public health infrastructure, resources and mechanisms, the significant resource constraints across our health systems present a major challenge in our current response. Federal emergency measures must be developed in the context of the current state of health resources: hospitals across the country are already at overcapacity, millions of Canadians lack access to a regular family doctor, countless communities are grappling with health care shortages, virtual care is in its infancy, and so on. Another core concern is the chronic underfunding and ongoing budget cuts of public health resources and programming. Public health capacity and leadership at all levels is fundamental to preparedness to respond to an infectious disease threat, particularly one of this magnitude. It is in this context that the Canadian Medical Association recommends that the following emergency measures be implemented by the federal government to support the domestic response to the COVID-19 pandemic: 1410, pl. des tours Blair / Blair Towers Place, bur. / Suite 500, Ottawa ON K1J 9B9 1) FEDERAL RECOMMENDATION AND SUPPORT FOR SOCIAL DISTANCING In this time of crisis, Canadians look to the federal government for leadership and guidance. The single most important measure that can be implemented at this time is a consistent national policy calling for social distancing. This recommendation by the federal government must be paired with the resources necessary to ensure that no Canadian will be forced to choose between financial hardship — whether by losing employment or not being able to pay rent — and protecting their health. The CMA strongly recommends that the federal government immediately communicate guidance to Canadians to implement social distancing measures. The CMA further recommends that the federal government deliver new financial support measures as well as employment protection measures to ensure that all Canadians may engage in social distancing. 2) NEW FEDERAL EMERGENCY FUNDING TO BOOST PROVINCIAL/ TERRITORIAL CAPACITY AND ENSURE CONSISTENCY It is the federal government’s role to ensure a coordinated and consistent national response across jurisdictions and regions. This is by far the most important role for the federal government in supporting an effective domestic response, that is, protecting the health and well-being of Canadians. The CMA strongly recommends that the federal government deliver substantial emergency funding to the provinces and territories to ensure health systems have the capacity to respond to the pandemic. Across the OECD, countries are rapidly stepping up investment in measures to respond to COVID-19, including significant investment targeting boosting health care capacity. In considering the appropriate level of federal emergency funding to boost capacity in our provincial/territorial systems, the CMA urges the federal government to recognize that our baseline is a position of deficit. New emergency federal funding to boost capacity in provincial/territorial health systems should be targeted to:
rapidly enabling the expansion and equitable delivery of virtual care;
establishing a centralized 24-hour national information hotline for health care workers to obtain clear, timely and practical information on clinical guidelines, etc.;
expanding the capacity of and resources for emergency departments and intensive care units;
coordinating and disseminating information, monitoring and guidance within and across jurisdictions; and
rapidly delivering income stabilization for individuals and families under quarantine. Finally, the inconsistencies in the provision and implementation of guidance and adoption of public health measures across and within and jurisdictions is highly concerning. The CMA strongly encourages the federal government enable consistent adoption of pan-Canadian guidance and measures to ensure the health and safety of all Canadians. 1410, pl. des tours Blair / Blair Towers Place, bur. / Suite 500, Ottawa ON K1J 9B9 3) ENSURING AN ADEQUATE SUPPLY OF PERSONAL PROTECTIVE EQUIPMENT FOR CANADIAN HEALTH CARE WORKERS AND ENSURING APPROPRIATE USAGE The CMA is hearing significant concerns from front-line health care workers, including physicians, about the supply and appropriate usage of personal protective equipment. It is the CMA’s understanding that pan-Canadian efforts are underway to coordinate supply; however, additional measures by the federal government to ensure adequate supply and appropriate usage are required. Canada is at the outset of this public health crisis — supply issues at this stage may be exacerbated as the situation progresses. As such, the CMA strongly recommends that the federal government take additional measures to support the acquisition and distribution throughout health systems of personal protective equipment, including taking a leadership role in ensuring our domestic supply via international supply chains. 4) ESTABLISH EMERGENCY PAN-CANADIAN LICENSURE FOR HEALTH CARE WORKERS In this time of public health crisis, the federal government must ensure that regulatory barriers do not prevent health care providers from delivering care to patients when and where they need it. Many jurisdictions and regions in Canada are experiencing significant shortages in health care workers. The CMA urges the federal government to support piloting a national licensure program so that health care providers can opt to practice in regions experiencing higher infection rates or where there is a shortage of providers. This can be accomplished by amending the Canadian Free Trade Agreement (CFTA) to facilitate mobility of health care workers. Specifically, that the following language be added to Article 705(3) of the CFTA: (j) A regulatory authority of a Party* shall waive for a period of up to 100 days any condition of certification found in 705(3)(a) - (f) for any regulated health care worker to work directly or indirectly to address the Covid-19 pandemic or any health care emergency. Any disciplinary matter emanating from work in any province shall be the responsibility of the regulatory authority of the jurisdiction where the work is performed. Each Party shall instruct its regulatory authorities to set-up a rapid check-in/check-out process for the worker. *Party refers to a signatory of the CFTA To further enable this measure, the CMA recommends that the federal government deliver targeted funding to the regulatory colleges to implement this emergency measure as well as targeted funding to support the provinces/territories in delivering expanded patient care. 1410, pl. des tours Blair / Blair Towers Place, bur. / Suite 500, Ottawa ON K1J 9B9 5) ESTABLISH AN EMERGENCY NATIONAL MENTAL HEALTH SUPPORT SERVICE FOR HEALTH PROVIDERS Health care providers may experience trauma and hardship in meeting the increasing health needs and concerns of Canadians in this time of crisis. The CMA strongly recommends that the federal government establish an emergency National Mental Health Support Services hotline for all health care providers who are at the front lines of patient care during the pandemic. This critical resource will ensure our health care providers have the help they may need as they care for patients, including helping them to deal with an increasing patient load. 6) IMPLEMENT A TARGETED TAX CREDIT FOR HEALTH PROVIDERS EXPERIENCING FINANCIAL LOSS DUE TO QUARANTINE In addition to supporting income stabilization measures for all Canadians who may benefit from support, the CMA recommends that the federal government establish a time-limited and targeted tax credit for health providers who may experience financial loss due to quarantine. Many health care providers operate independently and may face significant fixed expenses as part of their care model. As health care providers may have an increased risk of contracting COVID-19, this may result in significant financial loss. A time-limited tax credit to ease this loss may help ensure the continued viability of their care model. Further, the CMA supports extending the federal tax filing timeline in recognition of the fact that health care workers and all Canadians are focused on emergency matters. CLOSING The CMA’s recommendations align with the OECD’s call to action: “Governments need to ensure effective and well-resourced public health measures to prevent infection and contagion, and implement well-targeted policies to support health care systems and workers, and protect the incomes of vulnerable social groups and businesses during the virus outbreak.” Now is the time to ensure that appropriate leadership continues and that targeted investments are made to protect the health of Canadians.
Documents
Less detail

Protecting and supporting Canada’s health-care providers during COVID-19

https://policybase.cma.ca/en/permalink/policy14260
Date
2020-03-23
Topics
Physician practice/ compensation/ forms
Health systems, system funding and performance
Health human resources
  1 document  
Policy Type
Parliamentary submission
Date
2020-03-23
Topics
Physician practice/ compensation/ forms
Health systems, system funding and performance
Health human resources
Text
Dear First Ministers: Re: Protecting and supporting Canada’s health-care providers during COVID-19 Given the rapidly escalating situation both globally and in our country, we know that the health and safety of all people and health-care providers in Canada is uppermost on your minds. We appreciate the measures that have been taken by all levels of government to minimize the spread of COVID-19. However, we must ensure those working directly with the public, including physicians, nurses, pharmacists, and social workers, are properly protected and supported, so that they can continue to play their role in the response. First and foremost, we urge all levels of government to put measures in place to ensure the personal protective equipment that point-of-care providers require to deliver care safely throughout this outbreak is immediately deployed and ready to use. Coordinated measures and clear, consistent information and guidelines will ensure the appropriate protection of our health-care workforce. Given the increased pressure on point-of-care providers, we ask that all governments support them by providing emergency funding and support programs to assist them with childcare needs, wage losses due to falling ill or having to be quarantined, and support of their mental health needs both during and after the crisis has subsided. We also expect all governments to work together to provide adequate, timely, evidence-based information specifically for health-care providers. Clear, consistent and easily accessible guidance will enable them to do their jobs more efficiently and effectively in times of crisis. This can and should be 1/2… done on various easily accessible platforms such as online resources, an app, or through the creation of a hotline. We know there will be challenges in deploying resources and funding, particularly around the supply of personal protective equipment. We ask that you consider any and all available options to support health-care providers through a coordinated effort both during and following this crisis. Our organizations look forward to continuing to work with you in these difficult times. If there is anything we can do to help your teams, you need only ask. Sincerely, Claire Betker, RN, MN, PhD, CCHN(C) President, Canadian Nurses Association president@cna-aiic.ca Jan Christianson-Wood, MSW, RSW President, Canadian Association of Social Workers kinanâskomitin (I’m grateful to you) Lea Bill, RN BScN President, Canadian Indigenous Nurses Association president@indigenousnurses.ca Sandy Buchman, MD, CCFP(PC), FCFP President, Canadian Medical Association sandy.buchman@cma.ca
Documents
Less detail

Responding to the COVID-19 pandemic: Federal measures to recognize the significant contributions of Canada’s front-line health care workers

https://policybase.cma.ca/en/permalink/policy14211
Date
2020-05-28
Topics
Health care and patient safety
  1 document  
Policy Type
Parliamentary submission
Date
2020-05-28
Topics
Health care and patient safety
Text
During these unprecedented times, Canada’s physicians, along with all front-line health care workers (FLHCWs), have not only put themselves at risk but have made enormous personal sacrifices while fulfilling a critical role in life-threatening circumstances. The CMA recognizes and strongly supports the measures the federal government has taken to date to mitigate the health and economic impacts of COVID-19 on Canadians. However, given the unique circumstances that Canada’s FLHCWs face, additional measures are required to acknowledge their role, the risks to themselves and their families, and the financial burden they have taken on through it all. To gain a better understanding of this issue, the CMA commissioned MNP LLP (MNP) to conduct a thorough economic impact study. They assessed the effects of the COVID-19 pandemic on physician practices in Canada and identified policy options to mitigate these effects. This brief summarizes the findings, provides an overview of the impact of the COVID-19 pandemic on physician practices across the country and highlights targeted federal measures that can significantly mitigate the evident challenges physicians are experiencing. It is important to note that the recommended measured were developed through the lens of recognizing the important contribution of Canada’s FLHCWs. UNDERSTANDING HOW THE PANDEMIC IS IMPACTING PHYSICIAN PRACTICES Canada’s physicians are highly skilled professionals, providing an important public service and making a significant contribution to the health of Canadians, our nation’s health infrastructure and our knowledge economy. In light of the design of Canada’s health care system, the vast majority of physicians are self-employed professionals operating medical practices as small business owners. Like most small businesses in Canada, physician practices have been negatively impacted by the necessary measures governments have established to contain this pandemic. Under the circumstances of the pandemic, the provinces postponed non-emergent procedures and surgeries, indefinitely. According to data from the 2019 Physician Workforce Survey conducted by the CMA, approximately 75% of physicians reported practising in settings that would be expected to experience a reduction in patient volumes as a result of COVID-19 measures. This suggests “the vast majority of physicians in Canada anticipate declines in earnings as a result of COVID-19 restrictions.” Physician practices include a variety of structures, which relate to the practice setting or type. In their economic impact study, MNP estimates that across the range of practice settings, the after-tax monthly earnings of physician practices are estimated to decline between 15% and 100% in the low-impact scenario, and between 25% and 267% in the high-impact scenario. These two scenarios are in comparison to a baseline scenario, prior to the pandemic. The low-impact scenario is based on the reduction of physician services reported during the 2003 experience with the Severe Acute Respiratory Syndrome (SARS) while the high-impact scenario estimates more significant impacts, being approximately double those observed during SARS. Unlike salaried public sector professionals, such as teachers, nurses or public servants, most physicians operate as small business owners who are solely responsible for the management of their practices. They employ staff, rent office space and have numerous other overhead costs related to running a small business, which they are still responsible for regardless of decreased earnings. According to data published by Statistics Canada in 2019 there were 120,241 people employed in physician offices in Canada and an additional 28,054 employed in medical laboratories. Additionally, physicians manage significant overhead expenses that are unique to medical practice such as practice insurance, licence fees and continuing medical education. It’s important to understand that even hospital-based physicians may be responsible for significant overhead expenses, unlike other hospital staff. Like any small business owner grappling with drastic declines in revenue, physicians may be forced to reduce their staffing levels or even close their practices entirely in response to the COVID-19 pandemic. ADDRESSING THE GAPS: ENSURING THAT FEDERAL ECONOMIC PROGRAMS CAPTURE PHYSICIAN PRACTICES To reiterate, the CMA supports the federal government’s decisive and meaningful response to the pandemic, including delivering critical economic relief programs. However, more detailed analysis is revealing that segments of physician practices are not eligible for these critical economic programs, because of technicalities. At this time, the CMA has identified three key segments of physician practice models who may not currently be eligible for the economic relief programs because of technicalities. These are: 1. hospital-based specialists 2. physician practices that operate as a small business but may not meet technical criteria 3. physicians delivering locum medical care These technical factors reflect the complexity of the health system infrastructure in Canada. Although hospital-based specialists may receive some form of salary, they may still be structured as a small business and be responsible for paying overhead fees to the hospital. Many physicians may operate as a small business and remit a statement of self-employment, and they may not have a business number or a business bank account. As is common amongst other self-employed professionals, many physicians operate practices within cost-sharing structures. The CMA is deeply concerned that these structures are presently being excluded for the federal government’s critical economic relief programs. As a result, this exclusion is affecting the many employees of practices structured as cost-sharing arrangements. Finally, physicians providing care in other communities, known as locum practice, would also be responsible for overhead expenses. It is the CMA’s understanding that the federal government is seeking to be inclusive in delivering economic relief programs to mitigate the impacts of the pandemic, such as closures or unemployment. For physician practices, eligibility for federal economic relief programs would extend the reach of these mitigation measures to maintaining Canada’s critical health resources and services, as physician practices are responsible for a significant portion of health system infrastructure. As such, the CMA respectfully recommends that the federal government ensure that these critical economic programs be made available to all segments of physician practices. To this end, the CMA recommends that the federal government expand eligibility for the federal economic relief program to: 1. Include hospital-based specialists paying fees for overhead expenses to the hospitals (e.g., staff, equipment, space); 2. capture physician-owned medical practices using a “personal” banking account as well as those in cost-sharing structures to access programs; and, 3. include physicians who provide locum medical care. NEW FEDERAL TAX MEASURES TO SUPPORT AND RECOGNIZE FRONT-LINE HEALTH CARE WORKERS It is also important to note that the impact of COVID-19 on FLHCWs goes well beyond the financial impacts. All FLHCWs face numerous challenges trying to carry out their work during these difficult times. They put their health and the health of their families at risk. They make enormous sacrifices, sometimes separating themselves from their families to protect them. These risks and sacrifices can strain an individual’s mental health, especially when coupled with anxiety over the lack of proper personal protective equipment (PPE). A survey conducted by the CMA at the end of April showed that almost 75% of physicians who responded to the survey indicated feeling very or somewhat anxious about the lack of PPE. FLHCWs deserve to be recognized for their unique role during this pandemic. Given the enormous sacrifices and risks that FLHCWs are making every day, the federal government should enact measures to recognize their significant contributions during these unprecedented times. The CMA recommends that the federal government implement the following new measures for all FLHCWs: 1. An income tax deduction for FLHCWs put at risk during the COVID-19 pandemic, in recognition of their heroic efforts. All FLHCWs providing in-person patient care during the pandemic would be eligible to deduct a designated amount against their income earned. This would be modelled on the deduction provided to members of the Canadian Armed Forces serving in moderate- and high-risk missions. 2. A non-taxable grant to support the families of FLHCWs who die in the course of responding to the COVID-19 pandemic or who die as a result of an occupational illness or psychological impairment related to this work. The grant would also apply to cases in which the death of an FLHCW’s family member is attributable to the FLHCW’s work in responding to the pandemic. The CMA is recommending that access to the Memorial Grant program, or a similar measure, be granted to FLHCWs and their family member(s). 3. A temporary emergency accommodation tax deduction for FLHCWs who incur additional accommodation costs as well as a home renovation credit in recognition of the need for FLHCWs to adhere to social distancing to prevent the spread of COVID-19 to their family members. The CMA recommends all FLHCWs earning income while working at a health care facility or in a capacity related thereto (e.g., paramedics or janitorial staff) be eligible for the deduction and credit. 4. Provide additional child-care relief to FLHCWs by doubling the child-care deduction. The CMA recommends the individuals listed above be eligible for the enhanced deduction. It is important that any measures enacted be simple for the government to implement and administer as well as simple for FLHCWs to understand and access. The recommendations above will ensure that relief applies to a wide range of Canada’s FLHCWs who are battling COVID-19. More details on these recommendations are provided in Appendix A to this brief. INCREASING FEDERAL HEALTH FUNDING TO SUPPORT SYSTEM CAPACITY It is due to the action of the federal and provincial/territorial governments, together with Canadians, in adhering to public health guidance that our health systems have been able to manage the health needs of Canadians during the pandemic. However, as governments and public health experts consider how we may proceed in lifting certain restrictions, we are beginning to comprehend the enormity of the effort and investment required to resume health care services. During the pandemic, a significant proportion of health care services, such as surgeries, procedures and consults considered “non-essential” have been delayed. As health services begin to resume, health systems will be left to grapple with a significant spike in already lengthy waiting times. Further, all health care facilities will need to adopt new guidance to adhere to physical distancing, which may necessitate longer operating hours, increasing staff levels and/or physical renovations. Given these issues, the CMA is gravely concerned that Canada’s already financially struggling health systems will face significant funding challenges at a time when provincial/ territorial governments are grappling with recession economies. The CMA is strongly supportive of new federal funding to ensure Canada’s health systems are resourced to meet the care needs of Canadians as the pandemic continues. CONCLUSION As outlined in this brief, the overwhelming majority of Canada’s physician practices will be negatively impacted financially by COVID-19. The indefinite postponement of numerous medical procedures, coupled with restrictions related to physical distancing resulting in reduced patient visits, will have a material effect on physician practices, risking their future viability. As well, all FLHCWs will be severely impacted by COVID-19 personally, through risks to themselves and their families. Many families of FLHCWs will also be impacted financially, from increased child-care costs to, tragically, costs associated with the death of a loved one because of COVID-19. In light of these substantial risks and sacrifices, the CMA urges the adoption of the above-mentioned recommendations designed to recognize the special contribution of Canada’s FLHCWs during these extraordinary times.
Documents
Less detail

Submission in Response to the Consultation on the Canada Emergency Wage Subsidy: Keeping Medical Clinic Employees on the Payroll

https://policybase.cma.ca/en/permalink/policy14258
Date
2020-06-05
Topics
Physician practice/ compensation/ forms
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2020-06-05
Topics
Physician practice/ compensation/ forms
Health systems, system funding and performance
Text
Submission in Response to the Consultation on the Canada Emergency Wage Subsidy: Keeping Medical Clinic Employees on the Payroll June 5, 2020 Since the outset of the COVID-19 pandemic, the CMA has been actively engaged as part of Canada’s domestic response. In addition to our engagement on key public health issues such as the supply and distribution of personal protective equipment, the CMA has addressed physician practice needs, including releasing a Virtual Care Playbook to support the rapid conversion of medical practices to virtual care delivery. In the context of physician practices operating as small businesses, the CMA strongly supports the federal government’s emergency economic relief programs. Access to these programs is critical to the viability of many physician practices — and the ability of medical clinics across Canada to retain vital front-line health care workers (FLHCWs) and keep their doors open to continue serving the needs of their patient population. However, despite the dire need for these programs by medical professionals — who constitute a strategic resource and sector at the best of times, but particularly in a pandemic — presently, the CMA is concerned that many physicians are experiencing administrative barriers to accessing these critical federal support programs for their employees. This submission provides a briefing on physician practices and the need to access the CEWS, an overview of the technical and administrative factors impeding access, as well as proposed remedies to enable a rapid federal response. Physician Practices and Access to the CEWS While health care in Canada is predominantly publicly funded, it is primarily privately delivered. In Canada’s health care system, the vast majority of physicians are self-employed professionals operating medical practices as small business owners. Physician-owned and -run medical practices ensure that Canadians are able to access the health care they need, in communities across all jurisdictions. In doing so, Canadian physicians are directly responsible for 167,000 jobs across the country, contributing over $39 billion to Canada’s GDP. Including the expenses and overhead associated with running physician practices, nearly 289,000 jobs indirectly relate to physician practices. However, as much as physician practices resemble small businesses on the basis of key criteria like employing staff and paying rent, it is imperative to recognize that they are in fact core stewards of a substantial portion of Canada’s health care system and critical health system infrastructure. It is a national imperative to ensure the viability of such a core component of Canada’s health care system as our medical clinics and the staff they employ. To this end, both federal and provincial/territorial governments have a role in ensuring Canada’s medical clinics are there to serve the health care needs of Canadians, through the pandemic and beyond. Physician practices have experienced significant impacts related to changing volumes of patient care and delivery models of care in light of public health restrictions since the pandemic was declared on Mar. 11, 2020. The CMA commissioned an economic impact analysis to better understand the impacts across various practice settings. This analysis reveals that across the range of practice settings, the after-tax monthly earnings of physician practices are estimated to decline between 15% and 100% in the low-impact scenario, and between 25% and 267% in the high-impact scenario. Despite meeting the revenue reduction and employer eligibility factors, the CMA is concerned that many physicians are ineligible for the CEWS because of technical and administrative factors that are inconsistent with other existing federal legislative frameworks. The CMA conducted a survey of its membership between May 22 and June 1 to better understand physicians’ experiences accessing the federal economic relief programs; 3,730 physicians participated in this survey. Overall, about a third (32%) of physicians polled had attempted to apply to at least one of the federal programs available and 15% of all physicians who responded applied for the CEWS, making it the second most applied-to program. Of those physicians who applied to the CEWS, 60% were successful, 7% were denied and the remaining 33% were still awaiting response at the time of the survey. Of those who applied but were denied the CEWS, a third (33%) indicated it was because of their cost-sharing structure, 3% responded it was because they worked in a hospital-based setting and a further 22% simply didn’t know. Finally, as part of the survey, physicians shared comments that speak to the issues outlined in this brief. A few excerpts are below:
“We are a group of 4 surgeons and have a cost sharing agreement to pay our office expenses. Our office is outside of the hospital. We tried to apply for the CEWS but have recently received accounting advice supported by legal advice that cost sharing agreements will not be candidates for the CEWS. We are therefore presently exploring other options such as a work share situation or temporary/permanent layoffs.” CMA member, survey respondent
“I work in a group with 11 other OBGYNs. We are still unsure to this point about whether the CEWS applies to our situation. Our revenue is certainly down by ~30% or more. The issue is that our structure doesn't fall into one of the neat categories for CEWS … We are awaiting clarification from our accountant on our status but it seems that the way the rules are currently written, we will not benefit from CEWS, and unfortunately, we are reducing staff hours to cope with our reduction in revenue.” CMA member, survey respondent
“My main frustration is that I can't find a clear answer on whether a clinic made up of multiple doctors with a cost sharing agreement is eligible for CEWS for our employees. I imagine many family practice clinics are set up this way … So as it stands we have not been able to access any financial programs in order to help pay our overhead/staff despite 50% reduction in patient volume.” CMA member, survey respondent A. Cost-Sharing Arrangements — Front-Line Health Care Workers Employed in Physician Clinics One of the main types of practices that are unable to access the CEWS because of technical administrative barriers, despite meeting the key eligibility criteria, are physicians operating independently within a cost-sharing business structure. Like many other independent professionals, physicians operate in group settings. In fact, according to the Canadian Institute for Health Information, in 2019, 65% of family practices operated in a group setting. However, unlike other independent professionals, physicians have been encouraged to operate in a group setting, both by accreditation bodies as well as by provincial health authorities, to meet system delivery goals. Appendix A provides a case study based on Sudbury Medical Associates (SMA), an illustrative example of three doctors (Dr. Brown, Dr. Lee and Dr. Assadi) who coordinated the operations of their medical practices together to open an integrated health care clinic. While they provide care to their own respective patient rosters, these three physicians share in the clinic space rent and employ 10 employees together. Because of the way SMA is structured, these physicians are unable to access the CEWS for their proportionate share of their employees’ salaries. Each physician has met all the CEWS criteria except for the fact that SMA administers the payroll for their 10 employees under its own payroll number. SMA illustrates a typical family medicine clinic representative of the many medical practices in Canada who employ numerous FLHCWs. B. Cost-Sharing Arrangements — Front-Line Health Care Workers Employed by Specialist Physicians Practising in a Hospital-Based Environment Another type of physician structure unable to access the CEWS because of the use of cost-share arrangements are specialist physicians practising in a hospital-based environment or academic health science centre (an “AHSC”). The purpose of an AHSC is to provide specialized health care services, carry out medical research and train the next generation of Canada’s health care professionals. Provincial funding agreements are designed to align the interest of all parties in an AHSC (clinical care, teaching, research and innovation) and often contain governance and accountability requirements. In order to discharge responsibilities under provincial funding agreements and to run a practice that can meet certain metrics, physicians are required to hire their own staff. Consequently, cost-sharing arrangements are utilized by these physicians to efficiently hire staff while meeting their other responsibilities. In response to the COVID-19 pandemic, hospitals have implemented strategies designed to protect the health care system from collapsing or being overwhelmed. For example, many hospitals have cancelled elective surgeries; coupled with the fear many patients have of going to the hospital, this has resulted in a decline in patient care volume as hospitals and physician practices adhere with public health guidelines. This has led to a significant decline in revenue, requiring physicians to access the CEWS program in order to continue to employ their staff. Like all physicians in Canada, specialist physicians practising in a hospital-based health care setting are responsible for significant levels of fixed overhead expenses related to a medical practice. This includes medical insurance, licensing fees, maintaining an office and other professional fees. As a standard practice, employees of physicians who practise in AHSCs are often paid by a third party. In many instances, physicians have established an agency relationship pursuant to which they delegate authority to the hospital to act as their agent with respect to withholding taxes, source deductions and filing T4 returns. The main reason for this agency is to ensure that the physician focuses on teaching, researching and patient care. For clarity, the administrator (hospital) has no legal authority to conclude on any employment matter such as the determination of a bonus or a wage increase or the payout of any severance. All these matters would be the responsibility of the physician in his/her capacity as employer. Anticipating a second wave of COVID-19, many physicians are concerned about maintaining their staff during a future work stoppage given their current inability to apply for the CEWS. As employers, physicians can appreciate that the hospital’s payroll number is creating additional administrative complexity for the Canada Revenue Agency (CRA). However, as an employer and small business, their ability to access the CEWS program is an integral part of their strategy to retain and maintain their staff. C. Technical Analysis — CEWS Legislation and the Principal-Agent Relationship i) CEWS Legislation — Qualifying Entity Pursuant to the COVID-19 Emergency Response Act, an entity will qualify for CEWS to the extent that it is a Qualifying Entity under ss. 125.7(1) of the Income Tax Act (ITA). One of the criteria to be a qualifying entity is that the entity had, on Mar. 15, 2020, a business number in respect of which it is registered with the Minister to make remittances required under ITA s. 153. By virtue of how cost-sharing arrangements are structured, the administrator (agent) handles the payroll filings using their own payroll number, which can be different from the employing physician (principal). On the basis of the uniqueness of cost-sharing structures and the definition in the legislation, physicians who employ individuals under these arrangements need to rely on principal-agent concepts in order to qualify for the CEWS provided all other criteria are met. Presently, the CEWS application portal does not recognize principal-agent arrangements, which are common among physician practices as they employ FLHCWs. It is recognized that each participant or physician in a cost-sharing arrangement is in fact its own business and that physicians share the costs of certain overhead expenses, which include wage-related costs for FLHCWs. In these structures, the payroll number for the employee(s) may be associated with one of the independently operating physicians or it may be associated with a separate entity. As such, these physicians are not likely to have a distinct payroll number associated with their eligible employee under the CEWS. The case law and the administrative position of the CRA demonstrate the following: 1. The principals in a cost-sharing arrangement are the employers; and 2. The agent’s payroll number should be considered the payroll number for the principal for the purposes of making a CEWS application. ii) Case Law Subsection 9(1) of the ITA provides for the basic rules as they relate to computing the income or loss from business or property. In both Avotus Corporation v The Queen and Fourney v The Queen , the Tax Court of Canada determined that where a person carries on business as agent for another, it is the principal that is carrying on the business and not the agent. The Fourney case provides for several concepts that extend to the unique nature of cost-sharing arrangements. These concepts should provide clarity about a principal’s ability to make a CEWS claim if it had a payroll agent that had a business number to make remittances before Mar. 15, 2020. The concepts are summarized as follows: 1. Corporations can act as Agent In Fourney, at paragraphs 41 and 42, it was concluded that a corporation can act as its shareholder’s agent: It is established, then, that corporations can act as agents, and this concept is not repugnant to the rule that corporations have separate legal personality a matter addressed in the oft-cited Salomon case. 2. Business Activities belong to the Principal At paragraphs 60 and 65 of Fourney, the Tax Court examined the following activities and ultimately concluded that the activities were in fact the activities of the principal and not the agent. The following conclusions can be drawn from the case:
Payments made to the corporate agent were found to be revenues of the principal.
Contracts entered into by the corporate agent were contracts entered into by the principal.
T4s issued under the corporate agent’s name were deductible expenses to the principal. Lastly, at paragraph 65, the Tax Court characterized the corporate agent as a mere conduit for the appellant. iii) Administrative Policy For GST/HST purposes, the CRA accepts the concept of an agency relationship typically utilized by physicians in cost-sharing practices. In RITS 142436 “Implementation of Cost Sharing Arrangement,” the CRA concluded that GST/HST does not apply to payments made to “Company A” because it was an agent in relation to remuneration paid to the employees of Company B and Company C. In this ruling, Companies A, B and C were all employers with Company A administrating the payroll as agent. The CRA’s conclusions appear to take the follow matters into account:
Employees are jointly employed by the principals in the cost-sharing arrangement.
Principals have legal responsibility for the employees.
The principals would delegate responsibility or authority to an agent, which could be a corporation or another physician.
That agent would be given discretion to pay the employees, withhold and remit the appropriate amount of taxes, file T4 slips, hire and terminate at the determination of the principals.
Each principal would pay the agent for their proportionate share of payroll and report such payroll on their respective financial statements and tax returns. The CRA also concluded that the “employment status of a person for GST/HST purposes is the same for income tax purposes.” The Department of Finance provides that the CEWS helps businesses keep employees on the payroll, encourages employers to rehire workers previously laid off, and better positions businesses to bounce back following the crisis. In keeping with this objective, a payroll number for an agent should extend itself to the principals for the purposes of applying for the CEWS because it is supported by case law and the administrative practices of the CRA. Application of any federally legislated program should be conceptually consistent with historical frameworks already established. Recommendations: The CMA holds that the legislation as written can remain as currently drafted as it provides for the majority of applicants looking to access the CEWS. However, to address the unintended exclusion of cost-sharing arrangements, the CMA recommends that the CRA provide administrative guidance consistent with and based on existing case law and administrative positions. The CMA recommends that the Federal Government and the CRA enable physicians to claim their proportionate share of eligible remuneration paid through a cost-sharing arrangement provided all other program eligibility criteria are met. Administratively, this may be achieved by the following:
a “check-box” on the application denoting the applicant is a participant in a cost sharing arrangement
identification of the cost-sharing arrangement payroll number
a joint election between the agent and employer allowing the employer to utilize the agent’s payroll number and denoting the percentage allocation of salary costs to the particular employer If this recommendation is not feasible, the CMA recommends that the Federal Government and the CRA implement an alternate approach whereby a cost-share administrator is permitted to make a CEWS claim in their capacity as agent on behalf of each eligible entity (principal). Since period 3 is almost complete, there could be less administration regarding these claims as agents have not made application. Similar to the preferred remedy above, this may be achieved by the following:
a “check box” on the application indicating that an “agent” is filing the claim on behalf of eligible employers
the applicant could also provide (either initially or upon desk audit) the business numbers to CRA for each employer
a joint election among the agent and the employers allowing the agent to act on behalf of the employers for purposes of the CEWS This would provide ease of audit for the CRA as the claim can be verified against the T4 and payroll remittances. The election and disclosure requirements would also alleviate any concerns the CRA or Department of Finance may have regarding potential abuse of the program. In Appendix B we also outline supporting documentation to be retained for a CEWS Claim by a Cost-Sharing Entity, which will ensure cost-sharing entities have the appropriate documentation to submit a claim and also assist the CRA in conducting pre-assessment audits. The CMA would be pleased to provide further detail on this issue or consider other alternatives to ensure FLHCWs receive wages during these unprecedented times. Conclusion Canada’s physicians are important employers. Not only are they responsible for almost 167,000 in direct employment, together with their staff, they are at the front lines of Canada’s response to the COVID-19 pandemic. Our health care system cannot withstand loss of employment or risks to the viability of medical clinics, at this crucial time — and indeed at any time. The CMA strongly encourages the Federal Government to address the issues outlined above in preventing physicians from accessing this critical economic relief program. On behalf of the doctors of Canada, the CMA stands ready to collaborate in resolving these technical and administrative barriers. Appendix A: Welcome to Sudbury Medical Associates (SMA) Dr. Christopher Brown (60) settled in his hometown of Sudbury to practise family medicine about 30 years ago. He operated in his own space, with his own employees until SMA was formed. Dr. Jennifer Lee (45) has been practising in Sudbury for her entire career. Dr. Lee handles all family patients with a special focus on maternity and young family care. Dr. Sarah Assadi (30) recently completed her residency. Dr. Assadi spent time in Sudbury as a locum and enjoyed the strong community feel. Dr. Brown and Dr. Lee are long-time colleagues and recently approached Dr. Assadi to open an integrated health care clinic. Together they would require 10 employees (comprised of nurse practitioners, medical assistants and receptionists) to effectively operate the clinic. Optically, SMA appears to be one business when in fact it is comprised of three distinct medical practices. Each physician or their professional corporation maintains their own distinct patient list. Upon the advice of professional advisors, the physicians entered into a cost-sharing agreement to realize cost efficiencies related to the integrated health care clinic (administration and lease). This structure will ensure the needs of the community are met by the expansion of operating hours facilitated by a flexible staffing model. Understanding that cost-sharing arrangements are accepted by provincial health authorities and the Canada Revenue Agency (CRA), Dr. Brown, Dr. Lee and Dr. Assadi documented this arrangement, which includes the following details: Dr. Brown Dr. Lee Dr. Assadi SMA Legal entity Prof corp Prof corp Sole-proprietor Corp Proportionate share of costs 20% 40% 40%
0% Legal employer (10 staff) ü ü ü Legally responsible — all contracts ü ü ü Payroll, T4 and remittances ü Report for income tax purposes:
Individual billings
Proportionate share of costs administered by SMA including payroll ü ü ü The impact of COVID-19 resulted in a significant slowdown of patient visits between Mar. 15 and May 31 as the residents of Sudbury were social distancing and were only leaving their homes for urgent matters. Dr. Brown, Dr. Lee and Dr. Assadi are concerned about keeping their front-line health care workers employed and at the same time maintaining a sufficient level of family health care in the community. Considering a possible second wave of COVID-19, these physicians need to ensure that their community health clinic remains open and safe so there is no unintended stress on hospitals. Like many small businesses that have experienced significant revenue declines, these physicians are hopeful to access the Canada Emergency Wage Subsidy (CEWS) to ensure they can retain their specialized employees and pivot to the new environment they need to operate within. Upon further review, only Dr. Lee and Dr. Assadi experienced sufficient revenue declines to access the CEWS, but currently they do not qualify because of how they structured the payroll for these 10 employees. They are concerned that without the CEWS, they will not be able to retain all of their staff or see as many patients. The following table summarizes the CEWS analysis: CEWS criteria Dr. Brown Dr. Lee Dr. Assadi SMA Eligible entity ü Prof corp ü Prof corp ü Sole proprietor ü Corp Revenue decline test: March 2020 Not met ü ü No revenues to report Payroll number
ü Payroll expense (eligible remuneration ) ü ü ü
Qualified for the CEWS No (revenue decline test not met) No (payroll account number held by SMA, which manages payroll on behalf of Dr. Lee) No (payroll account number held by SMA, which manages payroll on behalf of Dr. Assadi) No (has no revenue and is not the legal employer) As employers, Dr. Lee and Dr. Assadi do not understand why their businesses are unable to access the CEWS for their proportionate share of their employees’ salaries. Each has met all of the CEWS criteria except for the fact that SMA administers the payroll for their 10 employees under its own payroll number. Appendix B: Illustration of Supporting Documentation to be Retained for a CEWS Claim by Cost-Sharing Entity To the extent that employers operating through a cost-sharing structure are permitted to make a CEWS claim, the following documentation could be requested by the CRA to verify the claim upon desk audit. For illustrative purposes, let’s assume that Dr. Lee and Dr. Assadi both made a CEWS claim. Supporting Documentation Request 1. The legal documentation establishing the agency relationship pursuant to which Dr. Lee and Dr. Assadi delegated authority to SMA to handle the income tax remittances, source deductions and T4 reporting. 2. The employment contracts, which clearly indicate that each of Dr. Lee, Dr. Assadi (and Dr. Brown) are the employers. Alternatively, confirmation from the employees that SMA is not the employer and that they are employed by Drs. Lee, Assadi and Brown. 3. SMA’s accounting records or financial statements, which clearly support its position as an agent. Note: Typically, most cost-share administrators will have NIL revenue and account for all cash inflows and outflows on their balance sheet in a manner similar to a lawyer’s trust account. 4. An analysis demonstrating the revenue decline for the relevant period for Dr. Assadi’s business and Dr. Lee’s business. 5. Calculations supporting the proportionate share of “baseline remuneration” and “eligible remuneration” paid to the employees by Dr. Assadi’s business and Dr. Lee’s business. 6. A reconciliation of the wage subsidy received along with their proportionate share of the wage subsidy so it can be properly accounted for and taxed.
Documents
Less detail

CMA Pre-budget Submission

https://policybase.cma.ca/en/permalink/policy14259
Date
2020-08-07
Topics
Physician practice/ compensation/ forms
Health information and e-health
Health care and patient safety
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2020-08-07
Topics
Physician practice/ compensation/ forms
Health information and e-health
Health care and patient safety
Health systems, system funding and performance
Text
RECOMMENDATION 1 That the government create a one-time Health Care and Innovation Fund to resume health care services, bolster public health capacity and expand primary care teams, allowing Canadians wide-ranging access to health care. RECOMMENDATION 2 That the government recognize and support the continued adoption of virtual care and address the inequitable access to digital health services by creating a Digi-Health Knowledge Bank and by expediting broadband access to all Canadians. RECOMMENDATION 3 That the government act on our collective learned lessons regarding our approach to seniors care and create a national demographic top-up to the Canada Health Transfer and establish a Seniors Care Benefit. RECOMMENDATION 4 That the government recognize the unique risks and financial burden experienced by physicians and front line health care workers by implementing the Frontline Gratitude Tax Deduction, by extending eligibility of the Memorial Grant and by addressing remaining administrative barriers to physician practices accessing critical federal economic relief programs. RECOMMENDATIONS 3 Five months ago COVID-19 hit our shores. We were unprepared and unprotected. We were fallible and vulnerable. But, we responded swiftly.
The federal government initiated Canadians into a new routine rooted in public health guidance.
It struggled to outfit the front line workers. It anchored quick measures to ensure some financial stability.
Canadians tuned in to daily updates on the health crisis and the battle against its wrath.
Together, we flattened the curve… For now. We have experienced the impact of the first wave of the pandemic. The initial wake has left Canadians, and those who care for them, feeling the insecurities in our health care system. While the economy is opening in varied phases – an exhaustive list including patios, stores, office spaces, and schools – the health care system that struggled to care for those most impacted by the pandemic remains feeble, susceptible not only to the insurgence of the virus, but ill-prepared to equally defend the daily health needs of our citizens. The window to maintain momentum and to accelerate solutions to existing systemic ailments that have challenged us for years is short. We cannot allow it to pass. The urgency is written on the faces of tomorrow’s patients. Before the onset of the pandemic, the government announced intentions to ensure all Canadians would be able to access a primary care family doctor. We knew then that the health care system was failing. The pandemic has highlighted the criticality of these recommendations brought forward by the Canadian Medical Association. They bolster our collective efforts to ensure that Canadians get timely access to the care and services they need. Too many patients are succumbing to the gaps in our abilities to care for them. Patients have signaled their thirst for a model of virtual care. The magnitude of our failure to meet the needs of our aging population is now blindingly obvious. Many of the front line health care workers, the very individuals who put themselves and their families at risk to care for the nation, are being stretched to the breaking point to compensate for a crumbling system. The health of the country’s economy cannot exist without the health of Canadians. INTRODUCTION 4 Long wait times have strangled our nation’s health care system for too long. It was chronic before COVID-19. Now, for far too many, it has turned tragic. At the beginning of the pandemic, a significant proportion of health care services came to a halt. As health services are resuming, health care systems are left to grapple with a significant spike in wait times. Facilities will need to adopt new guidance to adhere to physical distancing, increasing staff levels, and planning and executing infrastructure changes. Canada’s already financially atrophied health systems will face significant funding challenges at a time when provincial/territorial governments are concerned with resuscitating economies. The CMA is strongly supportive of new federal funding to ensure Canada’s health systems are resourced to meet the care needs of Canadians as the pandemic and life continues. We need to invigorate our health care system’s fitness to ensure that all Canadians are confident that it can and will serve them. Creating a new Health Care and Innovation Fund would focus on resuming the health care system, addressing the backlog, and bringing primary care, the backbone of our health care system, back to centre stage. The CMA will provide the budget costing in follow-up as an addendum to this submission. RECOMMENDATION 1 Creating a one-time Health Care and Innovation Fund 5 It took a global pandemic to accelerate a digital economy and spark a digital health revolution in Canada. In our efforts to seek medical advice while in isolation, Canadians prompted a punctuated shift in how we can access care, regardless of our location or socio-economic situation. We redefined the need for virtual care. During the pandemic, nearly half of Canadians have used virtual care. An incredible 91% were satisfied with their experience. The CMA has learned that 43% of Canadians would prefer that their first point of medical contact be virtual. The CMA welcomes the $240 million federal investment in virtual care and encourages the government to ensure it is linked to a model that ensures equitable access. A gaping deficit remains in using virtual care. Recently the CMA, the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada established a Virtual Care Task Force to identify digital opportunities to improve health care delivery, including what regulatory changes are required across provincial/territorial boundaries. To take full advantage of digital health capabilities, it will be essential for the entire population, to have a functional level of digital health literacy and access to the internet. The continued adoption of virtual care is reliant on our ability to educate patients on how to access it. It will be further contingent on consistent and equitable access to broadband internet service. Create a Digi-Health Knowledge Bank Virtual care can’t just happen. It requires knowledge on how to access and effectively deliver it, from patients and health care providers respectively. It is crucial to understand and promote digital health literacy across Canada. What the federal government has done for financial literacy, with the appointment of the Financial Literacy Leader within the Financial Consumer Agency of Canada, can serve as a template for digital health literacy. We recommend that the federal government establish a Digi-Health Knowledge Bank to develop indicators and measure the digital health of Canadians, create tools patients and health care providers can use to enhance digital health literacy, continually monitor the changing digital divide that exists among some population segments. Pan-Canadian broadband expansion It is critical to bridge the broadband divide by ensuring all those in Canada have equitable access to affordable, reliable and sustainable internet connectivity. Those in rural, remote, Northern and Indigenous communities are presently seriously disadvantaged in this way. With the rise in virtual care, a lack of access to broadband exacerbates inequalities in access to care. This issue needs to be expedited before we can have pride in any other achievement. RECOMMENDATION 2 Embedding virtual care in our nation’s health care system 6 Some groups have been disproportionately affected by the COVID-19 crisis. Woefully inadequate care of seniors and residents of long-term care homes has left a shameful and intensely painful mark on our record. Our health care system has failed to meet the needs of our aging population for too long. The following two recommendations, combined with a focus on improving access to health care services, will make a critical difference for Canadian seniors. A demographic top-up to the Canada Health Transfer The Canada Health Transfer (CHT) is the single largest federal transfer to the provinces and territories. It is critical in supporting provincial and territorial health programs in Canada. As an equal per-capita-based transfer, it does not currently address the imbalance in population segments like seniors. The CMA, hand-in-hand with the Organizations for Health Action (HEAL), recommends that a demographic top-up be transferred to provinces and territories based on the projected increase in health care spending associated with an aging population, with the federal contribution set to the current share of the CHT as a percentage of provincial-territorial health spending. A top-up has been calculated at 1.7 billion for 2021. Additional funding would be worth a total of $21.1 billion to the provinces and territories over the next decade. Seniors care benefit Rising out-of-pocket expenses associated with seniors care could extend from 9 billion to 23 billion by 2035. A Seniors Care Benefits program would directly support seniors and those who care for them. Like the Child Care Benefit program, it would offset the high out-of-pocket health costs that burden caregivers and patients. RECOMMENDATION 3 Ensuring that better care is secured for our seniors 7 The federal government has made great strides to mitigate the health and economic impacts of COVID-19. Amidst the task of providing stability, there has been a grand oversight: measures to support our front line health care workers and their financial burden have fallen short. The CMA recommends the following measures: 1. Despite the significant contribution of physicians’ offices to Canada’s GDP, many physician practices have not been eligible for critical economic programs. The CMA welcomes the remedies implemented by Bill C-20 and recommends the federal government address remaining administrative barriers to physicians accessing federal economic relief program. 2. We recommend that the government implement the Frontline Gratitude Tax Deduction, an income tax deduction for frontline health care workers put at risk during the COVID-19 pandemic. In person patient care providers would be eligible to deduct a predetermined amount against income earned during the pandemic. The Canadian Armed Forces already employs this model for its members serving in hazardous missions. 3. It is a devastating reality that front line health care workers have died as a result of COVID-19. Extending eligibility for the Memorial Grant to families of front line health care workers who mourn the loss of a family member because of COVID-19, as a direct result of responding to the pandemic or as a result of an occupational illness or psychological impairment related to their work will relieve any unnecessary additional hardship experienced. The same grant should extend to cases in which their work contributes to the death of a family member. RECOMMENDATION 4 Cementing financial stabilization measures for our front line health care workers 8 Those impacted by COVID-19 deserve our care. The health of our nation’s economy is contingent on the health standards for its people. We must assert the right to decent quality of life for those who are most vulnerable: those whose incomes have been dramatically impacted by the pandemic, those living in poverty, those living in marginalized communities, and those doubly plagued by experiencing racism and the pandemic. We are not speaking solely for physicians. This is about equitable care for every Canadian impacted by the pandemic. Public awareness and support have never been stronger. We are not facing the end of the pandemic; we are confronting an ebb in our journey. Hope and optimism will remain elusive until we can be confident in our health care system. CONCLUSION
Documents
Less detail

Recommendations for Canada’s long-term recovery plan - open letter

https://policybase.cma.ca/en/permalink/policy14262
Date
2020-08-27
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2020-08-27
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
Re: Recommendations for Canada’s long-term recovery plan Dear Prime Minister Trudeau, We would like first to thank and commend you for your leadership throughout this pandemic. Your government’s efforts have helped many people in Canada during this unprecedented time and have prevented Canada from facing outcomes similar to those seen in other countries experiencing significant pandemic-related hardship and suffering. We are writing to you with recommendations as you develop a plan for Canada’s long-term recovery and the upcoming Speech from the Throne on September 23rd. The COVID-19 pandemic has further exposed and amplified many healthcare shortfalls in Canada such as care for older adults and mental health-care. Added to that, the economic fallout is impacting employment, housing, and access to education. These social determinants of health contribute to and perpetuate inequality, which we see the pandemic has already exacerbated for vulnerable groups. Action is needed now to address these challenges and improve the health-care system to ensure Canada can chart a path toward an equitable economic recovery. To establish a foundation for a stronger middle class, Canada must invest in a healthier and fairer society by addressing health-care system gaps that were unmasked by COVID-19. We firmly believe that the measures we are recommending below are critical and should be part of your government’s long-term recovery plan: 1. Ensure pandemic emergency preparedness 2. Invest in virtual care to support vulnerable groups 3. Improve supports for Canada’s aging population 4. Strengthen Canada’s National Anti-Racism Strategy 5. Improve access to primary care 6. Implement a universal single-payer pharmacare program 7. Increase mental health funding for health-care professionals We know the months ahead will be challenging and that COVID-19 is far from over. As a nation, we have an opportunity now, with the lessons from COVID-19 still unfolding, to bring about essential transformations to our health-care system and create a safer and more equitable society. 1. Ensure pandemic emergency preparedness We commend you for your work with the provinces and territories to deliver the $19 billion Safe Restart Agreement as it will help, in the next six to eight months, to increase measures to protect frontline health-care workers and increase testing and contact tracing to protect Canadians against future outbreaks. Moving forward, as you develop a plan for Canada’s long-term recovery, we strongly recommend the focus remains in fighting the pandemic. Beyond the six to eight months rollout of the Safe Restart Agreement, it is critical that a long-term recovery plan includes provisions to ensure a consistent and reliable availability of personal protective equipment (PPE) and large-scale capacity to conduct viral testing and contact tracing. 2.Invest in virtual care to support vulnerable groups The sudden acceleration in virtual care from home is a silver lining of the pandemic as it has enabled increased access to care, especially for many vulnerable groups. While barriers still exist, the role of virtual care should continue to be dramatically scaled up after COVID-19 and Canada must be cautious not to move backwards. Even before the pandemic, Canadians supported virtual care tools. In 2018, a study found that two out of three people would use virtual care options if available.i During the pandemic, 91% of Canadians who used virtual care reported being satisfied.ii We welcome your government’s $240 million investment in virtual health-care and we encourage that a focus be given to deploying technology and ensuring health human resources receive appropriate training in culturally competent virtual care. We also strongly recommend accelerating the current 2030 target to ensure every person in Canada has access to reliable, high-speed internet access, especially for those living in rural, remote, northern and Indigenous communities. 3.Improve supports for Canada’s aging population Develop pan-Canadian standards for the long-term care sector The pandemic has exposed our lack of preparation for managing infectious diseases anywhere, especially in the longterm care sector. The result is while just 20% of COVID-19 cases in Canada are in long-term care settings, they account for 80% of deaths — the worst outcome globally. Moreover, with no national standards for long-term care, there are many variations across Canada in the availability and quality of service.iii We recommend that you lead the development of pan-Canadian standards for equal access, consistent quality, and necessary staffing, training and protocols for the long-term care sector, so it can be delivered safely in home, community, and institutional settings, with proper accountability measures. Meet the health-care needs of our aging population Population aging will drive 20% of increases in health-care spending over the next years, which amounts to an additional $93 billion in spending.iv More funding will be needed to cover the federal share of health-care costs to meet the needs of older adults. This is supported by 88% of Canadians who believe new federal funding measures are necessary.v That is why we are calling on the federal government to address the rising costs of population aging by introducing a demographic top-up to the Canada Health Transfer. This would enhance the ability of provinces and territories to meet the needs of Canada’s older adults and invest in long-term care, palliative care, and community and home care. 4.Strengthen Canada’s National Anti-Racism Strategy Anti-Black racism exists in social structures across Canada. Longstanding, negative impacts of these structural determinants of health have created and continue to reinforce serious health and social inequities for racialized communities in Canada. The absence of race and ethnicity health-related data in Canada prevents identification of further gaps in care and health outcomes. But where these statistics are collected, the COVID-19 pandemic has exploited age-old disparities and led to a stark over-representation of Black people among its victims. We are calling for enhanced collection and analysis of race and ethnicity data as well as providing more funding under Canada’s National Anti-Racism Strategy to address identified health disparities and combat racism via community-led projects. 5. Improve access to primary care Primary care is the backbone of our health-care system. However, according to a 2019 Statistics Canada surveyvi, almost five million Canadians do not have a regular health care provider. Strengthening primary care through a teambased, interprofessional approach is integral to improving the health of all people living in Canada and the effectiveness of health service delivery. We recommend creating a one-time fund of $1.2 billion over four years to Page 3 of 4 expand the establishment of primary care teams in each province and territory, with a special focus in remote and underserved communities, based on the Patient’s Medical Home visionvii. 6. Implement a universal single-payer pharmacare program People across Canada, especially those who are vulnerable, require affordable access to prescription medications that are vital for preventing, treating and curing diseases, reducing hospitalization and improving quality of life. Unfortunately, more than 1 in 5 Canadians reported not taking medication because of cost concerns, which can lead to exacerbation of illness and additional health-care costs. We recommend a comprehensive, universal, public system offering affordable medication coverage that ensures access based on need, not the ability to pay. 7.Increase mental health funding for health-care professionals During the first wave of COVID-19, 47% of health-care workers reported the need for psychological support. They described feeling anxious, unsafe, overwhelmed, helpless, sleep-deprived and discouraged.viii Even before COVID- 19, nurses, for instance, were suffering from high rates of fatigue and mental health issues, including PTSD.ix Furthermore, health-care workers are at high risk for significant work-related stress that will persist long after the pandemic due to the backlog of delayed care. Immediate long-term investment in multifaceted mental health supports for health-care professionals is needed. We look forward to continuing to work with you and your caucus colleagues on transforming the health of people in Canada and the health system. Sincerely, Tim Guest, M.B.A., B.Sc.N., RN President Canadian Nurses Association (CNA) president@cna-aiic.ca Tracy Thiele, RPN, BScPN, MN, PhD(c) President Canadian Federation of Mental Health Nurses (CFMHN) tthiele@wrha.mb.ca Lori Schindel Martin, RN, PhD, GNC(C) President Canadian Gerontological Nursing Association (CGNA) lori.schindelmartin@ryerson.ca E. Ann Collins, BSc, MD President Canadian Medical Association (CMA) Ann.collins@cma.ca Miranda Ferrier President Canadian Support Workers Association (CANSWA) mferrier@opswa.com Dr. Cheryl L. Cusack RN, PhD President Community Health Nurses of Canada (CHNC) president@chnc.ca Lenora Brace, MN, NP President Nurse Practitioner Association of Canada (NPAC) president@npac-aiipc.org ~ r. Cheryl Cusack, RN PhD CC.: Hon. Chrystia Freeland, Minister of Finance Hon. Patty Hajdu, Minister of Health Hon. Deb Schulte, Minister of Seniors Hon. Navdeep Bains, Minister of Innovation, Science and Industry Ian Shugart, Clerk of the Privy Council and Secretary to Cabinet Dr. Stephen Lucas, Deputy Minister of Health Dr. Theresa Tam, Chief Public Health Officer of Canada
Documents
Less detail

Valuing Caregivers and Recognizing Their Contribution to Quebec’s Health System

https://policybase.cma.ca/en/permalink/policy14373
Date
2020-09-29
Topics
Health human resources
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2020-09-29
Topics
Health human resources
Health systems, system funding and performance
Text
Submission prepared by the CMA – Quebec office Valuing Caregivers and Recognizing Their Contribution to Quebec’s Health System Bill 56, An Act to recognize and support caregivers and amend to various legislative provisions September 2020 1 600 De Maisonneuve Blvd. West, Suite 500, Montréal, Quebec H3A 3J2 Table of contents Introduction ....................................................................................................................... 2 About the CMA .............................................................................................................. 2 National policy on caregivers and home care ................................................................ 2 Importance of caregivers in Quebec .............................................................................. 3 CMA’s observations on Bill 56 .......................................................................................... 3 Definition of informal caregivers .................................................................................... 4 Better financial support for family caregivers ................................................................. 4 More respite for caregivers ............................................................................................ 4 Supporting caregivers through virtual care .................................................................... 5 Meeting caregivers’ training needs ................................................................................ 5 Conclusion……………………………………………………………………………………….5 2 600 De Maisonneuve Blvd. West, Suite 500, Montréal, Quebec H3A 3J2 Introduction About the CMA Founded in Quebec city in 1867, the Canadian Medical Association (CMA) unites the medical profession in Canada to improve the health of Canadians and strengthen the various health care systems. Speaking on behalf of the medical profession, the CMA stands for professionalism, integrity and compassion. The CMA and its Quebec office complement and collaborate with Quebec’s existing medical bodies. The CMA has in recent years defined the need to improve seniors’ care and well-being as a priority. Optimizing the performance of our health care system is largely dependent on our ability to improve the care provided to our seniors. The work done by the CMA includes seeking a coordinated national seniors’ health care strategy, seeking a United Nations convention on the human rights of older persons, and researching policies to support seniors and their caregivers. The CMA has also proposed solutions and recommendations to federal authorities: that the federal government ensure that the provinces’ and territories’ health care systems meet the care needs of their aging populations by means of a demographic top-up to the Canada Health Transfer, and that the federal government create a Seniors Care Benefit that would be an easier, fairer and more effective way to support caregivers and care receivers alike. The CMA applauds the government of Quebec’s commitment to “making known the contribution and commitment of caregivers and supporting them in their role.” For a number of years, the CMA has been calling for greater recognition of caregivers’ contribution to the health care system as partners in health care delivery. By recognizing caregivers in its legislation, Quebec is leading the way as the second Canadian province, after Manitoba, to grant legal status to these essential persons. National policy on caregivers and home care According to the CMA, it is vital that the government of Quebec consider the situation of caregivers, but it is also important to recognize the wider context in which this bill has been proposed. Firstly, we recognize and strongly suggest that a rethink of how long-term care is dispensed in Quebec is needed. For example, we believe that a rethinking of senior care in residential and long-term care homes (CHSLDs) is needed. This is an area that needs reform, and the CMA looks forward to commenting on the draft bill that will be introduced by the government of Quebec on this matter in the fall. In order to properly support our seniors, the CMA supports a major and urgent change to home care and community care. According to a new study conducted by Campaign Research Inc. on behalf of Home Care Ontario, almost all seniors in Ontario (91%) wish to remain in their own homes for as long as possible.1 We believe that this figure is similar among Quebec seniors. A good example of aging in place is Denmark, which has implemented a number of progressive policies such as: increasing investment in community care to support seniors at home; at least one preventive home visit per year for all seniors age 75 and 3 600 De Maisonneuve Blvd. West, Suite 500, Montréal, Quebec H3A 3J2 up; and a freeze on the construction of new long-term care homes that has been in pace for close to 20 years. These types of changes require better support to improve home services and new measures to support caregivers. A recent report by the Canadian Institute for Health Information indicates that 96% of long-term care recipients have an unpaid caregiver and that one third of them are distressed. The report also notes that caregivers who are distressed spend an average of 38 hours a week providing care—the equivalent of a full-time job.2 Importance of caregivers in Quebec In 2016, the demographic portrait of caregivers in Quebec indicated that 35% of Quebecers, or 2.2 million people, provided care to a senior. Of these, around 15% acted as caregivers for more than 10 hours a week. With the aging of the population—including the senior and caregiver population—set to accelerate in the coming years and decades, caregivers’ unpaid working hours will increase significantly. In Canada, according to a 2011 University of Alberta study, close to 80% of all assistance to recipients of long-term care was provided by family caregivers. This represents a contribution of over five billion dollars’ worth of unpaid services for the public health network.3 We should also note that the pandemic has highlighted the importance of caregivers and of their contributions to the health system and the services provided to seniors. As many health care services were closed during the pandemic, caregivers have been asked to work twice as hard and play an even bigger role, which has placed these individuals under even more stress than usual. We believe there is no better time to acknowledge the contributions of caregivers. Now it’s time to take action. We need to learn the lessons from the first wave of the pandemic and avoid the horrors of potential subsequent waves. According to Statistics Canada, seniors in Quebec are more likely to live alone than seniors in other provinces. It is important to note that many caregivers do not live with the person they are caring for. In addition, many seniors live alone and do not have a caregiver. CMA’s observations on Bill 56 Caregivers are the backbone of our health care system. They provide in-home care as well as care in hospitals, homes for seniors and CHSLDs. They deserve all the support we can give them. Unfortunately, the measures in place to support caregivers in Quebec and elsewhere in Canada are inadequate. Other countries have been doing a lot more and are way ahead of us on this issue. The CMA supports the main objectives of Bill 56. We commend the government for recognizing the important contribution caregivers make in our society. The CMA supports the creation of a committee to monitor government action and a committee of partners concerned by caregiver support, and also supports the creation of a Quebec observatory on informal caregiving. 4 600 De Maisonneuve Blvd. West, Suite 500, Montréal, Quebec H3A 3J2 Definition of caregivers The pandemic has revealed a number of shortcomings in our health care system. One of these shortcomings is the lack of support and services provided to seniors during lockdowns of health care facilities, CHSLDs and senior centres. We must provide better support to seniors during these lockdowns. The Canadian Foundation for Healthcare Improvement (CFHI) and a consulting group have determined a number of specific steps to guide the examination of policies, including reviewing policies on family presence as well as the participation of patients and family members and caregiver partners. The CFHI also indicated that it is important to distinguish between family caregivers, who are essential partners in care, and visitors.4 The role of family caregivers should be officially recognized throughout the delivery of care. The CMA is pleased to note that this was the case with the recent action plan for the second wave of the pandemic.5 Better financial support for family caregivers Seniors and their caregivers are an important and growing segment of the population. Family caregivers often provide funding for their family members’ home and long-term care. These added expenses can also coincide with the caregiver’s withdrawal from the workforce in order to provide care. Caregivers carry many responsibilities, including financial ones. It is estimated that private expenditures for seniors’ care will increase 150% faster than available household income between 2019 and 2035.6 Given their enormous contributions, caregivers need help in the form of financial support, education, peer support and respite care. The CMA recommends: 1. Implementing a caregivers’ allowance to deal with increased home care expenses (similar to the family allowance); a caregiver’s allowance exists in Nova Scotia7 and the United Kingdom8 2. An increased tax credit for caregivers More respite for caregivers The CMA supports the desire of the Minister Responsible for Seniors and Informal Caregivers to “ensure that more seniors are able to stay at home.” Indeed, the vast majority of seniors remain at home (93.2%),9 even though many are dealing with reduced autonomy. Caregivers are essential wellness supports for seniors. However, these caregivers are at risk of developing health problems such as stress, anxiety and exhaustion. They need a complete range of support services to prevent health problems. Even though the CMA applauds the refundable tax credit announced in Quebec’s 2020–2021 budget, we believe that the draft bill should include concrete measures to provide greater respite to caregivers. The CMA recommends: 1. Increasing the tax credit for caregiver respite 2. Increasing resources for caregiver respite, such as respite and psychological support centres, and the rollout of respite homes for caregivers across the province 3. Increasing home support services for seniors and caregivers 5 600 De Maisonneuve Blvd. West, Suite 500, Montréal, Quebec H3A 3J2 Supporting caregivers through virtual care New technologies such as telemedicine and telehealth offer quick access to health care while eliminating travel and related expenses. In February 2020, the CMA, the Royal College of Physicians and Surgeons of Canada, and the College of Family Physicians of Canada created a framework for expanding virtual medical services in Canada, identifying the national standards, legislation and policy that must be put in place. As we have seen during the pandemic, telemedicine and telehealth can play an important role in improving seniors’ access to primary care. Several recommendations have come from the Report of the Virtual Care Task Force, such as: 1. Maintaining the fee schedule for virtual care that was put in place for the COVID-19 pandemic 2. Simplifying the licensing system to allow the provision of virtual care throughout the country 3. Integrating virtual care into physician learning 4. Creating national standards for patients’ access to health information10 The CMA also recognizes the need to improve digital health literacy. Accordingly, we have asked the federal government to recognize and support the adoption of virtual care and address inequities in access to digital health services by creating a digital health care knowledge bank and accelerating the expansion of high-speed internet services to the entire Canadian population. Meeting caregivers’ training needs Another key support element for caregivers is the provision of accessible training. Caregiver training must comprise a significant element of the government’s action plan, particularly with respect to our capacity to respond more effectively to the second wave of the pandemic. The CMA is encouraged that the government’s action plan recognizes the important role that caregivers play in supporting seniors and the fact that their safety must not be compromised: “Maintain secure access to CHSLD and RPA facilities for family and informal caregivers.”11 Conclusion The CMA looks forward to developing solutions with government authorities and offers its full cooperation with respect to recommendations on the national policy, action plans and the situation of caregivers in Quebec. One of the objectives of the CMA in Quebec is to disseminate knowledge, skills and best practices in senior care from other Canadian and international regions. The CMA is ready and willing to work with governments, caregivers and health care providers so that caregivers may prosper along with the people they care for. 6 600 De Maisonneuve Blvd. West, Suite 500, Montréal, Quebec H3A 3J2 1 Home Care Ontario. New Poll Shows Over 90% of Ontario Seniors Want to Live at Home as They Age, and Want Government to Invest to Help Them Do It. August 7, 2020. https://www.newswire.ca/news-releases/new-poll-shows-over-90-of-ontario-seniors-want-to-live-at-home-as-they-age-and-want-government-to-invest-to-help-them-do-it-857341964.html. 2 Canadian Institute for Health Information. 1 in 3 unpaid caregivers in Canada are distressed. August 6, 2020. https://www.cihi.ca/en/1-in-3-unpaid-caregivers-in-canada-are-distressed. 3 Fast, J., lero, D., Duncan, K., and coll. Employment consequences of family/friend caregiving in Canada. Edmonton: Research on Aging, Policies and Practice, University of Alberta, 2011. 4 Canadian Foundation for Health care Improvement. Re-Integration of Family Caregivers as Essential Partners in Care in a Time of COVID-19. July 8, 2020. https://www.cfhi-fcass.ca/about/news-and-stories/news-detail/2020/07/08/re-integration-of-family-caregivers-as-essential-partners-in-care-in-a-time-of-covid-19. 5 Government of Quebec, 2020. COVID-19: Action Plan for a Second Wave. https://publications.msss.gouv.qc.ca/msss/fichiers/2020/20-210-257W.pdf. 6 The Conference Board of Canada (2019). Measures to Better Support Seniors and Their Caregivers. https://www.cma.ca/sites/default/files/pdf/health-advocacy/Measures-to-better-support-seniors-and-their-caregivers-e.pdf. 7 https://novascotia.ca/dhw/ccs/caregiver-benefit.asp. 8 https://www.carersuk.org/help-and-advice/financial-support/help-with-benefits/carers-allowance. 9 Statistics Canada, 2016 Census. 10 Canadian Medical Association, College of Family Physicians of Canada and Royal College of Physicians and Surgeons of Canada. Virtual Care: Recommendations For Scaling Up Virtual Medical Services. Report of the Virtual Care Task Force. February 2020. https://www.cma.ca/sites/default/files/pdf/virtual-care/ReportoftheVirtualCareTaskForce.pdf. 11 Government of Quebec, 2020. COVID-19: Action Plan for a Second Wave. https://publications.msss.gouv.qc.ca/msss/fichiers/2020/20-210-254W-A.pdf.
Documents
Less detail

17 records – page 1 of 1.