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Authorizing Cannabis for Medical Purposes

https://policybase.cma.ca/en/permalink/policy11514
Last Reviewed
2020-02-29
Date
2015-02-28
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2015-02-28
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
Authorizing Cannabis for Medical Purposes The legalization of cannabis for recreational purposes came into effect with the Cannabis Act in October 2018, and patients continue to have access to cannabis for therapeutic purposes. The Cannabis Regulations have replaced the Access to Cannabis for Medical Purposes Regulations. Patients can obtain cannabis for medical purposes when a physician or nurse practitioner provides a “medical document” , authorizing its use, and determining the daily dried cannabis dose in grams. With the authorization, patients have the choice whether to (a) buy directly from a federally licensed producer; (b) register with Health Canada to produce a limited amount for personal consumption; (c) designate someone to produce it for them; or (d) buy cannabis at provincial or territorial authorized retail outlets or online sales platforms, if above the legal age limit. While acknowledging the unique requirements of patients suffering from a terminal illness or chronic disease for which conventional therapies have not been effective and for whom cannabis may provide relief, physicians remain concerned about the serious lack of clinical research, guidance and regulatory oversight for cannabis as a medical treatment. There is insufficient clinical information on safety and efficacy for most therapeutic claims. There is little information around therapeutic and toxic dosages and knowledge on interactions with medications. Besides the need for appropriate research, health practitioners would benefit from unbiased, accredited educational modules and decision support tools based on the best available evidence. The Canadian Medical Association has consistently expressed concern with the role of gatekeeper that physicians have been asked to take as a result of court decisions. Physicians should not feel obligated to authorize cannabis for medical purposes. Physicians who choose to authorize cannabis for their patients must comply with their provincial or territorial regulatory College's relevant guideline or policy. They should also be familiar with regulations and guidance, particularly:
Health Canada’s Information for Health Care Practitioners – Medical Use of Cannabis (monograph, summary and daily dose fact sheet),
the Canadian Medical Protective Association’s guidance;
the College of Family Physicians of Canada’s preliminary guidance Authorizing Dried Cannabis for Chronic Pain or Anxiety; and
the Simplified guideline for prescribing medical cannabinoids in primary care, published in the Canadian Family Physician. The CMA recommends that physicians should:
Ensure that there is no conflict of interest, such as direct or indirect economic interest in a licensed cannabis producer or be involved in dispensing cannabis;
Treat the authorization as an insured service, similar to a prescription, and not charge patients or the licensed producer for this service;
Until such time as there is compelling evidence of its efficacy and safety for specific indications, consider authorizing cannabis only after conventional therapies are proven ineffective in treating patients’ conditions;
Have the necessary clinical knowledge to authorize cannabis for medical purposes;
Only authorize in the context of an established patient-physician relationship;
Assess the patient’s medical history, conduct a physical examination and assess for the risk of addiction and diversion, using available clinical support tools and tests;
Engage in a consent discussion with patients which includes information about the known benefits and adverse health effects of cannabis in its various forms (e.g., edibles), including the risk of impairment to activities such as driving and work;
Advise the patient regarding harm reduction strategies and the prevention of accidental exposure for children and other people;
Document all consent discussions in patients' medical records;
Reassess the patient on a regular basis for its effectiveness to address the medical condition for which cannabis was authorized, as well as for addiction and diversion, to support maintenance, adjustment or discontinuation of treatment; and
Record the authorization of cannabis for medical purposes similar to when prescribing a controlled medication. The Cannabis Regulations provide some consistency with many established provincial and territorial prescription monitoring programs for controlled substances. Licensed producers of cannabis for medical purposes are required to provide information to provincial and territorial medical licensing bodies upon request, including healthcare practitioner information, daily quantity of dried cannabis supported, period of use, date of document and basic patient information. The Minister of Health can also report physicians to their College should there be reasonable grounds that there has been a contravention of the Narcotic Control Regulations or the Cannabis Regulations. Approved by CMA Board February 2015 Latest update approved by CMA Board in February 2020
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Palliative care

https://policybase.cma.ca/en/permalink/policy11809
Last Reviewed
2020-02-29
Date
2015-10-03
Topics
Ethics and medical professionalism
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2015-10-03
Topics
Ethics and medical professionalism
Text
Palliative care is an approach that aims to relieve suffering and improve the quality of life of those facing life-limiting acute or chronic conditions by means of early identification, assessment, treatment of pain and other symptoms and support of all physical, emotional and spiritual needs. It may coexist with other goals of care, such as prevention, treatment and management of chronic conditions, or it may be the sole focus of care. General principles Goals 1. All Canadian residents should have access to comprehensive, quality palliative care services regardless of age, care setting, diagnosis, ethnicity, language and financial status.1 2. The Canadian Medical Association (CMA) declares that its members should adhere to the principles of palliative care whereby relief of suffering and quality of living are valued equally to other goals of medicine. 3. The CMA believes that all health care professionals should have access to referral for palliative care services and expertise.2 4. The CMA supports the integration of the palliative care approach into the management of life-limiting acute and chronic disease.3 5. The CMA advocates for the integration of accessible, quality palliative care services into acute, community and chronic care service delivery models4 that align with patient and family needs. 6. The CMA supports the implementation of a shared care model, emphasizing collaboration and open communication among physicians and other health care professionals.5 7. The CMA recognizes that the practice of assisted dying as defined by the Supreme Court of Canada is distinct from the practice of palliative care. Access to palliative care services 8. The CMA believes that every person nearing the end of life who wishes to receive palliative care services at home should have access to them. 9. Comprehensive, quality palliative care services must be made available to all Canadians and efforts to broaden the availability of palliative care in Canada should be intensified.6 10. The CMA calls upon the federal government, in cooperation with provincial and territorial governments, to improve access to pediatric palliative care through enhanced funding, training and awareness campaigns.7 11. The CMA will engage in physician human resource planning to develop an appropriate strategy to ensure the delivery of quality palliative care throughout Canada.8 Education 12. All physicians require basic competencies in palliative care and may require enhanced skills appropriate to their practice. 13. The CMA requests that all Canadian faculties of medicine create a training curriculum in palliative care suitable for physicians at all stages of their medical education and relevant to the settings in which they practise.9 Role of governments 14. The CMA calls on governments to work toward a common strategy for palliative care to ensure equitable access to and adequate standards for quality palliative care.10 15. The CMA recommends that all relevant legislation be amended to recognize that any person whose medical condition warrants it is entitled to receive palliative care.11 16. The CMA supports emergency funding for end-of-life care for uninsured people residing in Canada.12 BACKGROUND In Canada, the impact of end-of-life care on both individuals and the health care system is "staggering," and the demand for this care will continue to grow as the population ages.13 It is estimated that the number of Canadians dying each year will increase by 40% to 330,000 by 2026. The well-being of an average of five others will be affected by each of those deaths, or more than 1.6 million people.14 Against this backdrop, the availability of and access to palliative care is an urgent policy and practice imperative. There has been mounting support for, and mounting criticism of the lack of, a national strategy for palliative care.15 The delivery of palliative care varies greatly across Canada due to differences in regional demographics, societal needs, government involvement and funding structures. Similarly, funding and legislation supporting access to palliative care services vary significantly between jurisdictions. A recent survey of Canadian physicians who provide palliative medicine found that: (1) Canada needs an adequate palliative medicine workforce; (2) primary care providers need more support for palliative care education and training; (3) palliative medicine as a distinct discipline must be further developed to better meet the complex needs of patients; and (4) Canada must ensure minimum palliative medicine standards are met.16 In an effort to address the current challenges in palliative care and improve both the quality of care and access to care, the CMA developed recommendations for a national call to action: 1. All patients should have a primary care provider that can support them with their palliative care needs or else refer these patients earlier to a palliative care team to establish goals of care. 2. Physicians should provide leadership at local, regional, provincial/territorial and federal levels to promote the establishment of integrated models of palliative care. 3. All physicians should obtain essential palliative care skills and knowledge to provide basic palliative care services to their patients. 4. Physicians should advocate for adequate and appropriate home palliative care resources so their patients can stay in their homes as long as possible. 5. Physicians should advocate for an adequate number of palliative and/or hospice care beds to meet their communities' needs. 6. Continuing care facilities and long-term care homes should have in-house palliative care physician support on their palliative care teams. 7. Physicians should support the valuable work of hospice volunteers. 8. Medical students are encouraged to look at palliative care as a rewarding career. 9. Practising palliative care physicians are encouraged, if needed, to obtain additional certified training in palliative care from either the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada. 10. Physicians acknowledge the value of and support the participation of family and friends in caring for their loved ones at the end of life. Integrated palliative approach to care There are four main models of palliative care delivery in Canada: integrated palliative care programs, continuing care and long-term care facilities, residential hospices, and home-based palliative care. Palliative care was originally developed in cancer care to provide patients dying of cancer with care at the very end of life by a specialized palliative care team.17 This model has evolved significantly in response to the increasing occurrence of, and burden posed by, complex chronic disease18. Palliative care is now also provided to patients with multiple co-occurring morbidities who require multiple interventions. It is now recognized to benefit all those living with life-limiting acute or chronic conditions, including, or perhaps especially, when it is initiated earlier in the disease trajectory. Evidence shows that integrated and early provision of palliative care leads to: (1) better outcomes than those obtained with treatment alone (e.g., improvements in symptoms, quality of life and patient satisfaction; positive effects on emotional wellness; decreased suffering; and at times increased longevity) and (2) better use of resources (e.g., less burden on caregivers, more appropriate referrals to hospice palliative care, more effective use of palliative care experts, less use of emergency and intensive interventions and decreased cost of care).19-20-21-22 Taken together, these studies validate the benefits of integrating palliative care services with standard treatment and involving palliative care providers early, a collaborative approach that transcends the conventional view that palliative care is care delivered at the very end of life. At present, there is strong support for the development and implementation of an integrated palliative approach to care. Integration effectively occurs: * throughout the disease trajectory; * across care settings (primary care, acute care, long-term and complex continuing care, residential hospices, shelters, home); * across professions/disciplines and specialties; * between the health care system and communities; and * with changing needs from primary palliative care through to specialist palliative care teams. The integrated palliative approach to care focuses on meeting a person's and family's full range of physical, psychosocial and spiritual needs at all stages of frailty or chronic illness, not just at the end of life.23 It is provided in all health care settings. The palliative approach to care is not delayed until the end stages of an illness but is applied earlier to provide active comfort-focused care and a positive approach to reducing suffering. It also promotes understanding of loss and bereavement (Fig. 1). Figure 1 Specialized palliative units and hospices are essential for end-of-life care for some individuals but are not appropriate for all persons facing life-limiting chronic conditions. When a palliative approach is offered in multiple settings, people and their families can receive better care through the many transitions of chronic conditions like dementia, lung, kidney and heart diseases, and cancer. This requires that all physicians be competent in initiating a primary palliative approach: they must be able to engage in advance care planning discussions, ask about physical and emotional symptoms and make appropriate, timely referrals to other providers and resources. Primary care physicians may need to develop more expertise in palliative care. A cadre of expert palliative care physicians will be required to provide care in complex cases, engage in education and research, and provide support for health professional colleagues providing palliative care in multiple settings. All health professionals must be able to practise competently in an integrated palliative approach to care. At the heart of an integrated palliative approach to care are a patient and family surrounded by a team of multidisciplinary professionals and community providers (Fig. 2). While team members vary depending on the needs of the patients and families, the principles of whole-person care and family care do not change. This allows patients and families to have their symptoms managed, receive care in the setting of their choice, engage in ongoing discussions about their preferences for care and experience a sense of autonomy in living their lives well. Figure 2 A report on The Way Forward, a project of the Quality End-of-Life Coalition of Canada and the Canadian Hospice Palliative Care Association, summarizes the situation as follows: "Only a small proportion of Canadians will need the kind of complex, intensive or tertiary hospice palliative care provided by expert palliative care teams in institutional settings, such as residential hospices and acute care hospitals. However, everyone who is becoming frail or is faced with a chronic illness could benefit from certain key palliative care services. As our population ages, we must ensure that all Canadians have access to palliative services integrated with their other care that will help them manage symptoms, enhance their lives, give them a greater sense of control, and enable them to make informed decisions about the care they want. More equitable access to palliative care integrated with their other care will enable more Canadians to live well with their illness up to the end of life. It will also enable more people to receive care in the setting of their choice and reduce the demand on acute care resources." 24 Access to palliative care services There are currently no reliable data on the number of specialized or semi-specialized palliative care physicians in Canada. It is difficult to count these physicians because palliative care has not historically existed as a specialty. Physicians practising palliative care have a wide variety of backgrounds and training, and many provide palliative care on a part-time basis. The Canadian Society of Palliative Care Physicians is currently working with partner organizations including the CMA, the Royal College of Physicians and Surgeons and the College of Family Physicians of Canada to better define the different types of palliative care physicians to conduct a meaningful count. On the question of access, studies have found that palliative care services are not aligned with patient preferences. For example, while 70% of hospitalized elderly patients reported wanting comfort measures rather than life-prolonging treatment, more than two-thirds were admitted to intensive care units.25 Most patients and caregivers report wanting to die at home26 and in-home palliative team care is a cost-effective intervention,27 but the value of this form of care is not reflected in many provincial policies. Instead, Canadian families frequently shoulder 25% of the total cost of palliative care because they must pay for home-based services,28 such as nursing and personal care services, that are not provided by governments. With the goal of improving the congruence between patient treatment preferences for end-of-life care and the services provided, Health Quality Ontario developed an evidentiary platform to inform public policy on strategies to optimize quality end-of-life care in in-patient and outpatient (community) settings. It identified four domains in which access to end-of-life care should be optimized to align with patient preferences: (1) location (determinants of place of death); (2) communication (patient care planning discussions and end-of-life educational interventions); (3) team-based models of care; and (4) services (cardiopulmonary resuscitation [CPR] and supportive interventions for informal caregivers).29 Education It is well recognized that education in palliative care is lacking in medical school and residency training. In response, the Association of Faculties of Medicine of Canada, in partnership with the Canadian Hospice Palliative Care Association and the Canadian Society of Palliative Care Physicians, conducted the Educating Future Physicians in Palliative and End-of-Life Care Project30 to develop consensus-based competencies for undergraduate medical trainees and a core curriculum that was implemented in all 17 Canadian medical schools. Despite these efforts, a survey conducted by the Canadian Society of Palliative Care Physicians found that the competencies are not being consistently taught in medical schools, as evidenced by the fact that 10 medical schools offered less than 10 hours of teaching on palliative care and two offered none.31 Moreover, evidence suggests that Canadian physicians are not consistently or adequately trained in palliative care. There is a general lack of providers trained in palliative care for service provision, teaching, consultative support to other physicians and research. To fill the observed gap in education, the Royal College of Physicians and Surgeons of Canada is developing Palliative Medicine as a subspecialty, and the College of Family Physicians of Canada is developing a Certificate of Added Competence in Palliative Care. What is more, different levels of palliative care competencies are required for different physicians: * All physicians require basic skills in palliative care. * Palliative consultants and physicians who frequently care for patients with chronic illnesses and/or frail seniors require enhanced skills. * Palliative medicine specialists and palliative medicine educators require expert skills. More broadly, the undergraduate curricula of all health care disciplines should include instruction in the principles and practices of palliative care, including how to access specialized palliative care consultation and services. Role of governments Access to palliative care must be treated with the same consideration as access to all other medical care. Provincial/territorial and federal legislation, however, is vague in this regard and does not recognize access to palliative care as an entitlement. Government funding of community-based hospice palliative care has not increased proportionately to the number of institutionally based palliative care beds that have been cut, leaving a significant gap in the health care system.32 To address this issue, efforts to broaden the availability of and access to palliative care in Canada need to be intensified. It is imperative that governments develop a common palliative care strategy to ensure equitable access to and adequate standards for quality palliative care, including emergency funding for those who are uninsured. Glossary Integrated palliative approach to care: An approach that focuses on quality of life and reduction of suffering as a goal of care. This approach may coexist with other goals of care - prevention, cure, management of chronic illness - or be the sole focus of care. The palliative approach integrates palliative care services throughout the treatment of a person with serious life-limiting illness, not just at the very end of life. Palliative care services: Generally consists of palliative care provided by a multidisciplinary team. The team may include a primary care physician, a palliative care physician, nurses, allied health professionals (as needed), social workers, providers of pastoral care and counselling, bereavement specialists and volunteers. The team members work together in a shared care model. Shared care model: An approach to care that uses the skills and knowledge of a range of health professionals who share joint responsibility for an individual's care. This model involves monitoring and exchanging patient data and sharing skills and knowledge among disciplines.33 References 1 Policy Resolution GC99-87 - Access to end-of-life and palliative care services. Ottawa: Canadian Medical Association; 1999. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 2Policy Resolution GC14-20 - Palliative care services and expertise. Ottawa: Canadian Medical Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 3Policy Resolution GC13-67 - Palliative Care. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 4Policy Resolution GC13-66 - Palliative Care Services. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 5 Policy Resolution GC13-80 - Collaborative palliative care model. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 6Policy Document PD15-02 - Euthanasia And Assisted Death (Update 2014). Ottawa: Canadian Medical Association; 2015. Available: https://www.cma.ca/Assets/assetslibrary/document/en/advocacy/EOL/CMA_Policy_Euthanasia_Assisted%20Death_PD15-02-e.pdf#search=Euthanasia%20and (accessed 2015 Nov 26). 7 Policy Resolution GC06-12 - Access to pediatric palliative care. Ottawa: Canadian Medical Association; 2006. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 8Policy Resolution GC14-23 - Delivery of quality palliative end-of-life care throughout Canada. Ottawa: Canadian Medical Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 9Policy Resolution GC13-71 - Training in palliative care. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 10Policy Document PD10-02 - Funding the continuum of care.Ottawa: Canadian Medical Association; 2010. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 11Policy Resolution GC13-70 - Palliative Care. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 12Policy Resolution GC14-26 - Emergency funding for end-of-life care for uninsured people residing in Canada. Ottawa: Canadian Medical Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 13 OHTAC End-of-Life Collaborative. Health care for people approaching the end of life: an evidentiary framework. Toronto: Health Quality Ontario; 2014. Available: http://www.hqontario.ca/evidence/publications-and-ohtac-recommendations/ontario-health-technology-assessment-series/eol-evidentiary-framework. 14 Quality End-of-Life Care Coalition of Canada. Blueprint for action 2010 to 2012. Ottawa: Quality End-of-Life Care Coalition of Canada; 2010. Available: http://www.qelccc.ca/media/3743/blueprint_for_action_2010_to_2020_april_2010.pdf. 15 Fowler R, Hammer M. End-of-life care in Canada. Clin Invest Med. 2013;36(3):E127-E32. 16 Canadian Society of Palliative Care Physicians. Highlights from the National Palliative Medicine Survey. Surrey (BC): Canadian Society of Palliative Care Physicians, Human Resources Committee; May 2015. 17 Bacon J. The palliative approach: improving care for Canadians with life-limiting illnesses. Ottawa: Canadian Hospice Palliative Care Association; 2012. Available: http://www.hpcintegration.ca/media/38753/TWF-palliative-approach-report-English-final2.pdf. 18 Ontario Health Technology Advisory Committee OCDM Collaborative. Optimizing chronic disease management in the community (outpatient) setting (OCDM): an evidentiary framework. Toronto: Health Quality Ontario; 2013. Available: www.hqontario.ca/Portals/0/Documents/eds/ohtas/compendium-ocdm-130912-en.pdf. 19 Zimmermann C, Swami N, Krzyzanowska M, Hannon B, et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet. 2014;383(9930):1721-1730. 20 Klinger CA, Howell D, Marshall D, Zakus D, et al. Resource utilization and cost analyses of home-based palliative care service provision: the Niagara West end-of-life shared-care project. Palliat Med. 2013;27(2):115-122. 21 Temel JS, Greer JA, Muzikansky MA, Gallagher ER, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. NEJM. 2010;363:733-742. 22 Bakitas M, Lyons KD, Hegel MT, Balan S, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA. 2009;302:741-749. 23 Quality End-of-Life Care Coalition of Canada, Canadian Hospice Palliative Care Association. The Way Forward National Framework: a roadmap for an integrated palliative approach to care. Ottawa: Quality End-of-Life Care Coalition of Canada; 2014. Available: http://www.qelccc.ca/media/3743/blueprint_for_action_2010_to_2020_april_2010.pdf 24 Quality End-of-Life Coalition of Canada, Canadian Hospice Palliative Care Association. The Way Forward National Framework: a roadmap for the integrated palliative approach to care. Quality End-of-Life Coaltion of Canada; 2014. Available: http://www.hpcintegration.ca/media/60044/TWF-framework-doc-Eng-2015-final-April1.pdf. 25 Cook D, Rocker G. End of life care in Canada: a report from the Canadian Academy of Health Sciences Forum. Clin Invest Med. 2013;36(3):E112-E113. 26 Brazil, K, Howell D, Bedard M, Krueger P, et al. Preferences for place of care and place of death among informal caregivers of the terminally ill. Palliat Med. 2005;19(6):492-499. 27 Pham B, Krahn M. End-of-life care interventions: an economic analysis. Ontario Health Quality Technology Assessment Series. 2014;14(18):1-70. Available: http://www.qelccc.ca/media/3743/blueprint_for_action_2010_to_2020_april_2010.pdf. 28 Dumont S, Jacobs P, Fassbender K, Anderson D, et al. Costs associated with resource utilization during the palliative phase of care: a Canadian perspective. Palliat Med. 2009;23(8)708-717. 29 OHTAC End-of-Life Collaborative. Health care for people approaching the end of life: an evidentiary framework. Toronto: Health Quality Ontario; 2014. Available: www.hqontario.ca/evidence/publications-and-ohtac-recommendations/ontario-health-technology-assessment-series/eol-evidentiary-framework 30 Association of Faculties of Medicine of Canada. Educating future physicians in palliative and end-of-life care. Ottawa: Association of Faculties of Medicine of Canada; 2004. Available: http://70.38.66.73/social-educating-physicians-e.php. 31 Daneault S. Undergraduate training in palliative care in Canada in 2011. Montreal: Soins palliatifs, Hôpital Notre-Dame, Centre Hospitalier de l'Université de Montréal; 2012. 32 Canadian Hospice Palliative Care Association. Fact sheet 2012: hospice palliative care in Canada. Available: http://www.chpca.net/media/330558/Fact_Sheet_HPC_in_Canada%20Spring%202014%20Final.pdf. 33 Moorehead, R. Sharing care between allied health professional and general practitioners. Aust Fam Physician. 1995;24(11).
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Presentation to the House of Commons Standing Committee on Finance -December 7, 2007

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

https://policybase.cma.ca/en/permalink/policy9066
Last Reviewed
2020-02-29
Date
2007-12-01
Topics
Health care and patient safety
Resolution
BD08-03-29
The Canadian Medical Association recommends that children with a weight between 18 and 36 kg (40-80 lbs) and a height of less than 145 cm (4 feet 9 inches) (at approximately eight years old), be required to be fastened in a properly secured booster seat in the back seat when passengers in motor vehicles.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
2007-12-01
Replaces
Car Seat Restraints for Children (2001)
Topics
Health care and patient safety
Resolution
BD08-03-29
The Canadian Medical Association recommends that children with a weight between 18 and 36 kg (40-80 lbs) and a height of less than 145 cm (4 feet 9 inches) (at approximately eight years old), be required to be fastened in a properly secured booster seat in the back seat when passengers in motor vehicles.
Text
The Canadian Medical Association recommends that children with a weight between 18 and 36 kg (40-80 lbs) and a height of less than 145 cm (4 feet 9 inches) (at approximately eight years old), be required to be fastened in a properly secured booster seat in the back seat when passengers in motor vehicles.
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Counterfeit Drugs

https://policybase.cma.ca/en/permalink/policy9068
Last Reviewed
2020-02-29
Date
2007-12-01
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Health systems, system funding and performance
Resolution
BD08-03-31
The Canadian Medical Association calls on the Government of Canada to: - implement an anti-counterfeit drugs strategy which could include track-and-trace technology, severe penalties for infractions, and an alert network to encourage reporting by health professionals and patients; and - work with other countries and international organizations on a global effort to stop drug counterfeiting.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
2007-12-01
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Health systems, system funding and performance
Resolution
BD08-03-31
The Canadian Medical Association calls on the Government of Canada to: - implement an anti-counterfeit drugs strategy which could include track-and-trace technology, severe penalties for infractions, and an alert network to encourage reporting by health professionals and patients; and - work with other countries and international organizations on a global effort to stop drug counterfeiting.
Text
The Canadian Medical Association calls on the Government of Canada to: - implement an anti-counterfeit drugs strategy which could include track-and-trace technology, severe penalties for infractions, and an alert network to encourage reporting by health professionals and patients; and - work with other countries and international organizations on a global effort to stop drug counterfeiting.
Less detail

Physician resource planning (updated 2015)

https://policybase.cma.ca/en/permalink/policy11533
Last Reviewed
2019-03-03
Date
2015-05-30
Topics
Health human resources
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2015-05-30
Replaces
Physician resource planning (Update 2003)
Topics
Health human resources
Text
PHYSICIAN RESOURCE PLANNING (Updated 2015) The purpose of this policy statement is to identify the key elements required to properly undertake physician resource planning to support the delivery of appropriate medical care to all Canadians. A sustainable health care system requires effective physician resource planning and training that ensures an appropriate specialty mix that is responsive to population needs. CMA supports the need for the establishment of a coordinated national approach toward physician resource planning and an appropriately responsive undergraduate and postgraduate education system. CMA supports supply- and demand- projection models for health human resources using standardized approaches. National specialty societies should be actively engaged in physician resource planning for their respective discipline. Governments must work cooperatively with the medical profession to meet the needs of the population they serve in an affordable manner including funding the necessary infrastructure to support the appropriate number and mix of physicians. Recommendations: 1. Physician resource planning requires a pan-Canadian supply and needs-based projection model. 2. Infrastructure and resources as well as physician resources need to match the needs-based projection. 3. Strategies should be used throughout the undergraduate and postgraduate training system to address the current challenges matching physician resources to population needs. 4. Changing models of care delivery must be taken into consideration when developing physician resource projection models. Introduction The purpose of this policy statement is to identify the key elements required to properly undertake physician resource planning to support the delivery of appropriate medical care to all Canadians.1 Ensuring an adequate supply of physician human resources is a major tenet of the Canadian Medical Association's (CMA) Health Care Transformation initiative.2 While the number of students enrolled in Canadian medical schools increased by over 60 percent between 2001-02 and 2011-12, some enrollment reductions are now occurring despite significant physician resource issues remaining, affecting patient care delivery across the country. Currently, four to five million Canadians do not have a family physician. For older family physicians who may retire soon or wish to reduce their practice workload, there may be no colleagues able to take on new patients. Many new family physicians do not take on as large a roster of patients as those retiring. Even where overall supply has improved, recruiting and retaining physicians in underserved areas remains a challenge. Canada continues to license International Medical Graduates (IMGs) with 25% of practicing physicians receiving their medical degree from outside of the country3-the distribution of this group varies throughout Canada. Physician disciplines in short supply vary by jurisdiction. Some new physicians (especially those dependent on hospital based resources) are finding it hard to secure employment in their discipline.4 Concern for the future has spread to postgraduate residents and medical students. Completing fellowships, to make physicians more marketable, are now commonplace. A major contributor to underemployment in some specialties is a lack of infrastructure and related human resources (e.g., operating room time, nursing care). A sustainable health care system requires effective physician resource planning and training that ensures an appropriate specialty mix that is responsive to population needs. At present, there is no pan-Canadian system to monitor or manage the specialty mix. Few jurisdictions engage in formal health human resources planning and little cross-jurisdictional or pan-Canadian planning takes place. Currently, few Canadian jurisdictions have a long-term physician resource plan in place, particularly one that employs a supply and needs-based projection model. It has been almost four decades since the federal government has completed a needs-based projection of physician requirements in Canada.5 Physician resource planning must consider the population's health care needs over a longer term as the length of time to train a physician can be over a decade long depending on the specialty; this also means that practice opportunities can change during the period of training. The consequences of the lack of monitoring and management of the physician specialty mix can be long-lasting. A 2014 comparison of posted physician practice opportunities across Canada versus the number of post-graduate exits suggests a supply and demand mismatch for both family physicians (more positions posted than post-grad exits) and for medical and surgical specialists (more post-grad exits than available positions posted).6 Overall goal and considerations of physician resource planning The overall goal of physician resource planning is to produce a self-sustaining workforce that will effectively serve the health needs of Canadians by providing an adequate supply of clinicians, teachers, researchers and administrators. Physician resource planning should recognize the following considerations: * Physicians in training have a dual role of learner and clinical care provider.7 * Shifts in service delivery can occur with the development of new technologies, the changing prevalence of some disease states, the emergence of new illnesses and shifting public expectations (see Appendix A: The impact of emerging health technologies and models of care on physician resource planning). * Rural and remote communities possess unique challenges of not only attracting physicians but also in the nature of skills required to provide services. * Physicians are required for services to patient populations who fall under federal jurisdiction including members of the Canadian Armed Forces, First Nations and Inuit, refugees and refugee claimants, veterans, and prisoners in federal penitentiaries; this includes consideration of how they are attracted and the skills they require. * The full use of national medical services should be utilized instead of outsourcing to other countries. In instances where outsourcing of medical services occurs, Canadian training and certification standards must be met. * The emphasis from governments and the public for 24/7 access to a wide scope of physician and health care services must be balanced with the possibility of more fragmented care from multiple physicians involved in the care of a single patient. * There is a need for more clearly defined scopes of professional activity and optimal interactions among primary care physicians including family physicians who acquire enhanced/advanced skills to meet community needs, general specialists and subspecialists, particularly in the large urban areas where these three broad groups co-exist. * It is also relevant to define the role and most appropriate interactions of physicians with other healthcare professionals, including but not limited to physician assistants, specially trained nurses, dieticians, therapists and pharmacists. * The current shift to alternate payment plans and collaborative care models may, increase or decrease the non-clinical portion (e.g., research, teaching) of a physician's workload and thus increase the need for additional physicians. * The scheduling for the provision of after-hours care can have an effect on the use of physician resources (See CMA's policy statement on Management of Physician Fatigue for more information). * High tuition fees affect the social demographic mix of those seeking medical degrees while higher debt loads and the opportunity to practice in various models of care can influence specialty choice. 8 Similarly, advice from supervising faculty role models, negative/positive experiences during training, perceived lifestyle of the discipline, personal finances and earning potentials of medical disciplines all influence a medical student's specialty choice and in turn what health services will be available to future populations. Reliable and valid information on the current and future needs of the Canadian population can help trainees to make evidence-based decisions that allow them to select careers that match the needs of their patients. * Patterns in the transition of retiring physicians' practices need to be identified. It is essential to project not only the number of physicians but also some measure of their likely level of professional activity. Practice patterns may vary in response to changes in lifestyle among physicians, changing health technologies, group practices, interdisciplinary care models, and increased specialization of many generalist specialists and family physicians. Training The academic sector must ensure the provision of high-quality undergraduate, postgraduate and continuing education programs, and remain internationally competitive in the recruitment and retention of a first-class teaching and research community. Structured mentorship programs and formal career counseling should be a required component of all undergraduate and postgraduate curricula in Canada.9 Teaching institutions and postgraduate accreditation authorities need to recognize the risk in requiring students to make critical career choices before exploring all the options and should develop strategies to mitigate those risks, which may include tools for assessing aptitudes. Formal career counseling throughout medical education and training can boost employment success. Results of supply projection models should also be readily available to students and advisors so an informed choice can be made. There is a need to ensure flexibility at the undergraduate, postgraduate, and re-entry levels of medical education, with the recognition that the requirements for specialist services may change. It also allows room for standardized transfers of residents between programs and locations and for the integration of international medical graduates (IMGs). CMA recommends that a ratio of 120 postgraduate training positions per 100 medical graduates be re-established and maintained. Canadians studying medicine abroad and other IMGs who are permanent residents or citizens of Canada must be explicitly factored into the planning for the capacity of the post-MD training system. CMA supports measures to facilitate the acculturation of IMGs. The objective of seeking reasonable self-sufficiency for the full range of physician services must be paramount.10 Self-sufficiency is defined as ensuring that the annual output of the undergraduate and postgraduate sectors of Canadian medical schools meets the medical service needs of the Canadian public. This will reduce the need to attract physicians from countries that face a higher burden of disease whose requirements for physician services exceed those of Canada. It is important to facilitate the retention of physicians who train in the Canadian postgraduate system. There must be adequate human and physical infrastructure to support physician training. An adequate supply of clinical educators is required to prevent training bottlenecks. Strategies that utilize untapped health infrastructure resources within and outside the academic community such as satellite or distributive medical education training sites should be considered for not only training reasons but for retention purposes as well. Effectively matching supply to societal needs Residency training positions should reflect current and emerging population needs and if possible, job availability at the national level. Mechanisms should be in place to assist medical training programs to adjust to changing health needs in a timely manner. Physician resource planning can benefit from enhanced evaluation of community health needs, as established by thorough determinations of health status, epidemiological studies, input from communities and other needs assessments. In recent years, attention has been given to augmenting the provision of care to properly respond to Canada's growing seniors' population. This will require an assessment of physician resource trends among specialties that focus on seniors' care including the capacity to deliver quality palliative end-of-life care throughout Canada. To address geographic maldistribution, programs should train physicians in the wide spectrum of practice that is required for underserved communities-both rural and urban-as well as incorporate the involvement of the communities throughout the medical trainee life cycle. Programs to attract and retain physicians, including those from rural and underservice areas, need flexible incentives to address the professional and personal needs of physicians. Financial incentives, locum support, spousal employment, children's education and support from other specialists are key factors that need to be addressed. Also, the attraction and retention of physicians to underserved areas requires the presence of adequate technical equipment and personnel. Exposure to patterns of community practice-including generalist training-outside large urban tertiary/quaternary centres may help attract individuals into specialties best suited for rural and regional centres. CMA encourages family physicians to maintain their skills in comprehensive family medicine, while supporting their choice to acquire additional skills that will better serve the needs of their community. It is important to strive and budget for a critical mass of physicians required to deliver basic services to given populations to permit reasonable life-style management and the avoidance of professional isolation. Coercive measures that restrict physicians' choice of location and subsequent geographic mobility are not supported. Concentrated efforts are needed to assist new graduates of Canadian residency programs and established physicians find optimal employment in their discipline within Canada. The issue of facilitating the mobility of physicians among provinces and territories (including locum work) requires dialogue with and cooperation from individual provincial and territorial licensing authorities. CMA supports supply- and demand- projection models for health human resources using standardized approaches. Physician human resource plans should be reviewed on an ongoing basis, examining current supply and attrition patterns to determine if new policies are required or changes are needed to the undergraduate and postgraduate complement. Collaborative approach to physician resource planning Physician resource planning is complex, requiring the involvement of provincial/territorial medical associations, national specialty societies, the Royal Canadian Medical Service (Canadian Armed Forces), special medical interest groups, the medical education sector, the health care facilities sectors, governments, other health care professionals and other key stakeholders. CMA is committed to promoting a collaborative and respectful interaction among all the disciplines within the medical profession and recognition of the unique contributions of each to an efficient, high-quality and cost-effective health care delivery system. Governments must work cooperatively with the medical profession to meet the needs of the population they serve in an affordable manner including funding the necessary infrastructure to support the appropriate number and mix of physicians. National specialty societies should be actively engaged in physician resource planning for their respective discipline. CMA supports the establishment of a coordinated national approach toward physician resource planning and an appropriately responsive undergraduate and postgraduate education system. The recruitment and retention policies available at the provincial level can play a significant role in health human resources distribution and evolution. The federal government in conjunction with the provincial Deputy Ministers and Deans of Medicine, should continue to fund a pan-Canadian supply based planning model as laid out by the Physician Resource Planning Taskforce and extend its support to the second phase which is a comprehensive needs based planning model that will be accessible to governments and the profession. Given the importance of a planned, open and professional approach to physician resource planning, the CMA encourages all stakeholders to permit researchers, policy planners and other relevant organizations access to their physician resources database at the national and jurisdictional level while protecting the privacy of individual physicians. The CMA will continue to seek input into the design and structure of any such national databases. Appendix A: The impact of emerging health technologies and models of care on physician resource planning As in the past, a number of technological developments11 will alter the future demand for medical services and how medicine is practiced. Examples of such technological developments include: health information technologies (HITs); technologies to support distance care and self-monitoring (e.g., telemedicine, implantable or wearable sensors); surgical robotics; advanced diagnostic testing; genomic technologies; integrated care teams; and new funding models. It is important to consider how these developments will affect future supply and training (i.e., skill sets) of physicians as part of physician resource planning. There is little evidence about whether new technologies increase or reduce working hours.12 However, the adoption of new technologies can lead to new roles and opportunities for physicians as well as for other staff. New technologies can also lead to a greater role for patients in taking responsibility for their own health. There is extensive evidence that new technologies can improve the quality of patient care, especially when used in addition to existing care rather than as a substitution.13 A key factor in assessing the impact of new health technologies on physician resource planning is the rate of adoption and diffusion of new technologies. The rate can vary widely depending on an extensive range of factors including ease of use, safety, cost (both in terms of acquiring the technology and to train the clinician), compatibility and culture/attitudes. Not all new technologies are successfully adopted or lead to positive outcomes. Moreover, unlike other sectors, the adoption of health care technologies does not often lead to lower costs.14 The adoption can also be influenced by broader factors such as changing patient needs and the government's fiscal resources. One key impact of emerging health technologies is a shift in the location where care is received. For instance, less invasive surgery will lead to greater use of community services for follow up care rather than in-hospital care. Likewise, the technologies can support the provision of more specialized services in small and remote communities by family physicians with the appropriate training and support. Emerging health technologies can also impact the type of care provided. The literature suggests the impact will be felt more in sub-specialty areas with care shifting from one subspecialty to another.15 Advances in non-invasive surgical interventions will continue to drive practice convergence such as seen with cardiac related procedures.16 The accelerated use of HITs specifically could have the greatest overall impact on health human resources due to such factors as: the need for increased training to use HITs; and an increased need for health informatics specialists (both medical and non-medical).15 Automated knowledge work tools will almost certainly extend the powers of many types of workers and help drive top-line improvements with innovations and better decision making.17 The move to more collaborative care models, particularly in primary care, can be expected in the coming years. Common characteristics of these models include comprehensive chronic disease prevention, population-based services and programs, full use of electronic medical records, quality monitoring, dedicated time to team building and collaboration, and a wide range of health care providers functioning to their full scope of practice.18 Multi-disciplinary teams could also involve a wider range of providers such as IT specialists, bio-engineers and genetic counselors. While CMA has previously called for funding models to be in place to allow physicians and other health care providers to practice within the full scope of their professional activities,19 a significant issue will be how such collaborative care models can be funded by governments on a sustained basis. Physicians and other health care providers need to be trained to effectively adopt any new technology. The literature is clear that physicians must be engaged in any discussions regarding new and current health technologies to ensure their proper assessment and successful implementation.20 Previously, CMA has called for: * A flexible medical training system based on informed career choice to accommodate changes in medical practice and physician resource needs; * A sufficient and stable supply of re-entry positions within the postgraduate training system to enable practicing physicians to enhance their skills or re-enter training in another discipline.21 * Recognition that scopes of practice must reflect these changes in societal needs (including the need of the public for access to services), societal expectations, and preferences of patients and the public for certain types of health care providers to fulfill particular roles and functions, while at the same time reflecting economic realities.22 References 1 This policy is to be used in conjunction with CMA's policy statements on Management of Physician Fatigue (2014), Flexibility in Medical Training (Update 2009), Physician Health and Well-Being (1998), Tuition Fee Escalation and Deregulation in Undergraduate Programs in Medicine (Update 2009), and Rural and Remote Practice Issues (1998). 2 Canadian Medical Association. Health Care Transformation in Canada. Change That Works, Care That Lasts. Ottawa: The Association; 2010. Available: http://www.hpclearinghouse.ca/pdf/HCT-2010report_en.pdf (accessed 2015 May 04). 3 Canadian Institute for Health Information. Physicians in Canada, 2013: Summary Report Ottawa: The Institute; 2013 Sep. 4 College of Family Physicians of Canda, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada. National Physician Survey 2013. Backgrounder. Available: http://nationalphysiciansurvey.ca/wp-content/uploads/2013/10/OFFICIAL-RELEASE_NPS-2013-Backgrounder_EN.pdf 5 The last federally commissioned study, the Report of the Requirements Committee on Physician Manpower to the National Committee on Physician Manpower, was published by the Minister of National Health and Welfare in 1975. 6 Research conducted by the Canadian Medical Association. Fall 2014. 7 National Steering Committee on Resident Duty Hours. Fatigue, risk and excellence: Towards a Pan-Canadian consensus on resident duty hours. Ottawa: Royal College of Physicians and Surgeons of Canada. 2013. 8 Canadian Medical Association. Tuition fee escalation and deregulation in undergraduate programs in medicine (update 2009). Ottawa" The Association; 2003 June. Available: http://policybase.cma.ca 9 The Canadian Association of Internes and Residents. CAIR Position Paper on Mentorship. June 2013. http://residentdoctors.ca/wp-content/uploads/2014/12/CAIR-Position-Paper-on-Mentorship_June-2013_en.pdf (accessed 2015 Apr 29). 10 Self-sufficiency is a key principle of the Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources' Framework for Collaborative Pan-Canadian Health Human Resources Planning. Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources. 2009. How Many Are Enough? Redefining Self-Sufficiency for the Health Workforce: A Discussion Paper. The policy is also consistent with the World Medical Association and the World Health Organization (The WHO Global Code of Practice of the International Recruitment of Health Personnel). http://www.who.int/hrh/migration/code/code_en.pdf?ua=1 11 Definition of Health Technologies (World Health Organization): "The application of organized knowledge and skills in the form of devices, medicines, vaccines, procedures and systems developed to solve a health problem and improve quality of lives." 12 Evidence Centre for Skills for Health, How do technologies impact on workforce organisation? Bristol (UK): The Centre. Available: www.skillsforhealth.org.uk/index.php?option=com_mtree&task=att_download&link_id=101&cf_id=24 (accessed 2015 Feb 02). 13 Evidence Centre for Skills for Health, How do technologies impact on workforce organisation? Bristol (UK): The Centre. Available: www.skillsforhealth.org.uk/index.php?option=com_mtree&task=att_download&link_id=101&cf_id=24 (accessed 2015 Feb 2) 14 Skinner J. "The costly paradox of health-care technology". MIT Technology Review. 2013 Sep 5. 15 Anvari M. Impact of information technology on human resources in healthcare. Healthcare Quarterly, 10(4) September 2007:84-88. 16 Social Sector Metrics Inc., Health Intelligence Inc. Physician resource planning: a recommended model and implementation framework. Final report submitted to the Nova Scotia Department of Health and Wellness. 2002 Jan 31. Available: www.doctorsns.com/site/media/DoctorsNS/PhysicianResourcePlanning-finalreport.pdf (accessed 2015 Feb 2). 17 McKinsey Global Institute, Disruptive technologies: Advances that will transform life, business, and the global economy. McKinsey & Company 2013. 18 Social Sector Metrics Inc., Health Intelligence Inc. Physician resource planning: a recommended model and implementation framework. Final report submitted to the Nova Scotia Department of Health and Wellness. 2002 Jan 31. Available: www.doctorsns.com/site/media/DoctorsNS/PhysicianResourcePlanning-finalreport.pdf (accessed 2015 Feb 02). 19 Canadian Medical Association. The Evolving Professional Relationship Between Canadian Physicians and Our Health Care System: Where Do We Stand? Ottawa: The Association; 2012 20 Steven A. Olson et al., Healthcare technology: Physician collaboration in reducing the surgical cost. Clinical Orthopaedics and Related Research. (2013) 471:1854-64. 21 Canadian Medical Association. Flexibility in Medical Training (update 2009) Ottawa: The Association; 2009. 22 Canadian Medical Association. Scopes of practice. Ottawa: The Association; 2002.
Documents
Less detail

Obesity as a chronic medical disease

https://policybase.cma.ca/en/permalink/policy11700
Last Reviewed
2019-03-03
Date
2015-10-03
Topics
Population health/ health equity/ public health
Resolution
GC15-99
The Canadian Medical Association recognizes obesity as a chronic medical disease.
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
2015-10-03
Topics
Population health/ health equity/ public health
Resolution
GC15-99
The Canadian Medical Association recognizes obesity as a chronic medical disease.
Text
The Canadian Medical Association recognizes obesity as a chronic medical disease.
Less detail

CMA’s formal submission to the Federal External Panel on assisted dying

https://policybase.cma.ca/en/permalink/policy11750
Last Reviewed
2019-03-03
Date
2015-10-19
Topics
Ethics and medical professionalism
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2015-10-19
Topics
Ethics and medical professionalism
Text
Dear Members of the Federal External Panel: On behalf of the Canadian Medical Association (CMA), I appreciate the opportunity to provide input toward the Federal External Panel's national consultation to support the federal government's legislative response following the Supreme Court of Canada's ruling in Carter v. Canada. As the national professional association representing Canada's physicians, the CMA has played an important role in leading the public dialogue on end-of-life care, including assisted dying. In 2014, the CMA led a national consultation on end-of-life care which included a series of public and member town hall consultations across the country. This national dialogue focused on three main issues: advance care planning, palliative care, and physician-assisted dying. As highlighted in the summary report (enclosed as Appendix 1), the Canadian public emphasized the need for strict protocols and safeguards if the law on physician-assisted dying were to change. This initial consultation provided valuable insights to inform the concurrent CMA's in-depth and comprehensive consultation with its membership as well as medical and health stakeholders as an intervener before the Supreme Court and following the Carter decision. This consultation included engagement of the CMA's Ethics Committee, policy debates as part of the CMA's Annual Meetings in 2014 and 2015, in-person member forums across the country, and an online dialogue. The consultation was critical to the development of the CMA's Principles-based Recommendations for a Canadian Approach to Assisted Dying (enclosed as Appendix 2). These recommendations, guided by a set of ten foundational principles, address patient eligibility for access to and assessment for assisted dying, procedural safeguards for eligibility criteria, the roles and responsibilities of the attending and consulting physicians, and the issue of conscientious objection. Taken together, these recommendations form the CMA's position on the forthcoming legislative and regulatory framework to govern assisted dying in Canada. In addition to our recommendations, we would like to highlight key points that are of particular relevance to physicians: NATIONAL, PAN-CANADIAN LEGISLATIVE AND REGULATORY FRAMEWORK The CMA strongly recommends the establishment of national and coordinated legislative and regulatory processes and systems in response to the Carter decision. The CMA is deeply concerned that in the absence of federal action to support the establishment of national guidelines for assisted dying, a patchwork of differing and potentially conflicting approaches could emerge across jurisdictions. Legislative action at the federal level is needed to provide further clarity for physicians and their patients and support the promulgation of a coordinated and consistent approach across all jurisdictions in Canada. The CMA has been working with the medical regulatory colleges at the national level to mitigate this risk through the development of the CMA's Principles-based Recommendations for a Canadian Approach to Assisted Dying which has encouraged similar efforts by the regulatory colleges. In addition to these initiatives, federal action is required. CONSCIENTIOUS OBJECTION As the Federal External Panel is aware, the Carter decision emphasizes that any regulatory or legislative response must seek to reconcile the Charter rights of patients (wanting to access assisted dying) and physicians (who choose not to participate in assisted dying on grounds of conscientious objection). The notion of conscientious objection is not monolithic. While some conceptions of conscience encompass referral, others view referral as being connected to, or as akin to participating in, a morally objectionable act. It is the CMA's position that an effective reconciliation is one that respects, and takes account of, differences in conscience, while facilitating access on the principle of equity. To this end, the CMA's membership strongly endorses the recommendation on conscientious objection as set out in section 5.2 of the CMA's enclosed Principles-based Recommendations for a Canadian Approach to Assisted Dying. ADDITIONAL SUPPORTS The CMA recognizes, and supports addressing, the need to develop education materials for physicians. To this end, the CMA is actively developing education modules for physicians following an environmental scan of existing courses and discussions with other jurisdictions (e.g., the Royal Dutch Medical Association). The CMA has the support of the Royal College of Physicians and Surgeons of Canada, the College of Family Physicians of Canada, and the Canadian Medical Protective Association to lead this initiative. Finally, as previously stated, the CMA strongly encourages the federal government to make the report of the Federal External Panel publicly available once final. The CMA urges the members of the Federal External Panel to support this recommendation to the federal government. Thank you once again for the opportunity to provide input. The CMA looks forward to our meeting with the Federal External Panel on October 20, 2015. Sincerely, Cindy Forbes, MD, CCFP, FCFP President Jeff Blackmer MD, MHSc, FRCPC Vice-President, Medical Professionalism Enclosed: Appendix 1 - Summary Report: End-of-Life Care A National Dialogue (please see pdf for link to document) Appendix 2 - CMA's Principles-based Recommendations for a Canadian Approach to Assisted Dying Principles-based Recommendations for a Canadian Approach to Assisted Dying On Feb. 6, 2015, the Supreme Court of Canada unanimously struck down the law prohibiting assisted dying. The court suspended that decision for 12 months. This has provided an opportunity for the Canadian Medical Association (CMA) to build on its past work and pursue further consultation with provincial and territorial medical associations, medical and non-medical stakeholders, members, legislatures and patients for processes, whether legal, regulatory or guidelines, that respect patients' needs and reflects physicians' perspectives. The goal of this process is twofold: (a) discussion and recommendations on a suite of ethical-legal principles and (b) input on specific issues that are particularly physician-sensitive and are worded ambiguously or not addressed in the Court's decision. The touch points are reasonable accommodation for all perspectives and patient-centeredness. For purposes of clarity, CMA recommends national and coordinated legislative and regulatory processes and systems. There should be no undue delay in the development of these laws and regulations. The principles are not designed to serve as a tool for legislative compliance in a particular jurisdiction or provide a standard of care. Rather, the CMA wishes to provide physicians with guidance and a vision of what physicians might strive for to further their professional and legal obligations in a complex area. The CMA recommends adopting the following principles-based approach to assisted dying in Canada: Foundational principles The following foundational principles underpin CMA's recommended approach to assisted dying. Proposing foundational principles is a starting point for ethical reflection, and their application requires further reflection and interpretation when conflicts arise. 1. Respect for patient autonomy: Competent adults are free to make decisions about their bodily integrity. Specific criteria are warranted given the finality of assisted dying. 2. Equity: To the extent possible, all those who meet the criteria for assisted dying should have access to this intervention. Physicians will work with relevant parties to support increased resources and access to high quality palliative care, and assisted dying. There should be no undue delay to accessing assisted dying, either from a clinical, system or facility perspective. To that end, the CMA calls for the creation of a separate central information, counseling, and referral service. 3. Respect for physician values: Physicians can follow their conscience when deciding whether or not to provide assisted dying without discrimination. This must not result in undue delay for the patient to access these services. No one should be compelled to provide assistance in dying. 4. Consent and capacity: All the requirements for informed consent must clearly be met, including the requirement that the patient be capable of making that decision, with particular attention to the context of potential vulnerabilities and sensitivities in end of life circumstances. Consent is seen as an evolving process requiring physicians to continuously communicate with the patient. 5. Clarity: All Canadians must be clear on the requirements for qualification for assisted dying. There should be no "grey areas" in any legislation or regulations. 6. Dignity: All patients, their family members or significant others should be treated with dignity and respect at all times, including throughout the entire process of care at the end of life. 7. Protection of patients: Laws and regulations, through a carefully designed and monitored system of safeguards, should aim to minimize harm to all patients and should also address issues of vulnerability and potential coercion. 8. Accountability: An oversight body and reporting mechanism should be identified and established in order to ensure that all processes are followed. Physicians participating in assisted dying must ensure that they have appropriate technical competencies as well as the ability to assess decisional capacity, or the ability to consult with a colleague to assess capacity in more complex situations. 9. Solidarity: Patients should be supported and not abandoned by physicians and health care providers, sensitive to issues of culture and background, throughout the dying process regardless of the decisions they make with respect to assisted dying. 10. Mutual respect: There should be mutual respect between the patient making the request and the physician who must decide whether or not to perform assisted dying. A request for assisted dying is only possible in a meaningful physician-patient relationship where both participants recognize the gravity of such a request. Recommendations Based on these principles, the Supreme Court decision in Carter v. Canada (2015)1 and a review of other jurisdictions' experiences, CMA makes the following recommendations for potential statutory and regulatory frameworks with respect to assisted dying. We note that this document is not intended to address all potential issues with respect to assisted dying, and some of these will need to be captured in subsequent regulations. 1. Patient eligibility for access to assisted dying 1.1 The patient must be a competent adult who meets the criteria set out by the Supreme Court of Canada decision in Carter v. Canada (2015. 1.2 Informed decision * The attending physician must disclose to the patient information regarding their health status, diagnosis, prognosis, the certainty of death upon taking the lethal medication, and alternatives, including comfort care, palliative and hospice care, and pain and symptom control. 1.3 Capacity * The attending physician must be satisfied that: - the patient is mentally capable of making an informed decision at the time of the request(s) - the patient is capable of giving consent to assisted dying, paying particular attention to the potential vulnerability of the patient in these circumstances - communications include exploring the priorities, values and fears of the patient, providing information related to the patient's diagnosis and prognosis, treatment options including palliative care and other possible interventions and answering the patient's questions * If either or both the attending physician or the consulting physician determines that the patient is incapable, the patient must be referred for further capacity assessment. * Only patients on their own behalf can make the request while competent. 1.4 Voluntariness * The attending physician must be satisfied, on reasonable grounds, that all of the following conditions are fulfilled: - The patient's decision to undergo assisted dying has been made freely, without coercion or undue influence from family members, health care providers or others. - The patient has a clear and settled intention to end his/her own life after due consideration. - The patient has requested assisted dying him/herself, thoughtfully and repeatedly, in a free and informed manner. 2. Patient eligibility for assessment for decision-making in assisted dying Stage 1: Requesting assisted dying 1. The patient submits at least two oral requests for assisted dying to the attending physician over a period of time that is proportionate to the patient's expected prognosis (i.e., terminal vs non-terminal illness). CMA supports the view that a standard waiting period is not appropriate for all requests. 2. CMA recommends generally waiting a minimum of 14 days between the first and the second oral requests for assisted dying. 3. The patient then submits a written request for assisted dying to the attending physician. The written request must be completed via a special declaration form that is developed by the government/department of health/regional health authority/health care facility. 4. Ongoing analysis of the patient's condition and ongoing assessment of requests should be conducted for longer waiting periods. Stage 2: Before undertaking assisted dying 5. The attending physician must wait no longer than 48 hours, or as soon as is practicable, after the written request is received. 6. The attending physician must then assess the patient for capacity and voluntariness or refer the patient for a specialized capacity assessment in more complex situations. 7. The attending physician must inform the patient of his/her right to rescind the request at any time. 8. A second, independent, consulting physician must then also assess the patient for capacity and voluntariness. 9. Both physicians must agree that the patient meets eligibility criteria for assisted dying to proceed. 10. The attending physician must fulfill the documentation and reporting requirements. Stage 3: After undertaking assisted dying 11. The attending physician, or a physician delegated by the attending physician, must take care of the patient until the patient's death. 3. Role of the physician 3.1 The attending physician must be trained to provide assisted dying. 3.2 Patient assessment * The attending physician must determine if the patient qualifies for assisted dying under the parameters stated above in Section 1. * The attending physician must ensure that all reasonable treatment options have been considered to treat physical and psychological suffering according to the patient's need, which may include, independently or in combination, palliative care, psychiatric assessment, pain specialists, gerontologists, spiritual care, and/or addiction counseling. 3.3 Consultation requirements * The attending physician must consult a second physician, independent of both the patient and the attending physician, before the patient is considered eligible to undergo assisted dying. * The consulting physician must - Be qualified by specialty or experience to render a diagnosis and prognosis of the patient's illness and to assess their capacity as noted in Stage 2 above. 3.4 Opportunity to rescind request * The attending physician must offer the patient an opportunity to rescind the request at any time; the offer and the patient's response must be documented. 3.5 Documentation requirements * The attending physician must document the following in the patient's medical record: - All oral and written requests by a patient for assisted dying - The attending physician's diagnosis and prognosis, and their determination that the patient is capable, acting voluntarily and has made an informed decision - The consulting physician's diagnosis and prognosis, and verification that the patient is capable, acting voluntarily and has made an informed decision - A report of the outcome and determinations made during counseling - The attending physician's offer to the patient to rescind the request for assisted dying - A note by the attending physician indicating that all requirements have been met and indicating the steps taken to carry out the request 3.6 Oversight body and reporting requirements * There should be a formal oversight body and reporting mechanism that collects data from the attending physician. * Following the provision of assisted dying, the attending physician must submit all of the following items to the oversight body: - Attending physician report - Consulting physician report - Medical record documentation - Patient's written request for assisted dying * The oversight body would review the documentation for compliance * Provincial and territorial jurisdictions should ensure that legislation and/or regulations are in place to support investigations related to assisted dying by existing provincial and territorial systems * Pan-Canadian guidelines should be developed in order to provide clarity on how to classify the cause on the death certificate 4. Responsibilities of the consulting physician * The consulting physician must verify the patient's qualifications including capacity and voluntariness. * The consulting physician must document the patient's diagnosis, prognosis, capacity, volition and the provision of information sufficient for an informed decision. The consulting physician must review the patient's medical records, and should document this review. 5. Moral opposition to assisted dying 5.1 Moral opposition by a health care facility or health authority * Hospitals and health authorities that oppose assisted dying may not prohibit physicians from providing these services in other locations. There should be no discrimination against physicians who decide to provide assisted dying. 5.2 Conscientious objection by a physician * Physicians are not obligated to fulfill requests for assisted dying. There should be no discrimination against a physician who chooses not to participate in assisted dying. In order to reconcile physicians' conscientious objection with a patient's request for access to assisted dying, physicians are expected to provide the patient with complete information on all options available to them, including assisted dying, and advise the patient on how they can access any separate central information, counseling, and referral service. 1 Carter v. Canada (Attorney General), [2015] 1 SCR 331, 2015 SCC 5 (CanLII)
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CMA Letter to the Legislative Committee on Bill C-30: Clean Air Act

https://policybase.cma.ca/en/permalink/policy8714
Last Reviewed
2019-03-03
Date
2007-02-28
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2007-02-28
Topics
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) is pleased to participate in the review of the Clean Air Act, Bill C- 30. The CMA, first founded in 1867, currently represents more than 64,000 physicians across the country. Our mission includes advocating for the highest standard of health and health care for all Canadians and we are committed to activities that will result in healthy public policy. The Environment: A Key Determinant of Health The physical environment is a key determinant of a population's health and the medical profession is concerned about environmental conditions that contribute to declining health in individuals and the population as a whole. Physicians have been part of an early warning system of scientists and other health professionals calling attention to the effects on human health of poor air quality because we see the impact in our practice and in our communities. There is strong evidence that air pollution is the most harmful environmental problem in Canada in terms of human health effects. We know from the smog health studies undertaken by the Ontario Medical Association (OMA), Health Canada and others, about the public health crisis created by polluted air in many parts of Canada. And it is a crisis. A study by the federal government estimated that 5,900 premature deaths occur annually in eight large Canadian cities. This is a conservative estimate as the study focused on the short-term impact of smog pollutants using time-series studies. This study was never extrapolated to the whole Canadian population, but we know that only approximately one third of the Canadian population, mainly residents of large, urban areas, were included in the analysis.1 The OMA Illness Costs of Air Pollution study estimated that there were 5,800 premature deaths due to air pollution in Ontario alone in 2005, and examined both short-term and long-term health impacts. The OMA projected that the annual figure will grow to 10,000 premature deaths by 2026 unless effective steps are taken to reduce smog.2 In addition to premature deaths, the OMA estimated that there were 16,000 hospital admissions and 60,000 emergency room visits in Ontario in 2005 because of respiratory and cardiovascular illnesses associated with air pollution exposure. During that same year, the OMA also estimated that there were 29 million minor illness days, defined as days where individuals either suffered from asthma symptoms or had to restrict their activities. Most of the people affected by these so-called minor illness days are children. In British Columbia, the Provincial Officer for Health published a conservative estimate in 2004 that air pollution in B.C. is causing between 140 and 400 premature deaths, 700 to 2,100 hospital stays, and between 900 and 2,750 emergency room visits each year.3 The direct and indirect costs of air pollution on the health of Canadians are estimated to be in the billions of dollars. According to the Ontario Medical Association, in 2005, air pollution costs in Ontario were estimated at: - $374 million in lost productivity and work time; - $507 million in direct health care costs; - $537 million in pain and suffering due to non-fatal illness; and - $6.4 billion in loss due to premature death.4 In Canada the environment is currently considered to be the most important issue facing society. In a recent poll by the Strategic Counsel for the Globe & Mail/CTV5 a majority of respondents ranked the impact of toxic chemicals, air and water pollution and global warming as life threatening. The environment, while a major concern today for the general public, has been of concern to physicians for some time. CMA, Health and the Environment In 1991 the CMA, released a policy paper Health, the Environment and Sustainable Development6 that clearly linked health and the environment. Building on the 1987 Brundtland Report (World Commission on Environment and Development, Our Common Future) that tied sustainable development to the environment and the economy, the CMA inserted health into this pair of interactions and stated that "continued environmental degradation will increase hazard to human health." The paper concluded with a number of recommendations for governments, the health sector, and physicians in support of environmentally sustainable development. The CMA has continued to give attention to environmental issues urging the government, prior to Canada's ratification of the Kyoto Protocol, to commit to choosing a climate change strategy that satisfies Canada's international commitments while maximizing the clean air co-benefits and smog-reduction potential of any greenhouse gas reduction initiatives. In 2002, the CMA also recommended that the federal Environment and Health Ministers commit their departments to improved health-based reporting by regularly updating the health effects information for pollutants of concern. Clean Air Act: A Physicians Perspective Doctors understand the concept that success from an intervention can be nuanced. In the case of disease, physicians know and accept that there are benefits of treatment even if a patient cannot be cured. Sometimes we just reduce their symptoms, or slow their rate of decline. But when treating the natural environment, so critical to human health, we suggest that you cannot accept a palliative solution. We must aim for cure. We must commit to measures of success in terms of real improvement in health. It is through this lens that the CMA urges that you view the Clean Air Act to ensure that it is health-relevant. The CMA would like to commend this government for acknowledging the impact of the physical environment on human health and we are encouraged that the Act recognizes the intimate connection between greenhouse gas reductions and improved air quality. Air pollution does not respect provincial borders therefore it is very important to establish national objectives and Canada wide standards that are strong and consistent across the country. To be health relevant national air quality objectives must result in air quality improvements. To this end, regardless of whether they are called objectives or standards, national air quality targets must protect the health of all Canadians and must be binding. Voluntary air quality guidelines guarantee no health benefit. The federal government must ensure that there is a regulatory framework in place to ensure that the standards are mandatory across the country. The annual reporting to Parliament on the attainment of the national air quality objectives and the effectiveness of measures to attain the objectives, as outlined in the Act, is very important. Transparency in reporting is essential to the integrity of any program, but is integral to the determination of health benefit. The International Panel on Climate Change's Fourth Assessment report released on February 2, 2007, concluded that global warming is unequivocal and that human activity is the main driver, asserting with near certainty - more than 90 percent confidence - that carbon dioxide and other heat-trapping greenhouse gases from human activities have been the main causes of warming since 1950. Its Third Assessment report: Climate Change 2001: Working Group II: Impacts, Adaptation and Vulnerability noted that global climate change will have a wide range of impacts on human health. "Overall, negative health impacts are expected to outweigh positive health impacts. Some health impacts would result from changes in the frequencies and intensities of extremes of heat and cold and of floods and droughts. Other health impacts would result from the impacts of climate change on ecological and social systems and would include changes in infectious disease occurrence, local food production and nutritional adequacy, and concentrations of local air pollutants and aeroallergens, as well as various health consequences of population displacement and economic disruption."7 Given the indisputable impact of greenhouse gas increases on climate change and its connection to human health, it is critical to ensure that Canada is moving quickly to reduce greenhouse gas emissions. The Clean Air Act and the subsequent notice of intent sets out short, medium and long term targets and timelines for the reduction of greenhouse gas emissions in Canada. The target setting approach proposed in the Act, based on emission intensity in the short and medium term is not health relevant. To be health relevant, targets should be presented in the context of overall emissions, i.e., emissions reductions minus emissions increases. An emission reduction from a particular source is only health-relevant if we can guarantee that there is not a corresponding emissions increase at another source nearby, because it is the absolute exposure that an individual experiences that affects the risk of an adverse health effect. Just as slowing the progression of a disease can never be considered a cure, attempting only to limit the growth of those emissions cannot result in true success by any measure. It is not until 2050 that the government has committed to achieving an absolute reduction in greenhouse gas emissions of between 45 - 65% of 2003 levels. Based on the emission intensity targets in the Clean Air Act, emissions and air pollution levels will, in fact, continue to rise as will the health consequences. In order to protect the health of Canadians the government needs to set policies, with targets and timelines that maximize absolute reductions in greenhouse gases, which are consistent with the scale and urgency of the challenge. To ensure that prescribed policies result in the intended environment and health outcomes, short and medium-term targets for absolute emission reductions would benchmark progress and allow for mid-course corrections, if they were needed. With respect to indoor air quality, physicians have long been proponents of initiatives to reduce exposure to contaminants such as second-hand tobacco smoke. The CMA is concerned about the impact on human health of exposure to high levels of radon and the associated increased risk of lung cancer. The intention to develop measures to address indoor air quality through a national radon strategy is a positive step. It is important that our patients are made aware of such threats in their homes, and also that they are presented with a way to reduce their exposure. Environmentally related illness is essentially the combined result of exposure and vulnerability. We are vulnerable because we are human beings; each human being has different physical strengths and weaknesses. Some vulnerabilities to environmental influences are genetic, and some the results of pre-existing disease. There is not much that government can do about this part of the equation. Our exposure, on the other hand is related to the air we breathe, water we drink and food we eat. This is where the federal government is critical, and where the measures of success will be the most important. Proxy measures for the health outcomes that matter must be relevant from a health perspective. Health-based success can only be measured by quantifiable reductions in the exposure levels of contaminants in our air as well as in our water and soil. Clean air is absolutely fundamental to a healthy population - without it all else is irrelevant. Actions to curb air pollution must be taken in all sectors and levels of society in a concerted, non-partisan effort with the health of the population and the planet as our yardstick of success. Thank you for the opportunity to provide our comments on Bill C-30, the Clean Air Act. We look forward to working with you to improve the Clean Air Act and ensure that the measure of its success will benefit the health of Canadians. Sincerely Colin J. McMillan, MD, CM, FRCPC, FACP President 1 S. Judek, B. Jessiman, D. Stieb, and R. Vet. 2005. Estimated Number of Excess Deaths in Canada Due to Air Pollution". Health Canada and Environment Canada. http://www.hc-sc.gc.ca/ahc-asc/media/ nr-cp/2005/2005_32bk2_e.html#top 2 Ontario Medical Association. 2005. The Illness Costs of Air Pollution: 2005-2026 Health and Economic Damage Estimates. Toronto: OMA. 3 B.C. Provincial Health Officer. 2004. Every Breath You Take: Air Quality in British Columbia, A Public Health Perspective. 2003 Annual Report. Victoria: Ministry of Health Services. 4 Ontario Medical Association , 2005 5 GLOBE/CTV POLL Climate concerns now top security and health One in four label environmental issues as most important, The Globe and Mail, Fri 26 Jan 2007, Page: A1, Section: National News , Byline: Brian Laghi 6 Health, the Environment and Sustainable Development, Canadian Medical Association , 1991 7 WMO Intergovernmental Panel on Climate Change, Climate Change 2001, IPPC Third Assessment Report: Working Group II: Impacts, Adaptation and Vulnerability, accessed Feb 7, 2007 http://www.grida.no/climate/ipcc_tar/wg2/348.htm
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Submission to House of Commons Standing Committee on Health Regarding the Common Drug Review

https://policybase.cma.ca/en/permalink/policy8719
Last Reviewed
2019-03-03
Date
2007-05-14
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2007-05-14
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The Canadian Medical Association represents more than 65,000 physicians in Canada; its mission is to serve and unite the physicians of Canada and to be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care. In pursuit of this mission we are developing a growing body of policy on pharmaceutical issues. In November 2003, we presented to the House of Commons Standing Committee on Health during its study of prescription drug issues. In July 2006 CMA, along with four other national organizations representing patients, health professionals, health system managers and trustees, formed the Coalition for a Canadian Pharmaceutical Strategy and released a framework and principles that we believed should govern the development of pharmaceutical strategy in this country. We understand that the current study of the Common Drug Review (CDR) is part of a larger, more comprehensive study of prescription drugs being contemplated by the House of Commons Standing Committee on Health. We look forward to assisting you with this study. In the meantime, we will note that the CDR is intimately linked to related issues such as catastrophic coverage and a national formulary, and will also briefly discuss these in our presentation. Pharmaceuticals are important to the health of Canadians. For many patients prescription drugs have prevented serious disease, reduced hospital stays, replaced surgical treatment and improved their capacity to function productively in the community. Pharmaceuticals also offer health-care system benefits by reducing other costs such as hospital expenses and disability payments. While prescription drugs offer significant benefits, expenditures on them are also growing faster than any other component of health care. It is realistic to expect that the role of prescription drugs in health care will continue to increase and that as a result government expenditures on them will rise accordingly. As patients become increasingly knowledgeable and politically aware, they will continue to expect and demand access to an expanded range of prescription drugs. CMA believes that any pharmaceutical strategy should be predicated on two pre-eminent principles, which are in keeping with longstanding Canadian values: * All Canadians should have access to safe and effective prescription drugs; and * No Canadian should be deprived of medically necessary drugs because of inability to pay. Whether the CDR serves to further these goals has been a matter of vigorous debate. Federal and provincial representatives have told the House of Commons Committee that the CDR is meeting their needs and has in some cases provided them with a higher-quality review than they could have achieved on their own. On the other hand, patient groups have charged that the CDR is an unnecessary layer of bureaucracy and a barrier between them and potentially life-saving new therapies. It is possible, if not probable, that reforms to the CDR may never completely eliminate the tension between these two viewpoints. We understand the frustration of patients and their advocates when the CDR recommends against public reimbursement or even more, when the CDR approves a drug but individual provinces refuse to include that drug on their formularies. In both these cases, sustainability of the health care system is an important and valid consideration. It would be unfortunate if our limited health care dollars, which might otherwise have been spent on disease treatment or prevention strategies of proven effectiveness, went instead to funding expensive drugs which ultimately proved no more beneficial to patients than others which cost much less. 2) General principles regarding drug review The process of reviewing drugs for inclusion in public formularies did not begin with the CDR. Before it was created, each federal and provincial formulary conducted its own review. Without the CDR, separate reviews would still be taking place. To dismantle the review process entirely would be unacceptable, both economically and politically. Within the context of an overarching goal to enhance access to medically required pharmaceuticals to the extent that they are needed, the primary purpose of a drug review process should be to help ensure access to prescription drugs for which evidence indicates safety and effectiveness in the treatment, management and prevention of disease, and/or significant benefits in quality of life. To help ensure that it achieves this purpose, we believe the following principles should apply to drug review in Canada: * The review process should be impartial and founded on the best available scientific evidence. * The primary criteria for inclusion in a formulary should be whether the drug improves health outcomes, and offers an improvement over products currently on the market. * The review process should also incorporate evaluation of the drug's cost-effectiveness. * Drugs should be evaluated not in isolation but as an integral part of the health care continuum. The review should consider: * A drug's impact on overall health care utilization. If a drug reduces a patient's hospital stay, helps an otherwise disabled patient return to work, or replaces other costlier or more invasive therapies, this should be considered in evaluating its overall cost-effectiveness. * Alternatives to the drug under review. The review should compare a drug's performance to other drugs in the same class, and to available non-drug therapies. * The review process should be flexible, taking into account the unique needs and therapeutic outcomes of individual patients, and the expertise of physicians in determining which drugs are best for their patients. * The review process should be open and transparent. We support the CDR's intent to publish the rationales for its decisions, including lay-language versions. * CDR findings are a valuable source of information on the safety and effectiveness of the drugs physicians prescribe. As such, they should be communicated to caregivers and patients as part of an ongoing strategy to encourage best practices in prescribing. * Meaningful participation by patients and health professionals should be part of the review process; we note with approval the expansion of the Canadian Expert Drug Advisory Committee to include members of the public. We also suggest that the CDR experiment with open fora and other means of obtaining public input. * A process for appealing the review's decisions should be established. * Ongoing evaluation of the review process should be required. We note that the CDR has already undergone an evaluation, and is planning to implement some of the key recommendations. Impartial evaluations should continue to take place, to assess whether the CDR is having a positive impact on the health of Canadians and of their health care system. 3) The Larger Picture The Common Drug Review does not exist in isolation. As the Coalition for a Canadian Pharmaceutical Strategy - of which CMA is a member - stressed in its 2006 statement, the elements of a comprehensive Canadian pharmaceutical strategy are interdependent and should be developed concurrently to ensure that the strategy is coherent and holistic. The CDR is interlinked with other issues concerning access to health care generally and to prescription drugs more specifically, and we suggest that the Committee also consider the following issues: a) Drugs for Rare Disorders. One controversy surrounding the CDR is that its approval rates are low for drugs for very rare disorders, many of which are first-in-class. One reason may be the cost of these drugs, which is often extremely high. It is also alleged that the Canadian Expert Drug Advisory Committee's (CEDAC) current review standards, which place a high value on large-sample clinical trials, are unable to adequately capture the value of these drugs. It has been recommended that more drugs for rare disorders be approved based on interim targets or surrogate endpoints. The ultimate measure of a drug's effectiveness is its clinical endpoint; this should not be forgotten in any process of drug approval. This issue merits closer consideration, as do all issues related to drugs for rare disorders. CMA recommends that Canada develop a policy on drugs for rare disorders, which: * Encourages their development; * Evaluates their effectiveness; and * Ensures that all patients who might benefit have reasonable access to them. b) Common Formulary. CMA recommends that Canada's governments consider the possibility of establishing a pan-Canadian formulary. Canadian patients need a national standard; 18 different levels of coverage is not acceptable. Should the CDR form the basis of this formulary? That would depend on whether evaluation proves that the CDR is the most effective vehicle. We do believe that cost control, though not the primary function of a pan-Canadian formulary, is a valid system concern. If two drugs in the same class are equally effective, it is reasonable to expect that the less expensive drug should be preferentially covered and/or prescribed. On the other hand, a pan-Canadian formulary should be flexible. It should include a process to allow patients access to off-formulary drugs if in the opinion of the attending physician the recommended product is not the right choice for them. This process should be designed so as to minimize the administrative burden on health professionals. c) Catastrophic Drug Coverage. It is now generally accepted that a pan-Canadian catastrophic drug program is needed. The point of discussion now is what type of program should be put in place. To ensure that Canadians can access the drugs they need, regardless of where they live or how much they earn, CMA recommends that federal, provincial and territorial governments, in collaboration with private insurers, assess the drug needs of Canadians, particularly those who are uninsured or under-insured, and agree on an option for providing equitable and comprehensive prescription drug coverage. As a starting point, CMA has recommended that governments give priority to a national pharmacare program to provide necessary drugs for all Canadian children and youth. Conclusion In principle, CMA believes that a process for reviewing prescription drugs for their clinical effectiveness and cost-effectiveness can contribute to improving the health of Canada's patients and our health care system. The value of the CDR will be determined by how well it performs this function. Canadian Medical Association May 14, 2007
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CMA letter to the House of Commons Standing Committee on Justice and Human Rights. Bill C-32 (An Act to amend the Criminal Code (Impaired driving) and to make consequential amendments to other Acts)

https://policybase.cma.ca/en/permalink/policy8789
Last Reviewed
2019-03-03
Date
2007-06-11
Topics
Health care and patient safety
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2007-06-11
Topics
Health care and patient safety
Text
The Canadian Medical Association (CMA) welcomes the opportunity to provide comments to the Standing Committee on Justice and Human Rights of the House of Commons concerning the study of Bill C-32 (An Act to amend the Criminal Code (impaired driving) and to make consequential amendments to other Acts). The CMA supports measures aimed at reducing the incidence of drug-impaired driving. We believe impaired driving, whether by alcohol or another drug, to be an important public health issue for Canadians that requires action by all governments and other concerned groups. The CMA has, on several occasions, provided detailed recommendations on legislative changes concerning impaired driving. In 1999, the CMA presented a brief to the House of Commons Standing Committee on Justice and Human Rights during its review of the impaired driving provisions of the Criminal Code (attached). While our 1999 brief focuses primarily on driving under the influence of alcohol, many of the recommendations are also relevant to the issue of driving under the influence of drugs. Recently, the CMA has published the 7th edition of its guide, Determining Medical Fitness to Operate Motor Vehicles (attached). It includes chapters on the importance of screening for alcohol or drug dependency and states that the abuse of such substances is incompatible with the safe operation of a vehicle. This publication is widely viewed by clinical and medical-legal practitioners as the authoritative Canadian source on the topic of driver competence. While changing the Criminal Code is an important step, the CMA believes further actions are also warranted. In our 2002 presentation to the Special Senate Committee on Illegal Drugs (attached), the CMA put forth our long standing position regarding the need for a comprehensive long-term effort that incorporates both deterrent legislation and public awareness and education campaigns. We believe such an approach, together with comprehensive treatment and cessation programs, constitutes the most effective policy in attempting to reduce the number of lives lost and injuries suffered in crashes involving impaired drivers. Drug-impaired drivers may be occasional users of drugs or they may also suffer from substance dependence, a well-recognized form of disease. Physicians should be assisted to screen for drug dependency, when indicated, using validated instruments. Government must create and fund appropriate assessment and treatment interventions. Physicians can assist in establishing programs in the community aimed at the recognition of the early signs of dependency. These programs should recognize the chronic, relapsing nature of drug addiction as a disease, as opposed to simply viewing it as criminal behaviour. While supporting the intent of the proposed legislation, the CMA urges caution on several significant issues. With regard to Clause 4 that amends the act as follows: 254.1 (1) The Governor in Council may make regulations (a) respecting the qualifications and training of evaluating officers; (b) prescribing the physical coordination tests to be conducted under paragraph 254(2)(a); and (c) prescribing the tests to be conducted and procedures to be followed during an evaluation under subsection 254(3.1). CMA contends that it is important that medical professionals and addiction medicine specialists in particular, should be consulted regarding the training offered to officers to conduct roadside assessment and sample collection. Provisions in the Act conferring upon police the power to compel roadside examination raises the important issue of security of the person and health information privacy. As well, information obtained at the roadside is personal medical information and regulations must ensure that it be treated with the same degree of confidentiality as any other element of an individual's medical record. Thus, the CMA would respectfully submit that Clause 9 of Bill-32 on the issue of unauthorized use or disclosure of the results needs to be strengthened because the wording is too broad, unduly infringes privacy and shows insufficient respect for the health information privacy interests at stake. For instance, clause 9(2) would permit the use, or allow the disclosure of the results "for the purpose of the administration or enforcement of the law of a province". This latter phrase needs to be narrowed in its scope so that it would not, on its face, encompass such a broad category of laws. Moreover, clause 9(4) would allow the disclosure of the results "to any other person, if the results are made anonymous and the disclosure is made for statistical or other research purposes" CMA would expect the federal government to exercise great caution in this instance, particularly since the results could be of individuals who are not actually convicted of an offence. One should query whether the Clause 9(4) should even exist in a Criminal Code as it would not appear to be a matter required to be addressed. If it is, then CMA would ask the government to conduct a rigorous privacy impact assessment on these components of the Bill, studying in particular, such matters as sample size, degree of anonymity, and other issues, especially given the highly sensitive nature of the material. CMA would ask whether clause 9(5) should specify that the offence for improper use or disclosure should be more serious than a summary conviction. Finally, it is important to base any roadside testing methods and threshold decisions on robust biological and clinical research. CMA also notes with interest Clause 5, specifically the creation of a new offence of being "over 80" (referring to 80mg of alcohol in 100ml of blood, or a .08 blood alcohol concentration level or BAC) and causing an accident that results in bodily harm which will carry a maximum sentence of 10 years and life imprisonment for causing an accident resulting in death. (Clause 5) We would also urge the Committee to take the opportunity that the review of this proposed legislation provides to recommend to Parliament a lower BAC level. Since 1988 the CMA has supported 50 mg% as the general legal limit. Studies suggest that a BAC limit of 50 mg% could translate into a 6% to 18% reduction in total motor vehicle fatalities or 185 to 555 fewer fatalities per year in Canada.1 A lower limit would recognize the significant detrimental effects on driving-related skills that occur below the current legal BAC.2 In our 1999 response to this Committee's issue paper on impaired driving3 and again in 2002 when we joined forces with Mothers Against Drunk Driving (MADD), CMA has consistently called for the federal government to reduce Canada's legal BAC to .05. Canada continues to lag behind countries such as Austria, Australia, Belgium, Denmark, France and Germany, which have set a lower legal limit. 4 CMA expressed the opinion that injuries and deaths resulting from impaired driving must be recognized as a major public health concern. Therefore we once again recommend lowering the legal BAC limit to 50 mg%. or .05%. Finally, CMA believes that comprehensive long-term efforts that incorporate deterrent legislation, such as Bill C-32, must be accompanied by public awareness and education strategy. This constitutes the most effective approach to reducing the number of lives lost and injuries suffered in crashes involving impaired drivers. The CMA supports this multidimensional approach to the issue of the operation of a motor vehicle regardless of whether impairment is cause by alcohol or drugs. Again, the CMA appreciates the opportunity to provide input into the legislative proposal on drug-impaired driving. We stress that these legislative changes alone would not adequately address the issue of reducing injuries and fatalities due to drug-impaired driving, but support their intent as a partial, but important measure. Yours sincerely, Colin J. McMillan, MD, CM, FRCPC, FACP President Attachments (3) 1 Mann, Robert E., Scott Macdonald, Gina Stoduto, Abdul Shaikh and Susan Bondy (1998) Assessing the Potential Impact of Lowering the Blood Alcohol Limit to 50 MG % in Canada. Ottawa: Transport Canada, TP 13321 E. 2 Moskowitz, H. and Robinson, C.D. (1988). Effects of Low Doses of Alcohol on Driving Skills: A Review of the Evidence. Washington, DC: National Highway Traffic Safety Administration, DOT-HS-800-599 as cited in Mann, et al., note 8 at page 12-13 3 Proposed Amendments to the Criminal Code of Canada (Impaired Driving): Response to Issue Paper of the Standing Committee on Justice and Human Rights. March 5, 1999 4 Mann et al
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Tax Incentives for Better Living - The Canadian Medical Association's 2007 pre-budget consultation brief to the Standing Committee on Finance, August 15th 2007

https://policybase.cma.ca/en/permalink/policy8830
Last Reviewed
2019-03-03
Date
2007-08-15
Topics
Health systems, system funding and performance
Physician practice/ compensation/ forms
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2007-08-15
Topics
Health systems, system funding and performance
Physician practice/ compensation/ forms
Text
Summary of our seven recommendations Table - the fiscal impact of our seven recommendations A. Addressing the committee's questions on tax policy trade-offs 1 i. Should taxes be broadly based or targeted to a specific group of residents or business sectors? ii. What consideration should be given to the various levels and types of public goods provided by countries? iii. What is the appropriate level of corporate taxes and should they be competitive? iv. What is the appropriate form and level of personal taxes, fees and other charges and should they be competitive? B. Tax incentives supporting an enhanced and sustainable health system 2 I. Tax incentives for community-based health care practices 3 1. Accelerate health information technology investments - GST and tax incentives II. Tax incentives for healthier living 3 2. Introduce a tax on high-calorie, nutrient-poor foods to curb obesity 3. Double the Child Fitness Tax Credit 4. Increase federal Gas Tax Fund transfers for municipal transit to improve air quality III. Tax incentives supporting an efficient health care system 4 5. Bolster Health Human Resources - extend interest relief on Canada student loans for medical residents 6. Explore tax policy options for Long Term Care 7. Ensure that all Canadians are protected against catastrophic drug costs Summary 5 Summary of our seven recommendations for the Committee's consideration The Canadian Medical Association has a long-standing history of calling for a better fit for tax policy and health policy. The CMA recognizes that tax policy is important, but is just one type of policy instrument for health and health care. Accordingly we have seven principal recommendations for the Standing Committee on Finance. Recommendation 1 - Accelerate health information technology investments - GST and tax incentives That the federal government provides a one-time only $50,000 tax credit spread out over four years, for community-based health care practices to invest in interoperable electronic medical records (EMR) to allow for accelerated system integration. In addition, that the government provides a rebate for IT to physicians for the GST/HST on costs relating to health care services provided by a medical practitioner and reimbursed by a province or provincial health plan. Recommendation 2 - Introduce a tax on high-calorie, nutrient-poor foods to curb obesity That the government consider the use of taxes on sales of high-calorie, nutrient-poor foods as part of an overall strategy of using tax incentives and disincentives to help promote healthy eating in Canada. Moreover, we suggest that a portion of the revenue from this tax should be used to make healthier foods cheaper or more accessible, especially for low-income groups. Obesity costs our economy $9.6 billion per year.i Data collected for the recent Child Health Summit indicate that childhood obesity is a major issue, with 19.3% of Canadian youth aged 10 to 16 considered overweight. The Organization for Economic Cooperation and Development now ranks Canada 19th out of 20 countries surveyed. Recommendation 3 - Double the Child Fitness Tax Credit The CMA recognizes that a "high-calorie, nutrient-poor food tax" should be part of an integrated strategy to promote healthy lifestyles that would also involve better nutrition as well as physical fitness. Accordingly, we recommend that the federal government should increase the children's fitness tax credit to encourage physical fitness. Similar to Canada's Child Fitness Tax Credit, the Personal Health Investment Today (PHIT) bill in the U.S. allows for the use of up to $1,000 pre-tax dollars to cover expenses related to sports, fitness and other physical activities. We recommend that the government double the $500 children's fitness tax credit and include a retail sales tax exemption on tobacco cessation aids.ii Recommendation 4 - Increase federal Gas Tax Fund transfers for municipal transit to improve air quality The CMA suggests that the government immediately accelerate the federal Gas Tax Fund transfers to $2-billion in support of municipal transit infrastructure projects to improve air quality; with consideration of an escalator to close the municipal infrastructure gapiii. These transfers should be integrated into a national transit strategy that considers the heart and lung impacts of motor vehicle pollutioniv. Studies have proven that heart and lung disease among children increases significantly the closer they are to high density traffic. Recommendation 5 - Bolster Health Human Resources - extend the interest relief on Canada student loans for medical residents Many Canadians might not recognize that high medical student debt load is an important health human resource issue. High debt loads unduly affect both the kind of specialty that physicians-in-training choose and, ultimately, where they decide to practice. Medical student debt limits the accessibility of a medical education and may also affect the diversity of the medical profession. Thus, high medical student debt affects patients' access to quality care. Medical student debt is an area in which the federal government can make a direct difference. Unfortunately, current government policy - namely the Canada Student Loans Program (CSLP) - is a barrier and not a boost to medical students. Medical students are accumulating unprecedented levels of debt as tuition fees for medical school continue to skyrocket. Consequently, we recommend that the government introduce changes to the Canada Student Loans Program to extend the interest free status on Canada student loans for medical residents pursuing postgraduate training. Recommendation 6 - Explore tax policy options for Long Term Care That the government considers either tax pre-paid or tax-deferred options for funding long-term health care. For example, in the 2007 federal budget, the government announced the introduction of a Registered Disability Savings Plan (RDSP)v where parents and guardians can contribute to a lifetime maximum of $200,000, while, 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. Recommendation 7 - Ensure that all Canadians are protected against catastrophic drug costs The federal government could consider establishing a catastrophic pharmaceutical program to be administered through reimbursement of provincial/territorial and private prescription drug programs as was proposed by the Kirby/Lebreton Report.vi There are currently more than one-half million Canadians without catastrophic drug coverage. A. Addressing the committee's questions on tax policy trade-offs The CMA does not pretend to be an expert on optimal tax policy. However, we have, over the last five years engaged experts that have illuminated the advantages of aligning tax policy with health policyvii. In general, the CMA recognizes that the Canadian economy and its corporate and income tax rates must compete in the global economy, particularly relative to the United States. We also see that the tax system interfaces with health at three levels: health-care financing, health-care inputs and lifestyle choices. A balance must be struck considering all three of these levels of interaction. The following section provides our views on tax-policy trade-offs as they relate to health and the economy. i. Should taxes be broadly-based or targeted to a specific group of residents or business sectors? The CMA recognizes the three main principles of tax policy: equity, efficiency and economic growth. Our most precious resource is our people: Canada's human capital. Therefore, tax policy should be used to maximize the health of our citizens, particularly the health of our children - the labour force of the future. The CMA believes in broadly based tax policy that creates incentives for integrating good nutrition and active lifestyles for all Canadians. ii. What consideration should be given to the various levels and types of public goods provided by countries? The health-care sector currently represents 10% of our economy and is likely to grow. This makes the case for immediately implementing forward-looking tax policy that encourages healthy lifestyles as well as improving system efficiencies so that billions of dollars may be saved in the future. In addition, universal health care coverage facilitates labour mobility as employees are not tied to their employers for medical coverage. This is an advantage for Canadians as well as prospective overseas talent coming to Canada. iii. What is the appropriate level of corporate taxes and should they be competitive? The CMA also believes that corporate tax policy should create incentives for companies to invest in capital, as well as labour, in order to increase productivity. Consumption taxes like the GST should not fall on publicly funded physicians with respect to goods and services required to run their practices because they cannot pass on price increases to their patients. This is inefficient and inequitable. iv. What is the appropriate form and level of personal taxes, fees and other charges and should they be competitive? The CMA believes in a progressive personal income tax system that supports social services while at the same time is not so onerous as to discourage labour in fields that are considered strategic or in short supply. Accordingly, federal personal income tax should be mindful of international personal income tax rates especially for professions (such as physicians) that are currently and will be in short supply in the future. The CMA is concerned about being able to ensure sufficient health human resources for our health-care system in the future. In this regard, income-tax policy could be used to offer an expanded range of incentives for example, to encourage physicians to continue working in Canada or return to Canada from abroad. It is important to consider that over the last ten years; well over 4,800 physicians emigrated from Canada to other countries. B. Tax incentives supporting an enhanced and sustainable health system This pre-budget submission will next set out the CMA's recommended specific tax measures that can enhance both economic and health system performance. We believe that tax policy can create incentives for Canadians to live healthier lives, improve the efficiency of our health-care system, improve community-based health care, and reinforce the value of the publicly-funded system for business. Accordingly our submission outlines three principals of health and tax policy: I. Tax incentives for community-based health-care practices II. Tax incentives for healthier living III. Tax incentives to support an efficient health-care system I. Tax incentives for community based health care practices 1. Accelerate health information technology investments - GST and tax incentives A Booz, Allen, Hamilton studyviii on the Canadian health care system estimates that the benefits of an electronic medical record (EMR) could provide annual system-wide savings of $6.1 billion, due to a reduction in duplicate testing, transcription savings, fewer chart pulls and filing time, reduction in office supplies and reduced expenditures due to fewer adverse drug reactions. The physician community can play a pivotal role in helping the federal government make a connected health-care system a realizable goal in the years to come. Through a multi-stakeholder process encompassing the entire health-care team, the CMA will work toward achieving cooperation and buy-in. This will require a true partnership between provincial medical associations, provincial and territorial governments and Canada Health Infoway. Recommendation: That the federal government provide a $50,000 tax credit, spread-out over four years, for community-based health care practices to invest in interoperable EMRs to allow for system integration. In addition, the CMA recommends that the government provide a rebate for IT to physicians for the GST/HST on costs relating to health-care services provided by a medical practitioner and reimbursed by a province or provincial health plan. II. Why tax incentives for healthier living? Healthier individuals positively affect the economy in four ways.ix 1. They are more productive at work and so earn higher incomes. 2. They spend more time in the labour force, as less healthy people take sickness absence or retire early. 3. They invest more in their own education, which will increase their productivity. 4. They save more in expectation of a longer life (for example, for retirement) increasing the funds available for investment in the economy. 2. Obesity and absenteeism affect the bottom line today and tomorrow Almost 60% of all Canadian adults and 26% of our children and adolescents are overweight or obese.x Obesity costs Canada $9.6 billion per year.xi The programs and incentives in place now are clearly not working as the incidence of obesity continues to grow. The experts agree: "The economic drive toward eating more and exercising less represents a failure of the free market that governments must act to reverse."xii That is why the CMA is calling for a tax on high-calorie, nutrient-poor foods. We are not alone in calling for this tax; the World Health Organization anti-obesity strategy includes a call for "fat taxes"xiii. In addition there is support among voters for such a tax, as a recent consumer surveyxiv revealed that 75% of participants would support a tax designed to discourage consumers from purchasing high-fat, low-nutrition foods. Recommendation: That the government considers the use of taxes on sales of high-calorie, nutrient-poor foods as part of a strategy of using tax incentives to promote healthy eating in Canada. Moreover, a portion of the revenue from this tax should be applied to make healthier foods cheaper and more accessible, especially for low income groups. 3. Double the Child Fitness Tax Credit The CMA recognizes that a "high-calorie, nutrient-poor food tax" should be part of an integrated strategy to promote healthy lifestyles that would involve better nutrition as well as physical fitness. Accordingly, we recommend that the federal government increase the children's fitness tax credit to encourage physical fitness. Similar to Canada's Child Fitness Tax Credit, the Personal Health Investment Today (PHIT) bill in the U.S. allows for the use of up to $1,000 pre-tax dollars to cover expenses related to sports, fitness and other physical activities. In addition, we urge the federal government to introduce a Retail Sales Tax (RST) exemption on tobacco cessation aids, similar to the recent initiative in Ontarioxv. Recommendation: That the government doubles the $500 Children's Fitness Tax Credit and include a retail sales tax exemption on tobacco cessation aids.xvi 4. Increase federal Gas Tax Fund transfers for municipal transit to improve air quality Studies have proven that heart and lung disease among children increases significantly the closer they are to high-density traffic. The CMA suggests that the government immediately accelerate the federal Gas Tax Fund transfers to $2 billion in support of municipal transit infrastructure projects to improve air quality; with consideration of an escalator to close the municipal infrastructure gap.xvii These transfers should be integrated into a national transit strategy that considers the heart and lung impacts of motor vehicle pollution.xviii Recommendation: That the government increases the federal Gas Tax Fund tax transfers for municipal transit. III. Tax incentives supporting an efficient quality health care system 5. Bolster Health Human Resources - extend the interest relief on Canada student loans for medical residents Many Canadians might not recognize that high medical student debt load is an important health human resource issue. High debt loads unduly affect both the kind of specialty that physicians-in-training choose and, ultimately, where they decide to practice. Medical student debt limits the accessibility of a medical education and may also affect the diversity of the medical profession. Thus, high medical student debt affects patients' access to quality care. Medical student debt is an area in which the federal government can make a direct difference. Unfortunately, current government policy - namely the Canada Student Loans Program (CSLP) - is a barrier and not a boost to medical students. Medical students are accumulating unprecedented levels of debt as tuition fees for medical school continue to skyrocket. Recommendation: That the government introduce changes to the Canada Student Loans Program to extend the interest-free status on Canada student loans for medical residents pursuing postgraduate training. 6. Explore tax policy options for Long Term Care Canada is in a period of accelerated population aging that will increase the proportion of seniors aged 65-plus substantially over the next 25 years. These people will need long-term care. Recommendation: That the government considers either tax pre-paid or tax-deferred options for funding long-term health care. For example, in the 2007 federal budget, the government announced the introduction of a Registered Disability Savings Plan (RDSP). 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. 7. Ensure that all Canadians are protected against catastrophic drug costs This is not a tax policy proposal but it is desperately needed. There are currently over one-half-million Canadians without catastrophic drug coverage. Catastrophic Drug Coverage (CDC) aims to address the issue of undue financial hardship faced by Canadians in gaining access to required drug therapies, regardless of where they live and work. In the case of truly catastrophic health needs, these Canadians would probably face the loss of their homes and be destitute, according to the Fraser Groupxix. The founders of Medicare a half-century ago established the principle of equity of access to hospitals and doctors' services for all Canadians. First Ministers agree that no Canadian should suffer undue financial hardship in accessing needed drug therapies. Affordable access to drugs is fundamental to equitable health outcomes for all our citizens. Recommendation: That the federal government could consider establishing a catastrophic pharmaceutical program to be administered through reimbursement of provincial/territorial and private prescription drug programs as was proposed by the Kirby/Lebreton Reportxx. Summary The CMA recognizes the benefits of aligning tax policy with health policy in order to create the right incentives for citizens to realize their potential. We believe that tax policy can create incentives for Canadians to live healthier lives, improve the efficiency of our health care system, improve community based health care, and reinforce the value of the publicly funded system for business. On behalf of the members of the Canadian Medical Association, I wish you all the best in your deliberations. References i P.Katzmarzyk, I. Janssen "The Economic costs associated with physical inactivity and obesity in Canada: An Update" Can J Applied Physiology 2004 Apr; 29(2):90-115. www.phe.queensu.ca/epi/ABSTRACTS/abst81.htm Accessed August 14, 2006. ii Children's Fitness Tax Credit see:www.cra-arc.gc.ca/fitness/ iii The Conference Board argues that Canadian cities are incapable of addressing the infrastructure gap on their own. The report, Canada's Cities: In Need of a New Fiscal Framework, proposes a financing model that involves all three levels of government on the grounds that infrastructure is a national issue and a national priority. See: www.infrastructure.gc.ca/research-recherche/result/precis/rp08_e.shtml iv Gauderman WJ, Vora H, McConnell R, et al. Effects of exposure to traffic on lung development from 10 to 18 years of age: a cohort study. Lancet 2007; 369: 571-577. v Federal Budget 2007. see page 83. Budget 2007 acts on the recommendations of the Panel by announcing the introduction of a new registered disability savings plan (RDSP). The plan will be available commencing in 2008 and will be based generally on the existing registered education savings plan (RESP) design. vi Standing Senate Committee on Science, Technology and Social Affairs' study, The Health of Canadians - The Federal Role (Kirby/Lebreton Report). See Chapter 7 -Expanding coverage to include protection against catastrophic drug costs. Section 7.5.1 How the plan would work on page 138. vii On April 4, 2002, the Canadian Medical Association (CMA) presented its interim report to the Commission on the Future of Health Care in Canada (the Romanow Commission). In this submission, the CMA outlined what Mr. Romanow called "bold and intriguing" changes to reaffirm and realign our health system. Specifically, the CMA report laid out an approach for the renewal of Canada's health care system comprised of three components: a health charter; a health council; and supporting legislative initiatives, including tax system reform. See: Tax and Health - Taking Another Look, May 2002, the CMA. viii Pan-Canadian Electronic Health Record, Canada's Health Infoway's 10-Year Investment Strategy, Booz, Allan, Hamilton, March 2005-09-06. see: www.infoway-inforoute.ca/en/ResourceCenter/ResourceCenter.aspx (accessed August 14, 2007) ix Investment in health could be good for Europe's economies, Suhrcke, McKee, Arce, Tsolova, Mortensen, BMJ 2006;333:1017-1019 (11 November), doi:10.1136/bmj.38951.614144.68 x Source: ww2.heartandstroke.ca/Page.asp?PageID=1366&ArticleID=4321&Src=blank&From=SubCategory accessed 08/06. xi Apr; 29(2):90-115. www.phe.queensu.ca/epi/ABSTRACTS/abst81.htm Accessed August 14, 2006. xii Swinburn, et al. International Journal of Pediatric Obesity (vol 1, p 133) (accessed Sept. 19, 2006) xiii In December, 2003, The World Health Organization proposed that nations consider taxing junk foods to encourage people to make healthier food choices. According to the WHO report, "Several countries use fiscal measures to promote availability of and access to certain foods; others use taxes to increase or decrease consumption of food; and some use public funds and subsidies to promote access among poor communities to recreational and sporting facilities." See: http://en.wikipedia.org/wiki/Fat_tax xiv A recent consumer survey by conducted by eDiets.com reveals strong support for a 'fat tax' see: www.foodproductiondaily.com/news/ng.asp?n=66981-fat-tax-junk-food-obesity xv McGuinty Government Introduces Tax Break On Smoking Cessation see www.mhp.gov.on.ca/english/news/2007/073007.asp The national cost of the RST exemption would be about $12 million. xvi See endnote ii. xvii See endnote iii. xviii See endnote iv. xix Fraser Group's business is research, analysis and marketing information for financial service organizations. Our area of greatest expertise is the employee benefits sector including the group life and health and the group pension and retirement markets. Our clients include insurance companies, mutual fund companies, suppliers to the employee benefits sector and, pharmaceutical firms as well as government (estimates for the Kirby/Lebreton report on pharmaceutical strategy in 2002) and non-profit entities with a need to understand this sector. See www.frasergroup.com/aboutus.htm in addition xx See endnote v. CMA pre-budget submission to the Standing Committee on Finance Autumn 2007
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Guidelines for Physicians in Interactions with Industry

https://policybase.cma.ca/en/permalink/policy9041
Last Reviewed
2019-03-03
Date
2007-12-01
Topics
Ethics and medical professionalism
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2007-12-01
Replaces
Physicians and the pharmaceutical industry (Update 2001)
Topics
Ethics and medical professionalism
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
GUIDELINES FOR PHYSICIANS IN INTERACTIONS WITH INDUSTRY The history of health care delivery in Canada has included interaction between physicians and the pharmaceutical and health supply industries; this interaction has extended to research as well as to education. Physicians understand that they have a responsibility to ensure that their participation in such collaborative efforts is in keeping with their primary obligation to their patients and duties to society, and to avoid situations of conflict of interest where possible and appropriately manage these situations when necessary. They understand as well the need for the profession to lead by example by promoting physician-developed guidelines. The following guidelines have been developed by the CMA to serve as a resource tool for physicians in helping them to determine what type of relationship with industry is appropriate. They are not intended to prohibit or dissuade appropriate interactions of this type, which have the potential to benefit both patients and physicians. Although directed primarily to individual physicians, including residents, and medical students, the guidelines also apply to relationships between industry and medical organizations. General Principles 1. The primary objective of professional interactions between physicians and industry should be the advancement of the health of Canadians. 2. Relationships between physicians and industry are guided by the CMA's Code of Ethics and by this document. 3. The practising physician's primary obligation is to the patient. Relationships with industry are inappropriate if they negatively affect the fiduciary nature of the patient-physician relationship. 4. Physicians should resolve any conflict of interest between themselves and their patients resulting from interactions with industry in favour of their patients. In particular, they must avoid any self-interest in their prescribing and referral practices. 5. Except for physicians who are employees of industry, in relations with industry the physician should always maintain professional autonomy and independence. All physicians should remain committed to scientific methodology. 6. Those physicians with ties to industry have an obligation to disclose those ties in any situation where they could reasonably be perceived as having the potential to influence their judgment. Industry-Sponsored Research 7. A prerequisite for physician participation in all research activities is that these activities are ethically defensible, socially responsible and scientifically valid. The physician's primary responsibility is the well-being of the patient. 8. The participation of physicians in industry sponsored research activities must always be preceded by formal approval of the project by an appropriate ethics review body. Such research must be conducted according to the appropriate current standards and procedures. 9. Patient enrolment and participation in research studies must occur only with the full, informed, competent and voluntary consent of the patient or his or her proxy, unless the research ethics board authorizes an exemption to the requirement for consent. In particular, the enrolling physician must inform the potential research subject, or proxy, about the purpose of the study, its source of funding, the nature and relative probability of harms and benefits, and the nature of the physician's participation and must advise prospective subjects that they have the right to decline to participate or to withdraw from the study at any time, without prejudice to their ongoing care. 10. The physician who enrolls a patient in a research study has an obligation to ensure the protection of the patient's privacy, in accordance with the provisions of applicable national or provincial legislation and CMA's Health Information Privacy Code. If this protection cannot be guaranteed, the physician must disclose this as part of the informed consent process. 11. Practising physicians should not participate in clinical trials unless the study will be registered prior to its commencement in a publicly accessible research registry. 12. Because of the potential to influence judgment, remuneration to physicians for participating in research studies should not constitute enticement. It may cover reasonable time and expenses and should be approved by the relevant research ethics board. Research subjects must be informed if their physician will receive a fee for their participation and by whom the fee will be paid. 13. Finder's fees, whereby the sole activity performed by the physician is to submit the names of potential research subjects, should not be paid. Submission of patient information without their consent would be a breach of confidentiality. Physicians who meet with patients, discuss the study and obtain informed consent for submission of patient information may be remunerated for this activity. 14. Incremental costs (additional costs that are directly related to the research study) must not be paid by health care institutions or provincial or other insurance agencies regardless of whether these costs involve diagnostic procedures or patient services. Instead, they must be assumed by the industry sponsor or its agent. 15. When submitting articles to medical journals, physicians must state any relationship they have to companies providing funding for the studies or that make the products that are the subject of the study whether or not the journals require such disclosure. Funding sources for the study should also be disclosed. 16. Physicians should only be included as an author of a published article reporting the results of an industry sponsored trial if they have contributed substantively to the study or the composition of the article. 17. Physicians should not enter into agreements that limit their right to publish or disclose results of the study or report adverse events which occur during the course of the study. Reasonable limitations which do not endanger patient health or safety may be permissible. Industry-Sponsored Surveillance Studies 18. Physicians should participate only in post-marketing surveillance studies that are scientifically appropriate for drugs or devices relevant to their area of practice and where the study may contribute substantially to knowledge about the drug or device. Studies that are clearly intended for marketing or other purposes should be avoided. 19. Such studies must be reviewed and approved by an appropriate research ethics board. The National Council on Ethics in Human Research is an additional source of advice. 20. The physician still has an obligation to report adverse events to the appropriate body or authority while participating in such a study. Continuing Medical Education / Continuing Professional Development (CME/CPD) 21. This section of the Guidelines is understood to address primarily medical education initiatives designed for practicing physicians. However, the same principles will also apply for educational events (such as noon-hour rounds and journal clubs) which are held as part of medical or residency training. 22. The primary purpose of CME/CPD activities is to address the educational needs of physicians and other health care providers in order to improve the health care of patients. Activities that are primarily promotional in nature, such as satellite symposia, should be identified as such to faculty and attendees and should not be considered as CME/CPD. 23. The ultimate decision on the organization, content and choice of CME/CPD activities for physicians shall be made by the physician-organizers. 24. CME/CPD organizers and individual physician presenters are responsible for ensuring the scientific validity, objectivity and completeness of CME/CPD activities. Organizers and individual presenters must disclose to the participants at their CME/CPD events any financial affiliations with manufacturers of products mentioned at the event or with manufacturers of competing products. There should be a procedure available to manage conflicts once they are disclosed. 25. The ultimate decision on funding arrangements for CME/CPD activities is the responsibility of the physician-organizers. Although the CME/CPD publicity and written materials may acknowledge the financial or other aid received, they must not identify the products of the company(ies) that fund the activities. 26. All funds from a commercial source should be in the form of an unrestricted educational grant payable to the institution or organization sponsoring the CME/CPD activity. 27. Industry representatives should not be members of CME content planning committees. They may be involved in providing logistical support. 28. Generic names should be used in addition to trade names in the course of CME/CPD activities. 29. Physicians should not engage in peer selling. Peer selling occurs when a pharmaceutical or medical device manufacturer or service provider engages a physician to conduct a seminar or similar event that focuses on its own products and is designed to enhance the sale of those products. This also applies to third party contracting on behalf of industry. This form of participation would reasonably be seen as being in contravention of the CMA's Code of Ethics, which prohibits endorsement of a specific product. 30. If specific products or services are mentioned, there should be a balanced presentation of the prevailing body of scientific information on the product or service and of reasonable, alternative treatment options. If unapproved uses of a product or service are discussed, presenters must inform the audience of this fact. 31. Negotiations for promotional displays at CME/CPD functions should not be influenced by industry sponsorship of the activity. Promotional displays should not be in the same room as the educational activity. 32. Travel and accommodation arrangements, social events and venues for industry sponsored CME/CPD activities should be in keeping with the arrangements that would normally be made without industry sponsorship. For example, the industry sponsor should not pay for travel or lodging costs or for other personal expenses of physicians attending a CME/CPD event. Subsidies for hospitality should not be accepted outside of modest meals or social events that are held as part of a conference or meeting. Hospitality and other arrangements should not be subsidized by sponsors for personal guests of attendees or faculty, including spouses or family members. 33. Faculty at CME/CPD events may accept reasonable honoraria and reimbursement for travel, lodging and meal expenses. All attendees at an event cannot be designated faculty. Faculty indicates a presenter who prepares and presents a substantive educational session in an area where they are a recognized expert or authority. Electronic Continuing Professional Development (eCPD) 34. The same general principles which apply to "live, in person" CPD events, as outlined above, also apply to eCPD (or any other written curriculum-based CPD) modules. The term "eCPD" generally refers to accredited on-line or internet-based CPD content or modules. However, the following principles can also apply to any type of written curriculum based CPD. 35. Authors of eCPD modules are ultimately responsible for ensuring the content and validity of these modules and should ensure that they are both designed and delivered at arms'-length of any industry sponsors. 36. Authors of eCPD modules should be physicians with a special expertise in the relevant clinical area and must declare any relationships with the sponsors of the module or any competing companies. 37. There should be no direct links to an industry or product website on any web page which contains eCPD material. 38. Information related to any activity carried out by the eCPD participant should only be collected, used, displayed or disseminated with the express informed consent of that participant. 39. The methodologies of studies cited in the eCPD module should be available to participants to allow them to evaluate the quality of the evidence discussed. Simply presenting abstracts that preclude the participant from evaluating the quality of evidence should be avoided. When the methods of cited studies are not available in the abstracts, they should be described in the body of the eCPD module. 40. If the content of eCPD modules is changed, re-accreditation is required. Advisory/Consultation Boards 41. Physicians may be approached by industry representatives and asked to become members of advisory or consultation boards, or to serve as individual advisors or consultants. Physicians should be mindful of the potential for this relationship to influence their clinical decision making. While there is a legitimate role for physicians to play in these capacities, the following principles should be observed: A. The exact deliverables of the arrangement should be clearly set out and put in writing in the form of a contractual agreement. The purpose of the arrangement should be exclusively for the physician to impart specialized medical knowledge that could not otherwise be acquired by the hiring company, and should not include any promotional or educational activities on the part of the company itself. B. Remuneration of the physician should be reasonable and take into account the extent and complexity of the physician's involvement. C. Whenever possible, meetings should be held in the geographic locale of the physician or as part of a meeting which he/she would normally attend. When these arrangements are not feasible, basic travel and accommodation expenses may be reimbursed to the physician advisor or consultant. Meetings should not be held outside of Canada, with the exception of international boards. Clinical Evaluation Packages (Samples) 42. The distribution of samples should not involve any form of material gain for the physician or for the practice with which he or she is associated. 43. Physicians who accept samples or other health care products are responsible for recording the type and amount of medication or product dispensed. They are also responsible for ensuring their age-related quality and security and their proper disposal. Gifts 44. Practising physicians should not accept personal gifts of any significant monetary or other value from industry. Physicians should be aware that acceptance of gifts of any value has been shown to have the potential to influence clinical decision making. Other Considerations 45. These guidelines apply to relationships between physicians and all commercial organizations, including but not limited to manufacturers of medical devices, nutritional products and health care products as well as service suppliers. 46. Physicians should not dispense pharmaceuticals or other products unless they can demonstrate that these cannot be provided by an appropriate other party, and then only on a cost-recovery basis. 47. Physicians should not invest in industries or related undertakings if this might inappropriately affect the manner of their practice or their prescribing behaviour. 48. Practising physicians affiliated with pharmaceutical companies should not allow their affiliation to influence their medical practice inappropriately. 49. Practising physicians should not accept a fee or equivalent consideration from pharmaceutical manufacturers or distributors in exchange for seeing them in a promotional or similar capacity. 50. Practising physicians may accept patient teaching aids appropriate to their area of practice provided these aids carry at most the logo of the donor company and do not refer to specific therapeutic agents, services or other products. Medical Students and Residents 51. The principles in these guidelines apply to physicians-in training as well as to practising physicians. 52. Medical curricula should deal explicitly with the guidelines by including educational sessions on conflict of interest and physician-industry interactions.
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Achieving Patient-Centred Collaborative Care

https://policybase.cma.ca/en/permalink/policy9060
Last Reviewed
2019-03-03
Date
2007-12-01
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2007-12-01
Topics
Health systems, system funding and performance
Text
ACHIEVING PATIENT-CENTRED COLLABORATIVE CARE (2008) The Canadian Medical Association (CMA) recognizes that collaborative care is a desired and necessary part of health care delivery in Canada and an important element of quality, patient-centred care. The CMA considers patient-centred care to be the cornerstone of good medical practice. This is reflected in the first principle of the CMA Code of Ethics, which states that physicians have a fundamental responsibility to "Consider first the well-being of the patient." As patient advocates, physicians strive to ensure that their patients receive the best possible care. The CMA supports greater collaboration among providers in the interest of better patient care. In the context of clinical practice, the CMA defines collaborative care as follows: "Collaborative care entails physicians and other providers using complementary skills, knowledge and competencies and working together to provide care to a common group of patients based on trust, respect and an understanding of each others' skills and knowledge. This involves a mutually agreed upon division of roles and responsibilities that may vary according to the nature of the practice personalities and skill sets of the individuals. The relationship must be beneficial to the patient, and acceptable to the physician and other providers. If designed appropriately, collaborative care models have the potential to: * improve access to care; * enhance the quality and safety of care; * enhance the coordination and efficiency of care; and * enhance provider morale and reduce burnout within health professions. To realize this full potential, the profession acknowledges and accepts that it has a central role to play in the evolution of a team-based approach to care. These policy principles have been prepared by the Canadian Medical Association in order to ensure that the evolution of collaborative care in Canada is built around the needs of individual patients and groups of patients. This policy is founded on the CMA's document, Putting Patients' First: Patient-Centred Collaborative Care - A Discussion Paper. Principles for Collaborative Care The medical profession supports collaborative care, both in the hospital and in the community, as one of the essential elements of health care delivery in Canada. In the interests of enhancing the evolution of patient-centred collaborative care, the CMA proposes the following "critical success factors" and principles to address meaningfully the issues and barriers identified by physicians and bring clarity to the discussions. 1. PATIENT-CENTRED CARE First and foremost, medical care delivered by physicians and health care delivered by others should be aligned around the values and needs of patients. Collaborative care teams should foster and support patients, and their families, as active participants in their health care decision-making. New models should have the potential to empower patients to enhance their role in prevention and self-care. Models of collaborative care must be designed to meet the needs of patients. Collaborative models of practice must reduce fragmentation and enhance the quality and safety of care provided to patients. It is the patient who ultimately must make informed choices about the care he or she will receive. 2. RECOGNITION OF THE PATIENT-PHYSICIAN RELATIONSHIP The mutual respect and trust derived from the patient-physician relationship is the cornerstone of medical care. This trust is founded on the ethical principles that guide the medical profession as defined in the CMA Code of Ethics. The impact of collaborative models of practice on this relationship, and hence the patient's satisfaction and experience with their care, is unknown. Models of collaborative care must support the patient-physician relationship. Entry into and exit from a formal collaborative care arrangement must be voluntary for both the patient and the physician. A common Code of Ethics should guide the practice of collaborative care teams. Every resident of Canada has the right to access a personal family physician. † 3. PHYSICIAN AS THE CLINICAL LEADER Effective teams require effective leadership. A defined clinical leader is required to ensure proper functioning of the team and to facilitate decision-making, especially in complex or emergent situations. In collaborative care the clinical leader is responsible for maximizing the expertise and input of the entire team in order to provide the patient with comprehensive and definitive care. It is important to differentiate "clinical leadership" from "team coordination." The CMA defines a clinical leader as: "The individual who, based on his or her training, competencies and experience, is best able to synthesize and interpret the evidence and data provided by the patient and the team, make a differential diagnosis and deliver comprehensive care for the patient. The clinical leader is ultimately accountable to the patient for making definitive clinical decisions." Whereas, the team coordinator is defined as: "The individual, who, based on his or her training, competencies and experience, is best able to coordinate the services provided by the team so that they are integrated to provide the best care for the patient." The concept of "most responsible physician" has been and continues to be used to identify the individual who is ultimately responsible for the care of the patient. The "most responsible physician" is responsible for collecting, synthesizing and integrating the expert opinion of physician and non physician team members to determine the clinical management of the patient. Similarly, the presence of a defined clinical leader in a collaborative care setting creates clarity for patients, their families and the health care team by making lines of communication and responsibility clear, ultimately improving the quality and safety of care. In the CMA's opinion, the physician is best equipped to provide clinical leadership. This does not necessarily imply that a physician must be the team coordinator. Many teams will exist in which the physician will have a supporting role, including those focused on population health and patient education. We believe the most effective teams are ones in which the leadership roles have been clearly defined and earned. Some physicians may be prepared to play both roles; however, other members of the team may be best suited to serve as team coordinator. Currently, patients rely on, and expect, physicians to be clinical leaders in the assessment and delivery of the medical care they receive. In a collaborative care environment this expectation of physician leadership will not change. Team members will have specific knowledge and expertise in their respective disciplines. Physicians, by virtue of their broad and diverse knowledge, training and experience, have a unique appreciation of the full spectrum of health and health care delivery in their field of practice and are therefore best qualified to evaluate and synthesize diverse professional perspectives to ensure optimal patient care. The physician, by virtue of training, knowledge, background and patient relationship, is best positioned to assume the role of clinical leader in collaborative care teams. There may be some situations in which the physician may delegate clinical leadership to another health care professional. Other health care professionals may be best suited to act as team coordinator. 4. MUTUAL RESPECT AND TRUST Trust between individuals and provider groups evolves as knowledge and understanding of competencies, skills and scopes of practice are gained. Trust is also essential to ensuring that the team functions efficiently and maximizes the contributions of all members. Funders and providers should recognize the importance of team building in contributing to team effectiveness. Collaborative care funding models should support a more formalized and integrated approach to both change management and team building. As relationships are strengthened within the team, so too are trust and respect. Physicians and all team members have an opportunity to be positive role models to motivate and inspire their colleagues. All team members ought to make a commitment to respect and trust each other with the knowledge that it will lead to enhanced care for patients and a more productive work environment for all. To serve the health care needs of patients, there must be a collaborative and respectful interaction among health care professionals, with recognition and understanding of the contributions of each provider to the team. In order to build trust and respect within the team it is essential that members understand and respect the professional responsibility, knowledge and skills that come with their scope of practice within the context of the team. 5. CLEAR COMMUNICATION In collaborative care environments, it is essential that all members of the team communicate effectively to provide safe and optimal care. Effective communication is essential to ensure safe and coordinated care as the size of the team expands to meet patient needs. It is the responsibility of all team members to ensure that the patient is receiving timely, clear and consistent messaging. Physicians can take a leadership role in modeling effective communications throughout the team. In particular, there is an opportunity to enhance the consultation and referral process, in order to provide clear and concise instructions to colleagues and optimize care. Sufficient resources, including dedicated time and support, must be available to the team to maximize these communication requirements. Effective communication within collaborative care teams is critical for the provision of high quality patient care. Planning, funding and training for collaborative care teams must include measures to support communication within these teams. Mechanisms must be in place within a collaborative team to ensure that both the patients, and their caregiver(s) where appropriate, receive timely information from the most appropriate provider. Effective and efficient communications within the collaborative care team, both with the patient and among team members, should be supported by clear documentation that identifies the author. A common, accessible patient record in collaborative care settings is desirable to ensure appropriate communication between physicians and other health care professionals, to prevent duplication, coordinate care, share information and protect the safety of patients. An integrated electronic health record is highly desirable to facilitate communication and sharing among team members. 6. CLARIFICATION OF ROLES AND SCOPES OF PRACTICE In order for the team to function safely and efficiently, it is critically important that the scope of practice, roles and responsibilities of each health care professional on the team be clearly defined and understood. In turn, the patient, as a team member, should also have a clear understanding of the roles and scopes of practice of their providers. Collaborative care must first and foremost serve the needs of patients, with the goal of enhancing patient care; collaborative care is not contingent upon altering the scope of practice of any provider group and must not be used as a means to expand the scope of practice and/or independence of a health professional group. Changes in the scope of practice of all provider groups must be done with oversight from the appropriate regulatory authority. Where non-physicians have been provided with an opportunity to undertake activities related to patient care typically unique to the practice of medicine (e.g., ordering tests), they must not do so independently but undertake these activities within the context of the team and in a manner acceptable to the clinical leader. The role and scope of practice of each member of the collaborative care team should be clearly understood and delineated in job descriptions and employment contracts. A formal process for conflict resolution should be in place so that issues can be dealt with in a timely and appropriate manner. 7. CLARIFICATION OF ACCOUNTABILITY AND RESPONSIBILITY In the context of providing optimal care, providers must be accountable and responsible for the outcome of their individual practice, while sharing responsibility for the proper functioning of the collaborative care team. This individual responsibility is required so that regardless of the number and diversity of providers involved in the team, patients can be assured that their well-being is protected and that the team is working toward a common goal. In collaborative care teams, a physician should be identified as the person most responsible for the clinical care of individual patients, and as such must be accountable for the care rendered to patients. This is consistent with the commitment made by the physician in the doctor-patient relationship, mirrors the clinical training of the physician relative to other providers, is reflective of the current state of tort law as it applies to medical practice, and is compatible with the structure of care delivery in hospitals and in the community. Clearly, this type of arrangement does not eliminate the necessity for all providers to be accountable for the care that they provide. It is essential that all providers be responsible and accountable for the care that they provide and for the well-being of the patient. As clinical leader, the physician should be responsible for the clinical oversight of an individual patient's care. 8. LIABILITY PROTECTION FOR ALL MEMBERS OF THE TEAM As discussed earlier in this paper, the resolution of the multiplicity of liability issues that result from care delivered by teams requires clearly defined roles and responsibilities in the team setting and the absolute requirement for appropriate and sufficient liability coverage for each health professional. The August 2006 statement of the Canadian Medical Protective Association, Collaborative Care: A medical liability perspective, identifies issues of concern to physicians and proposes solutions to reduce those risks. All members of a collaborative care team must have adequate professional liability protection and/or insurance coverage to accommodate their scope of practice and their respective roles and responsibilities within the collaborative care team. Physicians, in their role as clinical leaders of collaborative care teams, must be satisfied with the ongoing existence of appropriate liability protection as a condition of employment of, or affiliation with, other members on collaborative care teams. Formalized procedures should be established to ensure evidence of this liability protection. 9. SUFFICIENT HUMAN RESOURCES AND INFRASTRUCTURE Collaborative models of health care delivery hold the promise of enhancing access to care for patients at a time of serious health human resource shortages. However, effective patient-centred collaborative care depends on an adequate supply of physicians, nurses and other providers. Governments and decision-makers must continue to enhance their efforts to increase the number of physicians and nurses available to provide health care services. Collaborative care should not be seen as an opportunity for governments to substitute one care provider for another simply because one is more plentiful or less costly than the other. In addition, governments must understand that co-location of individuals in a team is not a requirement for all collaborative care. Where team co-location does not exist, appropriate resources must be dedicated to ensure communication can be timely, effective and appropriate between providers. Governments, at all levels, must address the serious shortage of physicians to ensure quality patient care for Canadians. The effective functioning of a collaborative care team depends on the contribution of a physician. Governments must enhance access to medical care by increasing the number of physicians and providers, and not by encouraging or empowering physician substitution. 10. SUFFICIENT FUNDING & PAYMENT ARRANGEMENTS Funding must be present to support all aspects of the development of collaborative care teams. At the practice level, remuneration methods for physicians, irrespective of their specialty, must be available to facilitate collaborative care arrangements and environments in which physicians practice. All care delivery models, including collaborative care teams, must have access to adequate and appropriate resources. This includes, but should not be limited to, funding for health human resources, administration/management infrastructure, liability protection, clinical and team/administrative training, team building, and information technology. Remuneration models should be established in a manner that encourages providers to participate effectively in the delivery of care and team effectiveness. Reimbursement models must be configured to remunerate the communicator, coordinator, manager, and other roles and responsibilities of providers necessary for the success of collaborative care practice. The ability of a physician to work in a collaborative care team must not be based on the physician's choice of remuneration. Similarly, patients should not be denied access to the benefits of collaborative practice as a result of the physician's choice of payment model. Collaborative care relationships between physicians and other health care providers should continue to be encouraged and enhanced through appropriate resource allocation at all levels of the health care system. Physicians should be appropriately compensated for all aspects of their clinical care and leadership activities in collaborative care teams. Physicians should not be expected to incur the cost of adopting and maintaining health information technology capabilities that facilitate their ability to participate in collaborative practice teams. Governments must fund and support in an ongoing manner, both financially and technically, the development and integration of electronic health records. 11. SUPPORTIVE EDUCATION SYSTEM Canada is renowned for a quality medical education system and for the early efforts to enhance interprofessional training. The success of collaborative care requires a commitment towards interprofessional education and is contingent upon the positive attitudes and support of educators. To facilitate a sustainable shift toward collaborative practice, these efforts must be continued and enhanced in a meaningful way. However, governments and educators must ensure that the availability and quality of medical education is not compromised for medical trainees. Interprofessional education, at the undergraduate, postgraduate and continuing education levels, is necessary to facilitate a greater understanding of the potential roles, responsibilities and capabilities of health professions, with the overall goal of building better health care teams founded on mutual respect and trust. Governments must understand the importance of interprofessional education and fund educational institutions appropriately to meet these new training needs. Educational opportunities must exist at all levels of training to acquire both clinical knowledge and team effectiveness/leadership training. Interprofessional education opportunities must not come at the expense of core medical training. High quality medical education must be available to all medical trainees as a first priority. 12. RESEARCH AND EVALUATION More research and evaluations are necessary to demonstrate the benefits of collaborative care, to foster greater adoption by providers and to attract the necessary investment by governments. Quality management systems must be built into the team to ensure efficiencies can be recorded. Measures of the quality of care, cost effectiveness and patient and provider satisfaction should be evaluated. Research into the effectiveness of collaborative care models on health outcomes, patient and provider satisfaction and health care cost effectiveness should be ongoing, transparent and supported by governments. Quality assessment measures must be incorporated into the ongoing work of collaborative care teams. † Where the term "family physician" is used, it is also meant to include general practitioners.
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Canada’s child and youth health charter

https://policybase.cma.ca/en/permalink/policy10327
Last Reviewed
2018-03-03
Date
2007-05-29
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy endorsement
Last Reviewed
2018-03-03
Date
2007-05-29
Topics
Population health/ health equity/ public health
Text
CHILD AND YOUTH HEALTH IN CANADA THEIR CHARTER — OUR CHALLENGE “There can be no keener revelation of a society’s soul than the way it treats its children.” Nelson Mandela “One generation plants the trees; another gets the shade.” Chinese Proverb Children and youth have always been a priority for the doctors of Canada — the Child and Youth Health Initiative of the Canadian Medical Association, the Canadian Paediatric Society and the College of Family Physicians of Canada is evidence of that. We three organizations joined together in November 2006 to launch the Child and Youth Health Initiative. In September 2004, Canada’s first ministers committed to “improving the health status of Canadians through a collaborative process.” This led to an agreement on health goals for Canada. The first of them is “Our children reach their full potential, growing up happy, healthy, confident and secure.” At the international level, the United Nations Convention on the Rights of the Child sets out the wider rights of all children and young people, including the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. We now owe it to our children and youth to develop tangible health goals and targets. From the outset of the partnership, we were acutely aware that only a broad societal coalition could achieve the overarching goal of excellence in child and youth health in Canada. Making the health of children and youth a national priority requires a coalition of child and youth health champions, including governments, parents, health providers, businesses, schools, teachers and communities. To start that process, we created Canada’s Child and Youth Health Charter. An action framework was then developed called Canada’s Child and Youth Health Challenge because a charter alone will not deliver on the vision of the children and youth of Canada being among the healthiest in the world. Together, we believe they will help to build a coalition of child and youth health champions because they give the people who can make a difference in children and youth health a rallying point. The credibility and success of the Charter and the Challenge require broad, inclusive consultation and a commitment to child and youth health from society at large. The Child and Youth Health Summit, held April 25-26, 2007, was about consultation and commitment to making a difference to the health and well-being of children and youth. This document contains Canada’s Child and Youth Health Charter, which was one of the focuses of the summit. Canada’s Child and Youth Health Challenge and Canada’s Child and Youth Health Declaration, are the other components of our commitment and promise to take action for the children of Canada. These documents can be found at www.ourchildren.ca. Canada’s Child and Youth Health Charter In 2005, Canada’s federal, provincial and territorial governments created pan-Canadian health goals. The first of them is “Canada is a country where: Our children reach their full potential, growing up happy, healthy, confident and secure.” To reach their potential, children and youth need to grow up in a place where they can thrive — spiritually, emotionally, mentally, physically and intellectually — and get high-quality health care when they need it. That place must have three fundamental elements: a safe and secure environment; good health and development; and a full range of health resources available to all. Children and youth of distinct populations in Canada, including First Nations, Inuit and Métis, must be offered equal opportunities as other Canadian children and youth through culturally relevant resources. Canada must become: 1. A place with a safe and secure environment: a) Clean water, air and soil; b) Protection from injury, exploitation and discrimination; and c) Healthy family, homes and communities. 2. A place where children and youth can have good health and development: a) Prenatal and maternal care for the best possible health at birth; b) Nutrition for proper growth, development and long-term health; c) Early learning opportunities and high-quality care, at home and in the community; d) Opportunities and encouragement for physical activity; e) High-quality primary and secondary education; f) Affordable and available post-secondary education; and g) A commitment to social well-being and mental health. 3. A place where a full range of health resources is available: a) Basic health care including immunization, drugs and dental health; b) Mental health care and early help programs for children and youth; c) Timely access to specialty diagnostic and health services; d) Measurement and tracking the health of children and youth; e) Research that focuses on the needs of children and youth; and f) Uninterrupted care as youth move to adult health services and between acute, chronic and community care, as well as between jurisdictions. NOTES 1. The principles of this charter apply to all children and youth in Canada regardless of race, ethnicity, creed, language, gender, physical ability, mental ability, cultural history, or life experience. 2. Principles enshrined in all the goal statements include: a. Universality: The charter applies equally to all children and youth residing in Canada and covers all children and youth from 0-18 years of age. b. Without financial burden: All children and youth in Canada should have access to required health care, health services and drugs regardless of ability to pay. c. Barrier-free access: All children and youth, regardless of ability or circumstance should have appropriate access to optimal health care and health services. d. Measurement and monitoring: Appropriate resources will be available for adequate ongoing collection of data on issues that affect child and youth health and development. e. Safe and secure communities: Communities in Canada must create an environment for children and youth to grow that is safe and secure. 3. The purpose of this charter is to facilitate development of specific goals, objectives, actions and advocacy that will measurably improve child and youth health throughout Canada. 4. Success will be identified as simple, measurable, achievable, and timely goals and objectives for each of the 16 statements in this charter. 5. The initial draft of this charter has been developed by Canada’s physicians focusing on what they can best do to improve child and youth health; however, the support and participation of all individuals and groups interested in child and youth health is encouraged and desired. 6. The primary audience for actions and advocacy arising from this charter will be governments, agencies or individuals who, by virtue of legislation, regulation or policy have the ability to effect change for children and youth. 7. This charter is not a legal document; it represents a commitment by champions of child and youth health in Canada to the health and well-being of all children and youth in Canada. Charter Endorsers The following organizations have endorsed the Child and Youth Health Charter, as of October 9, 2007. Association of Canadian Academic Healthcare Organizations Boys and Girls Clubs of Canada Breakfast for Learning Canadian Association of Paediatric Health Centres Canadian Child and Youth Health Coalition Canadian Healthcare Association Canadian Institute of Child Health Canadian Medical Association Canadian Paediatric Society Canadian Pharmacists Association Canadian Psychological Association Centre of Excellence for Early Childhood Development Centre for Science in the Public Interest College of Family Physicians of Canada Landon Pearson Resource Centre for the Study of Childhood and Children's Rights Muttart Foundation National Alliance for Children and Youth National Anti-Poverty Organization Newfoundland and Labrador Medical Association Paediatric Chairs of Canada Safe Kids Canada, The National Injury Prevention Program of The Hospital for Sick Children Silken's ActiveKids Movement and Silken and Company Productions The Royal College of Physicians and Surgeons of Canada
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National multidisciplinary knowledge-sharing network for precision medicine research

https://policybase.cma.ca/en/permalink/policy11619
Last Reviewed
2018-03-03
Date
2015-08-26
Topics
Ethics and medical professionalism
Physician practice/ compensation/ forms
Resolution
GC15-43
The Canadian Medical Association supports the development of a national multidisciplinary knowledge-sharing network for precision medicine research.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2015-08-26
Topics
Ethics and medical professionalism
Physician practice/ compensation/ forms
Resolution
GC15-43
The Canadian Medical Association supports the development of a national multidisciplinary knowledge-sharing network for precision medicine research.
Text
The Canadian Medical Association supports the development of a national multidisciplinary knowledge-sharing network for precision medicine research.
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Supporting consultations while developing policies, regulations and guidelines on physician-assisted dying

https://policybase.cma.ca/en/permalink/policy11635
Last Reviewed
2018-03-03
Date
2015-08-26
Topics
Ethics and medical professionalism
Resolution
GC15-37
The Canadian Medical Association supports consultation with the Canadian Society of Palliative Care Physicians and other relevant physician societies when policies, regulations and guidelines are developed on physician-assisted dying.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2015-08-26
Topics
Ethics and medical professionalism
Resolution
GC15-37
The Canadian Medical Association supports consultation with the Canadian Society of Palliative Care Physicians and other relevant physician societies when policies, regulations and guidelines are developed on physician-assisted dying.
Text
The Canadian Medical Association supports consultation with the Canadian Society of Palliative Care Physicians and other relevant physician societies when policies, regulations and guidelines are developed on physician-assisted dying.
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Medical certification of death forms in cases involving physician-assisted death

https://policybase.cma.ca/en/permalink/policy11638
Last Reviewed
2018-03-03
Date
2015-08-26
Topics
Ethics and medical professionalism
Resolution
GC15-40
The Canadian Medical Association supports the development of pan-Canadian guidelines for physicians on the terminology to be used when completing medical certification of death forms in cases involving physician-assisted death.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2015-08-26
Topics
Ethics and medical professionalism
Resolution
GC15-40
The Canadian Medical Association supports the development of pan-Canadian guidelines for physicians on the terminology to be used when completing medical certification of death forms in cases involving physician-assisted death.
Text
The Canadian Medical Association supports the development of pan-Canadian guidelines for physicians on the terminology to be used when completing medical certification of death forms in cases involving physician-assisted death.
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Precision medicine into clinical care

https://policybase.cma.ca/en/permalink/policy11663
Last Reviewed
2018-03-03
Date
2015-08-26
Topics
Health systems, system funding and performance
Physician practice/ compensation/ forms
Resolution
GC15-84
The Canadian Medical Association supports the development of a national strategy to integrate precision medicine into clinical care.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2015-08-26
Topics
Health systems, system funding and performance
Physician practice/ compensation/ forms
Resolution
GC15-84
The Canadian Medical Association supports the development of a national strategy to integrate precision medicine into clinical care.
Text
The Canadian Medical Association supports the development of a national strategy to integrate precision medicine into clinical care.
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Policy Summary: Managing the Public-Private Interface to Improve Access to Quality Health Care

https://policybase.cma.ca/en/permalink/policy8826
Last Reviewed
2018-03-03
Date
2007-05-29
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2007-05-29
Topics
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) supports the concept of a strong publicly funded health care system where access to medical care is based on need and not on the ability to pay. Health care services in Canada have historically been funded and delivered by a mix of the public and private sectors. At the present time, approximately 70% of health expenditures are publicly funded from general tax revenues; the remaining 30% are privately funded either through private insurance or out-of-pocket payment. The public-private interface occurs in two key areas: the private delivery of publicly funded services, and the delivery of privately funded services in publicly owned facilities. Drawing on the key issues raised in the CMA's June 2006 discussion paper, It's About Access, this policy summary sets out guidelines for decision-making and policy development for managing the public-private interface within Canada's health care system in order to optimize timely access to high-quality care. Policy Principles The following principles provide a framework for guiding future strategies for managing the public-private interface. 1. Timely access: Canadians should have timely access to medically necessary care and individual recourse should wait times be unreasonably long. 2. Equity: Access to medically necessary care must be based on need and not on ability to pay. 3. Choice: Canadians should have choice of physician; and physicians should have choice with respect to their practice environment. 4. Comprehensiveness: Canadians should have access to a full spectrum of medically necessary care. 5. Clinical autonomy: Any care model should respect the autonomous decision-making within the patient-physician relationship. Physicians must be free to advocate on behalf of their patients. 6. Quality: The public and private health care sectors must be held to the same high quality standards and be independently monitored. To ensure professional accountability, any facility providing medical services must be subject to medical supervision. 7. Professional responsibility: The medical profession has a responsibility to promote the strongest possible health care system that best meets patients' needs. Both public and private sectors have a responsibility to train the next generation of health professionals and to advance knowledge through teaching and research. 8. Transparency: Decisions affecting the mix of public-private funding and delivery must be made through an open and transparent process. Providers faced with potential conflicts of interest have a duty to recognize and disclose them and to resolve them in the best interest of patients. 9. Accountability: The public and private health sectors should be held to the same high accountability standards including clinical outcomes, full cost accounting and value-for-money. 10. Efficiency: The public and private sectors should be structured to optimize the use of human and all other resources. Public-Private Interface Issues In light of the foregoing principles, the CMA has identified several key issues where improved management of the public-private interface could lead to better access to high-quality health care services for Canadians. Implementing a wait-time care guarantee Canadians face increasingly long wait times for necessary medical care, frequently beyond recommended maximum wait times. In the 2004 first ministers' agreement, wait time benchmarks were established for five priority areas in the publicly funded system: cardiac care, cancer care, diagnostic imaging, joint replacement and sight restoration. When care is not delivered within benchmarks, there is no effective "safety valve" to provide recourse. Patients are forced to wait for care in Canada or seek it within the private sector or in other jurisdictions at their own expense. A safety valve is needed to enable Canadians to obtain required care where wait time guarantees cannot be met. Ideally, Canadians would never have to use the safety valve, but its inclusion in Canadian health policy would help restore confidence in the public health system and focus governments upon meeting commitments to provide timely access to care. The Patient Wait Times Guarantee Trust announced in the 2007 federal budget is a positive first step. The CMA recommends that: * Governments work with the CMA and other medical organizations to establish clinically appropriate wait-time benchmarks for all major diagnostic, therapeutic, surgical and emergency services. * Where wait-time benchmarks can be established, governments implement them nationally. * If national wait-time benchmarks are not met, Canadians should be entitled to a publicly funded safety valve whereby the government would reimburse payment for treatment, travel and other appropriate costs if the service is provided outside the home jurisdiction or within the private sector. * When access to timely care cannot be provided in the publicly funded system, Canadians should be able to use private health insurance to reimburse the cost of care obtained in the private sector. Private insurance contracts are now permissible in Quebec for hip replacement and cataract surgery, with the stipulation that the insurer must fund all aspects of the treatment including rehabilitation. At present, it is not clear how this could work in practice in terms of risk rating of either the patient or on the performance of the public system. * In the interest of providing timely care within the publicly funded system, governments must ensure that Canada has sufficient health professionals and infrastructure to meet need. Improving performance measurement, quality assurance and accountability in the public-private interface It is essential that the health care system be accountable to Canadians, in particular with respect to the roles and responsibilities of different levels of government and their delegated agents, such as regional health authorities and specialty boards. Accountability becomes all the more pressing as public-private collaboration expands. There may be a growing role for the private sector in the delivery of publicly funded health care provided that it delivers services in a cost-effective manner. As with the public sector, any private sector involvement in health care must be patient-centered as well as transparent and accountable. Health care services in both sectors must be delivered to the same high standards of quality. In order to achieve this, solid means of quality assurance must be in place to ensure that value-for-money is being received where public funds are used to contract for service delivery in public and private settings and to monitor the impact of privately funded services on the public system. There are currently a number of data gaps that need attention. For example, there is a lack of formal comparative studies of the cost-effectiveness and quality of public and private delivery in Canada based on primary data; there is confusion surrounding the monitoring of quality for uninsured services; and there is uncertainty about the extent of voluntary accreditation of health care facilities in the public and private sectors. The CMA recommends that: * Governments establish uniform requirements and regulation where appropriate for measuring quality of care in both public and private settings, including: a) collection of data on process and outcomes of care; b) reporting of such data on all publicly insured services to regulatory bodies; c) accreditation standards for both public and private service delivery equivalent to those of the Canadian Council on Health Services Accreditation; and d) protection of health information privacy. * Governments and regional health authorities that enter into public-private partnerships do so through an open and transparent tendering process. * Where governments include public-private delivery mechanisms to expand system capacity, they do so with regulation to evaluate quality and cost-effectiveness. * Governments conduct ongoing evaluation of the quality and cost-effectiveness of public-private delivery options. Defining the public health care system and the basket of publicly insured services The delineation of publicly insured services is a fundamental policy issue for governments, health care providers and patients. The publicly-funded health system cannot be expected to meet all needs for all patients; choices must be made and trade-offs negotiated. However, decisions about the basket of insured services have typically been ad hoc and made behind closed doors. The system has also been slow to respond to emerging technologies and shifts in the delivery of care. At the present time the national medicare basket includes hospital and medical services. The provinces/territories also fund additional services at their discretion (e.g., seniors' drug coverage, home care). While this widens the scope of public coverage, it creates disparities in access across jurisdictions, and Canada is often referred to as a "patchwork quilt" in this regard. The CMA recommends that: * There should be ongoing periodic monitoring and reporting of the comparability of Canadians' access to a full range of medically necessary health services across the country. * In keeping with the CMA's 1994 document Core and Comprehensive Health Services: A Framework for Decision-making, there is a need to define a set of nationally comparable, publicly funded core services. The nature of these services should be continually assessed in an evidence-based and transparent manner. The mode of delivery for these services should be at the discretion of local jurisdictions and may involve both the public and private sectors. * Government health insurance plans should give adequate notice when services are to be delisted. Transparency and accountability in the regulation of physician activity within the public-private interface The ability of physicians to choose whether or not to participate in the public health insurance plan has been a key feature of Medicare since its inception. Physicians are willing to accept reasonable limits on their ability to opt in or out of the public health plan to ensure that adequate access to medical services is maintained. In order to achieve this, an effective regulatory framework is required to govern the intersection of public and private health care and there must be concerted effort on the part of stakeholders to investigate the implications of and opportunities to minimize conflicts of interest. When considering options for the delivery of publicly insured services by the private sector, it is critical that the integrity of the public system is maintained and that Medicare remain the cornerstone of Canadian health care. The reality for many physicians is that they must concurrently deal with multiple payers - patients covered by provincial/territorial health insurance plans, injured workers covered by workers' compensation boards and various groups of individuals covered by third-party insurers. Whatever the funding arrangement, the following fundamental characteristics of the physician-patient relationship cannot be altered: * Patients should be able to choose their physician. * Physicians must have freedom to advocate on behalf of their patients. * Physicians should be allowed to have choice in their practice environments, including the right to opt out of the publicly funded system. * It is the duty of providers to recognize and disclose potential conflicts of interest and to resolve them in the best interests of patients. The CMA will work with its divisions and affiliates to develop a code of conduct for physicians who provide services in the private sphere and for those who provide services in both sectors. The CMA recommends that: * Governments should allow physicians to have choice in their practice environments, including the right to opt out of the public health insurance program provided that patient access to publicly funded care is not compromised. This is presently permitted in all jurisdictions except Ontario. * Governments should examine practice arrangements where physicians are able to work in both the public and private sectors so as to maximize the availability of medical services, particularly in situations where there are budget constraints resulting in inefficient use of health human resources and physical infrastructure. * Governments should remove bans preventing physicians from opting out or preventing them from practising in both the public and private sectors where it can be shown that this would improve access to services for the entire population, increase the capacity of the health care system and reduce wait times. Medical education and training Physicians collectively have a responsibility to train future generations. Looking ahead, we may expect to see a continued trend toward the delivery of diagnostic, medical and surgical procedures in specialized facilities that are privately owned and operated. From the standpoint of medical education and training, this raises two issues. First, a significant number of the current complement of clinical teachers may perform an increasing proportion of their work in such facilities, which may have implications for public teaching hospitals. Second, to the extent that the delivery of services may migrate from teaching hospitals to specialized facilities, this may potentially limit the education and training exposure of medical residents. The CMA recommends that: * Physicians must be appropriately trained for the scope of practice in which they are engaged, whether in the public or private sector. * Medical trainees need exposure to all types of practice arrangements across the public-private interface. * Medical trainees need exposure to all areas of clinical medicine, including those areas predominately delivered by either the public or private sectors. * Governments that choose to contract out services to private delivery must ensure that training opportunities include exposure to both sectors. * The CMA, in partnership with medical student organizations, will promote education about the public-private interface and health care funding and delivery issues. Conclusion Canada's health care system is the product of a long-standing partnership between public and private funding and delivery. The interaction between both sectors will continue to be an important dimension of medicare that must be carefully managed. The framework of decision-making principles and recommendations set out in this policy will hopefully enhance debate among stakeholders and the public about future directions for how to best manage the public-private interface. CMA Board of Directors May 2007
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