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Active Transportation

https://policybase.cma.ca/en/permalink/policy9483
Last Reviewed
2020-02-29
Date
2009-05-31
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2009-05-31
Topics
Population health/ health equity/ public health
Text
The major diseases affecting the quality and quantity of life of Canadians, which include obesity, diabetes, coronary artery disease, depression and cancer, are all linked to physical inactivity. In Canada, 69% of women and 68% of men in Canada are considered physically inactive.(1) The cost of this inactivity and obesity was estimated at $4.3 billion in 2001.(2) A 10% increase in physical activity could potentially reduce direct health care expenditures by $150 million a year. This does not include indirect costs such as lost productivity due to illness, premature death or a range of other factors, including mental illness and poor quality of life.(3) Thus far, efforts to increase physical activity by changing the behaviour of individuals have had limited success. One reason is that many people have difficulty sustaining behaviours that involve additional time commitments. That is one reason for the increasing emphasis being placed on active transportation, which is any human-powered form of transportation, such as walking and cycling. Walking and cycling can be efficient alternatives to automobile travel. Cycling is usually the fastest mode of travel door to door for distances under five km, and for up to 10 km in city cores. Walking is simpler and nearly as fast for distances up to two km. When travel times are similar for active and motorized transportation, physical activity is gained with no net time lost, and at much lower cost. The cost of operating a motor vehicle is typically $10,000 per year,(4) while operating costs for a bicycle are much lower. Communities that have sidewalks, enjoyable scenery, street lights and nearby stores have improved levels of active transportation and physical activity. However, in recent decades communities have often been designed around the automobile. Street design, parking space, sidewalks and distance to retail destinations have all been planned assuming motorized transportation, and this often makes it difficult to move around communities by walking or cycling. Although individual decision-making remains important in any strategy for increasing active transportation, there is an essential role for communities and governments to play. Major improvements in the health of Canadians in the past 200 years have been due to improved sanitation, access to clean water and injury prevention. The role of individual decision-making in effecting these changes is dwarfed by the impact of the public health measures and infrastructure involved. Just as potable tap water is a health issue, so are decisions about land use, transportation policy and infrastructure. Community design is a major determinant of whether people use active transportation, whether they are physically active and whether they are obese. Canadians need communities that make it easy to be physically active in their daily living. Communities can create an environment in which the physically active choice is the easy choice. They can do this via sidewalks, trails, bicycle lanes and bicycle paths, and by providing pedestrian-friendly intersections, parks and green spaces, and safe bicycle parking spaces. They can also arrange zoning so that retail destinations are within walking or cycling distance of residential areas. This process also includes dedicating a sufficient portion of their street maintenance budget (including snow clearing) to maintaining active transportation routes as well as routes for motorized vehicles. It may include redesigning intersections, giving up vehicle lanes or parking spaces, or increasing the price of parking. Additional benefits to designing communities for pedestrians and cyclists. * a stronger sense of community with greater civic involvement by citizens * increased property values and retail activity * less noise pollution * lower crime rates * less smog and other air pollution * less greenhouse gas production * decreased risk of injury to pedestrians and cyclists * decreased costs of roadway and parking construction. A role for everyone Other sectors can support communities in making active transportation choices easy choices: * Businesses can create a work environment friendly to active transportation, including a corporate culture friendly to physical activity. They can incorporate active transportation planning into building design and create an environment friendly to physical activity. These steps could include making bicycle parking, showers and lockers available, and providing stairs that are pleasant and easier to access than elevators. They can also incorporate a culture of physical activity in decisions about where and how to hold meetings, and what people are allowed to wear to work. * School boards can develop policies to promote active transportation to and from school. These include building and maintaining secure bicycle parking, ensuring safe walking routes within communities, and assisting parents in walking their children to school. * Citizens can use active transportation themselves and treat with respect those who are already making active transportation choices. They can also lobby governments to make their community safer and easier places for cycling and walking. * Physicians can encourage patients to use active transportation as a way to boost their physical activity levels and improving their health. They can also lead by example and use active transportation themselves. Recommendations The CMA recommends that all sectors (government, business and the public) work together, as a matter of priority, to create a culture in their communities that supports and encourages active transportation. The CMA urges governments to: * Commit to long-term plans for active transportation networks that are in keeping with these goals and that include specific benchmarks to measure progress. * Require that active transportation be part of all infrastructure renewal projects, with investment in active transportation vs. motorized transportation in proportion to targeted active transportation use. (Some cities have achieved active transportation rates of up to 15%.) * Develop an awareness campaign to help Canadians to recognize the value of active transportation in their communities. * Require public health impact assessments for all land-use and transportation decisions, including the impact on the chemical environment and on physical activity. * Assess the impact that changes in the "built" environment can have on public health, and which interventions are most safe and effective. 1 Tremblay MS, Katzmarzyk PT, Willms JD. Temporal trends in overweight and obesity in Canada, 1981-1996. Int J Obes Relat Metab Disord 2002;26(4):538-43. 2 Katzmarzyk PT, Janssen I. The economic costs associated with physical inactivity and obesity in Canada: an update. Can J App Phys 2004;29(1):104. 3 Katzmarzyk PT, Gledhill N, Shephard RJ. The economic burden of physical inactivity in Canada. CMAJ 2000;163(11): 1435-40. 4 Canadian Automobile Association. Driving Costs: 2005 Edition. Available: www.carpool.ca/pdf/CAA-driving-costs-05.pdf (accessed 2007 Feb. 2).
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Flexibility in Medical Training (Update 2009)

https://policybase.cma.ca/en/permalink/policy9485
Last Reviewed
2020-02-29
Date
2009-05-31
Topics
Health human resources
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2009-05-31
Replaces
Flexibility in Medical Training
Topics
Health human resources
Text
Flexibility in Medical Training (Update 2009) The Canadian Medical Association (CMA) believes that the medical training system must be sufficiently flexible to enable medical students to make informed career choices, accommodate resident program changes, and allow practising physicians the opportunity to re-enter training to enhance their skills and knowledge, or to enter a new sphere of practice. The system must also be able to accommodate international medical graduates (IMGs) to provide them with a reasonable opportunity to attain their postgraduate credentials and become licensed to practise in Canada. For physicians-in-training, effective career guidance and positive influences on career options (e.g., role modelling, early clinical exposure, etc.) may foster confidence with career path selection and minimize program changes during residency. A flexible and well-designed re-entry postgraduate system would be characterized by: long-term stability, sufficient and appropriate capacity, accessibility, flexibility in the workforce and accountability. The CMA believes that, ultimately, society benefits from a flexible medical training system. These benefits may include enhanced patient care, improved access to physician services, as well as physician retention, particularly in rural and remote communities. A flexible system may also improve morale and satisfaction among students, residents and physicians, and facilitate better career choices. This policy outlines specific recommendations to help create and maintain a well-designed system for flexibility in physician training in Canada. Commitment and action by all stakeholders, including governments, medical schools, regulatory authorities and others, is required. The CMA believes that this policy must be considered in the context of other relevant CMA policies, including but not limited to the CMA's policies on physician resource planning, physician health and well-being, physician workforce issues and others. Definitions - Postgraduate trainee - Also known as a "resident," an individual who has received his/her MD degree and is currently enrolled in an accredited program in a Canadian school of medicine that would lead to certification by either the College of Family Physicians of Canada or the Royal College of Physicians and Surgeons of Canada. - Medical student - An individual enrolled in an undergraduate program in a Canadian school of medicine that would lead to an MD degree. - International medical graduate - An individual who received his/her MD degree from a training program other than from one of Canada's undergraduate schools of medicine. - Designated positions - Postgraduate positions within the determined complement of residency positions that are identified to meet a need other than that of accommodating the annual number of new graduates of Canadian medical schools to complete the usual training for certification and licensure. Designated positions may be identified for a variety of purposes. The need for informed career decision-making and positive influences Choice of practice discipline as lifelong career can be one of the most difficult aspects of physician training. Exacerbating this challenge are the vast array of available specialties, timing of choices, as well as practice considerations in terms of lifestyle and physician resource needs. The rapidly changing face of medical practice as well as the limited amount of information and time available to consider options, are also contributing factors. A number of other forces, both positive and negative, may affect students' choices of practice specialty. These can include financial considerations in light of student debt incurred by high tuition fees and insufficient financial support. 12 The biases of faculty, family and others may also impact decisions. In addition, limited training opportunities in general, as well as a lack of flexibility to switch training programs, may also restrict choice of practice specialty. While a myriad of personal factors are acknowledged to also play contributing roles in influencing program selection, these issues are too complex to discuss here. Ultimately, students need to have access to financial support so as to reduce stress and the influence of debt on specialty choice. They also need objective information and guidance and broad clinical experiences early in their medical training as this has been identified as a critical factor in making decisions about their future careers.3 The rotating internship, abolished in the early 1990s, used to permit residency selection at a later stage in medical training. The residency program match now takes place during the final year of undergraduate studies. As a consequence of this earlier timing, some students feel pressured to make their specialty choice too early in their medical education and often before their clerkship has even begun. This can include focusing research and program electives4 in one specific area, rather than sampling a broad range of disciplines, to demonstrate conviction of choice to residency program directors at the time of the match. Fifty-nine percent of respondents to the Canadian Resident Matching Service's (CaRMS) 2006 post-match survey indicated they completed more than half of their electives in their first-choice discipline.5 This, combined with the early timing of the residency match, can lead to an uninformed choice of residency program and the realization, at a later date, that a different training program would be more suitable. Eighty percent of medical leader respondents to the 2008 Core Competency Project survey indicated that timing of career choice was the biggest challenge for career decision-making.6 Those residents who wish to change to new training programs may not believe they have the opportunity to do so. Thirty-seven percent of resident respondents to the Core Competency Project survey considered switching disciplines during their residency training7 and 39% had spoken to a faculty member about switching programs.8 Others who do change programs are ultimately delayed entry into the workforce as a result of their prolonged training. This problem is exacerbated by an insufficient number of re-entry postgraduate training positions and large debt that confine trainees to a single career path. Lack of student confidence and preparedness in choosing a postgraduate training program, or lack of success in achieving a first choice in the postgraduate match, may predict subsequent program changes. A broad range of strategies must be available to help medical students make informed career choices. These include a wider choice of electives at an earlier stage of training, positive and unbiased mentoring experiences, improved access to career information from residents, as well as career seminars and other resources. In light of the above, the CMA recommends that: 1. the undergraduate medical school curriculum be re-designed to facilitate informed career choice and, in particular, to ensure that students enjoy a broad range of clinical experiences before they have to choose a specific discipline (i.e., via CaRMS match); 2. national career counselling curricula for both medical students and residents be developed and include the following components: national standardization; stakeholder input (students, residents and others); positive and fair role modelling by both residents and practising physicians/faculty, with appropriate professional respect among medical disciplines; and formal and informal mentorship programs; 3. a wide-range of elective opportunities be developed and communicated at a national level; 4. electives reflect a broad spectrum of experiences, including community-based opportunities; 5. clinical experiences be introduced at the earliest possible stage of undergraduate learning; 6. a national policy be implemented to ensure mandatory diversification of student elective experiences; and 7. medical schools be permitted and encouraged to model alternate systems of postgraduate learning. The need for broad-based medical education In order to provide medical students with the greatest options for flexibility in medical training, they should be actively encouraged to pursue a broad-based medical education. Previously, CMA advocated for a common postgraduate year (PGY1). In the 2008 Core Competency Project survey, 77% of physician respondents, 70% of medical student respondents and 67% of program director respondents expressed support for first year residents to do a broad-based common PGY1-like rotating internship.9 The rationale for and importance of ensuring flexibility has been outlined in the previous sections. Capacity of the postgraduate training system An essential component in ensuring flexibility within the medical training system is to establish and maintain sufficient capacity at the postgraduate training level. This is necessary for the following reasons: * Sufficient capacity may prevent highly-skilled and well-trained Canadian physicians from being forced to seek postgraduate training in the U.S. and remain there to practise medicine. * It is necessary to provide IMGs with a reasonable opportunity to attain their postgraduate credentials and become licensed to practise in Canada. This reflects the CMA's recognition of the important contribution that IMGs have made, and continue to make, in the provision of medical services, teaching and research in Canada. Opportunities for IMGs will also permit Canadians who study medicine abroad to pursue their medical careers in Canada. * It is essential to provide students with sufficient choice to seek the training that best matches their skills and interests as well as societal demands. * It is crucial to provide sufficient re-entry positions to allow practising physicians to seek training in other areas of medicine to meet the demands of their communities. [Please refer to the "Re-entry" section of this policy for more details.] In light of the above, the CMA recommends that: 8. mechanisms be developed to permit reasonable movement of residents within the overall residency structure and career counselling supports be made available to residents considering such a change; 9. the capacity of the postgraduate training system be sufficiently large to accommodate the needs of the graduating cohort, the re-entry cohort, and the training needs of international medical graduates; 10. there be a clearly defined pool of re-entry postgraduate positions and positions for international medical graduates; 11. government match and maintain undergraduate medical enrolment with a target of at least 120 ministry-funded postgraduate training positions per 100 Canadian medical graduates, to accommodate the training needs of the graduating cohort, the re-entry cohort and international medical graduates; and 12. options be explored for influencing governments to support a flexible postgraduate medical education system that also meets societal needs. Re-entry medical training system Note: This section addresses only one kind of designated position, specifically, those for licensed physicians wishing to re-enter training after a period in practice (also known as "re-entry positions"). The re-entry positions addressed in this paper would require no return for service. Designated positions for training in return for service in a specified discipline and location is a separate entity from general re-entry. Increased opportunity for exposure to the breadth of medical fields in undergraduate training, improved undergraduate career counselling and a postgraduate system that makes the changing of disciplines easier are some of the many aspects that should facilitate residents' satisfaction with career choice. There will, however, inevitably be individual cases where issues of societal need, personal health, lifestyle or personal choice necessitate a change in career direction after postgraduate training. This requires the availability of additional postgraduate positions allotted specifically to this sub-set. A sufficient and stable supply of re-entry positions is needed within the postgraduate training system to enable practising physicians to enhance their skills or re-enter training in another discipline. While this may apply mostly to family physicians and general practitioners wishing to train in a specialty discipline, it can also include practising specialists wanting to sub-specialize or train in another area, which could be Family Medicine. The additional or new training of primary care physicians, particularly in obstetrics, emergency medicine, anaesthesia, surgery, psychiatry and general internal medicine, will be of benefit to smaller communities lacking regular access to these specialty medical services. In addition, the availability of adequate re-entry positions may encourage new physicians to accept locum tenens, thus relieving overworked physicians in underserviced communities. Potentially, it could help to increase a community's long-term retention rate of established physicians. The CMA believes that a well-designed re-entry system for Canadian postgraduate medical education would be characterized by an accessible national registry, long-term stability, sufficient and appropriate capacity, accessibility, flexibility in the workforce and accountability. Stability Medical students need reassurance that re-entry positions will be available if they wish to re-enter training after a period in practice. This will enable them to better plan their careers, reduce anxieties about career selection and ultimately help to meet the health care needs of society. For physicians re-entering the postgraduate training system, there must also be the guarantee that sufficient program funding will be available to ensure completion of training. The CMA therefore recommends that: 13. a complement of clearly defined, permanent re-entry positions with stable funding be a basic component of the Canadian postgraduate training system and that the availability of these positions be effectively communicated to potential candidates; and 14. funding for re-entry positions be specifically allocated for the entire training period. Capacity The CMA believes that the capacity of the postgraduate training system must be sufficiently large to accommodate the needs of the re-entry cohort and that postgraduate re-entry positions should be supernumerary to the numbers required for the graduating cohort. [Please refer to the "Capacity of the Postgraduate Training System" section of this policy for specific recommendations.] Accessibility The CMA believes that re-entry physicians should not be restricted to competing for particular disciplines for which there is an identified need in their jurisdiction. Re-entry physicians should also be able to compete for any available disciplines across all training programs. Not every discipline will be available for re-entry each year but all should be accessible over the course of a three-year period. The CMA therefore recommends that: 15. there be accessibility within re-entry postgraduate training positions including: * open and fair competition at the national level among all re-entry candidates for the clearly defined pool of re-entry positions, * that the mix of positions available reflect the overall mix of positions in the postgraduate training system, and * recognizing the limited size of the re-entry pool, access to all specialties be available over a three-year period rather than on an annual basis; and 16. access to entry should be possible through both national and regional pools of re-entry positions, with a process comparable to that currently used for the postgraduate training system. Flexibility in the Workforce As previously mentioned, the re-entry positions discussed in this paper would require no return for service. Designated positions for training in return for service in a specified discipline and location is a separate entity from general re-entry. The CMA therefore recommends that: 17. physicians who have retrained through the re-entry system have the same practice opportunities as physicians entering the workforce for the first time. Accountability The CMA recognizes the importance of public accountability and sound fiscal management and therefore recommends that: 18. there be on-going evaluation of the re-entry system in Canadian postgraduate medical education. 1 Kwong JC, Dhalla IA, Streiner DL, Baddour RE, Waddell AE & IL Johnson. Effects of rising tuition fees on medical school class composition and financial outlook. CMAJ 2002; 166 (8): 1023-8. 2 2007 National Physician Survey Data. 3 Directions for Residency Education, 2009 - A final report of the Core Competency Project. February 2009. Royal College of Physicians and Surgeons of Canada and College of Family Physicians of Canada. 4 Ibid, page 23. 5 Ibid. 6 Ibid, page 59. 7 Ibid, page 27. 8 Ibid, page 60. 9 Ibid.
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Tuition fee escalation and deregulation in undergraduate programs in medicine (Update 2009)

https://policybase.cma.ca/en/permalink/policy9487
Last Reviewed
2020-02-29
Date
2009-05-31
Topics
Health human resources
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2009-05-31
Replaces
Tuition fee escalation and deregulation in undergraduate programs in medicine
Topics
Health human resources
Text
TUITION FEE ESCALATION AND DEREGULATION IN UNDERGRADUATE PROGRAMS IN MEDICINE (Update 2009) The Canadian Medical Association (CMA) is very concerned about high and rapidly escalating, undergraduate medical school tuition fees across Canada. Ontario set a precedent for the deregulation of tuition fees in May 1998 and many provinces have since followed. This policy gives universities, including medical schools, the discretion to set fees for training in those areas that lead to professional careers, such as medicine. For the 2008-2009 academic year, first-year tuition fees at most Ontario medical schools were triple the tuition fees in 1997-1998 at an average of $16,550 per year;1 this figure does not include compulsory "other fees" that can be as much as $1,700 per year.2 Irrespective of whether tuition fees have been regulated, some medical schools outside of Ontario have doubled their tuition fees within the same time period. Decreased government funding to universities is increasing the fiscal pressures on institutions and is driving these dramatic tuition fee increases. The CMA believes that high tuition fees, coupled with insufficient financial support systems, have a significant and detrimental impact on not only current and potential medical students, but also the Canadian health care system and public access to medical services. Broad Effects of High Tuition Fees Lack of Diversity Medical education in Canada has traditionally been affordable and accessible to individuals from a range of socioeconomic and ethnic groups who later serve an equally diverse population. Unfortunately, the introduction of high tuition fees may close the door to individuals who either cannot afford the high costs of a medical education or wish to avoid the prospect of significant debt load upon graduation. High tuition fees may therefore create an imbalance in admissions to medical school by favouring those who represent the affluent segment of society and not the variety of groups reflected in the Canadian population. The proportion of medical students from lower income families is already extremely low and decreasing further.3 Paradoxically, funds that should be injected to making tuition fees reasonable - and therefore more accessible by a broader range of society - may soon need to be allocated to creating career promotion and special financial support programs that target those groups that have been alienated by high tuition fees. Influence on Practice Choice and Practice Location ("Brain Drain") It is likely that paying off debts as quickly as possible will become a key consideration when determining practice location and specialty. For instance, more students may feel compelled to maximize their earning potential by pursuing those specialties that generate high incomes; others may choose those specialties with short training periods so they can enter the workforce and start to pay off debts sooner. Debt load may also influence where graduating physicians choose to practise medicine. The increasing willingness of American recruiters to pay off the debts of new graduates provides tremendous incentive to practise in the U.S. and explore research opportunities; unfortunately, it only aggravates the ongoing problem of the "brain drain" of Canadian physicians.4 While we have been enjoying a net gain of physicians from the U.S., we may experience net loss with physician shortages expected in the U.S. More physician retention and recruitment initiatives are needed to encourage physicians to remain in or return to Canada. This is especially true for rural and remote communities. Urban areas are often in a better financial position to offer incentives to new graduates than rural and remote communities where physician shortages are most pronounced. Effects on Rural and Remote Areas The CMA believes that governments must be made aware of the potentially negative impact of high tuition fees and student debt on physician workforce supply for the rural and remote areas of Canada. Research shows that medical students from rural and remote areas have a greater likelihood of returning to these communities to practise medicine.5 Research also shows that students of rural origin have higher student debts6 and are underrepresented in Canadian medical schools.7 Students from rural and remote communities face the challenge of not being able to live at home while they attend university. They must assume high relocation expenses and travel costs, as well as separation from their families while they are away at school. Of student respondents to the 2007 National Physician Survey, 53.1% of rural students compared with 67.4% of urban medical students had no debt upon entering medical school. When asked to predict their expected debt upon completion of medical school, 33.2% of rural students compared with 23% of urban students expected their debtload to exceed $100,000.8 Unfortunately, the introduction of high tuition fees might make both the personal and financial costs of pursuing a medical education too significant for students from rural and remote areas to even consider. As a result, this may generate fewer physicians willing to practise in these areas and exacerbate the problem most rural and remote communities already face in attracting and retaining physicians. High tuition fees might also further increase the reliance on international medical graduates in rural and remote communities. While the CMA values the contributions of international medical graduates in alleviating shortages in physician supply, it believes that Canadian governments must adopt the guiding principle of self-sufficiency in the production and retention of physicians to meet population needs. Effects on New and Potential Medical Students Medical students affected by high and escalating tuition fees will graduate with unprecedented debt loads. Enormous education costs, already a reality in some provinces, are a growing trend. In 2007, over one third (36%) of students said they expected debtloads of $80,000 or more upon completion of medical school.9 A number of factors, as highlighted below, contribute to students' financial burden and may affect their ability to pay off debts and meet financial obligations. This, in turn, may influence their choice of medical discipline and practice location. Exorbitant education costs may also result in students considering dropping out of, or taking longer to complete, their medical studies because they cannot afford the ongoing costs, or are too overwhelmed with the combined stress of their medical studies and trying to make financial ends meet. The CMA is very concerned that excessive debt loads will exacerbate the stress already experienced by medical students during their training and will have a significant and negative impact on their health and well-being. Previous Education Debt and Accumulative Debt Most Canadian medical schools make an undergraduate degree a prerequisite to application. As such, by the time most students are accepted into medical school, they may have already accumulated debt from a previous undergraduate degree. Many students have also completed postgraduate degrees before entering medical school.10 This debt continues to accumulate during the undergraduate years of medical school and into the postgraduate training period, which is anywhere from two years to seven years in duration. This does not include additional time spent doing fellowships. It may be very useful to establish a national clearinghouse of public and private financial assistance programs to help students in their search for financial support. Limited or No Employment Opportunities during Undergraduate Training Tuition fees, along with ongoing increases in living expenses, are already making it very difficult for some students to make ends meet. It makes matters worse that there are limited or no opportunities to generate income through employment during the academic year and the summer months. Given the intensity of the medical school program, some schools strongly advise against working part time. To further compound the problem, some schools have very short summer breaks. For those schools that do provide summer holidays, the holidays often start later than other university programs, by which time employment opportunities are scarce or low paying. There is also the common expectation that medical students will undertake unpaid clinical or research elective experiences during the summer to enhance their desirability for postgraduate medical programs. Limited or No Remuneration for the Clinical Clerkship During the clerkship years, there are no summertime breaks because students spend these years working in hospitals and other clinical settings. All Canadian medical students (outside of Québec) receive a relatively small stipend during their clerkship varying from $2,808 to $6,000;11 however, the stipend had previously been abolished in medical schools in Ontario and Québec in the early 1990s. Fortunately Ontario reinstated the stipend as the Final Year Medical Student Bursary in 2004.12 Unique Expenses In addition to very limited or no opportunities to generate employment income, medical students must bear a number of unique and significant costs. These include very high textbook and instrument costs, as well as a variety of expenses associated with their clerkship, such as travel to and from the clinical setting and the need for professional attire. The introduction of distributed medical education including satellite campuses, co-campuses and rural learning sites has increased the amount of travel required of medical students as well as the associated costs. Off-site electives also generate many additional expenses, including the cost for travel to the site - which may be in a different province - as well as accommodation and other living expenses. A 1999 survey of graduating medical students revealed that more than half took an off-site elective at a specific institution in order to increase their chances of being matched to that site.13 As postgraduate training becomes even more competitive, the number of students taking off-site electives may increase and so will the number of students who are adding this expense to their overall debt load. Medical students must also assume considerable costs related to interviews for residency training, including the high costs for travel to various interview sites, accommodation expenses, application fees for the resident matching service and other miscellaneous expenses. There is also a considerable fee for the qualifying examination that is written at the end of medical school. Insufficient Public Funding and Increasing Reliance on Bank Loans Government financial support programs (bursaries and loans) are not increasing to meet students' needs due to rising tuition costs and living expenses. As a consequence, the number of students who must rely on interest-bearing bank loans to help support themselves while they are in school may increase. Unlike some government programs, repayment of bank loans often cannot be postponed until after graduation and interest payment is required during the course of study; this further exacerbates students' financial stress. Residency Costs Upon graduation from medical school, students must pursue two to seven years of postgraduate training to obtain a licence to practise medicine. This training period is marked with fees for examinations as well as an annual tuition and/or registration fee. During 2008-2009, the tuition fee was as much as $3,900 in some provinces.14 Residents are also required to work long hours in hospitals and other clinical settings and have frequent on-call responsibilities. Although residents do receive a salary for this work, the remuneration is relatively modest when these factors and debt servicing payments are considered. In fact, mandatory debt maintenance can consume a very significant proportion of a resident's pay.15 The CMA opposes tuition fees for residents. While the CMA's opposition to residency tuition is based on a number of factors not limited to its financial impact, clearly, tuition fees exacerbate debt. High Practice Start-up Costs and Decreased Pay Potential Licensed physicians wanting to establish a clinical practice currently face start-up costs estimated between $30,000 and $50,000, depending on their practice specialty and type (e.g., solo versus group practice).16 Some specialties require capital investment over and above the basic start-up costs. These expenses will add to the significant debt that new physicians will bear in the next few years. Other Factors In addition to significantly higher debt load than the previous generation of new physicians, a number of factors may influence the net income of physicians and their ability to pay off debts. These include billing caps, stagnant fees for services, high malpractice insurance fees, overhead expenses and increasing non-remunerative administrative responsibilities. Summary In summary, the CMA believes that high tuition fees, coupled with insufficient financial support systems, have a significant impact on not only current and potential medical students, but also the Canadian health care system and public access to medical services. This impact includes: * creating socioeconomic barriers to application to medical school and threatening the diversity of future physicians serving the public * exacerbating the physician brain drain to the U.S. where new physicians can pay off their huge debts more quickly * generating fewer physicians available or interested in practising in rural and remote areas of Canada Recommendations In response to its concerns regarding the deregulation of tuition fees and high tuition fee increases, the CMA recommends that: 1 governments increase funding to medical schools to alleviate the pressures driving tuition increases 2 any tuition increase should be regulated and reasonable 3 financial support systems for students be developed concomitantly or in advance of any tuition increase, be in direct proportion to the tuition fee increase and provided at levels that meet the needs of students. Appendix Glossary of Terms Undergraduate Program in Medicine, also known as "Medical School" Medical school is the period of study, usually four years in duration that leads to the doctor of medicine or "MD" degree upon graduation. Most Canadian universities require applicants to the undergraduate medicine program to have at least a three-year degree (e.g., Bachelor of Science degree) before they are eligible to apply. Although the title "Doctor" is conferred upon successful completion of the undergraduate program, an additional two to seven years or more of residency training is required before these individuals can apply for a licence to practise medicine in Canada. Clerkship The clerkship is the period during the last one to two years of undergraduate studies in medicine during which medical students work in hospitals, clinics and physicians' offices. Off-site Elective Many students take off-site electives during their clerkship. An "elective" is a course or training that is not mandatory to the curriculum, but may be elected or chosen by the student. An "off-site" elective means that the training is being provided at a location different from the medical school where the student is enrolled; for example, the elective may be in a different city, province, or even a different country. Resident Matching During the last year of undergraduate training, most graduating medical students participate in a national process that matches them with available residency training positions in Canada. Residency/Postgraduate Training Period After earning his/her MD degree and receiving the title "Doctor," additional training is required in a specific area before an individual may practise medicine in Canada. This period of training is referred to as "residency" or "postgraduate training;" the individuals undergoing the training are called "residents." Residents usually work in hospitals (also called "teaching hospitals") under the supervision of a licensed physician. Depending on the field of study, residency training may range from two to seven years or longer if subspecialty training is pursued (e.g., pediatric cardiology). At the end of residency training, individuals must pass a number of examinations to practise medicine in Canada. Fellowship A fellowship is training sought by individuals who wish to obtain expertise in a specific area of medicine above and beyond basic residency requirements. References 1 Tuition Fees in Canadian Faculties of Medicine: Session Commencing Fall 2008. Office of Research and Information Services, Association of Faculties of Medicine of Canada, November 2008. 2 Ibid. 3 Kwong JC, Dhalla IA, Streiner DL, Baddour RE, Waddell AE & IL Johnson. Effects of rising tuition fees on medical school class composition and financial outlook. CMAJ 2002; 166 (8): 1023-8. 4 "Are We Losing Our Minds? Trends, Determinants and the Role of Taxation in Brain Drain to the United States," The Conference Board of Canada, July 1999. 5 Advisory Panel Report on the Provision of Medical Services in Underserviced Regions. Canadian Medical Association, 1992. 6 2007 National Physician Survey. 7 Dhalla IA, Kwong JC, Streiner DL, Baddour RE, Waddell AE, Johnson IL, et al. Characteristics of first-year students in Canadian medical schools. CMAJ 2002;166(8):1029-35. [0] 8 2007 National Physician Survey. 9 2007 National Physician Survey. 10 "Educational Attainment at Time of Application of Registered and Not Registered Applicants to Canadian Faculties of Medicine - 2006-2007 (Table 105)." 2008 Canadian Medical Education Statistics. Association of Faculties of Medicine of Canada, Volume 30, p154. 11 "Duration of Clinical Clerkship and Amount of Stipend in Canadian Faculties of Medicine 2008-2009 (Table 7)." 2008 Canadian Medical Education Statistics. Association of Faculties of Medicine of Canada, Volume 30, p9. 12 Clinical Clerkship Stipends by Faculty of Medicine, 1995-1996 to 1999-2000, Canadian Medical Association Research Directorate, January 2000. 13 Results of the Post-Match Survey of Students Graduating 1999, Canadian Resident Matching Service. 14 "Post-MD Clinical Trainee Fees in Canadian Faculties of Medicine - 2008-2009 (Table 6)." 2008 Canadian Medical Education Statistics. Association of Faculties of Medicine of Canada, Volume 30, p8. 15 2007 National Physician Survey. 16 Practice Management, MD Management Ltd.
Documents
Less detail

Household antibacterial products

https://policybase.cma.ca/en/permalink/policy9565
Last Reviewed
2020-02-29
Date
2009-08-19
Topics
Health care and patient safety
Resolution
GC09-90
The Canadian Medical Association calls upon the federal government to ban the sale of household antibacterial products due to the risk of bacterial resistance and to recognize that soap and alcohol-based solutions are as effective in preventing household infection.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
2009-08-19
Topics
Health care and patient safety
Resolution
GC09-90
The Canadian Medical Association calls upon the federal government to ban the sale of household antibacterial products due to the risk of bacterial resistance and to recognize that soap and alcohol-based solutions are as effective in preventing household infection.
Text
The Canadian Medical Association calls upon the federal government to ban the sale of household antibacterial products due to the risk of bacterial resistance and to recognize that soap and alcohol-based solutions are as effective in preventing household infection.
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Brief to the House of Commons Standing Committee on Finance 1995 Pre-Budget Consultation

https://policybase.cma.ca/en/permalink/policy1994
Last Reviewed
2019-03-03
Date
1994-11-18
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
1994-11-18
Topics
Health systems, system funding and performance
Text
I. PURPOSE While Canada is undergoing significant social, political and economic change, the Canadian Medical Association (CMA) remains committed to the delivery of high quality health care and to safeguarding the national integrity of the health system. However, given the need for the federal government to gain control over our deficit and national debt, it seems clear that putting Canada's fiscal house in order remains a high priority. In this regard, CMA appreciates the invitation to submit its views on the 1995 pre-budget consultations that are underway. One overriding objective of the brief is to provide the Committee with a better understanding of the current pressures on physicians across Canada that have arisen as a direct result of past government decisions in this area. It is our firmly-held position that the health care system in general, and the medical profession in particular, have paid more than their fair share in terms of contributing to debt management. This brief focusses on five somewhat distinct areas of concern to Canadian physicians: (1) federal health transfers to the provinces; (2) taxable health benefits; (3) the goods and services tax (GST); (4) Registered Retirement Savings Plan (RRSP) contributions, and (5) the Lifetime Capital Gains Exemption (LCGE) for Small Businesses. In each case, the brief contains specific recommendations as to what the government should do, and more importantly what the government should not do, to balance its short-term deficit reduction targets against longer-term Canadian values. To summarize, good health policy and prudent economic policy go hand-in-hand provided the principles of fairness and good management practices are observed. If change is to come within an overall policy framework that is strategic, coordinated and fair and which preserves (or augments) the integrity of Canada's health care system, it behooves us to avoid short-term, stop-gap initiatives. As the government's 1994 Throne Speech put it "...the agenda of the government is based on an integrated approach to economic, social, environmental and foreign policy". Accordingly, in establishing an appropriate fiscal framework for health, change must take place within the context of a longer-term integrated view. II. BACKGROUND...."Medicare Is A Shared Value" Canada's system of universal health insurance is still one of the best in the world. Experts from around the world travel many thousands of miles to study and, in some cases, emulate our system. For most Canadians, medicare is a highly cherished, integral component of our social fabric. While Medicare's popularity has not diminished over the past 30 years, it is sometimes taken for granted in these difficult economic times. Recent public opinion surveys indicate that 84% of Canadians (with the highest response in Quebec) see medicare as a defining characteristic of being Canadian. Furthermore, 84% of Canadians are of the opinion that the system provides high quality care. 1 At the same time, however, 65% of Canadians are concerned about continued accessibility to a full range of publicly-financed benefits. According to the same poll, 83% of Canadians see current financing of the system as being "unsustainable" over the longer-term 2 and they are right. As much loved as the Canadian medicare system is, there is a large and growing consensus that we need to make changes. This brief is not about maintaining the status quo. Rather, it is about managing the changes required in the long-term best interests of all Canadians and of the physicians who are ultimately responsible for serving those interests, subject to the fiscal realities confronting government. III. CONSIDERATIONS CMA acknowledges that there is a pressing need, now more than ever, for the federal government to balance a number of competing social and economic policy challenges. In a time when deficit reduction measures are required, all segments of society are being asked to do more with the same or less. Health care is no exception, having done so for quite some time. At the same time, we must re-evaluate the variety of services provided or paid for by government. Deficit Management, but at what Costs? As of 1993/94, Canada's net public debt stood at $508.2 billion, or $17,484 for every Canadian. Combined with the debts of the provinces and territories, our national debt is in excess of $700 billion. Not to understate the case, currently one-third of each revenue dollar the government collects is allocated to debt service payments on the federal debt. 3 CMA believes enough is enough: we must not pass this burden on to future generations of Canadians. The federal government has managed to run operating surpluses for five of the past seven years. 4 While this is necessary it is no longer sufficient to meet our fiscal challenges. Maintaining the status quo would mean that debt service payments would further crowd out government expenditures at an accelerated rate. While the government's first priority should be to get us "out of hock", there is an equally- compelling need to respect the longstanding and fundamental principle of fairness/equity that help define Canadian society. One step toward meeting these twin objectives is to consider all possible methods of repatriating that portion of the national debt held by the international lending community. Some experts have argued that Canada, as a country, can no longer afford to have "massive leakages" in interest payments to individuals/countries abroad. 5 In so doing, we would also repatriate our ability as a sovereign nation to set and maintain social policy objectives. This involves guarding against the persistent "tyranny of the deficit" and the influence that international bond rating agencies can exert on the economy. Facts and Fallacies about Health Spending In reviewing expenditures in the public sector, some would suggest that health and health care spending are "out of control". This is a myth. While it is true that Canada spends 10.0% (1993) of Gross Domestic Product (GDP) on health care (second highest among OECD countries), the reality is that the public sector share of total health care expenditures has fallen from 76.4% in 1975 to approximately 71.9% in 1993 6 (falling to the lowest third of OECD countries). This process of reducing real public sector expenditures, in the absence of a well-coordinated and planned framework, has not always been in the best interests of health and health care. Specifically, federal offloading in terms of unilateral reductions in health cash transfers to the provinces have been followed by: * the elimination of entire programs, such as dental insurance programs for children and universal drug insurance programs; * hospital closures (e.g., 52 hospitals in Saskatchewan); * massive regionalization of health programs and the attendant disempowerment of community hospital boards; * the reduction of total bed capacity by as much as 20% in some provinces; * the reduction in medical school enrolment by 10% and a planned 10% reduction in post-MD residency slots; * global medical care expenditure caps in virtually every province in Canada; * individual physician income thresholds in at least five provinces; * a moratorium on interprovincial mobility of physicians; * legislative overrides of duly-negotiated contracts for health care providers; * widespread restrictions on the operation of high technology equipment; and * the de facto "expropriation" of physician business practices without compensation (e.g., Saskatchewan pathologists). These repercussions also serve to underline the fact that change is the only constant in the health care system. Many physicians across the country have expressed concerns that such changes or "threats" to our health care system are already beginning to have serious consequences for individual patients in terms of access to needed medical facilities. If the national integrity of medicare is to survive, federal fiscal policy changes must be assessed within a larger and longer-term framework; one that respects the need for innovation and professionalism in the health care system. Physicians as Responsible Professionals Some mistakenly argue that physician expenditures are responsible for the increasing costs to the health care system. The reality is that physician expenditures as a proportion of total health care expenditures in Canada have declined from 15.7% in 1975 to 15.1 in 1991. 7 Furthermore, physician expenditures constitute a declining share of GDP. Given the recent round of unilateral reductions in medical care spending in many jurisdictions, this percentage share will continue to drop significantly as more recent data become available. As health care resources have become increasingly constrained, physicians have taken on added responsibilities at the macro, meso and micro levels to better manage our health resources. * At the "macro" level, within the provinces and territories, the medical profession has been engaged in formalized consultation structures known as "Joint Management Committees" or "Administrative Councils" with government and other stakeholders to ensure value for money within a diminishing "real" globe of publicly-available resources for health care. * At the "meso" or institutional level, physicians are working hand-in-hand with health care administrators and other community stakeholders to "rationalize" services so as to provide the best value for money in all areas. In addition, to give a greater voice for choice and improve overall accountabilities in the system, physicians are providing formal input to governments that are looking to regionalize health system operations. * At the "micro" or clinical level, physicians have been taking the lead in developing and disseminating clinical practice guidelines (CPGs) to ensure that the care provided is both appropriate and cost-effective. More can and is being done, in collaboration with government, to ensure responsible use of the taxpayer's dollar while meeting the needs of individual patients. At all levels, physicians will continue to involve themselves as capable and responsible professionals. As the health policy agenda continues its rapid pace, physicians and the organizations that represent them should be viewed as "agents" for, rather than "objects" of, change. Good Health Policy Means Good Economic Policy Agencies such as the World Economic Forum, 8 tell us that our system of financing health care is one of Canada's greatest assets in competing in the new world economic order. We should heed this advice, as the Prime Minister recently observed. Compared to the United States, this economic advantage takes the form of 30 percent lower health spending (measured as a percent of GDP or in per capita expenditures) while providing for universal medical benefits and high quality care. In terms of our European trading partners, the fact that health insurance programs are financed primarily through consolidated revenues (rather than employment-based taxes), also confers a unit cost advantage to Canadian exporters. In this sense, good health policy and good economic policy should be mutually reinforcing. Aside from the complementary nature of the relationship between health and the economy, this fundamental concept also suggests that we need to take a longer-term, more integrated and more strategic approach to managing our collective debt and debt-servicing challenges. The federal government can no longer simply shift its financial obligations onto the backs of lower levels of government or individual Canadians without consultation or advance notice. We need to re-evaluate the full range of government- provided or -funded services. Again, however, if federal fiscal reductions are to take place, the principles of fairness and equity must begin to guide the development of sustainable economic and health policies. While there are no doubt trade-offs that can and must be made, if the price of getting our fiscal house in order is losing a national treasure - i.e., our health care system, it is a price too high to be paid. To summarize, we have set out a series of principles that should serve to guide the Committee in its decision-making, they are: * take the longer-term view; * adopt a system-wide, integrated approach for fiscal management; * strive for a strategic approach that mutually reinforces health and economic policies; and * strengthen the fundamental foundation of fairness and equity. These four principles form the building blocks of the remainder of CMA's submission. IV. ISSUES Canada is at a social, political and economic crossroad. The challenge to this Committee and to this Government is to balance short-term fiscal pressures against the longer-term need to re-position Canada to take advantage of economic opportunity while preserving that which is of fundamental importance to Canadian society as a whole. As the Committee looks to striking the right balance, there are five specific areas of concern that the CMA wishes to bring to your attention on behalf of the Canadian medical profession. The Temptation to Reduce Federal Health Transfers CMA commends this Government for exempting EPF health transfers from the extended freeze that was applied to other provincial transfer programs in its spring 1994 budget. We would have been surprised had this Government done anything else, given that medicare is the "Liberal legacy" of the 1960s and given the Liberal Party's consistent opposition to the previous government's "policy by stealth" (i.e., Bill C-69; Bill C-96). The fact is that medicare's contribution to getting our "fiscal house in order" is already large and continues to grow. In specific terms, the Committee will know that over the 1986/87 to 1995/96 fiscal period, it is estimated that $42.108 billion will have been removed via reductions in Established Program Financing for health and post-secondary education. For health alone, over $30 billion will have been removed from the system by fiscal year 1995/96. 9 Even with a resumption of GNP minus three percent growth formula in per capita EPF entitlements for health, beginning next spring, reduced cash contributions to medicare programs will continue to contribute to the attainment of the government's fiscal targets. Given the unprecedented health reforms taking place across the country, Canadians and the health care system can ill afford another federal fiscal shock. The system is already balkanizing, with poorer regions not being able to fiscally sustain some basic health care benefits. Any further acceleration in the rate of reduction in federal cash transfers will all but assure the demise of the national integrity of medicare programs. Moreover, any further reductions in federal health-related cash transfers will: (1) significantly hamper or stall the work of the newly-created National Health Forum; (2) further reduce the capacity for enforcement of national health principles under federal law; (3) exacerbate health-related problems of dealing with child poverty and problems of reducing health inequalities by socio-economic class; and (4) increase other areas of federal direct program expenditures in the context of renewed efforts to provincial program "uploading" (e.g., Canada Pension Plan Disability Program). A propos of health and economy going hand-in hand, it is useful to remind ourselves of the importance of maintaining the comparability of health benefits across Canada in terms of promoting regional development, shared opportunity and efficient resource allocation. Poor regions of this country are already finding it difficult to compete for scarce new business investment capital. The implications of competing from a more uneven playing field in terms of being able to offer only "bare bones" publicly-financed health benefits will further widen the gap between the "have" and "have not" provinces. It is for these reasons that the CMA joins with other national health organizations 10 in recommending the following: 1. THAT THE FEDERAL GOVERNMENT AVOID FURTHER CUTS TO THE EPF HEALTH TRANSFER AND LOCK IN THE CASH PORTION; 2. THAT THE FEDERAL GOVERNMENT NEGOTIATE A STABLE FIVE-YEAR FUNDING ARRANGEMENT WITH THE PROVINCES/TERRITORIES; 3. THAT THE FEDERAL GOVERNMENT MUST ENSURE THAT ACCOUNTABILITY OF THE HEALTH TRANSFER BE SEPARATE AND EXPLICIT. Taxable Health Benefits Canadians have already been dealt one blow with the increasing de-insurance of health care services (e.g., reduction of out-of-country benefits to an unfair and dangerous level, elimination or reduction in drug benefit programs). In the context of funding those services that remain public benefits, only the cruellest government would strike yet another blow to individual Canadians and to Canadian business by taxing the very benefits that taxes were raised to pay. If implemented, this proposal would be tantamount to nothing less than double taxation. Fairness and equity would suggest that the government should be doing more, not less at the legislative and regulatory levels to promote the availability of private health insurance benefits in areas increasingly vacated by government cutbacks. This is why CMA makes the following recommendation: 4. THAT THE CURRENT FEDERAL GOVERNMENT POLICY WITH RESPECT TO NON-TAXABLE HEALTH BENEFITS BE MAINTAINED; Goods and Services Tax (GST) When the GST was introduced in 1991, preoccupation with implementation issues resulted in a number of fundamental injustices at the micro level. One such injustice was dealt to the medical profession. Physicians, like other Canadians, expect to pay their fair share of taxes. We do not however, accept what essentially amounts to double taxation. Physicians in practice in Canada are in the unique, unenviable and unfair position of being forced to absorb all the GST on business inputs. Unlike all other professions, physicians are precluded from being able to pass on the tax to consumers (with provincial health insurance plans as payment in full) or from claiming input tax credits (ITCs) since insured medical services are deemed to be "tax exempt". Unlike other professions, physicians cannot claim input credits for the imputed taxes associated with providing needed medical care. In fact, all of the following health professionals are capable of recouping from patients the GST paid on inputs because their revenues are not restricted by government: dentists; optometrists; chiropractors; physiotherapists; chiropodists; osteopaths; audiologists; speech therapists; occupational therapists and psychologists. Physicians are still angrily awaiting remedial steps to correct this injustice. To be clear, CMA is not asking for preferential treatment for Canadian physicians. What we want is the same fair and equitable treatment from the federal government accorded to other self-employed professional groups. Like physicians, other professions are purchasing inputs and paying GST; but unlike physicians, they are able to recoup the GST. Given this oversight in the legislation and regulations, physicians have already been asked to pay (over and above the GST paid by other professional groups) a cumulative total of $250 million since its introduction of the tax in 1991. The magnitude of this tax paid is not in dispute (as a result of a study prepared by KPMG). While the direct effects of the GST are significant and measurable, the indirect effects are even more significant though less measurable. It is estimated that the 55,000 physicians in Canada employ up to 100,000 Canadians. Given the disproportionate effects of the GST on the medical profession as employers, the employment dampening could be at least as high as 1,000 full-time jobs lost. In addition, the tax-induced distorting effects in terms of efficient resource allocation in the health care system cannot be measured, but are thought to be significant. A goal of health reform in many parts of the country is to move care services out of institutions and into the community. Current federal GST policy, by taxing supplies in a clinical practice setting but not in a hospital setting, acts to discourage this shift in emphasis. No other issue in recent years has raised the ire of individual practitioners as much as the imposition of this most unfair and inequitable tax on business inputs. Understanding that the Minister of Finance is in the process of consulting with the provinces as to the nature of a replacement tax for the GST, we are confident that this oversight will be remedied. In the interests of fundamental fairness/equity and allocative efficiency, CMA respectfully recommends the following: 5. THAT THE COMMITTEE WORK TO ENSURE THAT CANADIAN PHYSICIANS, AS SMALL BUSINESSES, PAY NO MORE THAN OTHER PROFESSIONS UNDER ANY REPLACEMENT TAX FOR THE GST; 6. THAT ALL TAXES ON BUSINESS EXPENSES BE FAIRLY AND FULLY REMOVED UNDER ANY REPLACEMENT TAX FOR THE GST; 7. THAT IF ANY REMEDIAL STEPS ARE TAKEN TO ENSURE NO TAXES ARE LEVIED ON BUSINESS INPUTS, THESE BE APPLIED UNIFORMLY ACROSS ALL EXEMPT SERVICES. Registered Retirement Savings Plan (RRSP) Canadian physicians, while receiving a large proportion of their professional earnings from the public sector (94%), do not benefit as self-employed individuals from defined benefit plans or from publicly-financed pension benefits that accrue to employed professionals. They, like other self-employed individuals, must plan and fund their own retirement. Fairness/equity once again demands that there be symmetry between money-purchase (MP) and defined-benefit (DB) retirement plans. This is all the more important for physicians because of their compressed period of lifetime earnings in relation to other groups. This Committee will have heard various calls for either reducing the annual contribution limit or taxing assets within RRSPs. Such arguments are both specious and patently unfair. Both propositions potentially involve double taxation. Experts both within and outside government argue, quite correctly, that the current policy be maintained, and that equity between employees and the self-employed before the taxman be assured. It is for these reasons, that CMA has led an unprecedented alliance for the preservation of retirement savings, and recommends the following: 8. THAT THE FEDERAL GOVERNMENT CONSIDER THE TOTAL COST OF THE RETIREMENT SAVINGS SYSTEM BEFORE MAKING ANY CHANGES TO THE INCOME TAX ACT; 9. THAT THE EQUITY ESTABLISHED DURING PENSION REFORM NOT BE DISTURBED BY DISCRIMINATORY CHANGES AND THAT ANY FUNDAMENTAL CHANGES TO THE SYSTEM INVOLVE A PROCESS OF INFORMED AND THOUGHTFUL INQUIRY AND DEBATE; 10. THAT THE FEDERAL GOVERNMENT FOSTER ECONOMIC DEVELOPMENT BY TREATING RRSP CONTRIBUTIONS AS ASSETS RATHER THAN LIABILITIES AND BY EXPLORING THE REGULATORY CHANGES NECESSARY TO ENSURE INCREASED ACCESS TO SUCH FUNDS BY SMALL AND MEDIUM-SIZED BUSINESSES. Lifetime Capital Gains Exemption (LCGE) for Small Businesses Most Canadian physicians are independent, self-employed practitioners. As such, they have the ability if they are incorporated to claim the LCGE when they sell their practices. Over time, several provinces have accorded physicians the right to incorporate (e.g., Prince Edward Island, New Brunswick, Alberta, British Columbia, and the Yukon Territory), in other jurisdictions, physician incorporation is under active review (e.g., Nova Scotia, Quebec, Ontario and the Northwest Territories). While physicians have benefited from incorporation on a limited basis, this issue takes on added importance when one considers the "national" move towards incorporation allowing a greater number of eligible physicians to claim the LCGE. Recent health reforms have also underscored the importance of maintaining the current policy. Previously, physicians were free to move their practices from one location to another to meet the changing health needs of Canadians. Over the past two years, provincial governments have moved to restrict inter-provincial mobility of physicians and indeed mobility within any given province or territory. These "barriers" not only restrict the number of new entrants into the system in addition to those who wish to move to other areas of the country, but also can be thought of as increasing the capitalized value of established practices. Indeed, with the advent of regional physician resource plans across Canada, the cost of establishing a new practice can be expected to continue to grow at an unprecedented rate. So while some physicians have yet to claim the LCGE, it is reasonable to think that they will some time in the future. As the health needs of Canadians change, and as people move, medical care services will have to respond accordingly. The elimination of the LCGE, by significantly increasing the purchase price of a new medical practice, unnecessarily and unfairly raises additional economic barriers to shifting practices in response to changing community health needs. CMA therefore recommends: 11. THAT THE FEDERAL GOVERNMENT MAINTAIN THE CURRENT POLICY FOR THE LIFETIME CAPITAL GAINS EXEMPTION FOR SMALL BUSINESSES. V. TRADE-OFFS To summarize: in broad terms the health care sector has already paid its fair (and to a larger extent unfair) share. Everyone who has appeared before this Committee will argue that cuts should not occur in their backyard. They can't all be right! The government of Canada must decide where its priorities lie over the longer-term. Deficit reduction targets can no longer be met by simply chipping away at the full range of federally-sponsored programs. The national integrity of national health insurance programs, given their importance to Canada's economic, social and political future must be on the short list of safeguarded social programs. If further reductions in federal health transfers are deemed appropriate, the Committee should be prepared to publicly acknowledge that the principles of universality or comprehensiveness (i.e., the choice between covering everyone versus everything) will have to be fundamentally re-examined. Given the degree of support for the universality principle, if the federal government is serious about further reducing its direct or indirect contributions to health, then it must reconsider the range of core benefits that will be made available to Canadians. In fact, we may now have reached the point where we need to get back to basics; reminding ourselves of the original medicare promise, which was to protect Canadians from the spectre of personal bankruptcy associated with large and unexpected health care bills. Not to pay the day-to-day ("grocery") bill of health care. The recently-announced National Health Forum, chaired by the Prime Minister, will provide an important opportunity to assess the breadth and depth of publicly-financed health care. The contribution of medicine to the health of Canadians and to the economy is just too important to be traded off. Physicians are still feeling the "aftershocks" of recent federal fiscal decisions. They have also had to absorb sharp unilateral reductions at the provincial level. The provinces of Nova Scotia, Prince Edward Island and Alberta - to name only three - have disproportionately singled out the medical profession on a net earnings basis in decreasing health funding. Taken together, these fiscal forces could trigger an unprecedented exodus of physicians from Canada. As governments move to restrict the ability of physicians to provide needed medical care, CMA is increasingly concerned about the growing number of physicians who are being actively recruited by the United States, and those who feel they have no alternative but to leave the country. At a macro level, we as a society, must recognize that we are in a North American labour market, and as such, each physician heading south represents both a short-term pain and long-term pain. VI. SUMMARY OF RECOMMENDATIONS The CMA offers the following recommendations to the Committee in its deliberations: 1. THAT THE FEDERAL GOVERNMENT AVOID FURTHER CUTS TO THE EPF HEALTH TRANSFER AND LOCK IN THE CASH PORTION; 2. THAT THE FEDERAL GOVERNMENT NEGOTIATE A STABLE FIVE-YEAR FUNDING ARRANGEMENT WITH THE PROVINCES/TERRITORIES; 3. THAT THE FEDERAL GOVERNMENT MUST ENSURE THAT ACCOUNTABILITY OF THE HEALTH TRANSFER BE SEPARATE AND EXPLICIT. 4. THAT THE CURRENT FEDERAL GOVERNMENT POLICY WITH RESPECT TO NON-TAXABLE HEALTH BENEFITS BE MAINTAINED; 5. THAT THE COMMITTEE WORK TO ENSURE THAT CANADIAN PHYSICIANS, AS SMALL BUSINESSES, PAY NO MORE THAN OTHER PROFESSIONS UNDER ANY REPLACEMENT TAX FOR THE GST; 6. THAT ALL TAXES ON BUSINESS EXPENSES BE FAIRLY AND FULLY REMOVED UNDER ANY REPLACEMENT TAX FOR THE GST; 7. THAT IF ANY REMEDIAL STEPS ARE TAKEN TO ENSURE NO TAXES ARE LEVIED ON BUSINESS INPUTS, THESE BE APPLIED UNIFORMLY ACROSS ALL EXEMPT SERVICES. 8. THAT THE FEDERAL GOVERNMENT CONSIDER THE TOTAL COST OF THE RETIREMENT SAVINGS SYSTEM BEFORE MAKING ANY CHANGES TO THE INCOME TAX ACT; 9. THAT THE EQUITY ESTABLISHED DURING PENSION REFORM NOT BE DISTURBED BY DISCRIMINATORY CHANGES AND THAT ANY FUNDAMENTAL CHANGES TO THE SYSTEM INVOLVE A PROCESS OF INFORMED AND THOUGHTFUL INQUIRY AND DEBATE; 10. THAT THE FEDERAL GOVERNMENT FOSTER ECONOMIC DEVELOPMENT BY TREATING RRSP CONTRIBUTIONS AS ASSETS RATHER THAN LIABILITIES AND BY EXPLORING THE REGULATORY CHANGES NECESSARY TO ENSURE INCREASED ACCESS TO SUCH FUNDS BY SMALL AND MEDIUM-SIZED BUSINESSES. 11. THAT THE FEDERAL GOVERNMENT MAINTAIN THE CURRENT POLICY FOR THE LIFETIME CAPITAL GAINS EXEMPTION FOR SMALL BUSINESSES. _______________ 1 The Angus Reid Group, The Reid Report. Vol. 8, No. 7, July/August, 1993 and Vol. 8, No. 8, September, 1993. 2 Ibid. 3 Agenda: Jobs and Growth: Creating A Healthy Fiscal Climate (The Economic and Fiscal Climate), Department of Finance, October 1994. 4 Economic and Fiscal Reference Tables, Department of Finance, September 1994; Annual Financial Report of the Government of Canada, Fiscal Year, 1993/94. 5 Valaskakis K.: The Debt Monster, Montreal Gazette, November 5, 1994. 6 National Health Expenditures in Canada, 1975-1993. Health Canada. 7 Ibid. 8 World Economic Forum 1991: The World Competitiveness report 1990, Institut pour l'étude des méthodes de direction de l'entreprise, Lausanne, Switzerland. 9 Thomson A 1991: Federal Support for Health Care: A Background Paper. Health Action Lobby, Ottawa, June 1991. 10 See the 1995/96 Pre-Budget Submission to the Standing Committee on Finance by the Health Action Lobby (HEAL), November 15, 1994.
Documents
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Registered retirement savings plans : Presentation to the House of Commons Standing Committee on Finance

https://policybase.cma.ca/en/permalink/policy1996
Last Reviewed
2019-03-03
Date
1994-11-17
Topics
Physician practice/ compensation/ forms
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
1994-11-17
Topics
Physician practice/ compensation/ forms
Text
Millions of Canadians are planning for their retirement relying on Registered Retirement Savings Plans (RRSPs) and private pension plans, either as their only future retirement income or to supplement the Canada Pension Plan (CPP) and Quebec Pension Plan (QPP). Approximately 5 million contribute to RRSPs. Another 3.7 million participate in registered pension plans (RPPs). Some are independent business people, others work in family businesses. Some are self-employed or work for organizations that have opted for RRSPs instead of RPPs. Our Alliance is representative of this Canadian diversity. The objective of the Alliance is to maintain the current provisions of the Income Tax Act (the Act) and Income Tax Regulations (the Regulations) governing retirement savings. The current system is fundamentally good for the economy of Canada, and any changes made for short term deficit reduction will ultimately harm the economy in general and small and medium-sized business, in particular. Research shows that RRSPs are an important tool for small business retirement planning. Only in recent years have limits been adjusted to bring similar protection to those afforded under RPPs. We have only just started to achieve a measure of equitable treatment for the retirement savings of the self-employed and employees not protected by employer pension plans. The current system provides for the harmonization of all tax-assisted retirement savings arrangements, which will only be achieved when the limits on money-purchase arrangements (including RRSPs) attain the equivalent limits already set for defined-benefit arrangements, such as employer pension plans. Changes to RRSPs alone will discriminate against the self-employed and against employees without employer pension plans. These Canadians form the majority of the workforce now and in the future. Arguments in favour of changes to the current system are based on two assumptions: firstly, that Canadians are saving sufficient income for their retirement and will continue to do so regardless of tax increases; and secondly, that the cost to the Government in lost tax revenues is enormous. Neither of these assumptions is valid. Background The fiscal theory underlying retirement savings is decades old. Contributions to registered plans are deductible and all earnings are exempt from tax until benefits are paid out from those plans. In essence the retirement savings system consists of a deferral of tax on contributions and earnings. The pension tax reform of 1989-1990 does not change the underlying fiscal theory. It aims to achieve equity between the employed and the self-employed and between defined benefit arrangements and money-purchase arrangements (including RRSPs). That equity was achieved by phasing in a higher contribution limit for money-purchase arrangements so that they could, in the future, provide a retirement income comparable to that furnished by a defined benefit arrangement. This objective of achieving equivalence permeates the Act and the Regulations and has resulted in a substantial and continuing realignment of retirement savings arrangements in Canada. That realignment, with its attendant compliance costs, borne by employers and employees, was based on the acceptance of the premises behind pension tax reform, which acceptance Canadians have demonstrated. This realignment had a gestation period of over 5 years. 1 From the 1984 federal budget, which sought complete equity but with massive compliance costs, to the 1985 federal budget, which sought lesser compliance costs but with diminished equity, there issued pension tax reform, which yields substantial equity with substantial compliance costs. The Auditor General, in his 1988 report, estimated that pension tax reform would necessitate $330 million in start-up costs and $15 million in annual reporting costs. The Department of Finance disagreed and estimated that start-up costs would be from $60 to $70 million and that the annual reporting costs would be between $10 and $15 million. The independent consultant's report, upon which the Auditor General's report was based, had said that the start-up costs would be $395 million. Accordingly, Canadians have already borne many of the costs of retooling the retirement savings system and will continue to do so. Having paid those costs, surely Canadians are entitled to the measure of equity that the system promises. Governing Principles There are disquieting rumours about possible changes to the current retirement savings system. As yet, the government has said little on this issue, other than to say that the retirement system is not inviolable. The Alliance seeks to maintain the status quo. We should, therefore, deal with the principles that underlie the current system, and which continue to hold true: internal fairness and the accumulation of sufficient retirement income. Internal Fairness The current system was reformed to deliver internal fairness - if not quite yet, by 1996. It allows individuals to accumulate a pre-determined amount of private retirement savings. Taxpayers may, on a tax-assisted basis, earn a lifetime pension at the rate of $1,722 per year. In other words, an employee with 35 years of service may be entitled, on retirement, to an annual lifetime pension of $60,270. That level of tax assistance has been available to members of defined benefit plans since 1977. It has been frozen at that level since that time and will remain frozen until 1996. The money purchase limits, including RRSP limits, have been phased in to eventually provide equivalent benefits. Accordingly, the annual RRSP limits, when fully instituted in 1996, will allow the self-employed to accumulate retirement savings equivalent to those of members of defined benefit plans. Thus, one of the rationales underlying the current retirement savings structure is to eliminate the earlier discrimination against the self-employed. The self-employed will now be allowed to achieve retirement savings equivalent to those available to employees. RRSPs are not an isolated program under the Act, but rather an integral component of an indissoluble whole. Accumulation of Sufficient Retirement Income The limits set by pension tax reform are intended to provide a level of retirement income that will allow retired individuals to maintain their standard of living. It is generally felt that a retirement income equal to about 60-70 percent of pre-retirement income should not result in a marked change in one's standard of living. Increasingly, it appears that individual taxpayers will need to rely more on private retirement savings and less on public programmes. It is important, therefore, that the tax system permit the accumulation of retirement savings sufficient to allow taxpayers to maintain their pre-retirement standard of living. Indeed, it does not appear possible for money-purchase arrangements to reach, in most cases, the replacement ratio of 60 to 70 percent. Consider the following example. 2 Let us consider two taxpayers earning $50,000 and $100,000 respectively, in 1993 who maximize their contributions to RRSPs. What replacement income ratio can these taxpayers attain? Assume that the taxpayers are married and that the annuity to be purchased from the RRSP, at retirement, has the following characteristics: post-retirement indexation at 3% per annum with a spousal survivor benefit of two-thirds. 3 The results of this hypothetical are: [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] RRSP as a percentage of final year's salary at a 1993 salary of $50,000 ($100,000) Retirement Age Savings Start Age 25 35 45 55 41.0% (31.6%) 24.7% (19.0%) 11.2% (8.6%) 60 54.4% (41.9%) 35.1% (26.7%) 19.0% (14.6%) 65 72.2% (55.7%) 48.8% (37.6%) 29.4% (22.6%) [TABLE END] The above table indicates, for example, that a 35-year old earning $50,000 in 1993 can, at most, earn a pension from an RRSP equal to 48.8% of his final year's income, if his retirement commences at age 65. In other words, after 30 years of working and saving, that individual will have a retirement income of less than half of his pre-retirement income. This is below the income replacement threshold assumed by pension tax reform itself. For the taxpayer earning $100,000 in 1993, his RRSP pension will be 37.6% of this pre-retirement income. The only individual who attains an adequate replacement ratio, on these assumptions, is the 25-year old who saves for 40 years. It follows that, although the pension tax system espouses equivalence with the defined benefit pension plan, it does not attain it in practice. Inequities in the Current System In the current North American context, the limits of Canadian tax assistance for retirement savings are not generous. The equivalent money purchase and defined benefit limits for the United States, for example, are more than twice as generous as the Canadian limits. In addition, the Canadian system does not provide for deferrals of salary, as does the United States system. Furthermore, inequities exist in the provision of supplementary retirement benefits. Supplementary benefits are those in excess of the $60,270 benchmark pension discussed above. They also include benefits that the Regulations, and the Department of National Revenue, do not allow to be paid from a registered pension plan. Servants of the people, such as Members of Parliament and Members of Provincial Legislatures, benefit from the privileged status of the payor of the pension, in that security of the pension promise is not an issue. Self-employed individuals and ordinary employees, on the other hand, must be concerned with the funding of their pension promise. Requirement for Informed and Thoughtful Debate In the early 1990s, annual contributions to RRSPs and RPPs exceeded $33 billion. Trusteed pensions, not including consolidated revenue fund plans, held $235 billion in assets at the end of 1992. The book value of the assets of such plans stood at $268 billion at the end of the first quarter of 1994. RRSP assets, not including self-directed plans, totalled $147 billion at the end of 1992. In his discussion paper entitled Creating a Healthy Fiscal Climate: The Economic and Fiscal Update, released October 18, 1994, the Minister of Finance has indicated that the tax expenditure associated with all retirement savings for 1991 was $14.9 billion. It is not surprising, therefore, that the Department of Finance should cast a covetous eye at the retirement savings system. We are concerned that a search for easy sources of revenue might prompt the government to change the existing rules in the Act governing retirement savings. It is submitted, however, that changes to the system, although fiscally attractive in the short term, would be detrimental to Canadian taxpayers in the long run. Deficit reduction should not be the sole motivating factor for change to the retirement savings system. The existing complex web of rules governing retirement savings should only be touched if there are compelling reasons, unrelated to immediate deficit reduction, to effect change. This is particularly so given the recent and unfinished reform of retirement savings arrangements in this country. It is clear that this debate has not yet begun and cannot be completed before the next federal budget. The prudent approach, therefore, is to defer any change to the retirement savings system until that debate has taken its course. A Framework for the Debate The following parameters should govern any consideration of the changes to the retirement savings system. 1. The Principle of Even-Handedness It is clear that all components of the retirement savings structure are interrelated. As a result, it would be unfair to single out RRSPs for detrimental treatment. RRSP savings are no different from other forms of retirement savings. 2. A Tax Increase According to a recent study of the Canada Tax Foundation, 3.7 million Canadians contributed to RPPs, and 4.8 million Canadians contributed to RRSPs, in the 1992 taxation year. 4 In that year, 69.7 percent of contributors to RPPs and 60.5 percent of contributors to RRSPs were in the middle income range ($25,000 to $60,000). Obviously, the participation rate by Canadians in retirement savings arrangements is quite high. A change to the retirement savings regime, by limiting deductibility of contributions for example, would be viewed as a tax increase by users of these arrangements. Indeed, for those individuals, any negative change to the retirement savings arrangement will have the same effect as a tax increase. 3. Job Creation The quest for deficit reduction should not obscure the important role that government can play in creating an environment conducive to increasing employment opportunities. As the government has previously stated, the bulk of job creation must come from small and medium-sized businesses. As a result, the current retirement savings regime, and in particular RRSP investments, should be viewed as an asset, and not a liability. The ability to deduct savings for retirement has the effect of increasing aggregate private savings as a source of funds for capital investment. 5 Reducing the tax incentive for retirement savings could have the effect of reducing the amount of "pooled" capital funds that could be made available for entrepreneurial activities. It would also add to the cost of doing business in Canada and stifle future employment opportunities. The rules in the Income Tax Act that permit RRSP contributors to put investments in small businesses are insufficient at present and must be strenghtened if the government wants to encourage job creation. Canada's Economic Challenges 6 shows that small business is playing an increasing role in the economy. Any reduction in the existing schedule of limits will hurt the ability of small business to create jobs. Indeed, the government should consider measures to increase the access by small and medium businesses to the retirement savings capital pool. The latest report of the House of Commons Industry Committee makes the point well: Ottawa should use tax incentives to help improve the competitiveness of the Canadian small business sector...One way the government can increase small business access to capital would be to permit owners, operators and other major shareholders to use funds from their registered retirement savings plans to buy equity in their business...that would increase the availability of such "love capital". 7 4. The Tax Expenditure Calculation As indicated earlier, it is said that the tax expenditure for all retirement savings for 1991 was $14.9 billion. That number suggests that the Government of Canada bears a high cost for its retirement savings system. However, it is our view that the calculation of that cost is not correct, with the result that the number is inflated. The Department of Finance's calculation of the tax expenditure cost is arrived at by adding the value of deductions associated with contributions and the value of the tax shelter on earnings. From that result is subtracted the revenue generated from withdrawals. For example, for the 1991 taxation year, the $14.9 billion number noted above is calculated as follows: Tax expenditure (RRSP) = value of deductions + value of tax shelter - taxes on withdrawals = $3.310 billion + $2.960 billion - .735 million = $5.535 billion Tax expenditure (RPP) = value of deductions + value of tax shelter - taxes on withdrawals = $4.460 billion + $8.950 billion - 4.030 billion = $9.38 billion Tax expenditure (RRSP + RPP) = $5.535 billion + $9.38 billion = $14.915 billion. The Government of Canada has itself admitted that its calculation of tax expenditures is subjective. In the case of tax deferrals, it has further stated that: Estimating the cost of tax deferrals presents a number of methodological difficulties since, even though the tax is not currently received, it may be collected at some point in the future. 8 The government has also specifically commented on tax expenditures associated with retirement savings: It should be noted that the RRSP/RPP tax expenditure estimates do not reflect a mature system because contributions currently exceed withdrawals. Assuming a constant tax rate, if contributions equalled withdrawals, only the non-taxation of investment would contribute to the net tax expenditure. As time goes by and more retired individuals have had the opportunity to contribute to RRSPs throughout their lifetime, the gap between contributions and withdrawals will shrink and possibly even become negative. An upward bias in the current estimates can therefore be expected to decline. 9 The method used to calculate the tax expenditure costs associated with retirement savings is based on the "current cash-flow" model. In effect, the calculation takes a snapshot of a given year and does not take into account future income flows. As indicated above, the calculation adds the value in a year of tax deductions to the lost tax on earnings, and subtracts the tax generated from withdrawals. We argue that that model is flawed. Current demographics show that the system is not yet mature since contributions will exceed withdrawals for some time. Once the baby boom generation begins to retire, withdrawals will exceed contributions. Substantial revenues will be generated for the fisc, revenues necessary to support government programs of the day. The value of the tax on those withdrawals is totally ignored in the static model adopted by the Department of Finance. Statistics Canada projects that the proportion of the Canadian population aged 70 and over will increase from 7.84% in 1991 to 10.6% in 2010. The numbers of such individuals will increase from 2.102 million in 1991, to 3.355 million in 2010, a 59.6 percent increase. Those individuals will be drawing pensions, both from RRSPs and RPPs. Those pensions will be taxed and will benefit the fisc. Furthermore, there is evidence to suggest that the calculation adopted by the Government greatly over-values the cost to the fisc. A US commentator has suggested that government also gains "additional corporate tax revenue on the extra capital stock that results from higher savings. The government's official revenue estimates ignore this increase in corporate tax receipts." 10 To restate the position, the tax expenditure calculation adopts a static approach, both by considering only the current year's cash flows and by ignoring any secondary effects of the retirement savings pool. Until the true cost of the retirement savings system can be ascertained, the current estimates cannot be relied upon to justify change to the tax rules governing retirement savings. Trade-Offs While the Alliance recognizes the need for the Government to get its fiscal house in order, with a particular emphasis on the expenditure side of the equation, a proper balance must be struck between short-term solutions and longer-term consequences. One important consideration is the long-term pain that would result from Canadians having less financial flexibility to properly plan for their retirement. This long-term consequence must be measured against the short-term gain in revenues that would result from a freeze or reduction in the contributions to RRSPs and RPPs. At a time when the Government is encouraging greater self-reliance in matters of finance, further limiting Canadians' ability to adequately plan for their retirement would serve to aggravate the public future dependence on government programs. Looking at current demographic trends, it is important to ensure that all Canadians have an opportunity to set aside necessary financial resources that will be drawn upon (and taxed) at the time of retirement. If the government is looking to become more efficient in its delivery of public sector programs, it should also ensure that the private sector is allowed sufficient flexibility to meet its needs. In this context, the current retirement savings plans should be considered an investment in the future and should not be tampered with or diminished. Recommendations I THE ALLIANCE RECOMMENDS THAT THE FEDERAL GOVERNMENT CONSIDER THE TOTAL COST OF THE RETIREMENT SAVINGS SYSTEM BEFORE MAKING ANY CHANGES TO THE INCOME TAX ACT. II THE ALLIANCE RECOMMENDS THAT THE EQUITY ESTABLISHED DURING PENSION REFORM NOT BE DISTURBED BY DISCRIMINATORY CHANGES AND THAT ANY FUNDAMENTAL CHANGES TO THE SYSTEM SHOULD INVOLVE A PROCESS OF INFORMED AND THOUGHTFUL INQUIRY AND DEBATE. III THE ALLIANCE RECOMMENDS THAT THE FEDERAL GOVERNMENT FOSTER ECONOMIC DEVELOPMENT BY TREATING RRSP CONTRIBUTIONS AS ASSETS RATHER THAN LIABILITIES AND BY EXPLORING THE REGULATORY CHANGES NECESSARY TO ENSURE INCREASED ACCESS TO SUCH FUNDS BY SMALL AND MEDIUM-SIZED BUSINESSES. _______________________ 1 Appendix A to this submission details the historical development of pension tax reform. 2 Taken from Sylvain Parent, FSA, FCIA, RRSP income replacement levels: a case study, 1993 Pension & Tax Reports; 4:93-94. 3 Further assumptions are as follows: rate of return is 7.5% per annum; yearly salary increases are 5.5% per annum; mortality is 80% of the average of the 1983 Group Annuity Mortality rates for males and females. 4 Perry, David B, Everyone's Tax Shelter At Risk, Canadian Tax Highlights, Volume 2, number 10, October 19, 1994; p. 75. 5 Andrews and Bradford, Savings Incentives in a Hybrid Income Tax, Studies of Government and Finance, The Brookings Institution, Washington, DC; February, 1988. 6 Department of Finance, January, 1994, p. 30. 7 Special Report, The Public Sector, October 24, 1994. 8 Government of Canada, Personal and corporate income tax expenditures, December 1993, p.4. 9 Ibid., p.53. 10 Feldstein, Martin. The Effects of Tax-Based Incentives on Government Revenue and National Saving, NBER Working Paper #4021, March 1992. This position has been dismissed, out of hand and with no reasons, by two Canadian commentators: Ingerman, Sid and Rowley, Robin, Tax Losses and Retirement Savings, Canadian Business Economics, Vol. 2, No. 4, Summer 1994, pp. 46-54.
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The Wait Starts Here: Final Report of the Primary Care Wait Time Partnership

https://policybase.cma.ca/en/permalink/policy9705
Last Reviewed
2018-03-03
Date
2009-10-03
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2009-10-03
Topics
Health systems, system funding and performance
Text
In 2007, The College of Family Physicians of Canada (CFPC) and The Canadian Medical Association (CMA) established a partnership to explore wait times in primary medical care - the CFPC-CMA Primary Care Wait Time Partnership (PCWTP). The goal of the Partnership is to advocate for timely access to health care for all Canadians. The first part of the wait time continuum that can be measured is when the patient schedules his or her first visit ith a family physician. A family physician may then refer the patient to specialty care. Both of these stages in the continuum have not been addressed in wait time discussions thus far. The available evidence suggests that one-half of the total waiting time for family physician referral to treatment is from family physician referral to when the patient is seen by the consulting specialist. Thus, there are three main issues around our focus on primary care wait times: Access to primary care for those without a family physician; Access to primary care for those with a family physician; and Referral from primary to more highly specialized care. The CFPC has proposed a target that 95% of Canadians in each community have a family physician by 2012. There are two ways to achieve this goal: 1. increase the number of family physicians practicing in Canada and 2. increase the capacity of existing family physicians. To help address the supply issue, medical schools must find innovative ways to encourage more medical students to choose family medicine. A second approach to increasing the supply of family physicians is to provide more training opportunities so that qualified International Medical Graduates can be integrated into the family physician workforce. In terms of capacity, there are a number of approaches that have been taken to help improve family physicians' ability to take on additional patients. For example, financial incentives geared towards this objective have been included in some physician contracts. However, much more can be done in this regard, such as improving patient flow with more efficient practice management procedures There are several models for primary care delivery operating in Canada, including various collaborative practice arrangements with different care providers working together. However, thus far there is no conclusive evidence that any one particular model is better than all of the others in terms of providing timely access to care. Many studies have compared various models in a variety of ways; each with different conclusions. While there is no definitive research on best models for primary care delivery, there is a range of innovative approaches to enhancing timely access to quality primary medical care. More research is necessary to help determine which model or models of primary care, if broadly implemented, will make considerable improvements to patient access. Aside from collaborative care practice models, we must look for solutions that increase patient access to care through enhanced practice efficiency and not by expecting family physicians to work harder and longer. Physicians should be educated on how to run a practice from a patient flow point of view as well as a financial one. To address this, enhanced practice management training should be provided during medical school education and residency levels and Continuing Medical Education programs should be created. One method of improving practice efficiency is through a process known as Clinical Practice Redesign (CPR). The main objective CPR is to improve patient flow through a medical practice. This involves the use of effective scheduling management techniques that allow appropriate prioritizing of patient visits. This undertaking requires commitment from physicians as well as effective information management and measurement tools, additional practice support and assistance from change management experts. These efforts can go a long way to help improve patient access and increase capacity to accommodate patient appointments. One of the key challenges of primary care wait times is to establish guidelines for timely access to specialty care. This is potentially an enormous undertaking given that there are some 60 recognized specialties and sub-specialties in Canada and each of them is responsible for treating a number of conditions presenting to the family physician. Due to the varying degree of complexity of a patient's medical problem, an appropriate wait time would be difficult to define by a particular disease or illness. Given the wide spectrum of illnesses that are assessed in a primary care setting, any approach to developing wait time targets must be done in consultation with family physicians and with clinical guidelines in mind. When a patient is referred to more highly specialized care, a concerted effort must be made to keep the lines of communication as open as is feasible between family physicians and consulting specialists, in both directions. Improved communication between providers is essential to improving the wait time at this point in the continuum. While timely access to family physicians and the referral time to other specialists is a nationwide concern, access to health care can be a greater challenge in rural locations. Any guidelines regarding wait times to specialty care must also account for the geographic factors that affect access. When considering the concept of target-setting, a significant investment in information infrastructure is required to facilitate the measurement and monitoring of access to primary care physicians and referrals to other specialists. Furthermore, it must be acknowledged that regardless of how targets are determined, even if they are met, not everyone will receive care within the most appropriate period of time for their particular situation. Introduction In 2007, The College of Family Physicians of Canada (CFPC) and The Canadian Medical Association (CMA) established a partnership to explore wait times in primary medical care - the CFPC-CMAPrimary Care Wait Time Partnership (PCWTP). The goal of the Partnership is to advocate for timely access to primary care for Canadians. The Partnership released its interim report, ... And Still Waiting: Exploring Primary Care Wait Times in Canada, in April 2008 to stimulate discussion and agreement about ways to improve timely access to primary care and from primary to more highly specialized care. It reviewed a broad range of issues faced by family doctors in a health system that has largely ignored the wait time challenges their patients face and was very well received by members of the CMA, CFPC and other stakeholders. This final report is a focused approach to some of the recommendations and solutions, especially of relevance in primary medical care. The difficulty in measuring primary care wait times for myriad illnesses and conditions was identified in the first report as one that may impede progress in finding solutions to the wait time challenges that family doctors experience. The PCWTP believes that the initial requirement is the ability to measure and track wait times along the continuum of the patient's care but that this capacity in primary as well as more highly specialized levels of care is still very limited. There is also the need to prioritize which benchmarks or targets should be attained along the patient's wait time continuum: 1) to find a family physician; 2) to be seen by a family physician; and 3) to have a diagnostic intervention or to be seen by a consulting specialist. The difficulty in measuring primary care wait times for myriad illnesses and conditions...may impede progress in finding solutions to the wait time challenges that family doctors experience. Methodology and Scope of Report Methodology This paper is an opportunity to draw attention to issues of relevance to family physicians and their patients waiting for care - either to find a family doctor, or to be seen by their family doctor or to be seen by another specialist. The paper is a reflection of several data sources, including: Expert opinion from family physician leaders in practice and research The National Physician Survey (NPS) results from 2004 and 2007 Stakeholder consultation Given the available expertise within the PCWTP representing two national medical organizations that advocate for patients in primary care and for the resources that support high quality care, the authors of this paper are in a unique position to use their knowledge and understanding to contribute to the proposed solutions and recommendations. Scope It is easier to define what is in than what is out of scope for this paper. There is a variety of important influences coming to bear on primary care wait times. Some are beyond the scope of this discussion. For example, the health system is promoting more collaborative care and while this is an increasingly important part of practice, its influence on primary care wait times has yet to be determined. There are also enablers and impediments to improved access to care, some of these still poorly defined. For example, where a physician practices and the influence of location, e.g. suburban in contrast to rural communities, makes a difference to access. The location of resources based on criteria such as cost-effectiveness and skill maintenance requires more attention. Likewise, new models of primary care are encouraging incentives to practice differently. But it is still uncertain how these new models of care are affecting access to timely care. Finally, there are many personal factors that affect patient choice and physician decision in determining when access is acceptable or when it is intolerable. Risk plays an important part in these decisions but not all risk is measurable. Some experts have also suggested not every waiting list is a bad list. These issues require much more analysis than this paper allows. In short, recommendations for further research will be reinforced as much by what we know as by what we still do not know. What Does It Mean? Primary Care In the first report by the PCWTP, primary care was defined as first-contact medical care and services provided by family physicians and general practitioners. In contrast, primary health care was defined as the broader determinants of health, including health services delivered by other professional providers. Likewise, in that report it was acknowledged that "primary care is the foundation and family physicians are the backbone of the health system as the first points of contact for most patients." Patients have access to a continuum of medical services by first presenting to their family physician at the primary care level. Individuals may require specialty care at various points in their lives. Patients may see several specialists for a variety of problems; however, patients' family physicians play an important role during interaction with specialty care throughout the continuum of lifelong care. (Figure 1) [SEE PDF FOR CORRECT DISPLAY] What does it mean to have a family physician? As set out in the CFPC's Four Principles of Family Medicine, a person may be said to have a family physician when they have established a patient-physician relationship that provides for continuing care through repeated contacts across the life cycle and in which the physician becomes an advocate for the patient by referring to other specialists and other health care resources as appropriate. While in the past this relationship has often been established through an unwritten contract, in some of the new practice models patients are formally "rostered", that is to say they sign a commitment to seek all of their non-emergent care from the particular physician or clinic. Patients may see several specialists for a variety of problems; however, patients' family physicians play an important role during interaction with specialty care throughout the continuum of lifelong care. What does it mean to not have a family physician? Persons without a family physician are those without an established relationship with a primary care physician who maintains a continuous medical record for them. The largest population-based surveys that collect data on health care use among the general population have been conducted by Statistics Canada. They have not asked specifically about "family physicians" but rather about "regular doctors" or "regular medical doctor". In its 2007 Canadian Community Health Survey (CCHS), Statistics Canada asked the simple question, Do you have a regular medical doctor?1 Nationally, 85% of the population aged 12 or older reported that they did. In 2008, the CFPC commissioned a Harris/Decima survey and found that 86% of respondents had a family physician. 2 The CFPC proposed a target that 95% of Canadians in each community have a family physician by 2012. Some regions of the country may be close to attaining this target while others have far to go. Persons with a regular doctor are more likely to report greater continuity of care. According to Statistics Canada's 2007 Survey of Experiences with Primary Health Care, among the 86% of the population reported to have a regular medical doctor, 95% said that they would either definitely or probably be taken care of by the same physician or nurse each time they visited their physician's office. In contrast, among the 10% of the population with no regular doctor but some regular place of care, just 31% said they would definitely or probably see the same physician or nurse with each visit. 3 What does it mean to not have a family physician? Persons without a family physician are those without an established relationship with a primary care physician who maintains a continuous medical record for them. These are referred to as unattached (or orphaned) patients. They obtain episodic care from places like walk-in clinics and hospital emergency rooms (ERs). A recent report by the Institute for Clinical Evaluative Sciences (ICES) found that there are significant excess visits to ERs among people with chronic conditions who do not have a regular family physician. 4 Reducing the number of unattached patients could therefore have a substantial impact on the problem of overcrowded ERs. Of the estimated 4.1 million Canadians aged 12 and over who indicated that they did not have a regular doctor in the 2007 CCHS, 78% reported that they had some other usual source of care. Among these individuals, the most frequently cited source of care was walk-in clinics (64%), followed by hospital emergency rooms (12%), community health centres (10%) and "other" (14%). 5 The Concept of the Medical Home For those with a family physician there has been an increase in the literature in the United States on the concept of a "medical home". In 2007 the American Academy of Family Physicians and three other medical associations adopted "joint principles of the patient-centered medical home" that include: -each patient having a personal physician -physician directed medical practice -whole person orientation -coordinated care across all elements of the health system -quality and safety (e.g. support for optimal patient-centered outcomes) -enhanced access to care (e.g. open appointment scheduling); and -appropriate payment incentives. 6 The Commonwealth Fund attempted to assess the proportion of patients with a medical home in their 2007 International Health Policy Survey. Their definition included patients that have "a regular doctor or place that is very/somewhat easy to contact by phone, always/often knows medical history, and always/often helps coordinate care (yes)." While 84% of Canadian respondents on the survey reported that they had a doctor that they usually see (consistent with all other survey estimates), just under one out of two (48%) were considered to have a medical home according to the Commonwealth Fund definition. Of the seven countries surveyed, respondents in New Zealand and Australia were the most likely to be considered as having a medical home (61% and 59% respectively). 7 Primary Care Models There are several models for primary care delivery and thus far there is no conclusive evidence that any one particular model is better than all of the others. Many studies have compared various models in a variety of ways; each with different conclusions. For example, a comprehensive comparative study on the productive efficiencies of four models of primary care delivery in Ontario concluded that no one type of model dominates and that further research is required. 8 Furthermore, another study comparing various primary health care models with regard to a number of variables including access and quality came to the same conclusion. It found that the fee-for-service physician practice model ranked highest in terms of patient access and responsiveness, while community health centres ranked highest in effectiveness, productivity, continuity and quality. 9 Finally, another study that compared patient satisfaction in walk-in clinics, ERs and family practices came to the conclusion that in terms of waiting time, patients were most satisfied with family practices. 10 While there is no definitive research on best models for primary care delivery, this report shows there is a range of innovative approaches to enhancing timely access to quality primary medical care. Timely Access The issue of wait times has dominated the health policy agenda in Canada, particularly since the First Ministers Accord in 2004. Prior to that however, in their February 2003 Accord, which they considered to be a "covenant", governments agreed to develop and report on common indicators. Among the 40 indicators listed in the 2003 Accord, in addition to access to primary care (measured as a percentage of the population with a regular family doctor and a percentage of doctors accepting new patients), the list included seven wait-time/volume indicators, of which the following were pertinent to primary care: -referral to specialists for cancers (lung, prostate, breast, colo-rectal), heart and stroke; -diagnostic tests (MRI, CT); and -proportion of services/facilities linked to a centralized (provincial/regional) wait list management system for selected cancers and surgeries, referral to specialists, emergency rooms and diagnostic tests. (11) These commitments were overtaken, however, by the 2004 Accord which called for evidence-based benchmarks for five procedures including cancer, heart, diagnostic imaging, joint replacements and sight restoration. (12) National benchmarks were achieved in December 2005, but they begin from the point where the decision has been reached on treatment between the consulting specialist and patient. (13) A. To Family Medicine In discussions regarding the total time patients wait for care, what is often overlooked is the fact that the wait time continuum starts when a patient has a medical problem. However, the first part of the continuum that can be measured is when the patient schedules his or her first visit with a family physician. Figure 2 below illustrates the full wait time continuum. [figure 2. SEE PDF] Access to a family physician is a major concern in this country. In a series of focus groups conducted by Ipsos-Reid across Canada in 2007 on behalf of the CMA, the following concerns/issues were raised by some patients: -people had been searching for a family physician for several years without success; -people with a family physician were frightened about the prospect of their doctor retiring; and -people with a family physician reporting waits of three or four weeks to get an appointment.(14) According to the Commonwealth Fund survey in 2007, Canada had the lowest rate of same-day physician appointments by a wide margin. 22% of respondents said they could see their physician on the same day, versus 30% in the US and 41% and higher for the remaining five countries. Canada also had the highest rate of respondents noting it took six or more days to see their physician, at 30%, as opposed to 20% for Germany and the US and lower for the other four countries surveyed (7). However, in the 2007 National Physician Survey (NPS), 65% of family physicians stated that their patients with urgent needs are able to see them within one day. For non-urgent cases, 41% are able to see their patients within one week and 66% are able to see their non-urgent patients within four weeks.(15) In the 2007 Health Council of Canada survey, of the 26% of respondents who stated they require routine or ongoing care, 45% noted that they had to wait too long for an appointment and 29% said it was difficult to get an appointment. 16 Furthermore, according to the 2007 NPS, when other specialists were asked to rate their patients' access to family physicians, only 13% gave it a very good or excellent rating, while over half (55%) gave it a fair or poor rating. This survey also found that 86% of family physicians stated they had made arrangements for care for their patients outside of their normal office hours. When asked to list the arrangements they have in place, one third (33%) said they extend their office hours, over one third (37%) operate an after-hours clinic that is staffed by members of their practice and 41% included calling a 24/7 telehealth phone line as an option. However, over half (52%) included going to an ER as one of these arrangements.(15) The aforementioned surveys have shown there is evidence of a disparity between patients' and physicians' perspectives regarding access to primary care. Moreover, Canada lags behind other countries in access to primary care. B. To Specialty Care The next stage of the wait time continuum is also often overlooked. This is when a family physician refers the patient to specialty care. The Fraser Institute's research on patient wait times does take this into account, however. According to their most recent survey, the average wait time between referral by a family physician and a consulting specialist fell from 9.2 weeks in 2007 to 8.5 weeks in 2008.(17) It is encouraging to see some movement in the right direction, but there is much more room for improvement. According to the 2007 NPS, only one quarter (24%) of family physicians rated patient access to other specialists as very good or excellent, while over one third (36%) of family physicians rated patient access to other specialists as fair or poor. 15 Some specialists will not take phone calls from family physicians - the only method of communication is by fax, which makes it difficult for the family physician to confirm whether the consulting specialist has received the referral and acted on it. Efforts must be made to keep the lines of both communication and access as open as is feasible between family physicians and consulting specialists, in both directions. Other specialists have noted having some difficulty scheduling appointments for their patients with their family physicians after consultation and/or treatment. The Canadian Medical Protective Association (CMPA) has identified a specific process for referring physicians to follow and includes the following guidance: When a patient is referred to a consulting specialist, the family physician should provide sufficient clinical information so that the consultant can appropriately prioritize his or her referrals. The consultant should notify the family physician of the patient's scheduled appointment. If the timing of this appointment does not seem reasonable to the family physician, he or she should then attempt to schedule an earlier appointment. If this is not possible, the family physician should consider alternative options to seek specialty care and discuss these with the patient. The patient should also be informed of what to expect if his or her condition changes while waiting for specialty care, and what to do and who to consult if this occurs. 18 The Collaborative Action Committee on Intra-professionalism (CACI) was established in 2006 by the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada to discuss enhancing intra-professionalism and exploring ways to encourage desired behaviours that will improve physicians' intra-professional relationships. This work is vital to ensure a seamless continuum of care for patients between family physicians and other specialists. Working groups have been established to focus on improving relations through medical education, training and accreditation and in practice by developing enhancements to the referral-consultation process. (19) Should a timely referral not be available, the CMPA's latest guidance on wait times in a September 2007 information sheet addresses the issue of liability when health-care resources such as specialty care are limited. The sheet notes that physicians may be requested to provide care outside their area of expertise when resources are scarce. While noting that the courts have yet to address this issue, it suggests the "courts will not evaluate your decisions against a standard of perfection. Rather, your decisions will be evaluated in light of what a reasonable and prudent physician like you would have decided in similar circumstances". 20 Nonetheless, given that the decision to refer implies that a physician has determined that a problem is beyond his or her scope of practice, the issue of support for the physician managing what might be long waits for specialty care will need to be addressed. An additional barrier to timely patient access to specialty care is the inconsistency in family physicians' abilities to order advanced diagnostic tests. The Canadian Association of Radiologists (CAR) has guidelines for all physicians to follow when ordering diagnostic tests. C. Rural Versus Urban Access While timely access to family physicians and the referral time to other specialists is a nationwide concern, access to health care is often considered a greater challenge in rural locations. The 2007 NPS survey found that this is not the case. In fact, the opposite is true. There is very little difference in same-day family physician access rates between urban and rural locations and with regard to other specialties, the difference between urban and rural physicians is notable, with 51% of rural physicians stating that urgent appointments can be made on the same day as opposed to only 37% of urban physicians. However, there is a difference between rural and urban settings with regard to factors that increase demand on a physician's time. For example, the 2007 NPS found a lack of availability of other specialists locally was a more significant factor for rural physicians (65%) than for urban (55%), as was the lack of other health care professionals, which was a concern for 66% of rural physicians in contrast to 54% for urban physicians. This survey shows that health human resources is a concern for all physicians, especially in rural settings. (15) It should be pointed out that rural and urban physicians' differing perceptions about access for their patients may have an effect on survey findings; the weather and distance to travel to obtain specialty care, for example, affect a rural family physician's view of the quality of access. The 2007 NPS found that access to Routine andAdvanced Diagnostics was rated very similarly by rural and urban physicians of all specialties, with access to routine services rated higher than access to advanced services in all respects. When the physician's specialty is taken into account, both rural and urban family physicians rated access to routine diagnostics higher than other specialists (very good or excellent - 48% versus 37%). The reverse is true for access to advanced diagnostics, with 15% of family physicians rating it very good or excellent, whereas 21% of other specialists gave it these rankings. (15) Any guidelines regarding wait times to specialty care must also account for the geographic factors that affect access. The most commonly regarded solution to the problem of access to specialty care in rural regions is to increase the number of specialty services in that area; for many specialties, however, this may not be feasible due to insufficient numbers of patients residing in the area to support an effective workload. Next Steps - Finding Solutions For the purposes of this paper, "target" is defined as a time-based standard for accessing care. A. Measuring Primary Care Wait Times What primary care wait times should be measured? How can they be measured? While the selection of the five priority areas noted earlier has stimulated progress in the measurement of waiting for treatment once the consulting specialist has been seen, as the Fraser Institute has reported for the past two years, nationally one-half of the total waiting time for family physician referral to treatment is from family physician referral to when the patient is seen by the consulting specialist. In 2008 the Institute estimated the average total wait from referral to treatment at 17.3 weeks; of this the wait from referral to specialty consultation was estimated at 8.5 weeks - 49% of the total (17). Among the recent provincial/territorial initiatives there has been no systematic effort to capture the time from family physician referral to specialty consultation. For its part, the Wait Time Alliance is launching a project in spring 2009 that will record the actual total waiting time from initial referral to treatment among a sample of consulting specialists and their patients. B. Setting Targets For the purposes of this paper, "target" is defined as a time-based standard for accessing care. This may be further graduated by the urgency for which the care is needed, and it may also be qualified by a percentage threshold of attainment. For example, "90% of patients with the least urgent requirement for care will be seen within one month of referral". When considering the concept of target-setting, two important points must be stressed: - before any reasonable wait time targets can be established, a significant investment in information infrastructure is required to facilitate the measurement and monitoring of access to primary care physicians, appointments and referral to other specialists; and - regardless of how the targets are determined, even if the targets are met, not everyone will receive care within the most appropriate period of time for their particular situation. Targets to Accessing Primary Care There are two key considerations in this paper with regard to targeting wait times in access to primary care. While other jurisdictions and researchers have considered other approaches, e.g. wait times to access a primary care setting, this paper is focused on ways to improve timely access to primary medical care for those Canadians who have their own family physician and for those who do not - as well as timely access to specialty care services from their family physician. Finding a Family Physician What would it take to reach the target of 95% of Canadians in each community having a family physician by 2012? An estimated 4.1 million Canadians aged 12 or older do not have a family physician. Statistics Canada further subdivides the 4.1 million into those who have not looked for a family physician (2.4 million) and those who have looked but cannot find one (1.7 million) (1). A telephone survey conducted by Harris/Decima in October and November 2008 found that of the 14% of respondents who do not have a family physician, 61% were not looking for a family physician for themselves or a family member. 45% of these stated they are not looking for one because they go to a walk-in clinic or an ER instead, whereas the other half were not looking because they presumed no family physicians were available.(2) It would seem reasonable that the population who has looked for but cannot find a family physician should be a priority target to advancing toward the 2012 goal. As advocated and explored by the CFPC, this may entail establishing registries for unattached patients in communities across Canada. Several provinces and territories have included incentives in their physician contracts for taking on unattached patients and it would be useful to assess their effectiveness. One way to increase the number of family physicians practicing in Canada is to encourage more medical students to choose family medicine by exposing them to family practices early on and to obtain placements in practices that are keenly interested in demonstrating the benefits of family practice to medical students. Support for family practice preceptors and teachers is also important. Incentives to attract more preceptors are required and facilities should be created to improve medical students' awareness of these opportunities across the country. Ontario has set a target of finding a family physician for 500,000 unattached patients over the next three years. 21 Ontario already has in place an incentive schedule for patients in its primary care models to take on new patients. The most common of these models (i.e. with the largest number of physicians participating) is the Family Health Group, which provides a payment of $100 each for up to 50 newly enrolled patients without a family physician per year with a premium of 10% for patients aged 65-74 and 20% for those aged 75 and over. There is also a payment of $150 for rostering unattached patients discharged from an inpatient hospital stay. Effective April 1, 2009 a complex/vulnerable new patient fee of $350 will also be introduced, with criteria still under development. New Brunswick has a pilot project in place that is based on a $150 premium, payable in addition to fee-for-service (FFS) billings in installments of $50 per visit up to the maximum. In the Yukon, family physicians who accept unattached patients are paid $200 over and above the initial visit fee. 95% of Canadians in each community should have their own family physician by 2012 Another option currently being discussed in a number of jurisdictions is to allow faster integration of qualified International Medical Graduates (IMGs) by evaluating the equivalency of family medicine training and qualification programs done in other countries. In order to increase the number of family physicians who are trained to provide high-quality care, the CFPC recently approved the following initiatives: -Expansion of the Alternative Route to Certification for practicing FPs interested in Certification in Family Medicine (practice eligible) to those who have been practicing for at least five years in Canada. -Granting Certification to family physicians who hold Certification with the American Board of Family Medicine (ABFM), are in good standing with the American Academy of Family Physicians and are moving to Canada. -Evaluate other postgraduate family medicine training and certification programs in jurisdictions outside Canada in order to consider granting reciprocity for family physicians with training and certification equivalent to family medicine programs in Canada. Access to Family Physicians In terms of targeting approaches to the time to get an appointment to see the family physician, it would appear that the "evidence-based" approaches of urgency scoring will be impractical because they require an assessment of the patient. It may be worth investigating the methodology used by the provincial health phone lines to triage patients based on the use of structured algorithms and exploring whether this can be used in a primary care physician office to better gauge the level of each patient's need to see their physician and to organize the physician's patient schedule in a more effective manner. This would require additional resources (both staff and technology) be made available to the family physician's practice. Want to learn more? Capital Health in Halifax is exploring "a program of supports for family physicians and family practice nurses working in fee-for-service practices in Nova Scotia: www.cfpc.ca/nursinginfamilypracticeTQVI When considering approaches to address the issue of increasing access for patients with a family physician, we must look for solutions that do so through enhanced practice efficiency and not by expecting family physicians to work longer. Improving practice efficiencies can be accomplished through enhanced practice management training during medical school education and residency levels. Continuing Medical Education programs on this topic will also be beneficial. Physicians should be educated on how to run a practice from a patient flow point of view as well as a financial one. To encourage interest in this aspect of running a medical practice it is important that they are made aware of all of the benefits of a well-managed office (e.g. more time spent doing direct patient care, the ability to increase patient load and attain a better work-life balance). New Approaches to Practice Management Some progress is being made to enhance Canadians' access to primary care. A variety of projects are underway that have already shown improvements in this area, including a number of successful efforts occurring in British Columbia, Alberta and Saskatchewan that include the implementation of a innovative practice management system known as Advanced Access. The term Clinical Practice Redesign (CPR) is becoming a more popular description of the process involved. "Advanced Access is about reengineering clinic practices so that patients can see a physician or other primary care practitioner at a time and date that is convenient for them. The advanced access model is often considered to be another scheduling system; however, it is in fact a comprehensive approach to effective patient care delivery."(22) The main objective of CPR is to improve patient flow through a medical practice. This involves the use of effective scheduling management techniques that allow appropriate prioritizing of patient visits. The main premise is that if patient demand for appointments is overall in balance with the physician capacity to schedule appointments, it should be possible to offer patients an appointment on the same day that they telephone for one. The challenge is to work down the backlog and achieve that balance. Once this is accomplished, the wait time to see the physician can be dramatically reduced. The originators of this concept have identified six steps in implementing CPR: 1. Measure and balance supply and demand 2. Eliminate the accumulated backlog 3. Reduce the number of appointment types 4. Develop contingency plans (e.g., flu season) 5. Reduce and shape demand (e.g., phone and e-mail for answering questions) 6. Increase effective supply by delegating tasks 23 Want to learn more? Family Physician Dr. Ernst Schuster presents advanced access in family practices through the Alberta Access Improvement Measures (AIM): www.cfpc.ca/advancedaccessTQVI The sentinel indicator that is used to monitor CPR is what is termed "third next available appointment" and is defined as the average length of time in days between the day a patient makes a request for an appointment with a physician and the third available appointment. Another common patient scheduling technique, often misinterpreted as Advanced Access, is more accurately referred to as the "carve out" model. It involves keeping a block of time open each day for patients who call that day for an urgent appointment. While it allows patients with an urgent problem to see their family physician the same day, it could potentially make the wait time for non-urgent problems longer as there are fewer appointment times that can be used for those cases. It is nonetheless a step in the right direction and shows that family physicians are making efforts to alleviate the primary care access problem. CPR is gaining momentum as a popular method of improving practice efficiency. The first group practice to adopt this system in Saskatchewan was able to reduce its average wait time from 17 days to just two. (24) In addition to reducing wait times, many practices in British Columbia, Alberta and Saskatchewan have been able to increase their patient load due to efficiency improvements. This is therefore also addressing the concern about the large number of Canadians who do not have a family physician. The United Kingdom Experience The UK has adopted fixed targets for primary care, irrespective of the patient's presenting condition. The 2004 National Health Service (NHS) Improvement Plan set out a 24/48 hour access target, by which UK patients would be guaranteed the opportunity of seeing a primary care provider within 24 hours and a GP within 48 hours. (25) The UK has since adopted an incentive approach to achieving this target through an Improved Access Scheme. First implemented on a voluntary basis in 2007, some 5 million surveys were sent to GPs' patients across England about their recent experience with access to their GP. The survey results are linked to a reward payment that has four elements: - 48 hour target reward element; - advance booking target reward element; - ease of telephone access target reward element; and - preferred health care professional target reward element. The level of payment for each element is linked to the satisfaction level reported by the patients. (26) The survey has now been successfully administered twice. In 2008, almost two million responses were received - a 41% response rate. Key findings from the 2008 survey include the following: - 87% of patients reported that they were satisfied with their ability to get through to their doctor's surgery on the phone. - 87% of patients who tried to get a quick appointment with a GP said they were able to do so within 48 hours. - 77% of patients who wanted to book ahead for an appointment with a doctor reported that they were able to do so. - 88% of patients who wanted an appointment with a particular doctor at their GP surgery reported that they could do this. (27) Any kind of patient-based reporting on access requires an up-to-date electronic roster of patients. The survey tool used in the UK is very simple and can be completed online. It should be noted however that the cost of the 2007 survey was estimated at £11 million although this also includes the patient choice survey. (28) No doubt less complex approaches could be developed for applying an incentive approach to reach targets in Canada. However, this would involve the types of supports and resources available to general practitioners in the UK. In addition, the views of the public and patients should be sought before adopting any targeting approaches in primary care. This was emphasized by Berta et al in a Canadian public opinion study of the importance of ten measures of primary care performance. They found that the most important factors for patients were related to the family physicians' knowledge and skills, while the access indicators were least important. (29) Targets to Accessing Specialty Care One of the key challenges of primary care wait times is to establish guidelines for timely access to specialty care. This is potentially an enormous challenge given that there are some 60 recognized specialties and sub-specialties in Canada and each of them is responsible for treating a number of conditions presenting to the family physician. Due to the varying degree of complexity of a patient's medical problem, an appropriate wait time would be difficult to define by a particular disease or illness. National and international experience would suggest that there have been two broad approaches: - the development of "condition-specific" approaches to target-setting linked to a clinical assessment of urgency; and - the adoption of targets that apply to all conditions that are progressively shortened as they are achieved. Since the early 1990s, the NHS has made remarkable progress in tackling wait times through the adoption of targets that have been gradually shortened. This began with the first UK patient charter that was adopted in 1991. Reflecting the long waiting lists at that time, it included the right, "to be guaranteed admission for treatment by a specific date within two years". (30) In 1995 a second version of the Patient Charter lowered this period to 18 months, and to one year for coronary artery bypass grafts. (31) In the late 1990s the NHS moved from the Charter to a series of national service frameworks for conditions such as heart disease and cancer. These frameworks evolved into shortened targets. For example in 2001 the target was a maximum one month wait from diagnosis to first treatment for breast cancer by the end of 2001, in 2005 this was extended to all cancers by December 2005. 32 The most recent development has been the 2004 commitment that by the end of 2008 no patient will have to wait longer than 18 weeks from GP referral to hospital treatment.(33) The UK is on track to meet this target, but it must be emphasized that this has been achieved through a combination of a large infusion of resources, plus policy changes such as the shift from block funding to Payment by Results that reimburses hospitals on the basis of the number of patients treated. It should also be emphasized that the NHS is a much more integrated system than Canada's health care system, and it would be more challenging to define accountability for reaching wait time targets. Past Work on Improving Specialty Care Access In Canada, the "gold standard" of target-setting is considered to be the work done by Naylor and colleagues in developing the urgency rankings for coronary revascularization procedures that underpin the Cardiac Care Network (CCN) of Ontario. This was done using a modified version of the techniques developed by the RAND Corporation in the 1980s to establish appropriateness guidelines for various procedures. In this work a panel of cardiologists and cardiac surgeons rated 438 fictitious case-histories on a seven-point scale of maximum acceptable waiting time for surgery. A regression model was then used to derive a scoring system based on the regression coefficients attached to the major determinants of urgency. (34) This system was implemented to prioritize waitlists by CCN which now works with 18 cardiac care centres in Ontario. A group urology practice in Saskatchewan has initiated a process whereby referring family physicians are provided with a standard form listing the necessary tests. The Diagnostic Imaging Program Standards Committee of the Winnipeg Regional Health Authority in Manitoba found that when physicians requesting a diagnostic test provided a time frame for the test to be completed as well as information about the patient's condition, the process of prioritizing requests became more manageable for radiologists. In Alberta and British Columbia, some family physicians have signed service agreements with other specialists. Such an agreement defines the scope of the work of family physicians and other specialists. It formally encourages all specialties to work collaboratively and to this end regular meetings are held to discuss all relevant matters. Manitoba has recently launched a pilot project called Bridging Generalist and Specialist Care - The Right Door, The First Time that will focus on reducing the wait time between family physician referral and specialty consultation. In the late 1990s a similar approach was used by the Western Canada Waiting List (WCWL) Project to develop priority scoring tools for cataract surgery, general surgery, hip and knee replacement, MRIs and children's mental health. (35) The tool for hip and knee replacement has been adapted for use by family physicians to determine priority of referral to orthopaedic surgeons,although to date it has only been tested on simulated paper cases.(36) The Saskatchewan Surgical network has applied the WCWL approach to develop scoring tools in 12 procedural areas. (37) Clearly it would be a large undertaking to adopt all these tools for use in primary care and to develop tools for the numerous areas that have yet to be tackled. Thus far, governments have concentrated, for the most part, on their initial five priorities. In the Fall of 2007 the Wait Time Alliance added five new benchmark areas, including emergency care, psychiatric care, plastic surgery, gastroenterology and anesthesiology (pain management) and it has challenged governments to adopt them. (38) Recent Efforts to Improve Specialty Care Access How can we work to achieve these targets? There are a variety of initiatives underway to expedite the referral and consultation process. In 2006, the CFPC and the Royal College of Physicians and Surgeons of Canada said that three steps could improve the referral and consultation process: - a defined single access point within local referral/consultation systems; - templates for referrals and consultations advice; - an agreement amoung key players (relevant GP/FP and other specialty organizations) on referral/consultation criteria."(39) As an example, a group urology practice in Saskatchewan has initiated a process whereby referring family physicians are provided with a standard form listing the necessary tests. This process has been very successful in reducing the need for repeat appointments. This practice also implemented a policy that the patient is referred to the first available urologist rather than to a specific physician. This new pooled referral system has reduced patient wait times remarkably and has been very well received by all parties. (40) In addition, other specialties in that province have shown interest in introducing a similar system in their practices. As an additional example of simple ways to gain efficiencies, the Diagnostic Imaging Program Standards Committee of the Winnipeg Regional Health Authority in Manitoba found that when physicians requesting a diagnostic test provided a time frame for the test to be completed as well as information about the patient's condition, the process of prioritizing requests became more manageable for radiologists. (41) In Alberta and British Columbia, some family physicians have signed service agreements with other specialists. Such an agreement defines the scope of the work of family physicians and other specialists. It formally encourages all specialties to work collaboratively and to this end regular meetings are held to discuss all relevant matters. Manitoba has recently launched a pilot project called Bridging Generalist and Specialist Care (BGSC) - The Right Door, The First Time that will focus on reducing the wait time between family physician referral and specialty consultation. This pilot project is intended to address priority areas, including: - mental health: anxiety and depression - lower back pain management - lower gi endoscopy - orthopaedics: arthroplasty - plastic surgery: carpal tunnel, breast reconstruction, breast reduction and skin lesions - lung cancer (42) One of the objectives of this pilot project is to establish guaranteed time frames from referral to consulting specialist in the specific practice areas and to offer alternative options to patients who may exceed these time lines. The BGSC software includes primary care pathways and an electronic referral process, allowing family physicians to send all necessary referral information, such as primary care workups, treatments and testing results, to the other specialist offices electronically. These specialists can then respond to the referrals electronically, advising family physician offices of referral acceptance, appointment dates and times and any additional information within days of receiving the referral request. Want to learn more? Ms. Brie DeMone offers an overview of the government of Manitoba's project to improve communication and coordination between family physicians and other specialists. "Bridging General and Specialist Care" and "the Catalogue of Specialized Services". www.cfpc.ca/BGSCTQVI In January 2009, the web-based Catalogue of Specialized Services (CSS) was launched, which, is, according to provincial director of patient access Dr. Luis Oppenheimer, "like a catalogue order entry system. If you're a GP/FP looking for a service, you will get a catalogue of who provides that service, [...] some idea of the waiting time or capacity for that service [...] and have immediate confirmation of whether [your request] is accepted." By clearly providing family physicians and their offices with information on "who does what", referrals can be accurately directed to the right specialist at the right time, saving time and effort for the family physician, other specialist and patient (42),(43). A third new initiative currently underway in Manitoba, the Patient Access Registry Tool (PART), will provide other specialists with the clinical information they need to manage patient demand. Patient demographics and provider information as well as a diagnosis and planned interventions will be available through this tool and it will also document several key wait time dates, including when a referral was first received, the date of the first specialist consultation and when a patient is ready for treatment. Once it is fully operational, PART will capture information on all patients needing a medical consultation or surgery in Manitoba. (44) British Columbia offers a Full Service Family Practice Program with a broad range of incentives The Nova Scotia agreement includes new Chronic Disease Management Incentives that will be linked to guideline-based care for chronic diseases such as diabetes, chronic heart failure and hypertension Given the wide spectrum of illnesses that are assessed in a primary care setting, any approach to developing wait time targets must be done in consultation with family physicians and with clinical guidelines in mind. Currently there is simply not enough information available to establish reasonable wait time targets. The ability to accurately measure and monitor access at all points along the care continuum will require a significant investment in information infrastructure and this system must be in place and used effectively before targets are developed. More importantly, this cannot be effectively implemented without coordinated support from all governments. The Manitoba Government is a pioneer with this particular effort and their pilot projects will be closely monitored for effectiveness. C. Remuneration Models Since the early 1990s there has been a steadily declining trend in fee-forservice (FFS) as the sole mode of payment for family physicians. In 1990, the CMA's Physician Resource Questionnaire (PRQ) survey results showed that 71% of family physicians received 90% or more of their professional income from FFS.45 Subsequent PRQ surveys showed successive decreases and on the 2007 NPS, fewer than one out of two (48%) family physicians reported receiving 90% or more of their income from FFS. 15 While the majority of physicians continue to receive some income from FFS, increasingly it is being blended with other remuneration methods. A blended payment model known as the Family Health Network is now available in Ontario. In this model, capitation accounts for about 65% of a family physician's remuneration. The remainder consists of fee-for-service and other incentive payments and premiums. Over the past decade there has been an international trend towards the adoption of "pay-for-performance" (P4P), in which a variety of payment incentives are used to promote certain physician behaviours. To date, these incentives have been used mainly to encourage process improvements in the delivery of care. The earliest forms of P4P focused on prevention screening, but more recently they have expanded to address chronic disease management. P4P generally works by linking a bonus payment to the achievement of a specific performance target in the patient population. In its new primary care models, Ontario provides bonus payments for cancer prevention screening and diabetes management, as well as other incentives for activities including palliative care and care for patients with serious mental illness. (46) Similarly, British Columbia offers a Full Service Family Practice Program with a broad range of incentives. (47) The recently concluded Nova Scotia agreement includes new Chronic Disease Management Incentives that will be linked to guideline-based care for chronic diseases such as diabetes, chronic heart failure and hypertension.(48) As previously noted, several jurisdictions also provide incentives to acquire new patients. Internationally the UK has gone further by providing a bonus to the attainment of timely access targets as reported by patients. However, the UK also has a long-established rostering system and it has a much less geographically dispersed population than does Canada. Nonetheless it might be interesting to assess the potential for incentives to enhance access to primary and specialty care in Canada. D. Electronic Medical Records Regardless of how a wait time management strategy might be implemented (e.g., at the level of the province, health region, hospital) it will be critical to be able to capture and monitor referral data electronically, starting with the family physician. It may be seen in Table 1 below that according to the 2007 National Physician Survey, there remains a large gap in this regard. Nationally almost two out of three family physicians (63%) continue to use paper charts as their method of record keeping. One out of five (19%) uses a combination of electronic and paper charts while just over one out of 10 (12%) report using electronic charts instead of paper charts.Across the country there is more than two-fold variation of those using paper charts ranging from a low of 36% inAlberta to a high of 81% in PEI and Quebec. [TABLE 1. SEE PDF] Internationally, the Commonwealth Fund has shown that Canada lags far behind comparator countries in the uptake of electronic medical records (EMRs). On its 2006 survey of primary care physicians in seven countries, fewer than one out of four (23%) Canadian respondents reported that they used EMRs in their offices compared to nine out of ten in the UK, New Zealand and the Netherlands.(49) Aside from the issues of wait times for those patients with a family physician there is also the challenge of capturing information about access to primary medical care for those without their own family physician. E. Practice Support Improvements in access to family physicians can also be accomplished through the addition of staff support, of which there are two types: 1 clinical practice support(ie nurse or MOA for patient care),and 2 change management practice support (those with knowledge of clinical practice redesign to support physicians in making, monitoring and sustaining change). The Practice Support Program in British Columbia offers training and financial incentives for family physicians working with medical office assistants and in one district health authority in Nova Scotia, a project is underway where family physicians can obtain financial support to employ family practice nurses through enhanced fee-for-service billings. At present, however, widespread deployment of practice support personnel is constrained by rules of fee-for-service payment that require the physician to have direct contact with each patient for whom a service is billed to the provincial or territorial medicare plan. In terms of change management practice support, thus far CPR has had limited uptake in the rest of the country, primarily due to a lack of awareness. However, stories of the successes with this program are now being heard in the rest of the country and it is increasing in popularity. For example, a new Advanced Access initiative has been recently introduced in Manitoba through their Ministry of Health. In Nova Scotia, one practice that has had great success with Advanced Access is managed by the 2008 recipients of the Health Care Provider of the Year Award in Cape Breton, Elaine Rankin and Steven MacDougall. They worked together on an Advanced Access research project beginning in 2006. Once Dr. MacDougall cleared his patient wait list, he began to operate a same day access practice where his patients can call in the morning for an appointment that day. Now, the number of non-urgent patients from his practice who go to the emergency department has dropped by 28%. 50 By all accounts, those who have implemented CPR indicate they would never return to the traditional model where the appointment schedule is full before the work day starts. CPR is not a tool to be used exclusively in family practices. The group urology practice in Saskatchewan that introduced the notion of pooled referrals with much success has also been engaged in the process of CPR since early 2007. Their practice is now beginning to enjoy the fruits of their labour through reduced wait times for patients who are referred to their practice. The "champion" of this undertaking, Dr. Visvanathan, noted that Clinical Practice Redesign involves improving practice work flow, the introduction of Electronic Medical Records and getting the right staff to do the right jobs. (40) The implementation of a more efficient practice management system such as CPR requires commitment from physicians as well as effective information management and measurement tools, additional practice support and assistance from change management experts. Experience to date suggests that these efforts pay off in terms of improved patient access and increased capacity to accommodate patient appointments. Recommendations There are three main issues that should concern our focus on primary care wait times: - Access to primary care for those without a family physician; - Access to primary care for those with a family physician; and - Referral from primary to more highly specialized care. There are general recommendations that would help address these issues and other recommendations that are more specific to each. This paper has provided valuable information that supports the following recommendations. General Recommendations As noted in the introduction to this paper, it is difficult to measure primary care wait times for myriad illnesses and conditions, and this difficulty may impede progress in finding solutions to the wait time challenges that family doctors experience. The Primary Care Wait Time Partnership (PCWTP) believes that the ability to measure and track wait times along the full continuum of the patient's care is of utmost importance, but that this capacity in primary as well as more highly specialized levels of care is still very limited. 1) Primary care wait time tracking, analysis and improvements should be patient-centred, taking into account the whole wait time continuum that patients experience, starting from the time they first seek medical care. 2) More research and evaluation is needed to analyze primary care wait times so that the inequities and inconsistencies in access to care can be addressed for patients from region to region across Canada. 3) More study on collaborative care is necessary. The PCWTP recognizes that collaboration has the potential to enhance access to primary care. But before we can state with certainty that access to primary care is improved through particular models of care delivery, we need to continue to collect data and analyze results. It makes little sense to invest tremendous resources into any model if patient access to primary care is not improved. 4) Primary care wait time measurement should be a priority for Canadian governments, health authorities and other stakeholders, (e.g. Canadian Institute for Healthcare Information). Reliable data that represents the patient's total wait time experience will need to be collected to support the development of primary care wait time targets in the future. This data must be validated and tracked for the purpose of continuous evaluation. 5) Before reasonable wait time targets can be established and effectively used in primary care, information infrastructures, (e.g. electronic medical records and communication tools) , must be adequately supported and in place. Enhancements in information technology and learning in family practice will be necessary to facilitate the adoption and widespread use of electronic medical records. No measuring or tracking of primary care wait times can be effectively accomplished without financial support from government for electronic communication systems in and between medical practices. 6) There are a number of jurisdictions pursuing important and different ways to improve timely access to care for patients, (e.g. Manitoba's catalogue system and registry tool, Alberta's formal service agreements between referring and consulting physicians). These worthwhile endeavours should be monitored at a national level for opportunities to implement more universal improvements to wait times in our Canadian health care system. Recommendations for Patients without a Family Physician The CFPC and CMA have recommended and supported several strategies to increase the supply of family physicians through education and training (e.g. promotion of family medicine to medical students and residents, better support for preceptors and teachers), to address changing patterns of family practice (e.g. supports for inter-professional collaboration), and to develop models of care that would attract and retain family physicians (e.g. blended remuneration methods). While these recommendations will not be repeated here, they should be given full consideration in seeking to achieve an adequate family physician workforce that can support timely access to care for all Canadians. 1) The PCWTP believes that every Canadian should have a family doctor and supports the CFPC position that all stakeholders, (e.g. governments, medical schools and professional organizations), should work together to achieve a target of 95% of the population in every Canadian community with a family doctor by 2012. 2) Patient registries should be developed and maintained to track patients who do not have a family doctor and are actively looking for one. 3) Other strategies should be more fully developed and supported to find family doctors for patients without a family doctor , (e.g. physician incentives to accept new patients and the use of tools for workload management and patient flow in family practice). 4) Efforts currently underway to integrate appropriately trained and certified international medical graduates as family physicians into our health care system are welcome, should be supported and enhanced. Recommendations for Patients who have a Family Physician 1) Family physicians who see a need to improve timely access to care for their patients could consider Clinical Practice Redesign tools such as Advanced Access . System support should be in place for family physicians who want to adopt these tools. The training and ongoing learning of new and practicing family physicians should include education in practice flow and design. To further assist physicians in the use of these tools, websites should be established with lists of those who have been successful at improving patient flow through their practices and who are willing to assist others attempting to do the same. 2) Practice management education and training should be enhanced in residency in order to teach new family physicians about effective office processes and practice flow efficiencies that improve timely access to care for patients, (e.g. electronic tracking tools). 3) Financial incentives should be available to support the valuable roles of office assistants as well as other health professionals in family practice, (e.g. family practice nurses), for better patient flow and more efficient use of the physician's time. In addition, family physician remuneration should compensate for patient encounters beyond just face-to-face in order to support increasingly important opportunities for electronic encounters with patients and members of the care team. Recommendations for Referral from Primary to Specialty Care 1) All recommendations to address timely access to more highly specialized care must include the wait time from the first visit with the family physician to referral and specialty consultation. 2) Based on four years' experience with benchmarks for the five procedural areas established in 2004, we do not believe it is possible to develop a broad array of condition-specific, evidence-based benchmarks for access to consultations in the near future. However, where they are or do become available and are supported by sufficient infrastructure, wait time targets should be used as guides to drive improvements in timely access to care. Nonetheless, family physicians must continue to be free to use their clinical judgment in the patient's best interests. 3) Good intra-professional relationships between family physicians and other specialists should be promoted and supported in the health care system to improve communications and the continuity of care for patients. Strategies to support good relationships should consider recommendations that have been developed by the Canadian Medical Protective Association as well as the Collaborative Action Committee on Intra-professionalism that is supported by the CFPC and Royal College of Physicians and Surgeons of Canada with CMA participation. 4) Tools that will improve the timeliness of the referral-consultation process between physicians should also be enhanced; however, any development of referral-consultation process tools must be undertaken collaboratively with family physicians, (e.g. referral-consultation frameworks that identify and support the availability of appropriate and timely information to and from referring and consulting physicians, electronic communication of patient information between physicians, and better system supports for electronic communication between physicians and patients). 5) Family physicians should have access to routine and advanced diagnostic tests for their patients in all clinical settings, equal to that of other specialists. There should be no difference in the criteria for access to advanced diagnostic testing from region to region. All physicians should be expected to follow appropriate clinical guidelines in the use of diagnostic tests. These guidelines should be readily available and easily understood by physicians and other health care professionals with whom they work. 6) Guidelines or targets for timely access from primary to specialty care must account for differences in geographic settings and proximity to care that are characteristic of rural and remote locations in contrast to urban and suburban locations. Concluding Remarks While the Canadian Medical Association (CMA) and The College of Family Physicians of Canada (CFPC) are proud to represent doctors across Canada, at the centre of everything we do stands the patient. We know that many Canadians are concerned about timely access to see their own family doctor while others continue a sometimes fruitless search for a family doctor of their own. In this paper we have presented many problems but also a number of solutions to addressing wait times in primary care. We've acknowledged that there are obstacles, but we do not think these obstacles are insurmountable. Canadians exercised considerable political courage, often in the face of adversity, to pioneer a health care system based on the principles of fairness, equality and social justice. Through political will, we are certain we can make the changes necessary to ensure timely access to primary care. The PCWTP hopes that governments, health care providers and the public will read this report and consider the recommendations. We know that these recommendations do not represent an exhaustive list and indeed we may have inadvertently omitted something you think is critical. We encourage you to let us know what you think and how we can work together to improve access to primary care. This is not a task merely for the CFPC or the CMA; all of us must work together to offer better access to health care to our patients. References 1Statistics Canada. Canadian community health survey: 2007 questionnaire. [Online][Accessed 2008 Nov 20]. Available from: http://statcan.gc.ca/imdb-bmdi/instrument/3226_Q1_V4-eng.pdf 2The College of Family Physicians of Canada. CFPC Decima survey results. Toronto: Decima Research; November 2008. 3Statistics Canada. Frequency of whether taken care of by same medical doctor or nurse each visit by source of regular care. Canadian survey of experiences with primary care, 2007. Custom Tabulation. 4Glazier RH, Moineddin R, Agha MM, Zagorski B, Hall R, Manuel DG, et al. The impact of not having a primary care physician among people with chronic conditions. ICES investigative report. Toronto: Institute for Clinical Evaluative Sciences; 2008 Jul. 5Canadian Community Health Survey, 2007. Statistics Canada The Daily. [Online] [Accessed 2008 Nov 18]. Available from: http://www.statcan.ca/Daily/English/080618/d080618a.htm 6American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint principles of the patient-centered medical home: March 2007. [Online] [Accessed 2008 Nov 19]. Available from: http://www.medicalhomeinfo.org/Joint%20Statement.pdf 7Schoen C, Osborn R, Doty MM, Bishop M, Peugh J, Murukutla N. Toward higher-performance health systems: Adults' health care experiences in seven countries, 2007. Health Aff 2007 Oct 31; 26(6):w717-34. 8Milliken O, Devlin RA, Barham V, Hogg W, Dahrouge S, Russell G. Comparative efficiency assessment of primary care models using data envelopment analysis. Ottawa: University of Ottawa; 2008 Mar. 9Lamarche PA, Beaulieu M-D, Pineault R, Contandriopoulos A-P, Denis J-L, Haggerty J. Choices for change: The path for restructuring primary healthcare services in Canada. Ottawa: Canadian Health Services Research Foundation; 2003 Nov. 10Hutchison B, Østbye T, Barnsley J, Stewart M, Mathews M, Campbell MK, et al. Patient satisfaction and quality of care in walk-in clinics, family practices and emergency departments: the Ontario walk-in clinic study. Can Med Assoc J 2003 Apr 15:168(8): 977-83. 11Canadian Intergovernmental Conference Secretariat. 2003 First Ministers' accord on health renewal. [Online] [Accessed Nov 24]. Available from: http://www.scics.gc.ca/pdf/800039004_e.pdf 12Canadian Intergovernmental Conference Secretariat. A 10-year plan to strengthen health care. [Online] [Accesssed Nov 24]. Available from: http://www.scics.gc.ca/cinfo04/800042005_e.pdf 13Ontario Ministry of Health. First ever common benchmarks will allow Canadians to measure progress in reducing wait times. [Online][Accessed 2008 Nov 25]. Available from: http://www.health.gov.on.ca/english/media/news_releases/archives/nr_05/nr_121205.pdf 14Ipsos-Reid. Physicians today: Respect, reputation and role. Ottawa: Canadian Medical Association; 2007 Nov. 15The College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons. National Physician Survey. [Online] [Accessed 2008 Nov 14]. Available from: http://www.nationalphysiciansurvey.ca/nps/2007_Survey/2007nps-e.asp 16 Health Council of Canada. Canadian survey of experiences with primary health care in 2007. [Online] [Accessed 2008 Nov 25]. Available from: www.healthcouncilcanada.ca/docs/rpts/2008/phc/HCC%20PHC_Supplement_ENG%20FA_WEB.pdf 17 th Esmail N, Hazel M, Walker M. Waiting your turn: Hospital waiting lists in Canada, 2008 report, 18 edition. Fraser Institute. [Online][Accessed 2008 Nov 18]. Available from: http://www.fraserinstitute.org/researchandpublications/publications/6240.aspx 18Canadian Medical Protective Association. Wait times: a medical liability perspective. [Online] [Accessed 2008 Nov 24] Available from: http://www.cmpa-acpm.ca/cmpapd04a/pub_index.cfm?LANG=E&URL=cmpa%5Fdocs%2Fenglish%2Fcontent%2Fissues%2Fcommon%2Fcom %5Fwait%5Ftimes%5F2007%2De%2Ehtml 19Borsellino, M. 10 questions with...RCPSC president Dr. William Fitzgerald. The Medical Post. 2009 Jan 13. [Online][Accessed 2009 Feb 11]. Available from: http://www.medicalpost.com/news/article.jsp?content=20090113_092248_28936 20Ross M. Limited health-care resources: the difficult balancing act. Information sheet IS0770E. Ottawa: Canadian Medical Protective Association; 2007. 21Ontario Medical Association, Ministry of Health and Long Term Care. Memorandum of agreement between: The OMA and the MOHLTC. 2008 Sep. 22Manitoba Health. Advanced access initiative. [Online][Accessed 2009 Jan 16]. Available from: http://www.gov.mb.ca/health/phc/advanced.html 23Murray N, Berwick D. Advanced access: reducing waiting and delays in primary care. JAMA 2003;289(8):1035-40. 24Bartok B. Experts offer 'CPR' for your practice: Saskatchewan's Advanced Access school revives struggling practices. Nat R Med 2008 Apr. [Online] [Accessed 2008 Nov 25];5(4):[3 screens]. Available from: http://www.nationalreviewofmedicine.com/issue/special_sections/2008/practice_management/5_your_practice02_4.html 25Department of Health. Patients get booking 'guarantee' on NHS GP appointments. [Online][Accessed 2008 Nov 26]. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Pressreleases/DH_4118856 26Department of Health. GMS statement of financial entitlements. [Online][Accessed 2008 Nov 26]. Available from: http://www.dh.gov.uk/en/Healthcare/Primarycare/Primarycarecontracting/GMS/DH_4133079 27The Information Centre. GP patient survey. [Online][Accessed 2008 Nov 26]. Available from: http:// www.ic.nhs.uk/webfiles/publications/gppatientsurvey2008/GP%20Patient%20Survey%20Access%20Summary%20Report%2 02007%2008.pdf 28Department of Health. FOI releases: GP patient survey. [Online][Accessed 2008 Nov 26]. Available from: http://www.dh.gov.uk/en/FreedomOfInformation/Freedomofinformationpublicationschemefeedback/FOIreleases/DH_072634 29Berta W, Barnsley J, Brown A, Murray M. In the eyes of the beholder: Population perspectives on performance priorities for primary care in Canada. Healthc Policy 2008;4(2):86-100. 30British Medical Journal. Patients first. 1991 Nov 9;303:1153. 31Department of Health. The patient's charter & you. London: DOH; 1996 Nov. 32Department of Health. The NHS cancer plan and the new NHS. [Online][Accessed 2008 Nov 26]. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4092531?IdcService=GE T_FILE&dID=11779&Rendition=Web 33Department of Health. About the programme - 18 weeks patient pathway. [Online][Accessed 2008 Nov 25]. Available from: http://www.18weeks.nhs.uk/Content.aspx?path=/What-is-18-weeks/About-the-programme 34Naylor CD, Baigrie RS, Goldman BS, Basinski A. Assessment of priority for coronary bypass revascularization procedures. Lancet 1990 May 5; 335:1070-73. 35Noseworthy TW, McGurran JJ, Hadorn DC, WCWL Steering Committee. Waiting for scheduled services in Canada: development of priority-setting scoring systems. J Eval Clin Pract 2002 Mar 22;9(1): 23-31. 36De Coster C, McMillan S, Brant R, McGurran J, Noseworthy T, WCWL Primary Care Panel. The western Canada wait list project: development of a priority referral score for hip and knee arthroplasty. J Eval Clin Pract 2005 Sep 26;13(2007):192-7. 37Saskatchewan Surgical Care Network. Patient assessment questionnaires, guides & urgency profiles for surgical procedures. [Online][Accessed 2008 Nov 25]. Available from: http://www.sasksurgery.ca/ayn-tools-scoringguides.htm 38Wait Time Alliance. Time for progress: new benchmarks for achieving meaningful reductions in wait times. Ottawa: Canadian Medical Association; 2007. 39The College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons. MD Lounge. 2008 Sep: 3. 40Canadian Medical Association. Health Policy & Negotiations Conference. Proceedings of the HP&N Conference. 2008 Oct 18-19; Ottawa. 41College of Physicians and Surgeons of Manitoba Newsletter. September 2005. [Online][Accessed 2008 Nov 24]. Available from: http://www.cpsm-secure.com/newsletter/05-09.php 42DeMone, B. Improving Family Physician and Specialist Communication & Coordination: Bridging General and Specialist Care (BGSC) & the Catalogue of Specialized Services (CSS). Presented at Taming of the Queue VI; 2009 Mar 26; Ottawa. [Online][Accessed 2009 Oct 28]. Available from: http://www.cfpc.ca/BGSCTQVI 43The College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons. MD lounge. 2008 Sep: 6-7. 44Borsellino, M. Manitoba developing wait time measurement registry. The Medical Post. 2008 Dec 22. [Online][Accessed 2009 Jan 19]. Available from: http://www.medicalpost.com/news/article.jsp?content=20081222_111206_13308&s=1 45Canadian Medical Association. Physician resource questionnaire. 1990. 46Primary care funding models in Ontario: new comprehensive care model available October 1, 2005. Ontario Medical Review 2005 Jul/Aug: 17-19. 47Ministry of Health Services. Full service practice incentive program. [Online][Accessed 2008 Nov 27]. Available from: http://www.health.gov.bc.ca/phc/gpsc_incentive.html 48Minister of Health, Medical Society of Nova Scotia. Physician services master agreement. 2008 Oct 29. 49Schoen C, Osborn R, Huynh PT, Doty M, Peugh J, Zapert K. On the front lines of care: Primary care doctors' office systems, experiences, and views in seven countries. Health Aff 2006 Nov 2; 25(2006): w555-71. 50King N. Doctor, administrator, advocate recognized for work in health care. The Cape Breton Post. 2008 May 13. [Online][Accessed 2008 Nov 25]. Available from: http://www.capebretonpost.com/index.cfm?sid=134095&sc=145
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Funding the continuum of care

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

https://policybase.cma.ca/en/permalink/policy532
Last Reviewed
2017-03-04
Date
1994-10-22
Topics
Population health/ health equity/ public health
Resolution
BD95-02-30
That the Canadian Medical Association endorse the principles on postgraduate medical training developed by the National Coordinating Committee on Post-Graduate Medical Training and encourage the Conference of Deputy Ministers to adopt these principles as guidelines for action. [Framework Principles: 1. Physicians are a national resource. 2. The physician to population ratio will be maintained or reduced. 3. The national ratio of general practitioners to specialists should be maintained. 4. The mix and content of training programs must reflect identified population health needs. 5. Further proliferation of sub-specialties should be constrained. 6. Portability of licensure between provinces should exist. 7. Reliance on the recruitment of graduates of foreign medical schools (GOFMS) into Canada should be reduced. 8. The recruitment of GOFMS into Canada for postgraduate training should be reduced, and those trainees who do enter on visas should receive training only in already recognized specialties and agree to return to their countries of origin. 9. The total number of all postgraduate training positions should approximate the number of medical school graduates times the length of post-graduate prelicensure training. 10. Training venues should closely resemble eventual practice settings. 11. Substandard training programs should be eliminated. 12. Regional coordination of sub-speciality training should be promoted. 13. Relocation of training positions across provinces should be considered. 14. As other health care providers have overlapping scopes of capability with physicians, medical training activities should coordinate with roles and training of other health care providers. 15. Trainees should be better informed of the effectiveness, efficiency and alternative allocations of existing or proposed resource commitments designed to improve health through medical care. 16. Better information about shifting human resource needs and context of practice will be provided to students, interns, residents and fellows.]
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
1994-10-22
Topics
Population health/ health equity/ public health
Resolution
BD95-02-30
That the Canadian Medical Association endorse the principles on postgraduate medical training developed by the National Coordinating Committee on Post-Graduate Medical Training and encourage the Conference of Deputy Ministers to adopt these principles as guidelines for action. [Framework Principles: 1. Physicians are a national resource. 2. The physician to population ratio will be maintained or reduced. 3. The national ratio of general practitioners to specialists should be maintained. 4. The mix and content of training programs must reflect identified population health needs. 5. Further proliferation of sub-specialties should be constrained. 6. Portability of licensure between provinces should exist. 7. Reliance on the recruitment of graduates of foreign medical schools (GOFMS) into Canada should be reduced. 8. The recruitment of GOFMS into Canada for postgraduate training should be reduced, and those trainees who do enter on visas should receive training only in already recognized specialties and agree to return to their countries of origin. 9. The total number of all postgraduate training positions should approximate the number of medical school graduates times the length of post-graduate prelicensure training. 10. Training venues should closely resemble eventual practice settings. 11. Substandard training programs should be eliminated. 12. Regional coordination of sub-speciality training should be promoted. 13. Relocation of training positions across provinces should be considered. 14. As other health care providers have overlapping scopes of capability with physicians, medical training activities should coordinate with roles and training of other health care providers. 15. Trainees should be better informed of the effectiveness, efficiency and alternative allocations of existing or proposed resource commitments designed to improve health through medical care. 16. Better information about shifting human resource needs and context of practice will be provided to students, interns, residents and fellows.]
Text
That the Canadian Medical Association endorse the principles on postgraduate medical training developed by the National Coordinating Committee on Post-Graduate Medical Training and encourage the Conference of Deputy Ministers to adopt these principles as guidelines for action. [Framework Principles: 1. Physicians are a national resource. 2. The physician to population ratio will be maintained or reduced. 3. The national ratio of general practitioners to specialists should be maintained. 4. The mix and content of training programs must reflect identified population health needs. 5. Further proliferation of sub-specialties should be constrained. 6. Portability of licensure between provinces should exist. 7. Reliance on the recruitment of graduates of foreign medical schools (GOFMS) into Canada should be reduced. 8. The recruitment of GOFMS into Canada for postgraduate training should be reduced, and those trainees who do enter on visas should receive training only in already recognized specialties and agree to return to their countries of origin. 9. The total number of all postgraduate training positions should approximate the number of medical school graduates times the length of post-graduate prelicensure training. 10. Training venues should closely resemble eventual practice settings. 11. Substandard training programs should be eliminated. 12. Regional coordination of sub-speciality training should be promoted. 13. Relocation of training positions across provinces should be considered. 14. As other health care providers have overlapping scopes of capability with physicians, medical training activities should coordinate with roles and training of other health care providers. 15. Trainees should be better informed of the effectiveness, efficiency and alternative allocations of existing or proposed resource commitments designed to improve health through medical care. 16. Better information about shifting human resource needs and context of practice will be provided to students, interns, residents and fellows.]
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Restrictions on the freedom to practise medicine in Canada

https://policybase.cma.ca/en/permalink/policy533
Last Reviewed
2017-03-04
Date
1994-10-22
Topics
Population health/ health equity/ public health
Resolution
BD95-02-32
That the Canadian Medical Association oppose the principle of the restriction of freedom to practise medicine in Canada based on location of training in Canada.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
1994-10-22
Topics
Population health/ health equity/ public health
Resolution
BD95-02-32
That the Canadian Medical Association oppose the principle of the restriction of freedom to practise medicine in Canada based on location of training in Canada.
Text
That the Canadian Medical Association oppose the principle of the restriction of freedom to practise medicine in Canada based on location of training in Canada.
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Last Reviewed
2017-03-04
Date
1974-06-26
Topics
Health human resources
Resolution
GC74-53
Whereas the profession has in the past demonstrated an interest in accreditation of certain institutions involved in the delivery of medical services, and whereas the profession is currently demonstrating an interest in the matter of encouraging the establishment of minimum standards of professional practice in the office setting, and whereas the acknowledged purposes of such standards of accreditation are to facilitate peer review and continuing professional education, and whereas the profession has demonstrated its willingness to participate in such voluntary self assessment procedures, Be it resolved that the Canadian Medical Association accept the principle of practice accreditation and continue to search for acceptable methods of practice assessment and accreditation and encourage each of its divisions to establish or enjoin committees to examine the matter of office practice accreditation, with a view to establishing procedural guidelines and standards for their various regions.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
1974-06-26
Topics
Health human resources
Resolution
GC74-53
Whereas the profession has in the past demonstrated an interest in accreditation of certain institutions involved in the delivery of medical services, and whereas the profession is currently demonstrating an interest in the matter of encouraging the establishment of minimum standards of professional practice in the office setting, and whereas the acknowledged purposes of such standards of accreditation are to facilitate peer review and continuing professional education, and whereas the profession has demonstrated its willingness to participate in such voluntary self assessment procedures, Be it resolved that the Canadian Medical Association accept the principle of practice accreditation and continue to search for acceptable methods of practice assessment and accreditation and encourage each of its divisions to establish or enjoin committees to examine the matter of office practice accreditation, with a view to establishing procedural guidelines and standards for their various regions.
Text
Whereas the profession has in the past demonstrated an interest in accreditation of certain institutions involved in the delivery of medical services, and whereas the profession is currently demonstrating an interest in the matter of encouraging the establishment of minimum standards of professional practice in the office setting, and whereas the acknowledged purposes of such standards of accreditation are to facilitate peer review and continuing professional education, and whereas the profession has demonstrated its willingness to participate in such voluntary self assessment procedures, Be it resolved that the Canadian Medical Association accept the principle of practice accreditation and continue to search for acceptable methods of practice assessment and accreditation and encourage each of its divisions to establish or enjoin committees to examine the matter of office practice accreditation, with a view to establishing procedural guidelines and standards for their various regions.
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Patient care, trade unions and the Code of Ethics

https://policybase.cma.ca/en/permalink/policy593
Last Reviewed
2017-03-04
Date
1974-12-07
Topics
Ethics and medical professionalism
Resolution
BD75-03-para 422
That the ethical physician who, because of the characteristics of his/her work is a member of a trade union or Association with the independent right of strike action, will always place his/her obligation to patient care and support of the Code of Ethics above adherence to the rules of the trade union or association.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
1974-12-07
Topics
Ethics and medical professionalism
Resolution
BD75-03-para 422
That the ethical physician who, because of the characteristics of his/her work is a member of a trade union or Association with the independent right of strike action, will always place his/her obligation to patient care and support of the Code of Ethics above adherence to the rules of the trade union or association.
Text
That the ethical physician who, because of the characteristics of his/her work is a member of a trade union or Association with the independent right of strike action, will always place his/her obligation to patient care and support of the Code of Ethics above adherence to the rules of the trade union or association.
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National principles for publicly funded health care insurance

https://policybase.cma.ca/en/permalink/policy629
Last Reviewed
2017-03-04
Date
1994-08-17
Topics
Health systems, system funding and performance
Resolution
GC94-25
That the Canadian Medical Association recommend that the federal government administer the national principles of publicly funded health care insurance in a fair and nonpreferential manner.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
1994-08-17
Topics
Health systems, system funding and performance
Resolution
GC94-25
That the Canadian Medical Association recommend that the federal government administer the national principles of publicly funded health care insurance in a fair and nonpreferential manner.
Text
That the Canadian Medical Association recommend that the federal government administer the national principles of publicly funded health care insurance in a fair and nonpreferential manner.
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Social consensus on national health goals and strategies

https://policybase.cma.ca/en/permalink/policy630
Last Reviewed
2017-03-04
Date
1994-08-17
Topics
Health systems, system funding and performance
Resolution
GC94-26
That the Canadian Medical Association recommend that the federal government, with the full involvement of the provincial/territorial governments, assume a leadership role with the physicians of Canada through their provincial and national medical associations and other stakeholders, in developing a social consensus on national health goals and strategies.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
1994-08-17
Topics
Health systems, system funding and performance
Resolution
GC94-26
That the Canadian Medical Association recommend that the federal government, with the full involvement of the provincial/territorial governments, assume a leadership role with the physicians of Canada through their provincial and national medical associations and other stakeholders, in developing a social consensus on national health goals and strategies.
Text
That the Canadian Medical Association recommend that the federal government, with the full involvement of the provincial/territorial governments, assume a leadership role with the physicians of Canada through their provincial and national medical associations and other stakeholders, in developing a social consensus on national health goals and strategies.
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Consumer/provider choice and alternative health care financing arrangements

https://policybase.cma.ca/en/permalink/policy632
Last Reviewed
2017-03-04
Date
1994-08-17
Topics
Health systems, system funding and performance
Resolution
GC94-30
That the Canadian Medical Association recommend that the governments of Canada review and, where necessary, revise current health legislation or regulations that unnecessarily restrict the personal choices of consumers and providers regarding alternatives in private insurance and other health care financing arrangements.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
1994-08-17
Topics
Health systems, system funding and performance
Resolution
GC94-30
That the Canadian Medical Association recommend that the governments of Canada review and, where necessary, revise current health legislation or regulations that unnecessarily restrict the personal choices of consumers and providers regarding alternatives in private insurance and other health care financing arrangements.
Text
That the Canadian Medical Association recommend that the governments of Canada review and, where necessary, revise current health legislation or regulations that unnecessarily restrict the personal choices of consumers and providers regarding alternatives in private insurance and other health care financing arrangements.
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Private health insurance benefits

https://policybase.cma.ca/en/permalink/policy633
Last Reviewed
2017-03-04
Date
1994-08-17
Topics
Health systems, system funding and performance
Resolution
GC94-31
That the Canadian Medical Association recommend that governments, the Canadian Medical Association and its divisions and the private health industry explore, on a priority basis, methods for appropriately accessing private health insurance benefits.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
1994-08-17
Topics
Health systems, system funding and performance
Resolution
GC94-31
That the Canadian Medical Association recommend that governments, the Canadian Medical Association and its divisions and the private health industry explore, on a priority basis, methods for appropriately accessing private health insurance benefits.
Text
That the Canadian Medical Association recommend that governments, the Canadian Medical Association and its divisions and the private health industry explore, on a priority basis, methods for appropriately accessing private health insurance benefits.
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Goods and Services Tax (GST) replacement tax

https://policybase.cma.ca/en/permalink/policy641
Last Reviewed
2017-03-04
Date
1994-05-07
Topics
Population health/ health equity/ public health
Resolution
BD94-08-229
That Canadian Medical Association continue to press for fair and equitable treatment of physicians under any GST replacement tax and that the Canadian Medical Association not publicly endorse any specific form of the tax.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
1994-05-07
Topics
Population health/ health equity/ public health
Resolution
BD94-08-229
That Canadian Medical Association continue to press for fair and equitable treatment of physicians under any GST replacement tax and that the Canadian Medical Association not publicly endorse any specific form of the tax.
Text
That Canadian Medical Association continue to press for fair and equitable treatment of physicians under any GST replacement tax and that the Canadian Medical Association not publicly endorse any specific form of the tax.
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Portability provisions of theCanada Health Act

https://policybase.cma.ca/en/permalink/policy643
Last Reviewed
2017-03-04
Date
1994-05-07
Topics
Population health/ health equity/ public health
Resolution
BD94-08-239
That as part of its commitment to work on behalf of the medical profession and Canadians, the Canadian Medical Association requests that Health Canada enforce the out of country and out of province portability provisions of the Canada Health Act.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
1994-05-07
Topics
Population health/ health equity/ public health
Resolution
BD94-08-239
That as part of its commitment to work on behalf of the medical profession and Canadians, the Canadian Medical Association requests that Health Canada enforce the out of country and out of province portability provisions of the Canada Health Act.
Text
That as part of its commitment to work on behalf of the medical profession and Canadians, the Canadian Medical Association requests that Health Canada enforce the out of country and out of province portability provisions of the Canada Health Act.
Less detail

Educating members on physician resources, health care administration and planning, regionalization, and costs

https://policybase.cma.ca/en/permalink/policy644
Last Reviewed
2017-03-04
Date
1994-05-07
Topics
Population health/ health equity/ public health
Resolution
BD94-08-240
That the Canadian Medical Association working through its divisions, affiliated societies and members, be committed to assist members in becoming more knowledgeable in matters of physician resources planning, health administration, health care planning, regionalization strategies and health cost.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
1994-05-07
Topics
Population health/ health equity/ public health
Resolution
BD94-08-240
That the Canadian Medical Association working through its divisions, affiliated societies and members, be committed to assist members in becoming more knowledgeable in matters of physician resources planning, health administration, health care planning, regionalization strategies and health cost.
Text
That the Canadian Medical Association working through its divisions, affiliated societies and members, be committed to assist members in becoming more knowledgeable in matters of physician resources planning, health administration, health care planning, regionalization strategies and health cost.
Less detail

Provincial health advisory councils

https://policybase.cma.ca/en/permalink/policy700
Last Reviewed
2017-03-04
Date
1973-06-16
Topics
Health systems, system funding and performance
Resolution
GC73-63
That in each province there be established a health advisory council to advise government in matters relating to health facilities and provision of health care services throughout the province, and that on this council there be representation from the provincial division of the Canadian Medical Association.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
1973-06-16
Topics
Health systems, system funding and performance
Resolution
GC73-63
That in each province there be established a health advisory council to advise government in matters relating to health facilities and provision of health care services throughout the province, and that on this council there be representation from the provincial division of the Canadian Medical Association.
Text
That in each province there be established a health advisory council to advise government in matters relating to health facilities and provision of health care services throughout the province, and that on this council there be representation from the provincial division of the Canadian Medical Association.
Less detail

75 records – page 1 of 4.