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)
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.
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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.
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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
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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.
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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
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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.
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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.
That the Canadian Medical Association seek clarification and definition of the term "medically required service", as applied to health funding legislation.
That the Canadian Medical Association seek clarification and definition of the term "medically required service", as applied to health funding legislation.
Text
That the Canadian Medical Association seek clarification and definition of the term "medically required service", as applied to health funding legislation.
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
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
That Canadian Medical Association recommend to the federal, provincial and territorial governments that they should immediately review the creation of tax-related programs that will help patients offset the ever-increasing out-of-pocket cost of health care services, which should include:
1. an increase in the currently allowable medical tax credit, and
2. a health savings plan similar to the RRSP program for application to anticipated future expenses such as long-term care, home care and pharmacological expenses.
That Canadian Medical Association recommend to the federal, provincial and territorial governments that they should immediately review the creation of tax-related programs that will help patients offset the ever-increasing out-of-pocket cost of health care services, which should include:
1. an increase in the currently allowable medical tax credit, and
2. a health savings plan similar to the RRSP program for application to anticipated future expenses such as long-term care, home care and pharmacological expenses.
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That Canadian Medical Association recommend to the federal, provincial and territorial governments that they should immediately review the creation of tax-related programs that will help patients offset the ever-increasing out-of-pocket cost of health care services, which should include:
1. an increase in the currently allowable medical tax credit, and
2. a health savings plan similar to the RRSP program for application to anticipated future expenses such as long-term care, home care and pharmacological expenses.
