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Taking action on drug shortages during Covid-19 - open letter

https://policybase.cma.ca/en/permalink/policy14261
Date
2020-08-13
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Date
2020-08-13
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
Dear Prime Minister, We are writing to you today to ask you to bring attention and resources to Canada’s drug supply challenges. These shortages have existed for the past decade but have been greatly exacerbated due to the COVID-19 pandemic. As frontline pharmacists and physicians, we have seen and heard of serious shortages of essential, critical medications. These drugs are often used simultaneously in ORs, ERs and palliative care wards, as well as ICUs. And while our ICUs are thankfully seeing fewer COVID-19 patients, the pandemic has been placing a heavy burden on their drug supply, where patients often require weeks’ worth of treatment on ventilators. The shortages of these drugs imperil the lives of patients seeking care all over the country. Currently, the vast majority (24/32) of the drugs on Health Canada’s own Tier 3 list, which represents drugs for which there are no suitable alternatives, are essential for treating COVID-19. With the likely upcoming second wave in Canada, the potential for further exacerbation of these shortages is inevitable unless we implement rigorous preparedness measures. At first glance, the federal government may conclude that this is a provincial and territorial area of jurisdiction. We can assure you, that there is a considerable role for the federal government to play on this issue of national concern if you so choose to take action. We believe you should. Many of these critical care drugs should be part of the National Strategic Emergency Stockpile. However, it is clear that Canada simply did not invest enough into its stockpiles to meet the demand during the COVID-19 pandemic. In order for the stockpiling strategy to be effective, it is vital that the federal, provincial, and territorial governments work closely with hospitals, long-term care facilities, hospices and primary care facilities nationwide to establish a 2 comprehensive list of critical medicines and develop a plan to procure medicines in a coordinated manner to prevent unintended competition for resources. The 2019 budget had earmarked funds for a new Canada Drug Agency which would have oversight over a national formulary. This proposed agency could similarly identify essential medicines to aid in an efficient stockpiling response, whether through stimulating domestic production or through importation and coordination of purchasing strategies to ensure that jurisdictions that have a greater need for medications gain access to them. We know that COVID-19’s impact on the health system across provinces and territories and within each and every jurisdiction was not equal or consistent. We appreciate the active efforts of Health Canada to resolve current or projected shortages of critical drugs through its Tier Assignment Committees. Furthermore, Ontario has a Critical Care COVID-19 Command Centre and has created a Critical Care Drug Shortage Task Team. Certainly, the short-term deficit will need to be resolved through this mechanism and importing from all available suppliers. However, to support the system at large, provincial and territorial governments will need national support, resources and (where welcomed by provinces) a certain level of national coordination. Regardless of well-established Federal-Provincial-Territorial dynamics, without concrete preventative action, Canada will perpetually face drug shortages. This is why we recommend that your government commit to working on a long-term solution involving a three-pronged strategy: 1. Stockpiling of a Critical Medications List which the government commits to ensuring are always in stock for long enough to meet the needs in an emergency (likely through the Canada Drug Agency). a. A Critical Medications List would allow the parties involved in addressing the drug shortages to have a clear picture of what drugs to monitor closely, and provides a more comprehensive approach to the problem. 2. A publicly owned generic, critical drugs manufacturer, or at the bare minimum, public support for spare capacity by Canadian-based and controlled drug manufacturers to be used for critical drugs. a. This manufacturer or manufacturers would specialize in manufacturing the critical drugs on the Critical Medications List, and would be primarily involved in satisfying significant portions of our national demands. 3. Greater transparency and communications to and from governments and the health sector around the essential drug supply. This would include efforts to 3 better track the supply of drugs in hospitals across the country and push notifications on shortages through the appropriate channels to frontline workers. We encourage your government to give this urgent issue attention and efforts now, so that Canadians can have the confidence that their healthcare system will be there when they most need it.
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CMA Pre-budget Submission

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

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

https://policybase.cma.ca/en/permalink/policy14247
Date
2020-06-02
Topics
Physician practice/ compensation/ forms
  1 document  
Policy Type
Parliamentary submission
Date
2020-06-02
Topics
Physician practice/ compensation/ forms
Text
Re: Federal measures to recognize the significant contributions of Canada’s front-line health care workers during the COVID-19 pandemic Dear Ministers Morneau and Hajdu: On behalf of the Canadian Medical Association (CMA) and HEAL’s member organizations, representing 650,000 health care workers in Canada, we are writing to you with recommendations for new federal measures to support the financial hardships and risks posed to front-line health care workers (FLHCWs) during the COVID-19 pandemic. To begin, we strongly support the measures the federal government has taken to date to mitigate the health and economic impacts of COVID-19. However, given the unique circumstances that FLHCWs face, additional measures are required to acknowledge their role, the risks being posed to themselves and their families, and the financial burden they have taken on through it all. All FLHCWs face numerous challenges trying to carry out their life-saving work during these incredibly difficult times and they deserve to be recognized for their significant contributions. As such, we are recommending that the federal government implement the following new measures for all FLHCWs: 1) An income tax deduction for FLHCWs put at risk during the COVID-19 pandemic, in recognition of their heroic efforts. All FLHCWs providing in-person patient care during the pandemic would be eligible to deduct a designated amount against their income earned. This would be modelled on the deduction provided to members of the Canadian Armed Forces serving in moderate- and high-risk missions. 2) A non-taxable grant to support the families of FLHCWs who die in the course of responding to the COVID-10 pandemic or who die as a result of an occupational illness or psychological impairment related to this work. The grant would also apply to cases in which the death of a FLHCW’s family member is attributable to the FLHCW’s work in responding to the pandemic. We are recommending that access to the Memorial Grant program, or a similar measure, be granted to FLHCWs and their family member(s). 3) A temporary emergency accommodation tax deduction for FLHCWs who incur additional accommodation costs as well as a home renovation credit in recognition of the need for FLHCWs to adhere to social distancing to prevent the spread of COVID-19 to their family members. We are recommending all FLHCWs earning income while working in a health care facility or public health unit or in a capacity related thereto (e.g. paramedics or janitorial staff) be eligible for the deduction and credit. 1410, pl. des tours Blair / Blair Towers Place, bur. / Suite 500 Ottawa ON K1J 9B9 Page 2 Ministers Morneau and Hajdu June 2, 2020 4) Provide additional child-care relief to FLHCWs by doubling the child-care deduction. We recommend the individuals listed above be eligible for the enhanced deduction. We recognize that it is important that any measures enacted be simple for the government to implement and administer, as well as simple for FLHCWs to understand and access. The recommendations above will ensure that relief applies to a wide range of Canada’s FLHCWs who are battling COVID-19, where the primary intention is to be as inclusive as possible. Once again, we commend the federal government for its decisive and meaningful response to the pandemic. Now is the time to ensure comprehensive supports are provided to those who have stepped up to protect the health and safety of all Canadians. We welcome the opportunity to discuss these recommendations with you. Sincerely, Sandy Buchman, MD, CCFP(PC), FCFP President, Canadian Medical Association This letter is signed by the following organizations: 1410, pl. des tours Blair / Blair Towers Place, bur. / Suite 500 Ottawa ON K1J 9B9 Page 3 Ministers Morneau and Hajdu June 2, 2020 Canadian Medical Association Canadian College of Health Leaders Canadian Podiatric Medical Association Association of Faculties of Medicine of Canada Canadian Counselling and Psychotherapy Association Canadian Psychiatric Association Canadian Association of Community Health Centres Canadian Psychological Association Canadian Association for Interventional Radiology Canadian Dental Association Canadian Association of Medical Radiation Technologists Canadian Dental Hygienists Association Canadian Society for Medical Laboratory Science Canadian Society of Nutrition Management Canadian Association of Midwives Canadian Association of Nuclear Medicine Canadian Massage Therapist Alliance Canadian Society of Respiratory Therapists Canadian Association of Occupational Therapists Royal College of Physicians and Surgeons of Canada College of Family Physicians of Canada Canadian Association of Optometrists Canadian Nurses Association Dietitians of Canada Canadian Association of Social Workers Canadian Ophthalmological Society HealthCareCAN Canadian Cardiovascular Society Canadian Orthopaedic Association Paramedic Association of Canada Pallium Canada Canadian Chiropractic Association Canadian Pharmacists Association Canadian Physiotherapy Association Speech-Language & Audiology Canada
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Protecting and supporting Canada’s health-care providers during COVID-19

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

https://policybase.cma.ca/en/permalink/policy188
Last Reviewed
2020-02-29
Date
2002-09-30
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2002-09-30
Replaces
Position paper on direct to consumer prescription drug advertising (1986)
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
Direct-to-Consumer Advertising (DTCA) Policy Statement Canadians have a right to information about prescription drugs and other therapeutic interventions, to enable them to make informed decisions about their own health. This information must be evidence based and provide details about side effects and health risks as well as benefits. Brand-specific direct-to-consumer advertisements, such as those permitted in the United States, do not provide optimal information on prescription drugs. We are concerned that DTCA: * is not information but marketing, and sends the message that a prescription drug is a “consumer good” rather than a health care benefit. * may not provide enough information to allow the consumer to make appropriate drug choices. For example, it generally does not provide information about other products or therapies that could be used to treat the same condition. In addition, it may stimulate demand by exaggerating the risks of a disease and generating unnecessary fear. * may strain the relationship between patients and providers, for example if a patient’s request for an advertised prescription drug is refused. * drives up the cost of health care, and undermines the efforts of physicians, pharmacists and others to promote optimal drug therapy. Patient groups, health care providers, governments and pharmaceutical manufacturers should be supported in activities to develop objective, reliable plain-language information about prescription drugs to ensure that Canadians are able to make informed health care decisions. Therefore we: * Support the provision of objective, evidence-based, reliable plain-language information for the public about prescription drugs. * Oppose direct-to-consumer prescription drug advertising in Canada.
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Rural and remote practice issues

https://policybase.cma.ca/en/permalink/policy211
Last Reviewed
2020-02-29
Date
2000-05-09
Topics
Physician practice/ compensation/ forms
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2000-05-09
Replaces
Promoting medicine as a career for rural high school students (Resolution BD88-03-78)
Topics
Physician practice/ compensation/ forms
Text
CMA Policy : Rural and Remote Practice Issues The Canadian Medical Association (CMA) believes that all Canadians should have reasonable access to uniform, high quality medical care. The CMA is concerned, however, that the health care infrastructure and level of professional support in rural and remote areas are insufficient to provide quality care and retain and recruit physicians relative to community needs. The CMA has developed this policy to outline specific issues and recommendations that may help retain and recruit physicians to rural and remote areas of Canada and thereby improve the health status of rural and remote populations. The following 3 key issue areas are addressed in this policy: training, compensation and work/lifestyle support. Commitment and action by all stakeholders, including governments, medical schools, professional associations and others, are urgently required. Preamble Canadian physicians and other health care professionals are greatly frustrated by the impact that health care budget cuts and reorganization have had, and continue to have, on the timely provision of quality care to patients and general working conditions. For many physicians who practise in rural and remote communities, the impact is exacerbated by the breadth of their practice, as well as long working hours, geographic isolation, and lack of professional backup and access to specialist services. This policy has been prepared to help governments, policy-makers, communities and others involved in the retention and recruitment of physicians understand the various professional and personal factors that must be addressed to retain and recruit physicians to rural and remote areas of Canada. This policy applies to both general practitioners/family physicians as well as specialists. The CMA believes that this policy must be considered in the context of other relevant CMA policies, including but not limited to Physician Health and Wellbeing, Physician Compensation, Physician Resource Planning, Principles for a Re-entry System in Canadian Postgraduate Medical Education and Charter for Physicians. In addition, any strategies that are developed should not be coercive and must include community and physician input; they must also be comprehensive, flexible and varied to meet and respond to local needs and interests. Definitions Rural and remote There are no standard, broadly accepted terms or definitions for "rural" and "remote" since they cannot be sufficiently defined to reflect the unique and dynamic nature of the various regions and communities that could presumably be labelled as such. The terms "rural" or "remote" medicine may be applied to many things: the physicians themselves, the population they serve, the geography of the community or access to medical services. For each of these factors, there are a number of ways to define and measure rurality. For example, a 1999 CMA survey of rural physicians showed that the most frequently mentioned characteristics of a rural community were (1) high level of on-call responsibilities, (2) long distance to a secondary referral centre, (3) lack of specialist services and (4) insufficient family physicians. As another example, Statistics Canada defines rural and small town residents for some analyses as those living in communities outside Census Metropolitan Areas (population of at least 100 000) or Census Agglomerations (population between 10 000 and 99 999), and where less than 50% of the workforce commute to a larger urban centre. Medical school For the purposes of this policy, a medical school is understood to encompass the entire continuum of medical education, i.e., undergraduate, postgraduate, continuing medical education and maintenance of competence. Training Some Canadian studies have shown that medical trainees who were raised in rural communities have a greater tendency to return to these or similar communities to practise medicine. Some studies also show that individuals who do clerkships in rural or remote communities, or have some exposure to the rural practice environment during residency training, have a greater tendency to consider practising in rural or remote communities upon graduation. The CMA applauds those medical schools that promote careers in medicine to individuals from rural and remote areas and provide medical students and residents with exposure to rural practice during their training. Regular collaboration and communication among training directors for rural and remote programs, as well as rural medical educators and leaders from other health disciplines, are strongly encouraged so that rural training issues and possible linkages may be discussed. The benefits of rural training extend not only to those physicians who ultimately end up in rural practice; those who remain in urban areas also benefit by having an enhanced understanding of the challenges of rural and remote practice. As outlined in the CMA’s 1992 Report of the Advisory Panel on the Provision of Medical Services in Underserviced Regions, the CMA believes that partnerships among medical schools, the practising profession and communities need to be formalized, particularly since medical schools have a crucial role in helping to recruit and retain physicians for rural and remote communities. The medical school’s role in such a partnership takes the form of a social contract. This contract begins with the admission of students who demonstrate a prior interest in working in rural or remote communities and may come from these communities. It also includes the exposure of students to rural practice during their undergraduate and postgraduate training. It is followed by the provision of specialized training for the conditions in which they will work and ongoing educational support during their rural and remote practice. For these reasons, the CMA strongly encourages academic health science centres (AHSCs), provincial governments, professional associations and rural communities to work together to formally define the geographic regions for which each AHSC is responsible. The AHSCs are also encouraged to include within their mission a social contract to contribute to meeting the health needs of their rural or remote populations. Practising physicians are committed to lifelong learning. In order to preserve a high standard of quality care to their patients, they must be knowledgeable about new clinical and technological advances in medicine; they must also continually develop advanced or additional clinical skills in, for example, obstetrics, general surgery and anaesthesia, to better serve the patients in their communities, especially when specialist services are not readily available. There are many practical and financial barriers that physicians in rural and remote communities face in obtaining and maintaining additional skills training, including housing, practice and other costs (e.g., locum tenens replacement expenses) while they are away from work. The CMA strongly encourages governments to develop and maintain mechanisms, such as compensation or additional tax relief, to reduce the barriers associated with obtaining advanced or additional skills training. In light of these issues, the CMA recommends that 1. Universities, governments and others encourage and fund research into criteria that predispose students to select and succeed in rural practice. 2. All medical students, as early as possible at the undergraduate level, be exposed to appropriately funded and accredited rural practice environments. 3. Medical schools develop training programs that encourage and promote the selection of rural practice as a career. 4. Universities work with professional associations, governments and rural communities to determine the barriers that prevent rural students from entering the profession, and take appropriate action to eliminate or reduce these barriers. 5. A Web site based compendium of rural experiences and electives for medical students be developed, maintained and adequately funded. 6. Advanced skills acquisition and maintenance opportunities be provided to physicians practising in or going to rural and remote areas. 7. CMA divisions and provincial/territorial governments ensure that physicians who work in rural and remote areas receive full remuneration while obtaining advanced skills, including support for the locum tenens who will replace them. 8. Any individual formally enrolled in a Royal College of Physicians of Surgeons of Canada or College of Family Physicians of Canada program be covered by the collective agreement of their housestaff organization. 9. Providers, funders and accreditors of continuing medical education for rural physicians ensure that the continuing medical education is developed in close collaboration with rural physicians and is accessible, needs-based and reflective of rural physicians’ scope of practice. 10. Physicians who practise in rural or remote areas be given reasonable opportunities to re-enter training in a postgraduate program without any return-in-service obligations. 11. In order to promote mutual understanding, universities encourage teaching faculty to work in rural practices and that rural physicians be invited to teach in academic health science centres. 12. Medical schools develop training programs for both students and residents that encourage and promote the provision of skills appropriate to rural practice needs. 13. Medical schools support rural faculty development and provide full faculty status to these individuals. Compensation The CMA believes that compensation for physicians who practise in rural and remote areas must be flexible and reflect the full spectrum of professional and personal factors that are often inherent to practising and living in such a setting. These professional factors may include long working hours and the need for additional competencies to meet community needs, such as advanced obstetrics, anaesthesia and general surgery, as well as psychotherapy and chemotherapy. They may also include a high level of on-call responsibilities as well as a lack or total absence of backup from specialists, nurses and other complementary services that are usually available in an urban environment. Other challenges are professional isolation, limited opportunities for education or training, and high practice start-up costs. Also, if for a number of reasons a physician wishes to relocate to an urban setting, he or she may face billing restrictions as well as challenges in finding a replacement physician. Compensation for these factors is necessary to help retain physicians and recruit new ones. In addition, compensation should guarantee protected time off, paid continuing medical education or additional skills training, and locum tenens coverage. Any pool of locum tenens for rural and remote practice should be adequately funded and cross-jurisdictional licensure issues should be minimized. Living in a rural or remote community can be very satisfying for many physicians and their families; however, they must usually forgo — often for an extended period of time— a number of urban advantages and amenities. These include educational, cultural, recreational and social opportunities for their spouse or partner, their children and themselves. They may also face altered family dynamics due to a decrease or significant loss of family income if there are limited or no suitable employment opportunities for their spouse or partner. The CMA believes that all physicians should have a choice of payment options and service delivery models to reflect their needs as well as those of their patients. Physicians must receive fair and equitable remuneration and have a practice environment that allows for a reasonable quality of life. Although the CMA does not advocate one payment system for urban physicians and another for rural physicians, it believes that enhanced total compensation should be provided to physicians who work and live in rural and remote communities. In recognition of these issues, the CMA recommends that 14. Additional compensation to physicians working in rural and remote areas reflect the following areas: degree of isolation, level of responsibility, frequency of on-call, breadth of practice and additional skills. 15. In recognition of the differences among communities, payment modalities retain flexibility and reflect community needs and physician choice. 16. Financial incentives focus on retaining physicians currently practising in rural or remote areas and include a retention bonus based on duration of service. 17. Factors affecting the social and professional isolation of physicians and their families be considered in the development of compensation packages and working conditions. 18. Eligibility criteria for including physicians in a pool of locum tenens for rural or remote practice be developed in consultation with rural physicians. 19. Provincial/territorial licensing bodies establish portability of licensure for locum tenens and ensure that any fees or processes associated with licensure do not serve as barriers to interprovincial mobility. 20. Rural locum tenens programs be funded by provincial/territorial governments and include adequate compensation for accommodation, transportation and remuneration. As previously noted, some studies show that exposure to rural and remote areas during training influences students’ decision to practise in those communities upon graduation. The CMA is concerned, however, that travel and accommodation costs relating to these experiences place an undue financial burden on students. In addition, most physicians in rural and remote areas are already burdened with significant patient loads and find that they have limited time and resources to act as preceptors. The CMA believes that, to ensure the ongoing viability of student rural experiences, physician preceptors should be compensated for their participation and should not incur any additional expenses, such as student or resident accommodation costs. The CMA recommends that 21. Costs for accommodation and travel for student and resident rural training experiences in Canada not be borne by the trainees or the preceptors. 22. Training programs assume responsibility for adequately remunerating preceptors in rural or remote areas. Work and lifestyle support issues To retain and recruit physicians in rural and remote communities, there are issues beyond fair and adequate compensation that must be considered. It is crucial that the aforementioned working conditions, professional issues and array of personal and family-related issues be addressed. The ultimate goal should be to promote physician retention and implement measures that reduce the possibility of physician burnout. Like most people, physicians want to balance their professional and personal responsibilities to allow for a reasonable quality of life. Physicians in rural and remote areas practise in high stress environments that can negatively affect their health and well-being; as a consequence, the standard of care to their patients can suffer. The stress is intensified by excessive work hours, limited professional backup or support (including locum tenens), limited access to specialists, inadequate diagnostic and treatment resources, and limited or no opportunity for vacation or personal leave. At particular risk for burnout is the physician who practises in isolation. For these reasons many physicians, when considering practice opportunities, tend to seek working conditions that will not generate an excessive toll on their non-working lives. This reinforces the need for rural and remote practice environments that facilitate a balance between physicians’ professional and personal lives. In light of these issues, the CMA recommends that 23. Regardless of community size, there should always be at least 2 physicians available to serve the needs of the community. 24. Ideally, the on-call requirement for weekends never exceed 1 in 5 in any Canadian practice. (This is consistent with current CMA policy.) 25. Provincial/territorial governments have professional support and other mechanisms readily available to physicians who practise in rural and remote areas, such as sabbaticals and locum tenens. 26. Governments recognize the service of rural and remote physicians by ensuring that mechanisms exist to allow future access to practise in an urban area of their choice. The CMA believes that rural and remote physician retention and recruitment initiatives must address matters relating to professional isolation as well as social isolation for physicians and their families. This sense of isolation can increase when there are cultural, religious or other differences. For unattached physicians, zero tolerance and unreasonable restrictions with regard to relationships with potential patients can be disincentives to practise in rural or remote communities. Although the CMA believes that such policies and restrictions should be reviewed, the CMA encourages physicians to refer to the CMA policy on The Patient-Physician Relationship and the Sexual Abuse of Patients and the Code of Ethics of the Canadian Medical Association. Also, the CMA recommends that physicians abide by any provincial/territorial policies or legislation that may currently be in place. The medical services infrastructure in rural and remote areas is usually very different from that in urban settings. In addition to a lack of specialist services, physicians in these areas may often have to cope with a number of other factors such as limited or no appropriate diagnostic equipment or limited hospital beds. Physicians and their patients expect and deserve quality care. The diversity and needs of the populations, as well as the needs of the physicians who practise in rural and remote areas, must also be recognized and reflected in the infrastructure (e.g., demographic and geographical considerations). The CMA recommends that 27. A basic medical services infrastructure for rural and remote areas be defined, such as hospital beds, paramedical staff, diagnostic equipment, transportation, ready access to secondary and tertiary services, as well as information technology tools and support. 28. Provincial/territorial governments recognize that physicians who work in rural and remote areas need an environment that appropriately supports them in providing service to the local population.
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Addressing professional issues of Canadian physicians and medical practice

https://policybase.cma.ca/en/permalink/policy465
Last Reviewed
2020-02-29
Date
1999-08-25
Topics
Physician practice/ compensation/ forms
Resolution
GC99-60
That the Canadian Medical Association be the national focus for enhancing organized medicine's effectiveness in addressing the variety of professional issues facing Canadian physicians and medical practice.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
1999-08-25
Topics
Physician practice/ compensation/ forms
Resolution
GC99-60
That the Canadian Medical Association be the national focus for enhancing organized medicine's effectiveness in addressing the variety of professional issues facing Canadian physicians and medical practice.
Text
That the Canadian Medical Association be the national focus for enhancing organized medicine's effectiveness in addressing the variety of professional issues facing Canadian physicians and medical practice.
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Cardiopulmonary resuscitation

https://policybase.cma.ca/en/permalink/policy722
Last Reviewed
2020-02-29
Date
1990-08-23
Topics
Health care and patient safety
Physician practice/ compensation/ forms
Resolution
GC90-96
The Canadian Medical Association recommends that all physicians ensure that they have the knowledge and skills necessary to provide basic cardiopulmonary resuscitation.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
1990-08-23
Topics
Health care and patient safety
Physician practice/ compensation/ forms
Resolution
GC90-96
The Canadian Medical Association recommends that all physicians ensure that they have the knowledge and skills necessary to provide basic cardiopulmonary resuscitation.
Text
The Canadian Medical Association recommends that all physicians ensure that they have the knowledge and skills necessary to provide basic cardiopulmonary resuscitation.
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A Public Health Perspective on Cannabis and Other Illegal Drugs : CMA Submission to the Special Senate Committee on Illegal Drugs

https://policybase.cma.ca/en/permalink/policy1968
Last Reviewed
2020-02-29
Date
2002-03-11
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2002-03-11
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
Cannabis has adverse effects on the personal health of Canadians and the well-being of society. In making this submission to the Special Senate Committee on Illegal Drugs, the Canadian Medical Association (CMA) wishes to make it clear that any change to the criminal status of cannabis must be done so with the recognition that cannabis is an addictive substance and that addiction is a disease. The CMA believes that the government must take a broad public health policy approach to address cannabis use. Focusing on the decriminalization issue alone is inadequate to deal with the complexity of the problem. Changes to the criminal law affecting cannabis must not promote normalization of its use, and must be tied to a national drug strategy that promotes awareness and prevention, and provides for comprehensive treatment. Under such a multidimensional approach the CMA would endorse decriminalization. In this document, we primarily focus on the health effects of cannabis use. However, we also present information and recommendations on the use of other illegal drugs. While we understand that this goes beyond the intended scope of the Senate Committee's study, this information is important to the development of comprehensive policy, which we believe is required. We also recognize and welcome the fact that many of the CMA's recommendations will require a closer working relationship among health providers, justice officials and law enforcement. The CMA's recommendations are: Section 1: Illegal Drugs 1. A National Drug Strategy: The federal government develop, in cooperation with the provinces and territories and the appropriate stakeholder groups, a comprehensive national drug strategy on the non-medical use of drugs. 2. Redistribution of Resources: The vast majority of resources dedicated to combating illegal drugs are directed towards law enforcement activities. Government needs to re-balance this distribution and allocate a greater proportion of these resources to drug treatment, prevention, and harm reduction programs. Law enforcement activities should target the distribution and production of illegal drugs. 3. Addiction is a Disease: Addiction should be regarded as a disease and therefore, individuals suffering with drug dependency should be diverted, whenever possible, from the criminal justice system to treatment and rehabilitation. Additionally, the stigma associated with addiction needs to be addressed as part of a comprehensive education strategy. 4. Increased Research: All governments commit to more research on the cause, effects and treatment of addiction. Further research on the long- term health effects associated with chronic cannabis use is specifically required. Section 2: Cannabis 1. National Cannabis Cessation Program: The federal government develop, in cooperation with the provinces and territories and the appropriate stakeholder groups, a comprehensive program to minimize cannabis use. This should include, but not be limited to: * Education and awareness raising of the potential harms of cannabis use including risks associated with use in pregnancy; use by those with mental illness; chronic respiratory problems; and chronic heavy use; * Strategies to prevent early use in adolescence; and, * Availability of assessment, counselling and treatment services for those experiencing adverse effects of heavy use or dependence. 2. Driving Under the Influence Prevention Policy: The CMA believes that comprehensive long-term efforts that incorporate both deterrent legislation and public awareness and education constitute the most effective approach to reducing the number of lives lost and injuries suffered in crashes involving impaired drivers. The CMA supports a similar multidimensional approach to the issue of the operation of a motor vehicle while under the influence of cannabis. 3. Decriminalization: The severity of punishment for simple possession and personal use of cannabis should be reduced with the removal of criminal sanctions. The CMA believes that resources currently devoted to combating simple marijuana possession through the criminal law could be diverted to public health strategies, particularly for youth. To the degree that having a criminal record limits employment prospects the impact on health status is profound. Poorer employment prospects lead to poorer health. Use of a civil violation, such as a fine, is a potential alternative. However, decriminalization should only be pursued as part of a comprehensive national illegal drug strategy that would include a cannabis cessation program. 4. Monitoring and Evaluation: Any changes need to be gradual to protect against any potential harm. In addition, changes to the criminal law in connection with cannabis, should be rigorously monitored and evaluated for their impact. This document also contains the policies and recommendations of the CMA affiliated association that has specific expertise in the field of substance use disorders the, Canadian Society of Addiction Medicine (CSAM). In addition, for an even broader health-sector perspective, the CMA has attached information on the policy positions of other key medical organizations from Canada and the United States in regard to decriminalization of cannabis. A PUBLIC HEALTH PERSPECTIVE ON CANNABIS AND OTHER ILLEGAL DRUGS INTRODUCTION The Canadian Medical Association (CMA) welcomes the opportunity to participate in the deliberations of the Special Senate Committee on Illegal Drugs. This document was developed by the CMA's new Office for Public Health in consultation with our Affiliate Societies, in particular the Canadian Society of Addiction Medicine, and our 12 provincial and territorial divisions. The use of illegal drugs and relevant policies is an extremely broad, multi-disciplinary and at times, controversial subject. Considering the breadth of this subject, the limited time-lines and the areas of particular interest of the Committee, this document will focus on the following: * What are the known health effects of cannabis and other illegal drugs? * What experience has there been with the decriminalization of cannabis? * What has been the impact of law enforcement on illegal drug use? * What changes need to be considered in Canada's approach to illegal drug use including the potential decriminalization of drugs? In addition to the above, this document will provide an overview of the relevant policy position statements and recommendations regarding cannabis and drug policy from other key medical organizations from both Canada and the United States. PUBLIC HEALTH PERSPECTIVE ON DRUG USE There are many different perspectives on the use of drugs including ethical and moral frameworks. This paper is prepared from a public health perspective where minimizing any harms associated with use is of primary concern. 1 This requires consideration of health issues related not only to the individual user and the drug being used, but also the key social factors associated with use. Drug use is a complex behaviour that is influenced by many factors. It is not possible to identify a single cause for drug use, nor will the set of contributing factors be the same among different drug users and populations. Public health objectives will vary depending upon the circumstances: preventing drug use in those who have not initiated use (e.g. pre-teens); avoiding use in circumstances associated with a risk of adverse outcomes (e.g. drug use and driving motor vehicle); assisting those who wish to stop using the drug (e.g. treatment, rehabilitation); and assisting those who intend to continue to use the drug to do so in such a manner as to reduce the risk of adverse effects (e.g. needle exchange program to reduce risk of HIV). To address this complexity, what is required is a public health strategy to combat drug use utilizing a comprehensive, multi-component approach. Public health strategies focus on the various predisposing, enabling, and re-enforcing factors that influence healthy behaviours and choices. 2 These sets of factors recognize the many influences upon individual behaviour including: individual and social attitudes, beliefs and values; skills; support, self-efficacy and re-enforcement. Public health actions can be grouped into the following major categories: 3 * Developing Personal Skills - education and skill-building (e.g. mass media, skill development to resist peer pressure, thinking skills); * Healthy Public Policy - policies, formal and informal that support health (e.g. school policy, substance use and driving, harm reduction initiatives); * Creating Supportive Environments - social and physical environments (e.g. adequate housing and food, community safety, non-chemical coping mechanisms); * Strengthen Community Action - community involvement in finding solutions (e.g. self-help, social support, community participation); * Health Services - range of services to meet needs (e.g. prevention, assessment, early intervention, treatment, rehabilitation, harm-reduction initiatives). This framework is useful in identifying the range of program components that need to be considered. Relative emphasis between components and the specific interventions selected will vary depending upon the target population (e.g. school students vs. injection drug users). The key is a balanced approach that will influence the factors contributing to less healthy behaviours with support for behaviour change and maintenance. CANNABIS Several commissions and task forces, in Canada and elsewhere, have addressed the issue of how to deal with cannabis use, although frequently their recommendations have not been implemented. 4, 5, 6 It has been suggested that "cannabis is a political football that governments continually duck...(but that) like a football, it bounces back." 7 This section of the paper will review current Canadian levels of use, health effects, law enforcement issues, and experience with decriminalization in other jurisdictions. Current Use The Ontario Student Drug Use Survey is conducted every two years in grades 7, 9, 11, and 13, although in 1999 all grades from 7-13 were surveyed. Use of cannabis within the preceding year increased from 11.7% of students in 1991, to 29.2% in 1999. 8 Increases were also observed for several other drugs during the same time period (tobacco, alcohol, glue, other solvents, hallucinogens, cocaine, PCP, and ecstasy). Increases in adolescent drug use have also been observed in the US, Europe and Australia through the 1990s. Compared with earlier cohorts, fewer students in 1999 reported early onset of cannabis use (before grade 7) compared with similarly aged students in 1997 and 1981. Past year drug use of cannabis, alcohol and tobacco by grade year is shown in Table 1. The proportion of students who have used one of these drugs increases with increasing grade level. [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 1 - Past Year Drug Use (%) by Grade Level, Ontario Students, 1999 7 8 9 10 11 12 13 Alcohol 39.7 53.7 63.1 74.9 82.0 84.6 83.0 Tobacco 7.4 17.8 27.8 37.4 41.7 38.6 38.0 Cannabis 3.6 14.9 25.5 36.4 48.1 39.4 43.3 1999 Ontario Student Drug Use Survey 9 [TABLE END] The last national survey of illicit drug use in Canada was conducted in 1994. 10 At that time, 23% of Canadians, aged 15 and over, reported having used cannabis more than once during their lifetime with 7% having used it within the preceding year. Current use is much more common in those under the age of 25 and diminishes significantly with age, (Table 2). Most cannabis use is sporadic with the majority of adult and adolescent users using it less than once a week. 11 [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 2 - Lifetime and Current Use of Cannabis in Canada, 1994 Age Lifetime Use (%) Current Use (%) (past 12 months) 15-17 30 24.0 18-19 32.9 23.8 20-24 37.7 19.0 25-34 38.2 9.6 35-44 32.9 5.7 45-54 14.8 1.4 55-64 3.7 - 65+ 0.8 - Canada's Alcohol and Other Drugs Survey: 1994 [TABLE END] Health Effects Our understanding of the health effects of cannabis continues to evolve. Hall summarizes the effects into acute and chronic effects and whether these are probable or possible (Table 3). 12 [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 3 - Summary of Probable and Possible Health Effects of Cannabis Use Pattern of Use Acute Chronic Probable anxiety, dysphoria, panic, cognitive impairment, psychomotor impairment; chronic bronchitis, lung cancer, dependence, mild cognitive impairment, exacerbation of psychosis; Possible (possible but uncertain, confirmation required in controlled studies) increased risk of traffic accident, psychosis, low-birth-weight babies; cancers in offspring, impaired immunity From CMAJ 2000; 162: 1690-1692. [TABLE END] Tetrahydrocannabinol (THC) is the main psychoactive substance in cannabis. THC is inhaled in the mainstream smoke and absorbed through the lungs, rapidly entering the bloodstream. Effects are perceptible within seconds and fully apparent in a few minutes. Cannabis combines many of the properties of alcohol, tranquilizers, opiates and hallucinogens; it has anxiolytic, sedative, analgesic and psychedelic properties. 13 Its acute toxicity is extremely low, as no deaths directly due to acute cannabis use have ever been reported. The main feature of its use is that it produces a feeling of euphoria (or 'high'). Toxic dose-related effects include anxiety, panic, depression or psychosis.14 It should also be noted that a significant incident of co-morbid addiction occurs in those with physical and mental diseases. People with major mental illnesses such as schizophrenia are especially vulnerable in that cannabis use can provoke relapse and aggravate existing symptoms. A chronic lack of energy and drive to work in chronic users has been referred to as an "amotivational syndrome," which is currently believed to represent an ongoing intoxication in frequent users. 14 Cannabis slows reaction times, impairs motor coordination and concentration as well as the completion of complex tasks. 13 Due to the extended presence of metabolites in the bloodstream, it is difficult to correlate blood levels with acute impairment making interpretation of crash data difficult. However, it is generally accepted that cannabis use is associated with an increased risk of motor vehicle and aircraft crashes. Impairments of attention, memory and the ability to process complex information can last for prolonged periods of time, even years, after cessation of heavy, chronic cannabis use. A cannabis withdrawal syndrome similar to alcohol, opiate and benzodiazepine withdrawal symptoms exist. 14 Cannabis use increases heart rate and causes blood vessels to dilate. These present a risk for those with pre-existing cardiac disease. Smoke from cannabis preparations contains many of the same compounds as tobacco cigarettes including increased levels of tar. Chronic cannabis smoking is associated with bronchitis and emphysema. Chronic cannabis use may have risks of chronic lung disease and lung cancer comparable to cigarette smoking. With increasing study and experience, it is clear that cannabis, like other substances such as tobacco or alcohol, can have a number of adverse physical and psychological effects. 15 Law Enforcement The 1997 data is the latest year with national drug offences' data for possession, cultivation, trafficking and importation (Figure 1). 16 The proportion of drug incidents is heavily skewed towards cannabis. This is intriguing since the health concerns of cannabis are substantially less than those of heroin or cocaine. [FIGURE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Figure 1: Proportion of All Drug Incidents by Drug Type, Canada, 1997 [FIGURE END] Of the 66,500 drug incidents in Canada in 1997, over 70% (47,908) were cannabis related. Of these, over two thirds (32,682) were for possession. The rate of cannabis offences has increased 34% since 1991 with cannabis-possession rates increasing steadily from 1991-1996 with a slight drop in 1997. Most (86%) of those charged with cannabis offences were under 25 years of age. It has been estimated that about 2,000 Canadians are sent to jail every year for cannabis possession.17 Despite the current level of enforcement, cannabis use has been increasing with over 40% of grade 11, 12 and 13 students having used cannabis in the preceding year. While it is obvious that only a small percentage of users are being charged, thousands of teens and young adults are being charged every year, receiving criminal records that can impact future employment, future interactions with the justice system, and be a barrier to acquiring citizenship. 11 Findings from several studies indicate that perceived health risk and social disapproval were much more important disincentives to cannabis use than legal threats. 18 Experience with Decriminalization in Other Jurisdictions A number of other jurisdictions have implemented alternative enforcement approaches to the personal use of cannabis. While none of these experiences directly predict what would happen in Canada, they do provide information to address some of the issues raised when decriminalization is considered. Despite the obvious interest in the impact of these policy changes, there is a paucity of well-designed evaluations (i.e. evaluations which were designed and implemented prior to policy change, rather than post-hoc analyses on available data). United States In the 1970s, several US states reduced the legal sanctions for possession of small amounts of cannabis to a maximum penalty of a fine. Despite the substantial potential interest in the effects of such policy changes, evaluative studies were relatively sparse. The available data, though based upon national high school student survey data as well as evaluations in two states, indicated that there was no apparent increase in cannabis use that could be attributed to decriminalization. 19 The high school student national survey data showed that while use of cannabis had increased in those states that had decriminalized possession, the rates of use had increased by a greater amount with stricter laws. California was one of the states which decriminalized possession, and similar to other states, experienced a decrease in cannabis use during the 1980s which based upon student surveys appeared to be due to changing perceptions of health risks rather than changes in the legal status of the drug. 19 Netherlands The Netherlands is the most frequently identified example of a country that altered its approach to marijuana. The Dutch impose no penalties for the possession of small amounts of cannabis and allow a number of coffee shops to openly sell the drug. 20 This policy therefore is not simply removing the potential for criminal records and imprisonment with possession, but actually partially legalized cannabis sales. This process began in 1976 and coffee shops were not allowed to advertise, could not sell hard drugs, no sales to minors, no public disturbances, and no sales transactions exceeding certain quantity thresholds. Initially this threshold was set at 30 gm of cannabis, a rather large amount which was reduced to 5 gm in 1995. Attempts have been made to compare the prevalence of cannabis use in the Netherlands with other countries. Since cannabis use changes dramatically with age and over different time periods, surveys need to be of similar populations during similar time periods to be comparable. Differences in the wording of questions between surveys also make comparison difficult. A recent review by MacCouin et al makes 28 comparisons between the Netherlands and the US, Denmark, West Germany, Sweden, Finland, France and the UK.21 Overall, it appears that Dutch rates are lower than rates of use in the US but somewhat higher than those of some of its European neighbours. Cannabis use is higher in Amsterdam compared to other Dutch cities and is comparable to use in the US. A limited number of surveys appear to show that from 1984 to 1992, there was a substantial increase in adolescent (aged 16 - 20) use of cannabis that did not occur in other countries. The increases observed from 1992 to 1998 however, were similar to the increases observed in other countries including Canada. Overall, it appears that while the increases in Dutch adolescent use started earlier than other countries, their prevalence of use was much lower than comparison countries so that by the late 1990s they had comparable rates of use to the US and Canada. Australia From 1987 to 1995, three Australian states decriminalized the possession and cultivation of cannabis for personal use by replacing penal sanctions with fines. 22 The courts in other states have tended to utilize non-penal sanctions such as a fine or a suspended sentence with a criminal record. The limited number of surveys conducted in Australia has failed to find evidence of any large impact on cannabis use (some of the surveys had small sample sizes and the trend in usage has been upwards in Australian states which did not decriminalize as well as in other countries that continue to prohibit cannabis use). Interestingly, despite the decriminalization, the number of notices issued by police exceeds the number of cannabis offences prior to the change in law. Summary The preceding sections have suggested that cannabis use is relatively common (particularly in teens and young adults); most use is sporadic; its use is increasing; and it is not harmless. Because of these potential harms, one would not wish to encourage its use. There is however, no necessary connection between adverse health effects of any drug or human behaviour and its prohibition by law. 22 The issue is therefore whether there are less coercive ways to discourage its use. Despite the current criminal justice approach where the bulk of all illegal drug charges are cannabis-related and the majority of these are for possession, use is increasing with thousands of teens and young adults receiving criminal records for possession each year. The available evidence from other jurisdictions suggests that decriminalization would not result in a substantial increase in use beyond baseline trends. Considering current trends, a comprehensive approach to discourage current usage is required. OTHER ILLEGAL DRUGS Illegal drugs other than cannabis present a different set of issues and concerns. While these drugs are not the primary focus of the Special Senate Committee's study, we have included a few key issues to better put the cannabis issue in proper context. Current Use The Ontario Student Drug Use Survey of students in grades 7, 9, 11 and 13 has shown that following a lengthy period of decline in drug use during the 1980s, there has been a steady increase in adolescent drug use. 8 Past year drug use in 1999 was reported as follows: ecstasy (4.8%); PCP (3.2%); hallucinogens (13.8%), and cocaine (4.1%). By comparison, tobacco, alcohol and cannabis were 28.3%, 65.7%, and 29.2% respectively. Canadian survey data of those aged 15 and over in 1994 found that about one in twenty reported any lifetime use of LSD, speed or heroin, or cocaine. 10 Rates of use of these drugs within the preceding year were 1% and 0.7% respectively. Health Effects The adverse effects of drugs such as heroin and cocaine are related not just to the drugs themselves, but also increasingly to their method of intake, which is predominantly by injection. Injection drug use (IDU) is an efficient delivery mechanism of drugs, but is also an extremely effective means of transmitting bloodborne viruses such as hepatitis B, hepatitis C and HIV. The proportion of HIV infections attributable to IDU has increased from 9% prior to 1985 to over 25% by 1995. 23 IDU is also the predominant means of hepatitis C transmission responsible for 70% of cases. 24 The increasing use of cocaine, which tends to be injected on a more frequent basis, increases the subsequent exposure to infection. It has been estimated that up to 100,000 Canadians inject drugs (not counting steroids). 25 Transmission of bloodborne pathogens is not limited to injection drug users as the disease can then be further spread to sexual contacts, including the sex trade, and vertical transmission from infected mother to child. An epidemic of overdose deaths among injection drug users has been experienced in British Columbia with over 2000 such deaths in Vancouver since 1991. 17 Despite the seriousness of the potential adverse effects of illegal drug use and the potential for this situation to worsen with increasing transmission of bloodborne diseases, on a population basis, legal drugs (alcohol and tobacco) are responsible for substantially more deaths, potential years of life lost and hospitalizations. 26 [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 4 - The Number of Deaths, Premature Mortality and Hospital Separations for Illicit Drugs, Alcohol and Tobacco, Canada, 1995. Deaths Potential Years of Life Lost Hospital Separations Illicit Drugs 805 33,662 6,940 Alcohol 123,734 172,126 82,014 Tobacco 34,728 500,350 193,772 From: Single et al. CMAJ 2000: 162: 1669-1675 [TABLE END] Expenditures on Illegal Drugs The direct costs associated with illicit drugs based on 1992 Canadian data are shown in the figure below: [FIGURE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [FIGURE END] The vast majority of expenditures related to illegal drugs are on law enforcement. Considering the distribution of drug incidents, a substantial proportion of these are related to cannabis offences although health and other costs will predominantly be associated with other drugs. A substantial proportion of drug charges are for possession as compared with trafficking or importation (cocaine 42%; heroin 42%; other drugs 56%). 16 Despite illegal drug use being primarily a health and social issue, current expenditures do not reflect this and are heavily skewed towards a criminal justice approach. Unfortunately, prisons are not an ideal setting for treating addictions with the potential for continued transmission of bloodborne viruses. RECOMMENDATIONS The Need for Balanced, Comprehensive Approaches Reasons for drug use, particularly "hard drugs," are complex. It is not clear how a predominantly law enforcement approach is going to address the determinants of drug use, treat addictions, or reduce the harms associated with drug use including overdoses and the transmission of bloodborne viruses including HIV. Costs of incarceration are substantially more than the use of effective drug treatment. 27 It appears that there is an over dependence on the law when other models might be more effective in achieving the desired objective of preventing or reducing harm from drug use. 18 Aggressive law enforcement at the user level could exacerbate these harms by encouraging the use of the most dangerous and addictive drugs in the most concentrated forms, 28 because these are easier to conceal and the efficacy of injecting is greater than that of inhaling as drug costs increase in response to prohibition and enforcement. 29 There have been several recent sets of recommendations from expert groups regarding the need for a comprehensive set of approaches to address the public health challenges due to drug use, particularly those associated with injection drug use (IDU). 17, 25, 30, 31 Recommendations include the following components: * address prevention; * treatment and rehabilitation; * research; * surveillance and knowledge dissemination; * national leadership and coordination. Many of the recommendations will require close working relationships with justice/enforcement officials. Drug abuse and dependency is a chronic, relapsing disease for which there are effective treatments.32 A criminal justice approach to a disease is inappropriate particularly when there is increasing consensus that it is ineffective and exacerbates harms.33 The CMA's recommendations have been separated into two separate sections. The first set of recommendations is focused on policies affecting illegal drugs in general. While this goes beyond the intended scope of the Senate Committee's study, in our opinion, these recommendations are equally important for the Committee to consider. The second set of recommendations is specifically focused on cannabis. Our recommendations in this section take into consideration the health impact profile of cannabis, current levels of use, extent and impact of law enforcement activities and experience from other jurisdictions. Section 1: Illegal Drugs The CMA recommends: 1. A National Drug Strategy: The federal government develop, in cooperation with the provinces and territories and the appropriate stakeholder groups, a comprehensive national drug strategy on the non-medical use of drugs. 2. Redistribution of Resources: The vast majority of resources dedicated to combating illegal drugs are directed towards law enforcement activities. Government needs to re-balance this distribution and allocate a greater proportion of these resources to drug treatment, prevention, and harm reduction programs. Law enforcement activities should target the distribution and production of illegal drugs. 3. Addiction is a Disease: Addiction should be regarded as a disease and therefore, individuals suffering with drug dependency should be diverted, whenever possible, from the criminal justice system to treatment and rehabilitation. Additionally, the stigma associated with addiction needs to be addressed as part of a comprehensive education strategy. 4. Increased Research: All governments commit to more research on the cause, effects and treatment of addiction. Further research on the long- term health effects associated with chronic cannabis use is specifically required. Section 2: Cannabis The CMA recommends: 1. National Cannabis Cessation Program: The federal government develop, in cooperation with the provinces and territories and the appropriate stakeholder groups, a comprehensive program to minimize cannabis use. This should include, but not be limited to: * Education and awareness raising of the potential harms of cannabis use including risks associated with use in pregnancy; use by those with mental illness; chronic respiratory problems; and chronic heavy use; * Strategies to prevent early use in adolescence; and, * Availability of assessment, counselling and treatment services for those experiencing adverse effects of heavy use or dependence. 2. Driving Under the Influence Prevention Policy: The CMA believes that comprehensive long-term efforts that incorporate both deterrent legislation and public awareness and education constitute the most effective approach to reducing the number of lives lost and injuries suffered in crashes involving impaired drivers. The CMA supports a similar multidimensional approach to the issue of the operation of a motor vehicle while under the influence of cannabis. 3. Decriminalization: The severity of punishment for simple possession and personal use of cannabis should be reduced with the removal of criminal sanctions. The CMA believes that resources currently devoted to combating simple marijuana possession through the criminal law could be diverted to public health strategies, particularly for youth. To the degree that having a criminal record limits employment prospects the impact on health status is profound. Poorer employment prospects lead to poorer health. Use of a civil violation, such as a fine, is a potential alternative. However, decriminalization should only be pursued as part of a comprehensive national illegal drug strategy that would include a cannabis cessation program. 4. Monitoring and Evaluation: Any changes need to be gradual to protect against any potential harm. In addition, changes to the criminal law in connection with cannabis, should be rigorously monitored and evaluated for their impact. CANADIAN SOCIETY OF ADDICTION MEDICINE The Canadian Society of Addiction Medicine (CSAM), which was formed in 1989, is a national organization of medical professionals and other scientists interested in the field of substance use disorders. Vision The Society shares its overall goals with many other organizations and groups in Canada; namely, the prevention of problems arising from the use of alcohol and other psychoactive substances, and the cure; improvement or stabilization of the adverse consequences associated with the use of these drugs. This Society aims to achieve these goals through the fostering and promotion of medical sciences and clinical practice in this field in Canada, particularly by: * fostering and promotion of the roles of physicians in the prevention and treatment of alcohol and drug related problems; * improvement in the quality of medical practice in the drug and alcohol field through: establishment and promotion of standards of clinical practice; fostering and promotion of research; and fostering and promotion of medical education; * promotion of professional and public awareness of the roles that physicians can play in the prevention and treatment of alcohol and drug related problems; * fostering and promotion of further development of programs for the prevention and treatment of problems of alcohol and drug use in physicians; and * contributing to professional and public examination and discussion of important issues in the drug and alcohol field. Policy Statement The CSAM National Drug Policy statement requires that: Canada must have a clear strategy for dealing with the cultivation, manufacture, importation, distribution, advertising, sale, possession and use of psychoactive substances regardless of whether they are classified as legal or illegal. Drug possession for personal use must be decriminalized and distinguished from the trafficking or illegal sale/distribution of drugs to others that must carry appropriate criminal sanctions. The individual and public health impact of substance use, substance abuse and substance dependence must be taken into account at all times. An assessment to ascertain the extent of a substance use disorder and screening for addiction must be an essential part of dealing with someone identified as an illicit drug user or possessor. Appropriate funding must be made available for supply reduction and demand reduction of various psychoactive substances that carry an abuse or addiction liability. Recommendations 1. National policies and regulations must present a comprehensive and coordinated strategy aimed at reducing the harm done to individuals, families and society by the use of all drugs of dependence regardless of the classification of "legal" or "illegal" 2. Prevention programs need to be comprehensively designed to target the entire range of dependence-producing drugs to enhance public awareness and affect social attitudes with scientific information about the pharmacology of drugs and the effects of recreational and problem use on individuals, families, communities and society. 3. Outreach, identification, referral and treatment programs for all persons with addiction need to be increased in number and type until they are available and accessible in every part of the country to all in need of such services. 4. Law enforcement measures aimed at interrupting the distribution of illicit drugs need to be balanced with evidenced based treatment and prevention programs, as well as programs to ameliorate those social factors that exacerbate addiction and its related problems. 5. Any changes in laws that would affect access to dependence-producing drugs should be carefully thought out, implemented gradually and sequentially, and scientifically evaluated at each step of implementation, including evaluating the effects on: * access to young people and prevalence of use among youth; * prevalence of use in pregnancy and effects on offspring; * prevalence rates of alcoholism and other drug dependencies; * crime, violence and incarceration rates; * law enforcement and criminal justice costs; * industrial safety and productivity; * costs to the health care system; * family and social disruption; * other human, social and economic costs. 6. CSAM opposes * any changes in law and regulation that would lead to a sudden significant increase in the availability of any dependence-producing drug (outside of a medically-prescribed setting for therapeutic indications). All changes need to be gradual and carefully monitored. * any system of distribution of dependence-producing drugs that would involve physicians in the prescription of such drugs for other than therapeutic or rehabilitative purposes. 7. CSAM supports * public policies that would offer treatment and rehabilitation in place of criminal penalties for persons with psychoactive substance dependence and whose offense is possession of a dependence-producing drug for their own use. Those who are found guilty of an offense related to Addiction, proper assessment and treatment services must be offered as part of their sentence. This goal may be attained through a variety of sentencing options, depending upon the nature of the offense. * an increase in resources devoted to basic and applied research into the causes, extent and consequences of alcohol and other drug use, problems and dependence, and into methods of prevention and treatment. RELEVANT POSITION STATEMENTS OF OTHER MEDICAL HEALTH ORGANIZATIONS The purpose of this section is to provide the Special Senate Committee on Illegal Drugs with information on the policy positions of other key medical organizations from Canada and the United States in regard to decriminalization of cannabis. Canadian Centre for Addiction and Mental Health34 The Centre for Addiction and Mental Health (CAMH) does not encourage or promote cannabis use. CAMH emphasizes that the most effective way of avoiding cannabis-related harms is through not using cannabis, and encourages people to seek treatment where its use has become a problem. Cannabis is not a benign drug. Cannabis use, and in particular frequent and long-term cannabis use, has been associated with negative health and behavioural consequences, including respiratory damage, problems with physical coordination, difficulties with memory and cognition, pre- and post-natal development problems, psychiatric effects, hormone, immune and cardio-vascular system defects, as well as poor work and school performance. The consequences of use by youth and those with a mental disorder are of particular concern. However, most cannabis use is sporadic or experimental and hence not likely to be associated with serious negative consequences. CAMH thus holds the position that the criminal justice system in general, and the Controlled Drugs and Substances Act (CDSA) specifically, under which cannabis possession is a criminal offence, has become an inappropriate control mechanism. This conclusion is based on the available scientific knowledge on the effects of cannabis use, the individual consequences of a criminal conviction, the costs of enforcement, and the limited effectiveness of the criminal control of cannabis use. CAMH thus concurs with similar recent calls from many other expert stakeholders who believe that the control of cannabis possession for personal use should be removed from the realm of the CDSA and the criminal law/criminal justice system. While harmful health consequences exist with extensive cannabis use, CAMH believes that the decriminalization of cannabis possession will not lead to its increased use, based on supporting evidence from other jurisdictions that have introduced similar controls. CAMH recommends that a more appropriate legal control framework for cannabis use be put into place that will result in a more effective and efficient control system, produce fewer negative social and individual consequences, and maintain public health and safety. An alternative legal control system for the Canadian context can be chosen from a number of options that have been tried and proven adequate in other jurisdictions. CAMH further recommends that such an alternative framework be explored on a temporary and rigorously evaluated trial basis, and that an appropriate level of funding be provided/maintained for prevention and treatment programs to minimize the prevalence of cannabis use and its associated harms. American Society of Addiction Medicine 35 The Society's 1994 policy which was updated September 2001 recommends the following: 1. National policy should present a comprehensive and coordinated strategy aimed at reducing the harm done to individuals, families and society by the use of all drugs of dependence. 2. Reliance on the distinction between "legal" and "illegal" drugs is a misleading one, since so-called "legal" drugs are illegal for persons under specified ages, or under certain circumstances. 3. Prevention programs should be comprehensively designed to target the entire range of dependence-producing drugs as well as to produce changes in social attitudes. (See ASAM Prevention Statement.) 4. Outreach, identification, referral and treatment programs for all persons suffering from drug dependencies, including alcoholism and nicotine dependence, should be increased in number and type until they are available and accessible in every part of the country to all in need of such services. 5. Persons suffering from the diseases of alcoholism and other drug dependence should be offered treatment rather than punished for their status of dependence. 6. The balance of resources devoted to combatting these problems should be shifted from a predominance of law enforcement to a greater emphasis on treatment and prevention programs, as well as programs to ameliorate those social factors that exacerbate drug dependence and its related problems. 7. Law enforcement measures aimed at interrupting the distribution of illicit drugs should be aimed with the greatest intensity at those causing the most serious acute problems to society. 8. Any changes in laws that would affect access to dependence-producing drugs should be carefully thought out, implemented gradually and sequentially, and scientifically evaluated at each step of implementation, including evaluating the effects on: a. prevalence of use in pregnancy and effects on offspring; b. prevalence rates of alcoholism and other drug dependencies; c. crime, violence and incarceration rates; d. law enforcement and criminal justice costs; e. industrial safety and productivity; f. costs to the health care system; g. family and social disruption; h. other human, social and economic costs. 9. ASAM opposes any changes in law and regulation that would lead to a sudden significant increase in the availability of any dependence-producing drug (outside of a medically-prescribed setting for therapeutic indications). Any changes should be gradual and carefully monitored. 10. ASAM opposes any system of distribution of dependence-producing drugs that would involve physicians in the prescription of such drugs for other than therapeutic or rehabilitative purposes. 11. ASAM supports public policies that would offer treatment and rehabilitation in place of criminal penalties for persons who are suffering from psychoactive substance dependence and whose only offense is possession of a dependence-producing drug for their own use. 12. ASAM supports public policies which offer appropriate treatment and rehabilitation to persons suffering from psychoactive substance dependence who are found guilty of an offense related to that dependence, as part of their sentence. This goal may be attained through a variety of sentencing options, depending upon the nature of the offense. 13. ASAM supports an increase in resources devoted to basic and applied research into the causes, extent and consequences of alcohol and other drug use, problems and dependence, and into methods of prevention and treatment. 14. In addition, scientifically sound research into public policy issues should receive increased support and be given a high priority as an aid in making such decisions. 15. Physicians and medical societies should remain active in the effort to shape national drug policy and should continue to promote a public health approach to alcoholism and other drug dependencies based on scientific understanding of the causes, development and treatment of these diseases. US Physician Leadership on National Drug Policy 32 The Physician Leadership on National Drug Policy (PLNDP) was started in 1997 when 37 senior physicians from virtually every medical society* met and agreed that the "current criminal justice driven approach is not reducing, let alone controlling drug abuse in America." Their extensive review of the literature found: * drug addiction is a chronic, relapsing disease, like diabetes or hypertension; * treatment for drug addiction works; * treating addiction saves money; * treating drug addiction restores families and communities; * prevention and education help deter youth from substance abuse, delinquency, crime and incarceration. In follow-up to an extensive review of the literature, their key policy recommendations are: * Reallocate resources toward drug treatment and prevention; * Parity in access to care, treatment benefits, and clinical outcomes; * Reduce the disabling regulation of addiction treatment programs; * Utilize effective criminal justice procedures to reduce supply and demand (e.g. community coalitions, community policing, drug courts); * Expand investments in research and training; * Eliminate the stigma associated with the diagnosis and treatment of drug problems; * Train physicians and (medical) students to be clinically competent in diagnosing and treating drug problems. REFERENCES 1 Mosher JF, Yanagisako KL. Public health, not social warfare: a public health approach to illegal drug policy. J Public Health Policy 1991; 12: 278-323. 2 Precede - proceed model of health promotion. Institute of Health Promotion Research. Available from: http://www.ihpr.ubc.ca/frameset/frset_publicat.htm. Accessed: Nov 27, 2001. 3 World Health Organization. Ottawa charter for health promotion. Ottawa: World Health Organization, 1986. 4 Dean M. UK government rejects advice to update drug laws. Lancet 2000; 355: 1341. 5 Curran WJ. Decriminalization, demythologizing, desymbolizing and deemphasizing marijuana. Am J Public Health. 1972; 62: 1151-1152. 6 Report of the Canadian Government Commission of Inquiry into the non-medical use of drugs. Ottawa, 1972. 7 Anonymous. Deglamorising cannabis. Lancet 1995; 346: 1241. (editorial) 8 Edlaf EM, Paglia A, Ivis FJ, Ialomiteanu A. Nonmedicinal drug use among adolescent students: highlights from the 1999 Ontario Student Drug Use Survey. CMAJ 2000; 162: 1677-1680. 9 Centre for Addiction and Mental Health. The 1999 Ontario Student Drug Use Survey - executive summary. Available from: http://www.camh.net/addiction/ont_study_drug_use.html. Accessed: October 15, 2001. 10 MacNeil P, Webster I. Canada's alcohol and other drugs survey 1994: a discussion of the findings. Ottawa: Health Canada, 1997. 11 Single E, Fischer B, Room R, Poulin C, Sawka E, Thompson H, Topp J. Cannabis control in Canada: options regarding possession. Ottawa, Canadian Centre on Substance Abuse, 1998. Available from: http://www.ccsa.ca/. 12 Hall W. The cannabis policy debate: finding a way forward. CMAJ 2000; 162: 1690-1692. 13 Ashton CH. Pharmacology and effects of cannabis: a brief review. Br J Psychiatr 2001; 178: 101-106. 14 Johns A. Psychiatric effects of cannabis. Br J Psychiatr 2001; 178: 116-122. 15 Farrell M, Ritson B. Br J Psychiatr 2001; 178: 98. 16 Tremblay S. Illicit drugs and crime in Canada. Juristat 1999; 19. 17 Riley D. Drugs and drug policy in Canada: a brief review and commentary. November, 1998. Available from: http://www.parl.gc.ca/37/1/parlbus/commbus/senate/com-e/ill-e/library-e/riley-e.htm. Accessed: October 15, 2001. 18 Erickson PG. The law, social control, and drug policy: models, factors, and processes. Int J Addiction 1993; 28: 1155-1176. 19 Single EW. The impact of marijuana decriminalization: an update. J Public Health Policy 1989; 10: 456-66. 20 MacCoun R. Interpreting Dutch cannabis policy: reasoning by analogy in the legalization debate. Science 1997; 278: 47-52. 21 MacCoun R, Reuter P. Evaluating alternative cannabis regimes. Br J Psychiat 2001; 178: 123-128. 22 Hall W. The recent Australian debate about the prohibition on cannabis use. Addiction 1997; 92: 1109-1115. 23 Centre for Infectious Disease Prevention and Control. HIV/AIDS among injecting drug users in Canada. May 2001. Available from: http://www.hc-sc.gc.ca/hpb/lcdc/bah/epi/idus_e.html. Accessed Oct 17, 2001. 24 Hepatitis C - prevention and control : a public health consensus. Can Communic Dis Rep 1999; 25S2. Available from: http://www.hc-sc.gc.ca/hpb/lcdc/publicat/ccdr/99vol25/25s2/index.html. Accessed: Oct 17, 2001. 25 F/P/T Advisory Committee on Population Health et al. Reducing the harm associated with injection drug use in Canada: working document for consultation. March 2001. Available from: http://www.aidslaw.ca/Maincontent/issues/druglaws.htm. Accessed: Oct 14, 2001. 26 Single E, Rehm J, Robson L, Van Truong M. The relative risks and etiologic fractions of different causes of death attributable to alcohol, tobacco and illicit drug use in Canada. CMAJ 2000: 162: 1669-1675. 27 Marwick C. Physician Leadership on National Drug Policy finds addiction treatment works. JAMA 1999; 279: 1149-1150. 28 Grinspoon L, Bakalar JB. The war on drugs - a peace proposal. N Eng J Med 1994: 330: 357-360. 29 Hankins C. Substance use: time for drug law reform. CMAJ 2000: 162: 1693-1694. 30 National Task Force on HIV, AIDS and Injection Drug Use. HIV/AIDS and injection drug use: a national action plan. Canadian Centre for Substance Abuse and Canadian Public Health Association. May 1997. Available from: http://www.ccsa.ca/docs/HIVAIDS.HTM. Accessed: Oct 15, 2001. 31 Canadian HIV/AIDS Legal Network. Injection drug use and HIV/AIDS: legal and ethical issues. Montreal: Network, 1999. 32 Physician Leadership on National Drug Policy. Position paper on drug policy. January 2000. Available from: http://center.butler.brown.edu/plndp/. Accessed: Nov 27, 2001. 33 The Fraser Institute. Sensible solutions to the urban drug problem. 2001. Available from: http://www.fraserinstitute.ca/publications/books/drug_papers/. Accessed: Nov 29, 2001. 34 Canadian Centre for Addiction and Mental Health. CAMH Position on the legal sanctions related to cannabis possession/use. April 2000. Available from: www.camh.net/position_papers/cannabis_42000.html. Accessed Oct 9, 2001. 35 American Society of Addiction Medicine. Public policy of ASAM. Adopted 1994. Updated Sept 29, 2001. Available from: www.asam.org. Accessed: Nov 27, 2001. ?? ?? ?? ?? A healthy population...a vibrant medical profession Une population en santé...une profession médicale dynamique A Public Health Perspective on Cannabis and Other Illegal Drugs Ottawa, March 11, 2002 Page 21 Canadian Medical Association
Documents
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Recommendations pertaining to children's mental health

https://policybase.cma.ca/en/permalink/policy8507
Last Reviewed
2020-02-29
Date
2006-08-23
Topics
Health systems, system funding and performance
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Population health/ health equity/ public health
Resolution
GC06-15
The Canadian Medical Association endorses all of the recommendations pertaining to children's mental health in the Senate report, Out of the Shadows at Last - Transforming Mental Health, Mental Illness and Addiction Services in Canada.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
2006-08-23
Topics
Health systems, system funding and performance
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Population health/ health equity/ public health
Resolution
GC06-15
The Canadian Medical Association endorses all of the recommendations pertaining to children's mental health in the Senate report, Out of the Shadows at Last - Transforming Mental Health, Mental Illness and Addiction Services in Canada.
Text
The Canadian Medical Association endorses all of the recommendations pertaining to children's mental health in the Senate report, Out of the Shadows at Last - Transforming Mental Health, Mental Illness and Addiction Services in Canada.
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Insurance fund of last resort

https://policybase.cma.ca/en/permalink/policy8520
Last Reviewed
2020-02-29
Date
2006-08-23
Topics
Population health/ health equity/ public health
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Resolution
GC06-16
The Canadian Medical Association urges governments to create an insurance fund of last resort to provide financial relief to parents for the catastrophic cost of drugs and other health care services provided to children as part of an accepted treatment protocol for childhood illnesses and disorders when not covered by public insurance.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
2006-08-23
Topics
Population health/ health equity/ public health
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Resolution
GC06-16
The Canadian Medical Association urges governments to create an insurance fund of last resort to provide financial relief to parents for the catastrophic cost of drugs and other health care services provided to children as part of an accepted treatment protocol for childhood illnesses and disorders when not covered by public insurance.
Text
The Canadian Medical Association urges governments to create an insurance fund of last resort to provide financial relief to parents for the catastrophic cost of drugs and other health care services provided to children as part of an accepted treatment protocol for childhood illnesses and disorders when not covered by public insurance.
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Coercive legislation

https://policybase.cma.ca/en/permalink/policy8539
Last Reviewed
2020-02-29
Date
2006-08-23
Topics
Physician practice/ compensation/ forms
Resolution
GC06-69
The Canadian Medical Association and its divisions staunchly oppose any form of coercive legislation in regard to the negotiation of working conditions and compensation of physicians.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
2006-08-23
Topics
Physician practice/ compensation/ forms
Resolution
GC06-69
The Canadian Medical Association and its divisions staunchly oppose any form of coercive legislation in regard to the negotiation of working conditions and compensation of physicians.
Text
The Canadian Medical Association and its divisions staunchly oppose any form of coercive legislation in regard to the negotiation of working conditions and compensation of physicians.
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Sale of clove, herbal and vitamin cigarettes

https://policybase.cma.ca/en/permalink/policy8547
Last Reviewed
2020-02-29
Date
2006-08-23
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Population health/ health equity/ public health
Resolution
GC06-77
The Canadian Medical Association will work with the federal government to study the possibility of national legislation governing the promotion and sale of clove, herbal and vitamin cigarettes.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
2006-08-23
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Population health/ health equity/ public health
Resolution
GC06-77
The Canadian Medical Association will work with the federal government to study the possibility of national legislation governing the promotion and sale of clove, herbal and vitamin cigarettes.
Text
The Canadian Medical Association will work with the federal government to study the possibility of national legislation governing the promotion and sale of clove, herbal and vitamin cigarettes.
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Pharmacists who are given independent prescribing authority

https://policybase.cma.ca/en/permalink/policy8557
Last Reviewed
2020-02-29
Date
2006-08-23
Topics
Population health/ health equity/ public health
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Health care and patient safety
Resolution
GC06-67
The Canadian Medical Association, in conjunction with its divisions and affiliates, without endorsing pharmacist independent prescribing strongly urges the Government of Alberta to require pharmacists who are given independent prescribing authority to: a) require explicit, informed consent from a patient; b) maintain a patient's record; c) provide 24-hour availability to the patient; d) carry appropriate coverage for legal liability; e) disclose any potential conflict of interest as both a prescriber and dispenser of medication; and, f) if the pharmacist changes a physician's prescription, advise the physician of the change(s).
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
2006-08-23
Topics
Population health/ health equity/ public health
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Health care and patient safety
Resolution
GC06-67
The Canadian Medical Association, in conjunction with its divisions and affiliates, without endorsing pharmacist independent prescribing strongly urges the Government of Alberta to require pharmacists who are given independent prescribing authority to: a) require explicit, informed consent from a patient; b) maintain a patient's record; c) provide 24-hour availability to the patient; d) carry appropriate coverage for legal liability; e) disclose any potential conflict of interest as both a prescriber and dispenser of medication; and, f) if the pharmacist changes a physician's prescription, advise the physician of the change(s).
Text
The Canadian Medical Association, in conjunction with its divisions and affiliates, without endorsing pharmacist independent prescribing strongly urges the Government of Alberta to require pharmacists who are given independent prescribing authority to: a) require explicit, informed consent from a patient; b) maintain a patient's record; c) provide 24-hour availability to the patient; d) carry appropriate coverage for legal liability; e) disclose any potential conflict of interest as both a prescriber and dispenser of medication; and, f) if the pharmacist changes a physician's prescription, advise the physician of the change(s).
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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.
Documents
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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.
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CMA Letter to the Senate Committee on Legal and Constitutional Affairs regarding Bill C-2, An Act to amend the Criminal Code and to make consequential amendments to other Acts

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

https://policybase.cma.ca/en/permalink/policy9210
Last Reviewed
2020-02-29
Date
2008-08-20
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Physician practice/ compensation/ forms
Resolution
GC08-21
The Canadian Medical Association urges Canadian medical schools to include in their curricula material related to the deleterious effect of negative stereotyping of Aboriginal peoples suffering from mental illnesses and substance use disorders.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
2008-08-20
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Physician practice/ compensation/ forms
Resolution
GC08-21
The Canadian Medical Association urges Canadian medical schools to include in their curricula material related to the deleterious effect of negative stereotyping of Aboriginal peoples suffering from mental illnesses and substance use disorders.
Text
The Canadian Medical Association urges Canadian medical schools to include in their curricula material related to the deleterious effect of negative stereotyping of Aboriginal peoples suffering from mental illnesses and substance use disorders.
Less detail
Last Reviewed
2020-02-29
Date
2008-08-20
Topics
Health systems, system funding and performance
Physician practice/ compensation/ forms
Health information and e-health
Resolution
GC08-95
The Canadian Medical Association, in consultation with provincial/territorial medical associations, the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada, will work with professional regulatory/licensing bodies to establish a harmonized policy environment that would support physicians who are providing telehealth care in multiple jurisdictions.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
2008-08-20
Topics
Health systems, system funding and performance
Physician practice/ compensation/ forms
Health information and e-health
Resolution
GC08-95
The Canadian Medical Association, in consultation with provincial/territorial medical associations, the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada, will work with professional regulatory/licensing bodies to establish a harmonized policy environment that would support physicians who are providing telehealth care in multiple jurisdictions.
Text
The Canadian Medical Association, in consultation with provincial/territorial medical associations, the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada, will work with professional regulatory/licensing bodies to establish a harmonized policy environment that would support physicians who are providing telehealth care in multiple jurisdictions.
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